XIV. European Stroke Conference
Bologna, Italy
25 - 28 May 2005
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Experimental studies Oral Session 1A    
Date: Thursday, 26 May 2005   Time: 11:40 - 11:50 -  Room: Sala Topazio
Chair: L. Hirt, Switzerland and S. Blecic, Belgium

05
Morphological data imply cortical neurogenesis in the human ischemic brain following stroke
P. Wester    S. Carlsson    C. Friedholm    T. Brännström    W. Gu    W. Jiang    P. Lindsberg                     
 

Umeå Stroke Center, Univ Umeå, Sweden

SWEDEN

Background and purpose: We have previously observed newborn nerve cells (neurogenesis) in the ischemic penumbra following focal cerebral ischemia in adult rodents. The present study aimed to explore whether this phenomenon also takes place in the human brain following acute ischemic stroke. Methods: Four patients (1 woman and 3 men, age 76-88 years) with ischemic stroke within the middle cerebral artery territory who died 48 – 72 hours after ischemic onset were investigated. Post-mortem time varied between 4 and 28 hours. Brain samples from the frontal, parietal and temporal ischemic and non-ischemic hemispheres were processed for single or double immunohistochemistry. Antibodies against the S-phase markers Ki67 and PCNA were used to detect proliferating cells, anti-Map2 and Neu N to identify post-mitotic neurons and GFAP for glial cell recognition. Results: Numerous Ki67 and PCNA immunolabeled cells appeared in the ischemic part of the human cortex at 48-72 hours after stroke. Some of these newborn cells were double labeled with Map2 and NeuN whereas others were double immuno-positive for GFAP. Conclusion: These data suggest that new neurons can be generated in the human cerebral cortex after ischemic stroke. Cortical neurogenesis may be a potential pathway for brain repair in stroke patients.

Vascular imaging Oral Session 1A    
Date: Thursday, 26 May 2005   Time: 17:25 - 17:35 -  Room: Sala Bianca
Chair: R. Baumgartner, Switzerland and J. Norris, UK

08
Natural History of complex plaque in the carotid arteries of symptomatic patients with moderate carotid stenosis.
A.L.Daniels    N. Altaf    P.S.Morgan    S.T.ManSweeny    A. Moody    D.P.Auer    J. Gladman                     
 

Nottingham University

UNITED KINGDOM

Background Carotid surgery prevents stroke in symptomatic patients with severe carotid stenosis. Patients with moderate stenosis and those with severe asymptomatic disease also benefit. Surgery should be targeted at patient likely to benefit; those who develop further strokes. Complex plaque is the condition that carotid imaging needs to identify, it is the form that causes distal embolism. Magnetic Resonance Direct Thrombus Imaging (MRDTI) is known to be a convenient, accurate way of identifying complex plaque in symptomatic severe carotid stenosis. Further information in moderate stenosis needs to be gained. Methods 68 patients with anterior circulation transient ischaemic attack (TIA) and moderate (30-69%) stenosis of the symptomatic artery were enrolled. Participants underwent MRDTI scanning upon entry and at 12 months. The MRDTI sequence is T1-weighted, abolishes fat signal and nulls signal from blood. Complex plaque was defined as high signal on MRDTI of the carotid artery. Signal was classified as strong, weak or negative. Results We report 40 patients who have completed both MRI scans. 2 scans were excluded due to movement artefact. Of the remaining 38 patients, 21(55%) were MRDTI+ (strong or weak signal) in the symptomatic artery. 21(55%) arteries were MRDTI+ on the asymptomatic side. The signal diminshed in 6 symptomatic and 6 asymptomatic arteries over 12 months. Further embolic symptoms developed in 3 patients, all were ipsilateral to their initial event and all had strong MRDTI+ signal in the symptomatic artery. 1 patient developed de novo MRDTI+ signal, this was asymptomatic. Discussion This interim report suggests prevalence of MRDTI+ is similar in moderate and severe carotid stenosis. The MRDTI signal is stable over 12 months.

Acute stroke: complications and early outcome     Poster Session II
Date: Friday, 27 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

16
Outcomes of thrombolysis of patients with basilar artery territory acute stroke
G. Panczel    Zs. May    I. Kakuk    Cs. Óváry    N. Szegedi    D. Varga                            
 

National Stroke Center

HUNGARY

Background Data regarding thrombolysis mostly refer to MCA territory stroke and few data is available on BA territory tPA-lysis. We evaluated the clinical outcomes of tPA-lysis in patients with BA territory stroke (BA patients) in comparison to MCA-territory stroke patients (MCA patients). Patients and Methods Among 151 tPA-lysis 19 lysis of BA patients were evaluated. Symptomatic intracranial hemorrhage (SICH), death and modified Rankin Scale (mRS) at 3 months were assessed. Results Average baseline NIHSS was 23 (MCA patients: 18). 53% of patients died (MCA patients: 22%). SICH occurred in 2 patients (11%; MCA patients: 8%), both were lethal; mRS 0-1 points were found in 5 cases (26%; MCA patients: 38%), 3 patients were dependent (mRS 3-5). Early recanalization occurred in 11 and failed in 8 patients. Time-window < 3 hours was associated with high rate (80%) early recanalization. The mRS scores at 3 months correlated significantly with baseline NIHSS scores (p < 0.05) and with disturbed consciousness at admission (p<0.005). Hypertension, diabetes, atrial fibrillation or ischemic heart disease in history and age had no significant impact on clinical outcome. Early recanalization did not significantly influence clinical outcome (p=0.08) although lack of recanalization was always associated with bad outcome (exit or bedridden state). Discussion In our study the proportion of favorable outcome was lower, death rate was higher and SICH occurred more frequently in BA patients, as compared with MCA patients. The cause of this difference was that BA patients had higher baseline NIHSS score than MCA patients. When taking into consideration only MCA patients with baseline NIHSS > 22, these differences were eliminated (death BA vs. MCA: 53% vs. 50%; mRS 0-1 points: 26% vs. 23%. Our data show that BA and MCA territory thrombolysis are equally effective and safe despite doubled time-window.

Imaging: new methods and applications Oral Session 1A    
Date: Thursday, 26 May 2005   Time: 11:40 - 11:50 -  Room: Sala Bianca
Chair: M. Forsting, Germany and F. Fazekas, Austria

05
Comparison of transcranial color-coded sonography and functional MRI in the assessment of cerebral vasomotor reactivity before EC/IC bypass surgery. Pilot study.
R. Herzig    P. Hlustik    M. Vaverka    S. Burval    J. Machac    I. Vlachova    B. Krupka    D. Sanak    J. Mares    P. Kanovsky
 

Stroke Unit, Dpt. of Neurology, Radiology, Neurosurgery, University Hosp., Olomouc, Czech Republic

CZECH REPUBLIC

Background: Several methods are being used to assess cerebral vasomotor reactivity (CVR), including transcranial color-coded sonography (TCCS). However, no standardized examination protocol exists for this examination. Alternative noninvasive hemodynamic imaging can be performed with blood oxygenation level dependent functional magnetic resonance imaging (fMRI). The aim of this study was to evaluate the accuracy of TCCS and fMRI in the assessment of CVR. Methods: Study group consisted of 18 patients, presenting with 20 occluded internal carotid arteries (ICAs), out of whom 13 patients suffered from ischemic stroke/transient ischemic attack in the ipsilateral arterial territory and in whom extra-intracranial arterial bypass surgery was considered. TCCS examination, including breath-holding/hyperventilation test (BH-HV) and breath-holding index (BHI), was used for the assessment of CVR. CVR evaluation using fMRI was performed in patients with ipsilateral pathological findings in both BH-HV and BHI test. fMRI employed a bimanual motor task within both a block paradigm and an event-related paradigm. Results: Using TCCS, impaired CVR was diagnosed in 7 out of the 20 ICA territories. fMRI examination confirmed CVR impairment in 4 (57%) out of these 7 cases. Impairment of cortical hemodynamics manifested consistently as diminished extent of active cortex, smaller magnitude and wider shape of the hemodynamic response and longer hemodynamic delay when compared to the normal side. Discussion: In the evaluation of CVR, fMRI seems to be more specific than TCCS. Thus, TCCS can be used as a screening method, but should be complemented with fMRI for this purpose. Acknowledgement: Supported by the IGA Ministry of Health CR grants number NR/7830-3/2004 and NR/8367–3/2005.

Vascular imaging – new developments     Poster Session I
Date: Thursday, 26 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

06
Acceleration of Cerebrovascular Reactivity as New Supplemental Parameter in Evaluation of Cerebral Hemodynamics by TCD
G. Telman    E. Kouperberg    I. Schlesinger    A. Hoffman    D. Yarnitsky                                   
 

Rambam Medical Center

ISRAEL

Background and Purpose. Cerebrovascular reactivity examined by Transcranial Doppler (TCD) is a useful tool for investigation of cerebrovascular reserve capacity of the normal and compromised brain. The aim of this study was to learn the acceleration of cerebrovascular reactivity (CVR) as possible additional index characterizing the process of cerebrovascular reserve recruitment and the application of this index in symptomatic and asymptomatic patients with severe unilateral carotid stenosis. Methods. Twenty seven patients with severe unilateral carotid stenosis were included into the study. TCD examination with acetazolamide test was used for the measurement of cerebrovascular reactivity before and after CEA. The acceleration (cm/sec²) of CVR was calculated as ratio of delta velocities and timing of velocities change measured by CVR trace from the point of beginning of increase of cerebral blood flow velocity up to the point of plateau of velocities. Results. The acceleration of CVR in patients with severe unilateral carotid stenosis before CEA was 0.038 +/- 0.031 cm/sec² and after the operation was 0.069 +/- 0.031 cm/sec² (p=0.004). CVR was 20.4 +/- 27.1 % and 41.7+/- 22/7 % correspondently (p =0.04). The correlation index between CV and acceleration was 0.86 before and 0.5 after the surgery. Conclusions. The CVR acceleration may be used as new supplemental index in evaluation of cerebrovascular reserve capacity.

Risk factors of stroke     Poster Session III
Date: Saturday, 28 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

16
PFO - Migraine - Stroke - A triangular relationship ?
Y.P.Shah    S.H.Kreisel    M. Daffertshofer    M.G.Hennerici                                          
 

Department of Neurology, Universitätsklinikum Mannheim, University of Heidelberg

GERMANY

Background: The patent foramen ovale (PFO) is a risk factor for recurrent stroke (4%/yr in PFO with atrial septum aneurysm (Mas. et al.2001)). Moreover PFO has been associated with migraine, which in turn is suggested to present as a co-factor in stroke. To further analyze this triangular relationship we studied a series of patients with PFO in respect to recurrent stroke and migraine. Methods: We included 77 patients (56 m, 21 f) with a diagnosis of cryptogenic stroke due to paradoxical embolism via PFO (identification of PFO and exclusion of other sources). A follow-up was performed after 3.0+/-1.5y; data in respect to recurrent stroke, migraine history, risk factors and treatment were acquired. Results: 9 patients (12%) had a recurrent cerebrovascular event. 16 patients (21%) had a pre-existing history of migraine (MA+ n=8, MA- n=8). However, no patient with a history of migraine had recurrent stroke. Secondary prophylactic medication showed no difference in the event-free outcome between the treatment with antiplatelets or anticoagulants; PFO-occlusion (n=10) preventing further stroke. The recurrence rate of stroke was significantly age-related. In conclusion, there is a missing link in the hypothetical triangular relationship between PFO, stroke and migraine: Patients with migraine stayed event-free through follow-up. Therefore, in our sample there is no evidence for a higher incidence of recurrent stroke in migraine patients. The overall recurrence rate in our sample matched results of previous studies, we found a higher rate of migraine prevalence compared to epidemiological data (4 to 15%). This supports an association of PFO and migraine.

Epidemiology of stroke Oral Session 1B    
Date: Friday, 27 May 2005   Time: 17:25 - 17:35 -  Room: Europauditorium
Chair: A. Czlonkowska, Poland and T. Truelsen, Denmark

20
TRENDS IN STROKE INCIDENCE AND CASE FATALITY RATE IN SOUTHERN GREECE
K. Xynos    G. Tsivgoulis    K. Spengos    M. Saliaris    M. Synetou    M.G.Bokis    K. Vemmos                     
 

University of Athens

GREECE

Background. Limited data exist regarding trends in stroke incidence and case fatality rate. We determined the incidence of first-ever stroke and the associated case fatality in a defined population for the year 2004 and compared these data with the previous reported in 1993-95. Methods. Identical methods were used to find and assess all cases of suspected any first-ever stroke in the Arcadia province of 81906 residents aged <20 years old. Case fatality was measured as vital status at 28 days after the onset of symptoms. For case ascertainment, information from death certificates, hospital records, public health centers, and general practitioners was used. Results. During a 12-month period (2004), 267 subjects with a first-ever stroke were registered. The crude incidence rate (per 100 000) was 326 (95% CI, 287-365) compared to 343.6 (95%CI, 315–372) 10 years before. A decreased incidence rates were observed for ages <74 years: 111.4 (95% CI, 86.9-135.9) compared to the previous 158.6 (95% CI, 137.8-179.4). The 28-day case fatality rate has not changed: 25.5 (95% CI, 20.3-30.7) for the year 2004 and 26.6% (95% CI, 22.9-30.2) 10 years ago. Discussion. Our results suggest that the overall incidence and case fatality rate were unchanged during a period of 10 years. A significant reduce of incidence was observed among ages less than 74 years old.

Risk factors of stroke     Poster Session III
Date: Saturday, 28 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

02
Does stopping Aspirin increase risk of brain ischemic stroke?
A.B.Maulaz    D.C.Bezerra    P. Michel    J. Bogousslavsky                                          
 

Centre Hospitalier Universitaire Vaudois - CHUV

SWITZERLAND

Background: Aspirin, or acetylsalicylic acid (ASA) is widely used in the prevention of ischemic vascular disease. Clinical and experimental data suggest the occurrence of a rebound effect £ 4 weeks after ASA interruption. We studied ASA discontinuation as a risk factor for ischemic stroke. Methods: From all patients with ischemic stroke or TIA admitted to our stroke unit between January 2002 and April 2004, we selected those on long-term ASA before their index event. In this case-control study, age-, sex-, and antiplatelet therapy-matched controls, selected from the outpatient stroke clinic who had not had a ischemic stroke in the previous 6 months, were interviewed about recent discontinuation of Aspirin. We compared the frequency of ASA discontinuation within the 4 weeks prior to ischemic cerebral event in cases and 4 weeks prior to interview in controls. Results: Among the 978 patients with ischemic stroke, 309 were on regular ASA therapy. When compared with the 309 matched outpatients, the two groups had a similar frequency of risk factors, except for coronary heart disease, which was more frequent in cases (36% versus 18%, p<0.05). ASA had been discontinued in 13 stroke patients and in 4 controls. ASA interruption yielded an odds ratio for ischemic stroke/TIA of 3.4 (95% CI 1.8-10.6; p < 0.005) after adjustment in a multivariable model. Conclusion: Our results highlight the importance of ASA compliance and give an estimate of the risk associated with discontinuation of ASA in patients at risk for ischemic stroke, particularly patients with coronary heart disease.

Acute stroke: complications and early outcome     Poster Session II
Date: Friday, 27 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

21
Which of the basic lab tests are of predictive value for poor outcome in ischemic stroke?
M. Niewada    M.  Mazurkiewicz    B.  Kamicski    A. Kobayashi    A. Czlonkowska                                   
 

Medical University of Warsaw

POLAND

Background: The association between results of basic lab tests in acute period of ischemic stroke and poor outcome was determined. Methods: The clinical database on 1677 ischemic stroke patients was analysed. Blood samples were collected on admission and basic lab test (white blood count, platelets, HCT, OB, serum glucose, fibrinogen, albumin, total cholesterol, LDL and HDL cholesterol, triglycerides) performed up to 12 hours. Poor outcome was defined as death or mRS >3 at hospital discharge. Logistic regression model was developed to control for age, sex, history of stroke, MI, diabetes, atrial fibrillation and neurological impairments at admission rated on Scandinavian Stroke Scale. Results: WBC, OB, glucose, fibrinogen were significantly higher while serum albumin, total cholesterol, LDL cholesterol and triglyceride level were lower for patients with poor outcome than patients with nonpoor outcome. Logistic regression model confirmed only albumin (OR: 0,613; 95%CI: 0,478 – 0,786), OB (OR: 1,013; 95%CI: 1,006 – 1,021) and fibrinogen (OR: 1,002; 95%CI: 1,000 – 1,003) were associated with poor outcome at hospital discharge. Conclusion: Serum albumin, fibrinogen levels and OB seems to be of significant predictive value for ischemic stroke early outcome.

Management and economics     Poster Session II
Date: Friday, 27 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

01
Long-Term Costs of Outpatient Stroke Care. Results from a Population-Based Study: the Erlangen Stroke Project
P.L.Kolominsky-Rabas    P.U.Heuschmann    B. Neundörfer    M. Emmert    O. Schöffski    D. Marschall                            
for the CompetenceNet Stroke

Unit for Stroke Research & Public Health Medicine, Interdisciplinary Center for Public Health Studies, University of Erlangen-Nürnberg, Bavaria, Germany

GERMANY

Background: Stroke is a major disease in both medical and economics terms. The prevailing emphasis on cost containment and managed care has led to increased interest in the economic aspects of stroke and the resource use during the natural course of stroke. In contrast to economic data on hospital care, there are few data published on costs of medical outpatient services as well as nursing care in the post-acute phase. We studied the direct costs over a period of five years in a large population-based cohort. Methods: Data from unselected patients after first-ever ischemic stroke recruited in the Erlangen Stroke Project (ESPro) were used to calculate the long-term costs of outpatient care after stroke. The ESPro is the first population-based stroke registry in Germany, monitoring epidemiology, risk factors and resource use over time within a study population of 100 000. Patients were registered and followed up prospectively 5 years after their first-ever stroke and direct costs of allowance for nursing care and for medical outpatient services were documented. Results: During a 10-year period 1994 – 2003 821 patients with ischemic stroke were registered in the ESPro (mean age 73.0; 55% were females). The overall cost for medical outpatient services was € 2.790 (SD +/- € 1067.0) per patient/ year, for nursing care € 1.250.0 (SD +/- € 1.886.0) per patient/ year. For medical care female stroke patients showed a constant level of cost in all age-groups, whereas in men the cost decreases by time from € 3.200 (year 1) to € 2.100 (year 5). Total nursing costs in the age group 75-84 were the highest in women with € 8.600 in comparison to men with € 4.400. Discussion: Direct costs for medical services and nursing care differ substantially during the long-term course of the disease. Therefore in the planning of managed-care structures and services more attention should be given to age-specific and gender-specific characteristics in order to meet the care needs of a growing older population. By providing a comprehensive figure for the details of direct costs of outpatient stroke care over time, our study gives some clues about the economic burden of stroke care.

Epilepsy and stroke     Poster Session I
Date: Thursday, 26 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

03
Stroke with seizures at onset or Todd’s palsy: a diagnostic problem frequently encountered in emergency rooms.
G. Procaccianti    M.  Crisci    A. Gabellini    A. Baldrati    S. Laudadio    F. Rizzuti    T. Sacquegna                     
 

Ospedale Maggiore - Bologna

ITALY

Our Stroke Unit (SU) admits almost every stroke occurring in the south-western part of Bologna and surrounding area. Reported here are data on epileptic seizures occurring during the acute phase of stroke. Methods. Relevant data (baseline characteristics, diagnostic tests, vascular risk factors, comorbid conditions, neurological deficits at entry/discharge, destination after discharge) from every patient admitted to our SU are routinely collected in a PC based registry. Stroke sub-types were defined according to the criteria in the Classification of Cerebrovascular Disease III (Stroke 1990;21:637). We defined heralding seizures (HS) those which are the presenting symptom of stroke and early seizures (ES) those occurring during the first two weeks from stroke onset. Results. During 2004, a total of 330 stroke patients (49% females) were admitted. Forty-seven were hemorrhagic and 283 ischemic strokes. First ever stroke occurred in 282 patients. Mean age at onset was 76.2 +/- 10.1. Ischemic stroke sub-types were: athero-thrombotic (ATS) (43), cardio-embolic (CES) (89), lacunar (LS) (73), other ethiology (10), undefined (US) (68). Mean duration of stay was 13.2 +/- 10.6 days. Only 4 patients had a history of epilepsy: none had seizures during hospitalisation. HS were seen in 9 patients (3 ATS, 2 CES and 4 US). ES occurred in 11 patients (3 ATS, 4 CES and 4 US). A total of 16 patients (4.8%) presented seizures in the early phase of stroke. During the same period 13 patients with late onset seizures and Todd’s palsy were admitted to our unit as they were presumed to have a stroke. Conclusions. Patients are directly admitted to our SU by emergency physicians. Heralding seizures are very rare in stroke, whereas late onset epilepsy is relatively frequent in the general population. These results have been object of a peer audit between emergency and stroke physicians in our hospital.

Epidemiology of stroke     Poster Session III
Date: Saturday, 28 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

30
WEATHER INFLUENCE ON STROKE OCCURENCE AND OTHER NEUROLOGICAL EMERGENCES
V. Vargek-Solter    M. Bosnar-Puretic    M. Delas    V. Demarin                                          
 

University Neurology Department, Sestre Milosrdnice University Hospital

CROATIA

Background: Influence of weather on human health and well being is well known. Different studies have showed association of cardiovascular and cerebrovascular disease and season and meteorological factors. The aim of this study is to investigate the weather conditions on days with high frequency of neurological emergencies and stroke admissions. Methods: We retrospectively analyzed data of all patients examined at emergency room at Neurology Department during three years period (from January 1st 2001 till December 31st 2003). We compared frequency of visits at emergency room (and stroke admissions) and weather conditions. In analysis we used relative increase or relative decrease in air temperature, air pressure and air humidity on the day of admission. Level of significance was calculated using Student T test. Results: We defined that 23 or more visits a day is high frequency of visits at our Neurology emergency department. 6 or more stroke admission a day was defined as high frequency of stroke admission at our Neurology department. The highest frequency of emergency visits and stroke admissions occurred at days with significant and rapid air pressure changes (p<0,05). Incidence of ischemic stroke was higher on days with rapid temperature increase and air pressure drop (p<0,05). Patients with all others types of vascular conditions (syncope, TIA and vertebrobasilar syndromes) also more frequently asked for help at days with rapid fall in air pressure. Conclusions: Ischemic stroke was significantly associated with rapid weather changes, especially air pressure. More meteorological parameters should be included for more precise explanation of weather influence on neurological diseases.

Management and economics     Poster Session II
Date: Friday, 27 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

08
Is thrombolysis an underused treatment for acute ischemic stroke?
E.vanBreda    M.  Dirks    W. Scholte op Reimer    S. Hoeks    D. Dippel                                   
 

Erasmus Medical Center Rotterdam

THE NETHERLANDS

Background: Thrombolysis with intravenous rTPA is the only treatment of proven benefit in acute ischemic stroke. However, surveys and case-series indicate that the proportion of patients treated with thrombolysis is low in Western countries. We estimated the rate of thrombolysis in a representative cohort of acute ischemic stroke patients and assessed the reasons for not treating patients who were admitted within 3 hours after onset of symptoms. Methods: The Netherlands Stroke Survey is an observational study with consecutive inclusion of ischemic stroke patients. 13 centers participated. Data were extracted from patient files by trained research assistants, and physicians were queried about their decisions within a few days after discharge, if necessary. The cohort represents approximately 10% of all patients admitted for acute stroke in the Netherlands. Results: 579 patients were included in this study. 123 patients (21%) were admitted within 3 hours from onset, and 37 patients (6%) were treated with rTPA. The rate of treated patients varied among the centers from 0 to 21%. Of the patients with contra-indications, 2 were treated and 78 were not. The most frequent contra-indications for thrombolysis were mild sympoms (n=36, 45%) or rapidly improving symptoms (n=23, 29%). The Barthel Index (BI) within 2 days after admission was suboptimal (BI<20) in 28 (78%) of the 36 patients with mild or rapidly improving symptoms, and the modified Rankin score at 12 months exceeded 2 in 10 of these patients (28%). Conclusion: The variation in thrombolysis rate between the centers suggests that it is an underused treatment; patients who were noted to have mild symptoms or to improve rapidly quite often had a poor outcome. These patients may also benefit from thrombolysis.

Etiology of stroke Oral Session 1A    
Date: Thursday, 26 May 2005   Time: 12:40 - 12:50 -  Room: Sala Maggiore
Chair: I. Henriques, Portugal and J. DeReuck, Belgium

11
The outcome of patients with Cryptogenic Strokes.
G. Remiche    S. Blecic    K. Decock    S. Jeangette    M. Pandolfo                                   
 

Ersame Hospital

BELGIUM

To determine the outcome of patients (pts) with cryptogenic strokes (CS) compared to general pts (GP) with stroke. CS represent in different series from 4 to 29 % of pts. The discrepancy varies among the series according to the CS definition, some limiting CS to the absence of both etiology and risk factors for stroke (RF), others accepting to have RF for stroke. In our study we included pts who had no RF and no etiology (pure CS) that we compared in term of evolution to the population of CS with RF and to the GPFrom 1991 to 2003,4326 pts (2230 males) were admitted to the Stroke Unit. Mean age was 66.8 years. All had a stroke work-up. Trans-oesophageal echography, catheter angiography, extensive coagulation study, skin biopsy and lumbar puncture were performed in selected cases. All CS pts had an extensive stroke work-up and were followed twice a year for a maximum of 5 years (average 3 years).393/4326 (9.1%) pts were diagnosed has having CS. 69 pts (1.6%), had pure CS while 324 pts (7.4%), had RF. Only 26 pts with 2 RF full-filled the criteria for CS. No pts with more than 2 RF were found to have CS. Mean age of the CS pts was 51 ±4.1 years (p<0.001 compared to GP), no difference being observed between pts with pure CS and pts with CS. All patients with CS and RF were treated with aspirin, while only 32 pts with pure CS were treated. Within the follow-up period only 12 pts (3.0%) with CS had a vascular recurrence only one being found in the group of pure CS. 4 had a stroke and 8 had a cardiac recurrence (p<0.05 pts with pure CS versus pts with CS). No death was observed in both groups with CS. A statistical difference (p <0.001) was observed for any vascular recurrences between pts with CS and GP, since a new vascular event was found in 1216/4326 pts of GP (28.1%) 554/ having a new stroke (12.8%). This study demonstrated that pts with CS and GP differ widely in the follow-up, the former population being at a particular low risk to have any vascular recurrence, pure CS being a particular protected entity.

Etiology of stroke Oral Session 1B    
Date: Thursday, 26 May 2005   Time: 16:45 - 16:55 -  Room: Sala Maggiore
Chair: P. Koudstaal, The Netherlands and Z. Nagy, Hungary

16
CAUSES AND OUTCOME OF LACUNAR STROKES
S.  Micheli    M. Paciaroni    V. Caso    M. Venti    P. Milia    M. Acciarresi    C. D'Amore    S. Biagini    G. Agnelli       
 

Stroke Unit,University of Perugia

ITALY

Background: Lacunar stroke is usually due to a small vessel disease (SVD), commonly associated with hypertension, but it may have a more complex etiology. Aim of this study was to investigate etiology, risk factors, and outcome (recurrence, mortality and disability) in a series of patients with lacunar stroke. Methods: Consecutive patients with first-ever stroke (January 2003–October 2004) were included in the study. Lacunar stroke was defined according to TOAST criteria. Patients with an atherothrombotic, cardioembolic, or other determined stroke etiology were classified as suffering a non-SVD lacunar stroke. Neurological outcome was evaluated by modified Rankin Scale (mRS). Results: 127 out of 810 admitted patients had a lacunar stroke: 65 patients (51.2%) had lacunar stroke due to non-SVD. Patients with SVD lacunar stroke were younger (68.2 years versus 75.0 years; p=0.001) and had a higher prevalence of hypertension( p=0.0001) and diabetes (p=0.05) but a lower prevalence of ischemic heart disease (p=0.0001). After a mean follow-up of 10.5 months (+/-14.1), 18.9% of the patients with SVD lacunar stroke died or were disabled compared with 22,7% of patients with non-SVD lacunar stroke (OR=0.8, CI 95% 0.3-2.1). Furthermore, 7.7% of patients with SVD lacunar stroke had recurrent ischemic stroke compared to 13.9% of patients with non-SVD lacunar stroke (OR=0.5, CI 95% 0.1-1.8). Conclusions: Our data suggest a different prevalence of risk factors in patients with lacunar stroke due to SVD compared with lacunar stroke due to non-SVD. No significant differences in outcome were found between the two groups.

Imaging: new methods and applications Oral Session 1A    
Date: Thursday, 26 May 2005   Time: 12:50 - 13:00 -  Room: Sala Bianca
Chair: M. Forsting, Germany and F. Fazekas, Austria

12
Validation of Doppler velocimetric criteria of internal carotid artery stenosis
G. Sousa    R. Santos    J. Guimarães    E. Azevedo                                          
 

Hospital of S.João

PORTUGAL

Introduction: In the majority of cases, duplex sonography is the sole imaging study necessary before carotid interventions. There is a wide variation in diagnostic colour duplex criteria and methods of grading stenosis among Neurossonology Units. Standardization of duplex criteria would ensure greater consistency but would not replace the need for validation of results within each centre. Objective: Internal validation of Doppler velocimetric criteria of stenosis of internal carotid artery (ICA), comparing with grade of stenosis measured by longitudinal and cross-section duplex sonography images. Material and Methods:Duplex scans of 1306 ICAs of consecutive patients routinely referred to the Neurossonology Unit from January to December of 2004 were reviewed. ICA stenosis >=50% graded by morphologic criteria were selected. Groups were defined by estimated stenosis: 50-59%, 60-69%, 70-79%, 80-89% and 90-99%. It was calculated for each group: means of ICA peak systolic velocity (PSV) and end-diastolic velocity (EDV), ICA/common carotid artery (CCA) PSV ratio, existence of distal hemodynamic repercussion. Results: There were 74 ICA with stenosis >= 50%. The mean age was 68,59+/-12,3 years. Considering the mean values of percentage of stenosis measured longitudinally and in cross section, the mean velocity in the most stenotic point and the ICA/CCA ratio were respectively in the different stenosis groups: 118/41 cm/s, IC 1,5; 150/48 cm/s, IC 1,9; 255/105 cm/s, IC 3,3; 362/141 cm/s, IC 4,9. There were no patients in the group 90-99%. The coefficient of Pearson correlation between the % stenosis and systolic velocity was r=0,777, p<0,001. Conclusion: There was a positive correlation between velocimetric criteria and grade of stenosis. This will enable a more accurate measurement of stenosis by velocimetric criteria in our Unit, especially when morphologic criteria are lacking.

Heart and brain (cardiac disorders and stroke)     Poster Session II
Date: Friday, 27 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

05
Effectiveness of transesophagic echocardiography in etiology research of acute ischemic stroke
I.  Henriques     L.   Rebocho    J.   Moniz    M.   Trinca    T.   Alves                                   
 

HOSPITAL ESPÍRITO SANTO ÉVORA

PORTUGAL

BACKGROUND: In stroke etiology research, there are still patients with unknown etiology although extensively examined. The percentage of unknown etiology of ischemic stroke depends on how much investigation is undertaken. Since treatment options differ according to stroke etiology, and concomitant cardiopathy is common in these patients, we compared the prevalence of changes observed in transesophagic echocardiography (TEE) with that observed by Cervical Triplex scan and Transcraneal Doppler and their contribution to stroke etiology definition and secondary prevention. METHODS: We studied 247 consecutive patients that entered our stroke unit during the first 10 months of its functioning (144 male, 58.3%). All patients were studied according to a protocol that includes CT or diffusion MRI, cervical Triplex scan and transcraneal Doppler, ECG and transthoracic echocardiography. Patients were studied with TEE when no stroke etiology could be presumed otherwise. We considered ischemic stroke etiology according to TOAST criteria and stroke type according to Oxfordshire criteria. Results: From 247 patients, 170 (69.1%) had an ischemic stroke. TEE was performed in 22 patients (12.9%). From those 22 TEE, 6 (27.2%) showed lesions that changed secondary prevention. Triplex scan showed mild to severe stenosis in 31 patients (18.2%) and Transcraneal Doppler showed mild to severe stenosis in 52 patients (31%). Discussion: In this subgroup of patients without identified etiology by other means, transesophageal echocardiography showed an effectiveness in changing secondary prevention comparable to other exams that are already accepted as standard tools for acute stroke evaluation. More generalized used of TEE may be advisable.

Vascular surgery and PTCA     Poster Session II
Date: Friday, 27 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

01
Technical failures after carotid surgery detected by early postoperative duplex sonography
T. Blaser    M. Czihal    T. Buerger    M. Goertler                                          
 

Depts. of Neurology and Surgery, University of Magdeburg

GERMANY

Background and Purpose: We aimed to investigate frequency and predictors of technical failures at carotid surgery, assessed by early postoperative duplex sonography. Methods: Investigations were performed on 447 consecutive patients who underwent carotid surgery (mean age 66.0 years, SD 9; 75% men). All patients had standardized preoperative and postoperative neurological examination and colour-coded duplex sonography, the latter performed 2 to 4 days after surgery. Results: Postoperative duplex sonography detected 11 (2.5%) residual stenoses > 50% diameter reduction, 11 (2.7%) strictures, 22 (4.9%) step-like transitions from the operated to the distal internal carotid artery, 22 (4.9%) intimal flaps, and 4 (0.9%) clamping induced aneurysms, the latter all localized in the common carotid proximal of the dissected artery. Univariate and multivariate analysis of preoperative and intraoperative parameters including sex, preoperative symptoms, degree of stenosis, side of stenosis, type of anesthesia, type of surgery (with/without shunt), experience of surgeon (< 20, < 50, > 50, > 50 and > 20/year) did not select any predictive variable for a specific technical failure or overall. There was a trend to more complications if the carotid bifurcation was localized more cranially than the thyroid cartilage. Technical failures were more often found in patients with postoperative stroke (27%) than in those without neurological deficit (15%). However, this difference was not statistically significant. Conclusions: Technical failures after carotid surgery can be detected by early postoperative duplex sonography in up to 15% of patients. However neither a predictive parameter for these failures nor an influence of these failures on operative neurological outcome could be detected.

Cerebral haemorrhage and SAH     Poster Session II
Date: Friday, 27 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

07
CORRELATION BETWEEN ADMISSION BLOOD PRESSURE AND HEMATOMA VOLUME IN PATIENTS WITH INTRACEREBRAL HEMORRHAGE
M.P.Lazarevic    D.I.Lukic    M. Zivkovic                                                 
 

Clinical center Nis

YUGOSLAVIA

OBJECTIVE: Permanent or transient blood pressure increase is often associated with the intracerebral hemorrhages. AIM: The aim of our study was to assess the relationship between mean arterial pressure (MAP) on hospital admission and volume of acute spontaneous intracerebral hemorrhage. PATIENTS AND METHODS: We randomly selected 73 patients, with CT confirmed deep putaminal intracerebral hemorrhages. All patients were admitted up to 24 h after the beginning of disease. Blood pressure was measured on admission, and the MAP correlated with hematoma and intraventricular volume. Hematoma volume was calculated using ABC/2 formula promoted by Kothari, and intraventricular blood extension quantified by Graeb score. RESULTS: On admission MAP was 134.61+/-20.37 mmHg (range 96.66–193.33), hematoma volume was 27.48+/-22.42 cm3 (range 2.94–103.92) and Graeb score was 3.59+/-4.03 (range 0–12). There was no significant correlation between MAP and hematoma volume (r=0.13) or Graeb score (r=0.28). Four subgroups based on MAPs were made: (intervals of 20 mmHg starting from 100 mmHg: MAP1 <119, MAP2 120-139, MAP3 140-159, MAP4 >160mmHg). Hematoma volume according to the groups was: 24.25+/-17.06; 29.21+/-26.6; 19.23+/-15.23; 36.27+/-18.91 and Graeb score in the groups: 2.54+/-3.07; 3.34+/-4; 4.21+/-3.28; 4.82+/-5.78, respectively. MAP2 subgroup includes 48% of patients, with the one with the biggest hematoma volume, and also shows the highest variability. There were no statistical differences in hematoma volume and Graeb score between subgroup 2 and 4, although the later lead in absolute values. DISCUSSION: Our data suggest that mean arterial pressure on admission cannot be used as a predictor of intracerebral and intraventricular blood volume, although the highest MAPs level indicate a gross volume.

Behavior and mood Oral Session 1A    
Date: Friday, 27 May 2005   Time: 17:05 - 17:15 -  Room: SalaAzzura (1st floor)
Chair: J. Ferro, Portugal and L.Pantoni, Italy

06
Influence of pre-existing dementia on the risk of post-stroke epileptic seizures
C. Cordonnier    H. Hénon    P. Derambure    F. Pasquier    D. Leys                                   
 

Neurology department, Lille University hospital

FRANCE

Background: seizures occur in 10% of stroke patients but their predictors have not been clearly identified. In the community, patients with dementia have an increased risk of seizures, and 12 to 16% of stroke patients have pre-existing dementia. However, the question of whether stroke patients with pre-existing dementia have a higher risk of seizures than stroke patients without pre-existing dementia has never been studied. Objective: to evaluate whether pre-existing dementia is associated with an increased risk of seizures after stroke. Methods: the study was conducted in the 202 consecutive stroke patients recruited in the Lille Stroke/Dementia study (97 men; median age: 75 years; range: 42-100). We evaluated pre-stroke cognitive functions using the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE), with a cut-off of 104 for the diagnosis of dementia. Seizures were defined as early (ES) when occurring within 7 days after stroke onset, and as late (LS) when occurring more than 7 days after stroke. Results: among the 202 patients, 33 (16.3%) patients were identified as demented before stroke; 11 (5.4%) developed ES and 14 (6.9%) developed LS. Pre-existing dementia was not associated with the occurrence of ES, but was independently associated with the occurrence of LS (adj OR=4.66; 95%: 1.34-16.21). Conclusion: stroke patients with pre-existing dementia have an increased risk of LS after stroke.

Vascular surgery and PTCA     Poster Session II
Date: Friday, 27 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

05
General and regional anesthesia in carotid endarterectomy
T. Martin    A. Oldag    T. Hofmann    T. Buerger    M. Goertler                                   
 

Depts. of Neurology and Surgery, University of Magdeburg

GERMANY

Background and Purpose: We aimed to investigate the effect of general and regional anesthesia on outcome in patients who underwent carotid endarterectomy. Methods: During a 8 year period 488 consecutive patients (mean age 66.5 years, SD 9 years; 76% men) underwent carotid endarterectomy at a single center. All patients had standardized preoperative and postoperative neurological examination including colour-coded duplex sonography. Postoperatively patients were examined 2 to 4 days and at 6 weeks after surgery. After endarterectomy in 325 patients under general anesthesia the type of anesthesia was switched to regional one, which was performed at the following 163 surgeries. Results: 1 of 163 (0.6%) patients with regional anesthesia suffered a perioperative stroke compared to 20 of 325 (6.2%) patients with general anesthesia (odds ratio 0.094; 95% confidence interval 0.013 to 0.708, P = 0.009). Regional anesthesia remained predictive for a lower perioperative stroke rate also after adjustment for sex, age, preoperative (recurrent) ischemic event, degree of ipsilateral and contralateral stenosis, and experience of surgeon (adjusted odds ratio 0.127, 95% confidence interval 0.016 to 0.975, P = 0.047). Conclusion: In patients who undergo carotid endarterectomy, regional anesthesia seems to be associated with a lower perioperative stroke risk when compared with general anesthesia.

Brain Imaging – new developments     Poster Session III
Date: Saturday, 28 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

06
New nomenclature to capture all clinical and MRI endpoints for early stroke prevention trials.
S. Subramaniam    C. Sivakumar    J. Roy    V. Palumbo    S.B.Coutts    JM. Boulanger    J. Kennedy    A.M.Buchan    M. Eliasziw    A.M.Demchuk J. Scott
 

University of Calgary, Foothills Hospitals

CANADA

Background: We assessed the feasibility of using clinical and MRI endpoint defintions as surrogate markers of stroke outcome. Methods: Patients with a TIA or minor stroke (NIHSS < 4) presenting with hemiparesis or aphasia lasting > 5 minutes within 12 hours from symptom onset were included. 3T MRI with DWI sequences were obtained at baseline and 1 month. Lesions were rated by a single neuroradiologist blind to clinical data. Outcomes were defined as follows: 1) New symptomatic infarct: infarct outside initial perfusion abnormality with new functional deficit 2) New symptomatic stroke without infarct: new stroke deficits outside initial infarct without evidence on imaging. 3) New silent infarct : new infarct on MRI without new functional deficit 4) Symptomatic infarct growth: functional deterioration with new infarct within baseline perfusion abnormality or extending from initial infarct. 5) Stroke progression without infarct growth: functional deterioration without infarct growth. 6) Silent infarct growth: new infarct within baseline perfusion abnormality without functional deterioration. Results: DWI abnormality at baseline (n=82) 1) New symptomatic infarct: 4 (4.8%) 2) New symptomatic stroke without infarct: 0 3) New silent infarct : 5 (6.1%) 4) Symptomatic infarct growth: 3 (3.6%) 5) Stroke progression without infarct growth: 9 (10.9%) 6) Silent infarct growth: 10 (12.2%) DWI normal at baseline (n=45) 1)New silent infarct: 1 (2.2%) 2)Stroke progression without infarct growth: 1 (2.2%) Patients with a DWI lesion at baseline were 5.4 times more likely to have a new infarct (95% CI: 0.7 to 36.2, p-value = 0.10) and 16.1 times more likely to have infarct progression (95% CI: 2.2 to 79.0, p-value < 0.001). Conclusion: The new nomenclature captures all clinical and MRI based endpoints and can be applied in early stroke prevention trials.

Etiology of stroke Oral Session 1B    
Date: Thursday, 26 May 2005   Time: 17:25 - 17:35 -  Room: Sala Maggiore
Chair: P. Koudstaal, The Netherlands and Z. Nagy, Hungary

20
Cervical Arterial Dissection – Identification of Procedures and Prognosis
F. Costa    R. Santos    E.EAzevedo                                                 
 

Hospital de São João

PORTUGAL

Introduction.It is estimated that arterial dissections are responsible for 1% of all cases of cerebral ischemia.Due to lack of international recommendations, dissections approach differs among centres. Objectives.Identification of diagnostic and therapeutic procedures, as well as prognostic factors evaluated on follow-up, on patients with cervical artery dissection(CAD).Methods.Retrospective analysis of a Neurology Department inpatients with CAD diagnosis in the last five years.Evaluation of demographic variables, acute phase and follow-up clinical and imagiologic characteristics, and therapeutic procedures. Results.From a total of 29 patients 24 were analyzed. Mean age was 44 years and 14 (59%) were men. Eighteen (75%) had carotid and 6 (25%) vertebral dissection. Eight (33%) had an traumatic event. Thirteen (54%) had homolateral pain. All performed cervical and transcranial duplex sonography: 21 were compatible with dissection and 3 were normal. Sixteen (66%) performed digital angiography: 14 showed dissection and 2 were normal due to recanalization. Four (17%) patients performed skull base MRI and 3 MRA, all revealing dissection. Twenty started anticoagulation during the acute phase.The remaining 4 patients started antiplatelet due to later diagnosis.One anticoagulated patient had an asymptomatic hemorrhagic transformation.There was no mortality or recurrence. During follow-up (mean 21 months) 50% improved in the mRankin scale - 80% of the patients had 0-2 and 20% 3-5 scores.Twenty-two patients performed duplex sonography during follow up: 68% had total and 13% had partial recanalization, and 18% didn´t recanalize.Good prognostic factors were lack of brain ischemia.Recanalization was not associated with a better prognosis.Conclusion.Duplex sonography was an useful exam both in acute phase (sensitivity 87,5%) and follow-up (evaluation of recanalization).All confirmed CAD cases in the acute phase were anticoagulated.Follow up revealed a good overall prognosis.

Brain imaging     Poster Session I
Date: Thursday, 26 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

10
Vertebrobasilar insufficiency only revealed with 99M-HMPAO. SPECT
S.A.Blecic    A. Dumarey    G. Remiche    S. Goldman    M. Pandolfo                                   
 

Erasme Hospital

BELGIUM

Two patients were seen to the neurovascular outpatient clinic for a transient sudden blurred of vision, for the latter accompanied by a transient severe hyperventilation. Both patients were in theirs seventies. Both suffered from important cervical arthrosis. The first was used to flying ultra light aviation and had several short episodes of blurred of vision while flying. The second was used to practicing sporting activities and had neurological symptoms when doing a smash while playing squash. Both had a normal neurological examination. Stroke work-up, which included trans esophageal echocardiography and catheter angiography, was normal for the first patient. In the second MRA disclosed V2 vertebral dissection without any brainstem or cerebellar infarction. Cervical spine X-Ray confirmed severe arthrosisin both patients. Both underwent r-CBF-SPECT. They were set in a quiet room and were instructed to keep their eyes open. A tracer bolus of 740 Mbq was injected intravenously. The tracer used for r-CBF scans were Tc-99M-HMPAO. SPECT acquisitions were all performed 45minutes post injections. In both patients SPECT were performed first in a rest condition. Thereafter a second examination was performed when the patients were set in cervical hyperextension. SPECT images were reconstructed by filtered back projection with Butterworth filter on a vision station and analyzed by two nuclear medicine physicians. In both patients the rest examination was normal while cervical hyperextension induced hypoperfusion defects in both occipital, temporal and parietal lobes. Theses two cases confirmed that a vertebro-basilar hypo-perfusion could occur when vertebral arteries are stressed by cervical arthrosis and could be the cause of transient neurological symptoms. It illustrates that SPECT could be a useful tool when other usual investigations remained un-conclusive to explain neurological symptoms

Brain Imaging – new developments     Poster Session III
Date: Saturday, 28 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

12
Sample size estimation using MRI endpoints as a surrogate marker of outcome in stroke prevention trials
S. Subramaniam    C. Sivakumar    J. Roy    V. Palumbo    S.B.Coutts    JM. Boulanger    J. Kennedy    A.M.Buchan    M. Eliasziw    A.M.Demchuk J. Scott
 

University of Calgary, Foothills Hospitals

CANADA

Background: Growing evidence suggests that MRI can be used as a surrogate marker of outcome in clinical trials. We assessed the feasibility of using MRI endpoints as a surrogate marker of stroke outcome in calculating sample size for a major stroke prevention trial. Methods: Patients with a TIA or minor stroke (NIHSS < 4) presenting with hemiparesis or aphasia lasting > 5 minutes within 12 hours from symptom onset were included. 3T MRI with DWI sequences was obtained at baseline and 1 month. Lesions were rated by a single neuroradiologist blind to clinical data. Results: Out of 127 patients, 82 had a DWI lesion at baseline and 45 did not. Of the 82 DWI lesions at baseline, 9 (10.9%) had new ischemic MRI lesions, 11 (13.4) had new stroke and 15 (11.8%) had growth of lesion within the 30 day period. This was compared to 45 patients who were lesion free at baseline, of whom 1 (2.2%) had new MRI lesion and 1 (2.2%) had a stroke. Patients with a DWI lesion at baseline were 5.4 times more likely to have a new infarct (95% CI: 0.7 to 36.2, p-value = 0.10) and 16.1 times more likely to have infarct progression (95% CI: 2.2 to 79.0, p-value < 0.001). In planning a clinical trial, considering a new infarct as an outcome would require 3406 patients to demonstrate a 30% relative difference in treatment effect between 2 groups (alpha 5%, power 80%). Restricting the inclusion criteria to patients with a DWI lesion at baseline would reduce the sample size to 2466. Conclusion: MRI can be useful in acute stroke prevention trial design by limiting the sample size requirements. This would result in reduction of cost and time in evaluating new therapeutic strategies for secondary prevention stroke clinical trials.

Epidemiology of stroke     Poster Session III
Date: Saturday, 28 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

27
Findings on computed tomography (CT) of the brain after first-ever stroke in black Caribbean patients related to clinical subtypes and outcome
D.OC.Corbin    C. Rambarat    V. Poddar    A. Hennis    G. Gay    N. Sobers    R. Wilks    A.G.Rudd    C. Wolfe    H.S.Fraser
 

Chronic Disease Research Centre, Tropical Medicine Research Institute, Bridgetown, Barbados

BARBADOS

Background Population-based studies of stroke in patients of African origin outside the USA and UK are rare and CT findings in a black population have not previously been reported. We studied the clinical, CT findings and outcome of patients with first-ever stroke on the Caribbean island of Barbados (population 268,000, 95.2% black). Methods In an on-going prospective population-based study, each case is assessed without reference to CT and clinically assigned to total or partial anterior circulation syndrome (TACS or PACS), posterior circulation syndrome (POCS), or lacunar syndrome (LACS). The CT findings within each stroke syndrome were analysed and correlated with case fatality rate (CFR) at 90 days. Results CT scans of 809 black patients who had CT done prior to day 30 post-stroke onset (89.9% prior to day 8) were analysed. Clinically appropriate lesions included intracerebral haemorrhage (ICH) in 91 (11.1%), subarachnoid haemorrhage in 19 (2.7%) and cerebral infarction (CI) in 330 (40.2%). Scans were normal in 269 (32.8%) or showed leukoaraiosis in 88 (10.8%). The most frequent clinical syndrome was LACS (46%): 50% had a normal CT and 2.9% had ICH, while 15.4% of patients with CI had died by 90 days. By contrast, only 5.7% of patients with TACS had a normal CT, while 26.4% showed ICH and 65.1% CI (CFR 69.9%). For patients with PACS, ICH was seen in 11.9% of cases while CI was visible in 51.9%: CFR for patients with visible CI was 29.4% compared to 24.5% if the scan was normal. Conclusions Within this black population, as in previous studies in white populations, the lacunar syndrome was a predictor of low probability of ICH.

Heart and brain (cardiac disorders and stroke) Oral Session 1A    
Date: Friday, 27 May 2005   Time: 12:00 - 12:10 -  Room: SalaAzzura (1st floor)
Chair: G. Di Pasquale, Italy and J.-L.Mas, France

07
Detection of atrial fibrillation after posterior cerebral artery infarcts of undetermined etiology
V.T.Cruz    J.M.Ferro                                                        
 

Department of Neurology, Hospital de Santa Maria, Lisboa

PORTUGAL

Introduction and objective. Posterior cerebral artery (PCA) infarcts frequently display a clinico-radiological pattern suggestive of cardiac embolism that often cannot be confirmed. Paroxysmal AF is often suspected but seldom documented, and probably accounts for a proportion of those remaining undetermined. We aim to investigate the proportion of patients with PCA infarcts of undetermined etiology that later develops sustained AF. Methods. From the stroke registry all patients with PCA infarcts between June 1995 and June 2004 were selected. Strokes were classified according to TOAST criteria. Patients with PCA infarcts of undetermined etiology were invited to a reassessment visit consisting of clinical interview and examination, ECG and 24h-Holter monitoring. Results. TOAST subtypes of 107 patients with PCA infarcts (mean age 61yrs) were: cardioembolic 32%, large vessel disease 15%, other determined etiology 2% and remaining undetermined 51% (N=55). From this last group 13 had died, 5 refused, 7 were unreachable and 30 (55%) could be reassessed. Mean age at reassessment was 65yrs, with mean follow-up time of 5.1yrs, 8 (27%) had a recurrent stroke or TIA. New AF was documented in 5 (17%): 2 had a recurrent stroke. Conclusion. The proportion of patients with PCA infarcts of undetermined etiology that develops sustained AF, was at least 3 times higher than expected for their age. Although all had negative screens for AF a mean of 5 yrs before, this data suggests that paroxysmal AF could be the initial cause of stroke. New AF was associated with a high risk of recurrent stroke, indicating the need for periodic cardiac reevaluations of patients with PCA infarcts of undetermined etiology.

Genetic disorders     Poster Session II
Date: Friday, 27 May 2005   Time: 7:30 - 8:30 -  Room:  
Chair:  

08
An atypical variant of Fabry disease
E. Azevedo    J. Guimarães    S. Ferreira    J.P.Oliveira                                          
 

Departments of Neurology and Genetics, Hospital S. João, Porto, Portugal

PORTUGAL

Background: Fabry disease is a rare sex-linked (GLA gene-chromosomal locus Xq22.1) disorder that results from deficient activity of the enzyme alfa-galactosidase A (a-GALA) and progressive lysosomal deposition of globotriaosylceramide (GL-3) in the vascular endothelium. In the classic form, in hemizygous males with <1% a-GALA activity, cerebrovascular disease is a major cause of morbidity. We present a case of a man with recurrent cerebrovascular events and a-GALA activity of 50%. Case Report: A 22-year-old-man, with no relevant family history, was firstly admitted at age 12 with an ataxic syndrome; brain MRI showed a brainstem ischemic lesion. At age 19 he was readmitted with a left sensorymotor deficit. MRI revealed a recent infarct in right lenticulocapsular region. Routine laboratory tests, screening for metabolic diseases, serology for infections, immunologic study, cardiac exams (electrocardiogram, transesophagic echocardiography and 24h-ECG), cervical and transcranial duplex ultrasound and cerebral angiography were normal. Prothrombotic study showed a slightly elevated homocystein with mutation for methylenetetrahydrofolate reductase. Two quantifications of a-GALA in lymphocytes detected an activity of 50%. Molecular genetic testing for a-GALA mutations revealed an alteration in pré-mRNA with change C>T at base 10 [AUG]. Discussion: We report a case of a young patient with recurrent stroke and a decreased a-GALA activity, without typical phenotype of Fabry disease. A-GALA gene is the only currently known to be associated with Fabry disease, associated with two major phenotypes, classic and cardiac variant. Over 300 GLA mutations have been described. The alteration we found is not considered by definition a mutation-causing disease, but a polymorphism. Nevertheless, this alteration is causing a decreased activity of a-GALA activity, which associated with the present clinical picture raises the hypothesis of an atypical variant of Fabry disease.

Cerebral haemorrhage and SAH Oral Session 1A    
Date: Saturday, 28 May 2005   Time: 9:30 - 9:40 -  Room: Sala Topazio
Chair: S. Davis, Australia and L. Caplan, USA

07
Apolipoprotein E (apoE) genotypes and primary intracerebral haemorrhage (PICH): a systematic review and meta-analysis
N.A.Martínez-González    J.Y.Kim    C. Sudlow                                                 
 

University of Edinburgh

UNITED KINGDOM

Background Pathological studies have suggested that the apoE ε2 and ε4 alleles may both predispose to cerebral amyloid angiopathy (CAA)-related haemorrhage, ε4 enhancing amyloid deposition and ε2 promoting rupture of amyloid laden vessels. If so, ε2 and ε4 should be over-represented in lobar (L) but not deep (D) PICH. Methods We sought all published studies of apoE genotype and PICH in any language and including all ethnic groups. We extracted data on apoE genotypes and allele frequencies, and assessed study characteristics, including: study setting and design; definition and selection of cases and controls; ethnicity; genotyping method. We calculated study specific and pooled odds ratios (ORs) and performed subgroup analyses by L and D subtypes. Results Of 8 studies identified, 6 (571 cases, 2401 controls) had genotype data, of which 3 had data on L and D subtypes. ε2-containing genotypes were associated with all PICH (OR 1.32, 95% CI 1.01 to 1.74). The association was more marked for L (OR 2.37, 95% CI 1.45 to 3.87) than D (OR 1.20, 95% CI 0.79 to 1.83) PICH. There was a trend towards an association between ε4-containing genotypes and all PICH (OR 1.16, 95% CI 0.93 to 1.44), more marked for L (OR 1.34, 95% CI 0.86 to 2.08) and absent in D (OR 0.98, 95% CI 0.69 to 1.40) PICH. Allele frequency analyses showed similar results, but the associations between ε4 and all or L PICH reached statistical significance. However, the studies were generally small and so prone to publication bias, the selection of controls in most studies was potentially biased, and reporting bias may have affected the studies reporting differences between L and D PICH. Conclusions ApoE ε2 and ε4 may influence L but not D PICH, but large studies of high methodological quality are needed to confirm this.

Etiology of stroke     Poster Session III
Date: Saturday, 28 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

01
Effects of Neuregulin-1 on Vascular Smooth Muscle Cell Function After Vascular Injury
C.M.Clement    D.R.Croslan    B. D.Ford                                                 
 

Morehouse School of Medicine

USA

Atherosclerosis is one of the major causes of stroke. It is a complex disease that involves multiple processes including endothelial dysfunction, vascular proliferation, and matrix modulation. Atherosclerosis causes migration and proliferation of vascular smooth muscle cells (VSMCs) to form a vascular lesion. Neuregulins are a group of neurotrophic growth and differentiation factors that regulate specialized functions such as angiogenesis, cell proliferation, and differentiation in various cell types. NRG-1 is expressed in the vascular endothelial cells and its receptors (ErbB 1-4) are located in the underlying VSMC layer of the vessel. The role of NRG-1 in VSMC function has not been well characterized. We hypothesize that NRG-1 may serve in the endothelial/smooth muscle cell crosstalk that regulates vascular function and remodeling, particularly after vascular injury. Results show that NRG-1 and ErbB receptor expression is increased in the neointima of the vascular lesion after rat carotid balloon injury, suggesting that NRG-1 may play a role in VSMC proliferation and/or phenotypic modulation. Therefore, we examined the effects of NRG-1 on SMC proliferation and phenotypic modulation in A7r5, rat aortic smooth muscle cells. VSMC proliferation was analyzed using Cell Titer 96 Aqueous Proliferation Assay (Promega). Phenotypic modulation was determined by analyzing smooth muscle alpha actin expression by reverse transcriptase polymerase chain reaction. Migration was analyzed using a transwell migration assay. Our results showed that in cultured VSMCs treated with the mitogen platelet derived growth factor NRG-1 prevents proliferation in vitro. Also, the expression level of smooth muscle alpha actin in VSMCs was upregulated by NRG-1, indicating that NRG-1 induces the contractile VSMC phenotype. The beneficial properties of NRG-1 may suggest it to be a candidate therapeutic agent in the treatment of atherosclerosis.

Behavior and mood     Poster Session II
Date: Friday, 27 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

04
Affective Disturbances After Stroke As Measured by the BNI Affect Test
S.R.Borgaro    J. Baker                                                        
 

Barrow Neurological Institute

USA

Introduction: Affective disturbances have been well documented after stroke, particularly during the early stages of recovery. One aspect of affective functioning that is often clinically observed, but not typically assessed, is affect. When affective communication is impaired, as is often clinically observed after stroke, interpersonal interactions may be significantly compromised. The purpose of the present study is to empirically assess affect disturbances in acute stroke patients using a new and standardized meaure of affect. Method: The BNI Affect Test consists of 4 subtests with 5 items each that are designed to assess a patient's ability to interpret facial and interpersonal affect. A total score can be calculated and translated into a T score for clinical interpretation. It takes approximately 15 minutes to administer in its entirety. The present study compared performances on the Total and Subtest scores of the BNI Affect Test in 40 inpatient stroke patients to the performances of 40 normal control subjects. Participants were matched on age and gender. Results: Independent T tests were calculated on the Total BNI Affect Test score and on each of the subtest scores. Results showed that the stroke patients produced significantly lower scores on the Total BNI Affect Test Score (p<.01). Individual subtest scores also discriminated the groups, with significantly lower scores observed among the stroke patients (p<.01). Conclusions: Affect disturbances are a problem during early recovery from stroke. Although this has been often clinically observed, few measures have been designed to specifically quantify and qualify disturbances in affect. The BNI Affect Test is a sensitive and cost effective method for assessing affect disturbances in acute stroke patients. Including a measure of affect in a neuropsychological examination may help to provide direction for early rehabilitation intervention.

Recovery and rehabilitation Oral Session 1A    
Date: Thursday, 26 May 2005   Time: 17:15 - 17:25 -  Room: Sala Azzura
Chair: P. Langhorne, UK and M. Brainin, Austria

07
Community mobility following stroke: The effect of secondary task and environment on gait parameters
S.  LORD    L. Rochester    M.M.Weatherall                                                 
 

Wellington School of Medicine and Health Sciences, University of Otago

NEW ZEALAND

Effective community mobility relies on the integration of multiple sources of sensory and cognitive information in unpredictable environments. Preliminary research shows a decrement in gait performance for people with post-acute stroke under dual task conditions, which may be due to altered attentional capacity. The type of environment may also impact on gait speed, with greater difficulty experienced outside the clinic. This 3x2 factorial design study investigated the effect of environment (clinic, suburban street and shopping mall) and task (no task, motor task, cognitive task) on gait performance in people with stroke. Gait speed and step length were assessed using an accelerometer with adjustable thresholds (Step Activity Monitor). Other clinical measures included balance (Berg Balance Scale), fatigue (Multidimensional Fatigue Inventory), anxiety and depression (Hospital Anxiety and Depression test) and attention (the Test of Everyday Attention). Twenty-seven people with chronic stroke (time since onset 45.8 +/- 34.2 months) aged 61+/-11.6 years with a baseline gait speed of 42.2 +/- 5.9 metres/min were randomized to one of nine groups and measured under one condition. ANOVA revealed a significant difference for environment (p = 0.04) but not for task. The interaction term for the two main effects was not significant (p =0.91). Adjusting for baseline gait speed, people walked on average 8.8 metres/min faster in the clinic (95% CI 0.33 to 17.3) than in the mall. This study suggests that people with chronic stroke cope well with the challenges of varied environments and can maintain their gait speed whilst performing a secondary task. The finding differs from earlier work carried out on more acute participants, and suggests that over time gait automaticity is restored in people with stroke.

Acute stroke: treatment concepts Oral Session 1A    
Date: Friday, 27 May 2005   Time: 11:00 - 11:10 -  Room: Sala Italia
Chair: D. Toni, Italy and P. Trouillas, France

01
Safety and therapeutical benefit of hemicraniectomy combined with mild hypothermia in comparison with hemicraniectomy alone in patients with malignant ischemic stroke
T. Els    E. Oehm    S. Voigt    J. Klisch    J. Kassubek    A. Hetzel                            
 

Dept. of Neurology and Neurophysiology, University of Freiburg

GERMANY

Introduction: Both for hemicraniectomy and for hypothermia, several reports describe a beneficial effect in patients with malignant supratentorial cerebral ischemia. We compared the safety and the clinical outcome in patients with a malignant supratentorial infarction who were treated with hemicraniectomy alone (H) or received a combination therapy with hemicraniectomy and hypothermia of 35°C (HH), respectively. Methods: In a prospective and randomized study, 25 consecutive patients were treated after an ischemic infarction of more than two thirds of one hemisphere by hemicraniectomy alone (n=13 patients), or HH combination therapy (n=12 patients). Safety parameter were compared between both treatment groups, clinical outcome was assessed during treatment and after 6 months. Results: Age, cranial CT or MRI findings, initial NIHSS, and level of consciousness were not significantly different between both groups. Hemicraniectomy was performed within 156hours after the ischemic event. Hypothermia was induced immediately after surgery. Overall mortality was 12% (2/13 vs. 1/12), but none of these three patients died due to treatment-related complications. There were no severe side effects of hypothermia. Duration of need for intensive care or for mechanical ventilation and infectious status did not differ significantly between both groups, but need for catecholamine application was increased in HH. Clinical outcome showed a tendency for a better outcome in the HH compared with H with respect to status after six months, as assessed by NIHSS (101 vs. 113, p<0.08). Discussion: The present study suggests that a combined therapy of mild hypothermia and hemicraniectomy in malignant brain infarction does not imply additional risks by side effects and improves quality of life as compared with hemicraniectomy alone.

Experimental studies Oral Session 1A    
Date: Thursday, 26 May 2005   Time: 12:00 - 12:10 -  Room: Sala Topazio
Chair: L. Hirt, Switzerland and S. Blecic, Belgium

07
VEGF Protects Brain Against Focal Ischemia Without Increasing Blood Brain Permeability When Administered Intracerebroventricularly
D. Kaya    Y. Gürsoy-Özdemir     M. Yemisci    N. Tuncer    S. Aktan    T. Dalkara                            
 

Institue of Neurological Sciences and Psychiatry, Hacettepe University

TURKEY

Delayed administration of vascular endothelial growth factor (VEGF) promotes functional recovery after focal cerebral ischemia. Early intravenous (iv) injection of VEGF increases blood-brain barrier (BBB) leakage, hemorrhagic transformation and infarct volume, but its application to cortical surface is neuroprotective. We investigated if early intracerebroventricular (icv) administration of VEGF also has a neuroprotective effect and the mechanism of action of this protection. Mice were subjected to 90 min middle cerebral artery occlusion and 24 h of reperfusion. VEGF (8 ng, icv) was administered 1 or 3 h after reperfusion. Compared to the vehicle-treated group, icv administered VEGF significantly reduced the infarct volume (27+/-7 vs. 49+/-7 mm3 in VEGF-and vehicle-treated groups, respectively) On the other hand iv administration of VEGF (15 µg/kg) enhanced the infarct volume to 73+/-12 mm3. Neurological disability scores were paralleled the changes in infarct volume. Independently of the decrease in infarct size, VEGF also reduced the number of TUNEL-positive apoptotic neurons by 52% in 3 h treatment group and displayed significantly higher Phospho-Akt levels compared to the vehicle-treated group (0.56+/-1.84 vs. 0.27+/-0.92 densitometric units). The brain volume showing BBB breakdown (albumin leakage) was 40+/-12 mm3 in 3 h vehicle-treatment groups whereas icv VEGF 3 h of reperfusion decreased albumin leakage to 22+/-14 mm3. In contrast, iv VEGF injection significantly enhanced the albumin leaking tissue to 64+/-10 mm3. In conclusion, single icv injection of VEGF protects brain against ischemia without adversely affecting BBB permeability, and has a relatively long therapeutic time window. This early neuroprotective action, observed well before recovery-promoting actions such as angiogenesis, possibly involves activation of the PI-3-Akt pathway.

Risk factors of stroke     Poster Session III
Date: Saturday, 28 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

25
ENDOTHELIAL DYSFUNCTION AND NITRIC OXIDE PRODUCTION IN SYSTEMIC SCLEROSIS
F. BARTOLI    S. CHIARPELLINI    M. BACCI    S. GUIDUCCI    M. CINELLI    A. PIGNONE    M. MATUCCI CERINIC    S. CASTELLANI              
 

Dipartimento di Medicina Interna I e Reumatologia - UNIVERSITA' DI FIRENZE

ITALY

BACKGROUND: Systemic sclerosis (SSc) causes a microvascular damage and a decrease in flow mediated dilatation (FMD) of the brachial arteries consistent with an arteriolar endothelial dysfunction. Nitric oxide (NO), angiotensin II (AII) and angiotensin 1-7 (A 1-7) are released by arterial endothelial cells and can powerfully affect vasomotion. AIM OF STUDY: The aim of this study was to evaluate whether the changes in FMD of SSc patients are related to the circulating NO levels or to the markers of angiotensin system activity. METHODS: In 14 SSc patients aged 60+ 9 yrs and 11 age matched healthy controls, brachial artery FMD was measured by high resolution ultrasound imaging (ATL HDI 3000 4-7 MHz linear probe). From each patient plasma samples were collected to measure AI, AII, A1-7 and angiotensin converting enzyme (ACE) that reflect angiotensin system activity and circulating nitrates as an index of nitric oxide production. RESULTS: Brachial artery FMD was significantly lower in SSc patients than in controls (3.66% + 3.47 vs. 8.4% + 3.9< p<0.001).Plasma nitrates were significantly lower in SSc patients (24.82 mM + 11,56 in SSc vs. 34.03 mM + 9.39 p<0.01 in controls). Angiotensin system compounds were also lower in SSc patients (ACE 408.4 ng/ml + 126.2 vs 593.9 ng/ml + 58.9, p<0.001; AI 25.86 pg/ml + 11.11 vs 39.7pg/ml + 17.24, p<0.001; AII 11.4 pg/ml + 3.55 vs 19.79 pg/ml + 7.36, p<0.01; A I – 7 9.08 + 2.02 vs 30.36 pg/ml + 22.4 p<0.01) but a significant positive correlation was found only between nitric oxide levels and FMD values (R=0,56;p<0.001). CONCLUSIONS: Endothelial function is impaired in SSc patients probably due to a reduced endothelial nitric oxide production; no relation could be found with the coexistent angiotensin system abnormalities.

Vascular imaging – new developments     Poster Session I
Date: Thursday, 26 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

01
Inflammatory carotid plaques detection with Fluorodeoxyglucose Positron Emission Tomography - pilot study
L. Hoyos    A. Arauz    E. Alexanderson    M.A.Fernández    R. Mendoza    I. García                            
 

Instituto Nacional de Neurología y Neurocirugía

MEXICO

Introduction Identifying inflammatory carotid plaques has a great benefit to offering an early drug therapy, select those patients that are eligible to receive different kinds of treatment (surgery vs. stent) and predict the risk of future plaque rupture even in the asymptomatic ones. The purpose of this clinical trial was to test that plaque inflammation could be visualized using FDG-PET in patients with symptomatic carotid artery disease. And to correlate those findings with systemic markers of inflammation, such as hs-CRP. Methods This was a pilot study done to 15 stroke patients due to atherosclerotic carotid disease between 50-100%. Identified by Doppler, angioCT scan o angiographic studies. PET was carried out in all patients previous written informed consent. We administered FDG intravenously. PET images were acquired in 3D mode, at 190 minutes after FDG administration for both carotid arteries. Patients were excluded if they had a systemic infection, poor life survival prognosis, or had a study contraindication. We took two separate measurements of hs-CRP for each patient by a difference of two weeks between each. Every patient mas clinically evaluated at the beginning of the study 1, 3 and 6 moths later with modified Rankin scale. Results The median patient´s age was 66.1 ( +9.7) years, 11(73%) were male. The main risk factors were hypertension in 10(66.6%); somoking in 9 (60%), Diabetes in 3(20%) and lipid disorder in 11(73%). In 12 (80%) patients was FDG accumulation and in 5 (33.3%) it was bilateral. Had a good clinical outcome (Rankin from 0 to 2) 7(46.6%), bad (Rankin from 3 to 5) in 7 (46.6%) y 1 died All patients had hs-CRP values below 1mg/dL, corresponding to low risk. Conclusions Inflammation is important in the pathogenesis of atherosclerosis. Imaging carotid plaques using FDG-PETcan demonstrate inflammatory activity on it.

Risk factors of stroke     Poster Session III
Date: Saturday, 28 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

35
Periodontal disease and sub-clinical atherosclerosis. Preliminary data
S. Castellani    E. Tesi    M. Bacci    F.  Cairo    M. Nieri    G.P. Pini Prato    R. Abbate                     
 

Dip. Area Critica Medico Chirurgica, Università di Firenze

ITALY

Background: In patients with periodontal disease (PD) cardiovascular morbidity has been shown to be higher. No information is presently available on the influence of PD on arterial intima media thickness (IMT), which is early marker of carotid and systemic atherosclerosis. To evaluate whether this aggressive PD may promote carotid atherosclerosis even in the young, we compared IMT and C-reactive protein (PCR) values in periodontally compromised patients with those observed in a group of age matched healthy volunteers (HV). Subjects and methods: 17 patients (mean age 35.5 yrs) with severe PD and 8 HV (mean age 33.3 yrs) were studied. In order to avoid the effects of associated atherosclerotic risk factors, diabetics, hypertensives, smokers and patients with dislipidemia were excluded from the study. High sensitivity PCR was determined by nephelometric assay. IMT was measured with an high resolution ultrasound machine (ATL HDI 3000) using a 4-7 MHZ linear probe. Results: PD patients showed higher IMT values although the difference between groups did not reach statistical significance (0.88 mm+ 0.09 in PD vs 0.81mm + 0.11 in HV, p< 0.09-NS). In PD patients PCR values were significantly higher than in HV (0.38 mg/dl + 0.29 vs 0.09 mg/dl + 0.09 in HV; p< 0.01). Conclusions: These preliminary data suggests that aggressive periodontal disease in young patients leads to significant systemic inflammatory reaction; the increase in PCR was associated by an IMT increase. These findings prompt us to continue this study in a large sample.

New clinical trials Oral Session 1A    
Date: Saturday, 28 May 2005   Time: 12:15 - 12:27 -  Room: Europauditorium
Chair: S. Davis, Australia and C. Warlow, UK

06
Predictors of Ischemic Stroke in the Territory of a Symptomatic Intracranial Stenosis
M. Chimowitz    S. Kasner    M. Lynn    H. Howlett-Smith    B. Stern    V. Hertzberg    M. Frankel    S.  Levine    S. Chaturvedi    C. Benesch
T Jovin, C Sila, J Romano, for the WASID Trial Investigators

Emory University

USA

Background: Intracranial arterial stenosis is an important cause of stroke. The pre-specified secondary aim of the Warfarin versus Aspirin for Symptomatic Intracranial Disease (WASID) trial was to identify patients at highest risk for stroke in the territory of the stenotic artery. Methods: WASID was an NIH-funded randomized, double-blinded, multicenter clinical trial in which 569 patients with TIA or ischemic stroke due to 50-99% stenosis of a major intracranial artery were randomly assigned to warfarin or aspirin. The median time from qualifying event to randomization was 17 days. Patients were followed for a mean of 1.8 yrs. A multivariable Cox proportional hazards model was used to identify baseline factors that predicted ischemic stroke in the territory of the stenotic artery. Results: Ischemic stroke occurred in 106 patients (19.0%), of which 77 (73%) were in the territory of the stenotic artery. Severe stenosis > 70% (HR=2.5; 95%CI:1.6-3.9), female gender (HR=1.7; 95%CI:1.1-2.7), and enrollment < 17 days after the qualifying event (HR=1.6; 95%CI:1.1-2.9) were independently associated with higher risk of stroke in the territory. Type of qualifying event (stroke or TIA) also influenced subsequent stroke risk, particularly when stratified by severity of stenosis (1 yr rates of stroke in the territory: 3.0% (95%CI: 1.0-5.9%) in patients with TIA and 50-69% stenosis vs. 22.5% (95% CI: 14.9-30.0%) in patients with stroke and 70%- 99% stenosis). Age, race, location of stenosis, vascular risk factors, and treatment assignment did not independently impact. Conclusions: Among patients with symptomatic intracranial stenosis, the risk of stroke in the territory of the stenotic artery is greatest with stenosis >70%, particularly among women. Stroke rather than TIA at presentation and recent symptoms also portend greater risk. These high-risk features should be incorporated into future studies evaluating more aggressive therapies such as intracranial stenting.

Etiology of stroke     Poster Session III
Date: Saturday, 28 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

10
Inherited thrombophilia, Cerebral Infarction and pregnancy: A case report
D.D.Uluduz    M. Bozluolcay    B. Ince                                                 
 

Istanbul University Cerrahpasa Medical Faculty Neurology Department

TURKEY

Inherited thrombophilias include antithrombin III deficiency, resistance to activated protein C (factor V Leiden), protein C, S deficiencies and some forms of dysfibrinogenemia. The management of the patient depend on the factors such as the patient’s individual and familial history, the site of thrombosis, and the presence of other prothrombotic risk factors. The use of prophylactic anticoagulation during pregnancy needs particularly careful consideration in thrombophilic women. We reported the case of a 32 year-old pregnant with cerebral infarction. Her claim was the numbness on her left hand. Neurologic examination was normal. Cranial MRI showed a right thalamic infarction. During etiological investigations we found that the patient had protein S deficiency. After that, the same diagnosis was established in her first daugther. She was 11 year-old and never had a thromboembolic disease. The patient admitted at the end of first trimester was put on low molecular weight heparin (nadroparine 0.6 ml/day). Anticoagulation therapy was continued during her pregnancy without complications but her newborn daughter had protein C and S deficiency. Genetic testing showed that the type of deficiency was heterozygous. Hereditary thrombophilia increases the risk of fetal loss and possibly other serious obstetric complications. During the pregnancy all women with cerebral infarction should be investigated for inherited thrombophilia regardless of a family history or a previous arterial / venous infarction.

Vascular surgery and PTCA     Poster Session II
Date: Friday, 27 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

04
Clot removal therapy in acute embolic stroke patients
M. Takahisa    K. Imai    H. Izumoto    S. Takakura                                          
 

Shonan Kamakura Genaral Hospital

JAPAN

It depends on the volume and composition of clots embedded in the vessel whether or not successful recanalization is achieved with fibrinolysis or angioplasty in treatment of acute embolic stroke patients. The purpose of our study was to investigate the feasibility, safety, and effectiveness of a clot removal therapy (CRT) for acute embolic stroke patients with total occlusion of the internal carotid artery (ICA) or the proximal middle cerebral artery (MCA). Inclusion criteria were patients with (1) serious neurological symptoms defined as NIHSS score≥10, (2) total occlusion of the ICA or the proximal MCA on angiograms, (3) neither cerebral hemorrhage on CT scans nor extensive high signal-intensity on MR diffusion-weighted images, and (4) decrease of cerebral blood flow. Clots were tried to remove with aspiration or microbaskets. Clinical outcome was evaluated with modified Rankin Scale (mRS) at 3 months after CRT. Between December 2002 and August 2004, eight patients underwent CRT. In five of eight patients, balloon-guide catheters were used to interrupt blood flow during clot removal by aspiration or microbaskets and total occlusion of the ICA was completely recanalized in three of them, who had anatomical cross flow via the anterior communicating artery (Acom A). By comparison, no complete recanalization was achieved in the other five patients. Three-month mRS was 2 or less in the three patients with complete recanalization, while 5 or more in five patients without complete recanalization. No procedural complications occurred. Balloon-guide catheters assisted CRT for embolic ICA occlusion may provide high recanalization rate and good clinical outcome in patients with anatomical cross flow via the Acom A.

Acute stroke: treatment concepts     Poster Session I
Date: Thursday, 26 May 2005   Time: 7:30- 8:30 -  Room: Padiglione(Pavilion)
Chair:  

06
FEELING SAD OR DEPRESSED AFTER STROKE IS ASSOCIATED WITH INCREASED DISABILITY AND HANDICAP
S. Loharuka    J. Barrett    G. Sangster    V. Owens    P. Weir    V. Little                            
 

Department of Geriatric Medicine,Wirral Stroke Service, Wirral, Merseyside

UNITED KINGDOM

Background: Low mood is common after stroke. The incidence of depression after stroke varies between 15% and 55%. Post stroke depression has frequently been overlooked and left untreated. Identification and successful intervention of mood disorder post stroke may facilitate rehabilitation. We have explored in this study the relationship between mood and recovery post stroke. Method: The anonymised stroke register details of patients who attended for their first stroke review clinic visit between January 1998 and May 2002 were studied. All patients attending the clinic routinely self complete a questionnaire which includes the Yale question (Are you sad or depressed?), a shortened General Health Questionnaire (GHQ-12), Barthel activity of daily living score, Nottingham extended activity of daily living (NEADL) score and Rankin score. Statistical analysis was done using SPSS 11.0. Results: Full data was available for 652 patients. 55.6% of the patients were male. Mean age of the patients was 66.3 years (95% confidence interval 65.4-67.3 years). The median (interquartile range) GHQ-12, Barthel, NEADL and Rankin scores of those who answered yes or no to the Yale are presented in the table. The patients who answered that they were sad or depressed had a significantly higher GHQ-12 score indicating low mood with lower disability Barthel ADL and NEADL scores and higher Rankin scores indicating greater disability and handicap than in those who did not feel sad or depressed. Discussion: Feeling sad or depressed after a stroke is associated with greater disability and handicap. It is not yet clear whether the level of functional recovery affects the mood or vice versa or both.

 
http://www.esc-archive.eu/bologna05/b_graphic/t_1004.htm

Brain imaging Oral Session 1A    
Date: Friday, 27 May 2005   Time: 11:20 - 11:30 -  Room: Sala Bianca (B)
Chair: J. M. Wardlaw, UK and J. Röther, Germany

03
Triaging TIA and minor stroke patients using acute MRI
S. Coutts    J. Simon    C.-H.Sohn    M. Eliasziw    M. Hill    P. Barber    J. Roy    V. Palumbo    A. Buchan    A. Demchuk
 

University of Calgary

CANADA

Background: Minor stroke and transient ischemic attack (TIA) patients herald significant risk of suffering a new stroke within 3 months. Our objective was to examine whether the presence of DWI lesions and vessel occlusion on an acute MRI of minor stroke and TIA patients predicts the occurrence of subsequent stroke and functional outcome. Methods: Prospective, cohort study of 120 consecutive TIA or minor stroke (NIHSS </=3) patients who were examined in the emergency room within 12 hours and had a Magnetic resonance brain scan within 24 hours of symptom onset. The imaging was assessed for the presence of a DWI hyperintensity and vessel occlusion. The main Outcome measure was occurrence of new strokes during follow-up and functional dependence 3 months using the modified Rankin scale. Patients were analysed in 3 separate groups; no DWI lesion (n=54), DWI lesion and no vessel occlusion (n=51); DWI lesion and vessel occlusion (n=15). Results: Patients with a DWI lesion were at higher risk of having a subsequent stroke than patients without a lesion and highest in the presence of a vessel occlusion and a DWI lesion. The Kaplan-Meier 90-day risks adjusted for baseline NIHSS and glucose, were 4.3% (no DWI lesion), 10.8% (DWI lesion, no vessel occlusion), and 32.6% (DWI lesion and vessel occlusion), respectively (p=0.02). The percentage of patients who were functionally dependent in the three groups was; 1.9%, 6.2% and 21% respectively (p=0.04). Discussion: The presence of a DWI lesion and vessel occlusion on an MRI among patients presenting acutely with a TIA or minor stroke is predictive of an increased risk of a future stroke and is predictive of subsequent functional dependence. Acute MRI is useful in making a triage decision for patients with TIA or minor stroke.

http://www.esc-archive.eu/bologna05/b_graphic/g_1006.htm
 

Cerebral haemorrhage and SAH     Poster Session II
Date: Friday, 27 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

03
Effect of prior antiplatelet therapy on haematoma volume in patients with primary intracerebral haemorrhage
A. Almeman    K. Lees    M. Walters                                                 
 

University of Glasgow

UNITED KINGDOM

Background We investigated the effect of pre-existing antiplatelet treatment upon haematoma volume and stroke severity in patients with primary intracerebral haemorrhage (PICH). Methods We studied a consecutive series of patients with PICH admitted to our hospital. Patients with extra-axial or anticoagulant-related haemorrhage were excluded. For each patient haemorrhage volume was calculated using the ABC/2 method. A validated prognostic score (the ICH score) including age, GCS, haemorrhage volume, and location of haemorrhage was also calculated. The influence of prior antiplatelet treatment (aspirin, clopidogrel, dipyridamole alone or in any combination) on these parameters was assessed in a univariate analysis, then using logistic regression to correct for other factors that may influence haematoma volume. Results Data from 264 consecutive patients with PICH and who met the other entry criteria were analysed. 54 of these patients were taking antiplatelet treatment (AP) at time of stroke, of whom 93% were on aspirin alone. 210 were on no antiplatelet treatment (NAP). Prevalence of coronary (36% vs 15%) and cerebrovascular (54% vs 9%) disease was higher in the AP group than the NAP group. There was no other significant demographic difference. No between-group difference in haemorrhage volume was seen (40ml (SEM 6.4) vs 47ml (SEM 3.9) for AP and NAP groups respectively, p= 0.383). ICH scores were similar (2.02 (SEM 0.2) vs 2.1 (SEM 0.1) for AP and NAP groups respectively, p= 0.727). Multivariate analysis including NIH score, GCS, BP, age and co-morbidity revealed no significant effect of prior AP therapy on haemorrhage volume or ICH score. Conclusion Our data suggests that prior antiplatelet treatment does not influence haemorrhage volume or ICH score after PICH.

Etiology of stroke Oral Session 1A    
Date: Thursday, 26 May 2005   Time: 11:10 - 11:20 -  Room: Sala Maggiore
Chair: I. Henriques, Portugal and J. DeReuck, Belgium

02
Spatial Patterns of Hemorrhage in Cerebral Amyloid Angiopathy (CAA): Is there Regional Specifity? Do Hemorrhages Cluster Together?
J. Rosand    A. Muzikansky    E.E.Smith    R.A.Betensky    S.M.Greenberg                                   
 

Massachusetts General Hospital-Harvard Medical School

USA

BACKGROUND: CAA, a common untreatable disease of the elderly, can cause symptomatic intracerebral hemorrhage (ICH) and asymptomatic microhemorrhage. Identification of a regional pattern of CAA-related hemorrhage may offer insight into mechanisms of amyloid deposition and vessel rupture. We used GRE-MRI to investigate whether particular brain lobes are at greater risk for hemorrhage and whether new hemorrhages tend to occur in proximity to previous hemorrhages. METHODS: For this prospective cohort study of 59 subjects with ICH and CAA, all subjects underwent GRE-MRI at time of ICH and follow-up research MRIs at 12-18 month intervals. Distribution of all baseline hemorrhages across the cohort and distribution within each individual were analyzed using a multinomial goodness-of-fit test. Location of new hemorrhages on follow-up imaging was analyzed with permutation testing. RESULTS: Baseline: Median number of hemorrhages per subject was 3 (range 1-35) with 57% located in the temporal and occipital lobes, which together account for only 40% of total lobar brain volume, p<0.0001. Within individual patients, hemorrhages were more likely to cluster together in a single lobe than be distributed randomly throughout the brain, p <0.0001. New Lesions: Recurrent ICH favored the location of the original ICH, p=0.007, occurring in the same lobe in 7/23(30%) subjects with new ICH. Location of new microhemorrhages favored lobes with previous hemorrhage, p=0.001. CONCLUSION: CAA-related hemorrhages favor temporal and occipital lobes and cluster in areas of pre-existing hemorrhage, suggesting a role for both regional brain differences and local factors. Identifying these factors may offer a path toward promising new strategies for preventing devastating ICH in this common disease.

Interesting cases     Poster Session I
Date: Thursday, 26 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

08
Flashing Carotids In Aortic Valve Disease
A. Croquelois    J. Bogousslavsky    G. Devuyst                                                 
 

University Hospital Lausanne

SWITZERLAND

A 71-year-old man was admitted to the cardiology department after dyspnea aggravation. An aortic valve regurgitation (grade IV) and stenosis (grade II) was diagnosed three years before, and a recent transthoracic echocardiography showed an aggravation of the aortic regurgitation that was rated as severe. Results of extracranial and intracranial ultrasounds (ATL 5000, Philips, Netherlands), part of the pre-operative work up for valvular replacement, demonstrated diastolic reversal flow in common, external (early diastole) and internal (late diastole) carotid arteries and very low anterograde end-diastolic flow in ipsilateral middle cerebral artery. The observed pattern demonstrates continuous brain perfusion (compensatory vasodilatation) despite pre-cerebral diastolic reversal flow. Two former studies described bilateral holodiastolic reversal flow in common carotid arteries as a sign of SAR, but, to our knowledge, no description of external and internal carotid and middle cerebral arteries flow in that clinical entity is available at that time. Further studies should explore if extracranial and intracranial ultrasound findings could help in grading severity of aortic regurgitation.

Epidemiology of stroke Oral Session 1A    
Date: Thursday, 26 May 2005   Time: 11:30 - 11:40 -  Room: Europauditorium
Chair: B. Pieschowski-Jozwiak, Poland and P. Rothwell, UK

04
STROKE RISK IN THE ITALIAN POPULATION
L. Palmieri    S. Panico    D. Vanuzzo    L. Pilotto    P. Chiodini    G. Cesana    M. Ferrario    R. Sega    S. Giampaoli       
 

Istituto Superiore di Sanità, Rome, Italy

ITALY

Background: For decades Italy has registered low coronary heart disease mortality rates; throughout these years stroke mortality has been increasing. This study aims to estimate stroke incidence in the Italian adult general population, impact of multiple risk factors and potential for stroke prevention. Methods: 10-year prospective study of 10 cohorts (Progetto CUORE) 7,477 men and 7,989 women baseline ages 35-69, free of stroke; suspected non-fatal/fatal strokes were validated using MONICA diagnostic criteria. Persons were stratified as low-risk (LR–all the following baseline risk factors: systolic blood pressure (SBP)<120 mmHg, diastolic (DBP)<80 mmHg, no antihypertensive medication (HBP-Med), total cholesterol (TC)<5.17 mmol/l, BMI<25.0 kg/m2, non-smoking, no diabetes, no Myocardial Infarction history (HISMI), no family history of premature cardiovascular disease (FHISCVD)); unfavourable but not high-risk (U-NHR-any one or more of SBP 121-139, DBP 80-89, TC 5.17-6.18, BMI 25.0-29.9, without high levels of other risk factors); all others were high-risk (HRi). Results: 87% of population was stroke HRi at baseline; only 2% LR. Age, gender, BP, HBP-Med, smoking, glycemia, diabetes, TC/HDL ratio, HISMI, FHISCVD were independently related to stroke risk. One standard deviation higher of SBP, TC/HDL, and current smoking were together associated with estimated stroke hazard ratio 3-times higher; corresponding favourable levels for these three, stroke rate 68% lower. No strokes occurred in the LR and U-NHR. Discussion: In this study, with the first data on stroke incidence in the Italian population, BP, smoking, glycemia, diabetes, serum lipids (all preventable and controllable) are significant independent stroke risk factors. Favourable levels of all or most risk factors were associated with no stroke risk. Prevention in the general population should be implemented, especially improving lifestyles, aiming to progressively increasing the proportion of LR population.

Interesting cases     Poster Session I
Date: Thursday, 26 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

33
Serial MR findings of angiopathy associated with pregnancy presenting features of reversible posterior leukoencephalopathy syndrome
J. Park    J. Kim    J. Paik                                                 
 

Sanggye Paik Hospital, Inje University

SOUTH KOREA

Background: It is well known that pregnancy is associated with an increased risk of stroke or vasculopathy, especially in the postpartum period. Postpartum angiopathy is a cerebral vasoconstriction syndrome affecting intracranial arteries. Case 1: A 27-year-old healthy woman, who delivered a baby 10 days ago, visited hospital because of headache, visual disturbance and generalized tonic clonic seizures. there was no preeclampsic signs during the pregnancy. The blood pressure was 160/90 mmHg at admission. The neurological examination was normal except decreased visual acuity. The MRI showed high signal intensities on bilateral occipital and parietal areas on T2 weighted and FLAIR sequences images without restricted diffusions on ADC maps. The MRA showed multiple segmental narrowings in intracranial arteries. During the admission, headache and visual symptoms were gradually improved. The follow up MRI and MRA reversed to normal. Case 2: A 31-year-old primiparous female in 36 weeks of gestation was hospitalized for diminished mentality. She was found in comatous mentality on the day of admission. There was no evidence of preeclampsia until a month before admission. The MRI and MRA showed multiple high signals on parietal and occipital areas on T2 weighted and diffusion images and vasoconstrictions on both PCAs. The MRI and MRA performed 2 weeks later showed marked resolutions of high signals and vasoconstrictions. Conclusion: Clinical and radiological features of these cases suggest reversible cerebral vasoconstriction syndrome(RCV). Postpartum angiopathy is one of the causes of RCV. However, similar syndrome can be developed before delivary, not in postpartum period.

Management and economics     Poster Session II
Date: Friday, 27 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

12
Causes of inefficient stroke-unit-bed use - Possibilities for freeing up capacity
M. Limburg    L. Vos    R. van Oostenbrugge    F. van Merode    S. Groothuis                                   
 

University Maastricht

THE NETHERLANDS

Background. Throughout Europe length of hospital stay for stroke patients surpasses optimum length of stay. Optimal from the perspective that in-hospital care should focus on diagnosis and therapy; while rehabilitation care is best provided by specialized centers. Little is known about effective measures to decrease length of stay and increase efficiency of care delivery. We systematically analyzed care for stroke patients and capacity use in a university hospital. We explored possibilities for efficiency increase. Methods. We identified 100 consecutive stroke patients admitted to the stroke unit of Maastricht University Hospital (June to December 2003). We systematically observed care process and interviewed involved personnel. Processes were described with GANTT charts. We collected demographic data and compared actual care process with clinical guidelines. Results. Major causes of inefficient capacity use are: relative shortage of stroke unit beds; partially outdated protocol; wating times for diagnostic procedures, consults from other disciplies and multidisciplinary team meetings; communication failures and waiting times for patient transfers to other facilities. Discussion. Hospital days may pass without diagnostic or therapeutic interventions taking place. Reorganization of care processes will lead to compact hospital admissions with focused daignostic and therapeutic care trajectories. Appropriate application of coordination measures can increase efficiency and will lead to shorter legth of hospital stay (4 versus 12 days). This will free up care capacity, facilitate possibilities to subject more patients to newer therapeutic modalities (intravenous of intra-arterial thrombolysis) and quality of care will be improved by better attuned care delivery.

http://www.eurostroke.org/b_graphic/g_1011.htm
 

Risk factors of stroke     Poster Session III
Date: Saturday, 28 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

07
Apolipoprotein E polymorphism in ischemic stroke subtypes: a case control study in Korean population
D.-I.Chang    S.-Y.Kang    W.-I.Lee    H.-K.Song    S.-H.Kim                                   
 

Department of Neurology, Kyunghee Medical Center, Seoul, Korea

SOUTH KOREA

Background: The association of apolipoprotein E (apoE) polymorphism and ischemic stroke has not been concordant in different racial populations. The aim of this study was to explore the association between apoE polymorphisms in ischemic stroke patients with or without atherosclerotic vascular lesion through a case-control study among the Korean population. Methods: First-ever ischemic stroke patients (n=214; large artery atherosclerosis, n=122, small artery occlusion, n=92) and 113 healthy controls were recruited from the Kyunghee Medical Center, Seoul, Korea. The diagnosis and classification of ischemic stroke were based upon clinical findings and magnetic resonance imaging and angiography. ApoE genotypes were determined by the real-time polymerase chain reaction and melting curve analysis. Results: The allele frequency of epsilon 2, 3, and 4 was 6.5%, 81.9%, and 11.6% respectively in patients with ischemic stroke; 7.5%, 85.8%, and 6.6% respectively in healthy control group. The allele frequency of epsilon 4 in ischemic stroke patient group was significantly higher than that of the control group (11.6% vs 6.6%; p=.04, odds ratio 1.83, confidence limits 1.00 to 3.34). There was no difference of epsilon 4 allele frequency between stroke patients with large artery atherosclerosis and those with small artery occlusion (11.4% vs 11.8%; p=.89). Conclusion: Our study suggests that apoE epsilon 4 is a risk factor for ischemic stroke among Korean population, whereas there was no difference between large artery atherosclerosis and small artery occlusion in apoE polymorphism.

Vascular imaging Oral Session 1A    
Date: Thursday, 26 May 2005   Time: 17:15 - 17:25 -  Room: Sala Bianca
Chair: R. Baumgartner, Switzerland and J. Norris, UK

07
Prediction of Microbleeds Using Computed Tomography in the Emergency Room
A. Gorner    R. Lemmens    M. Schrooten    V. Thijs                                          
 

University Hospitals Leuven

BELGIUM

Microbleeds detected on gradient echo magnetic resonance images (GRE) are a potential risk factor for intracerebral hemorrhage after thrombolysis or oral anticoagulation. We assessed whether the presence of microbleeds could be predicted from the extent of white matter disease on computed tomography (CT) and from easily obtained clinical factors in the emergency room (ER). Methods We studied consecutive patients with cerebral ischemia attending the ER who underwent both CT and GRE-MRI. White matter disease was rated on CT using a three point scale by two independent observers. The presence of microbleeds was assessed on GRE-MRI by two independent observers. Logistic regression was used to predict the presence of microbleeds on GRE-MRI. Results 199 consecutive TIA or stroke patients underwent both CT and GRE-MRI. Microbleeds were identified on GRE in 56 patients (28.1%). Age, sex, hypertension, diabetes or the presence of left ventricular hypertrophy on ECG were not different in patients with or without microbleeds. After adjustment for age and sex, microbleeds were more frequent in patients with leukoaraiosis (OR 2.8 per 1-point increase on the leukoaraiosis scale, p<0.001) and in patients presenting with a lacunar or posterior circulation syndrome (OR 2.0, p=0.048). The area under the ROC-curve derived from the logistic model was 0.70 (95% CI 0.61-0.79). Conclusion Increasing degrees of leukoaraiosis on CT and presentation with a posterior or lacunar syndrome increases the risk of microbleeds on GRE in patients attending the emergency room with cerebral ischemia.

Risk factors of stroke     Poster Session III
Date: Saturday, 28 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

15
Comparison of the effects of diuretics on blood pressure and arterial stiffness in stroke patients
M. Alem    P. Milia    S. Muir    K. Lees    M. Walters                                   
 

University of Glasgow

UNITED KINGDOM

Background Diuretics are widely used to lower blood pressure (BP) after stroke. We compared the effects of indapamide and bendrofluazide on BP and arterial stiffness in a group of stroke patients. Methods A cohort of patients within three months of first-ever stroke was randomised to receive either bendrofluazide 2.5 mg or indapamide 2.5 mg od for 4 weeks in a prospective, randomised, double-blind fashion. Measurement of augmentation index (AI), Time to reflection (Tr) and brachial pulse wave velocity (BPWV) was performed by the SphygmoCor technique before and after treatment. Results All data expressed as mean ± SD. 23 patients completed the protocol (age 70.0 yrs ± 9.55, SBP 137.9 mmHg ± 19.9, DBP 76.0 mmHg ± 9.1). 13 patients were randomised to indapamide (Group I) and 10 to bendrofluazide (Group B). There were no significant demographic differences between groups. Both drugs reduced mean arterial pressure to a similar degree (I= -14.3mmHg ± 10.3, B= -9.1mmHg ± 11.2, p=0.27). % change from baseline in AI, Tr and BPWV were affected to a similar extent with either drug (AI: I= -16.0 ± 19.8, B= -20.1 ± 28.9, p=0.7. Tr: I= -2.5 ± 6.7, B= -3.6 ± 4.0, p=0.63. BPWV: I= -1.7 ± 14.4, B= -0.5 ± 10.8, p=0.83.) Regression analysis suggested that the change in blood pressure explained up to 28% of the change in AI. Conclusion Diuretic treatment induced measurable changes in arterial stiffness parameters, however there was no evidence of a differential effect of the two agents studied. Blood pressure reduction contributed only partially to the change in arterial stiffness, suggesting possible direct effects of diuretic therapy on vascular function in stroke patients.

Longterm outcome of stroke     Poster Session I
Date: Thursday, 26 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

10
Classification of cause of death after stroke in clinical research
P. Halkes    J. van Gijn    L.J.Kappelle    P.J.Koudstaal    A. Algra                                   
 

University Medical Center Utrecht

THE NETHERLANDS

Background- Classification of outcome events, such as stroke or death, is essential in clinical research. The Executive Committee of ESPRIT repeatedly encountered problems in classifying the cause of death after a stroke if the interval between the two events was counted in months or years. Therefore, we consulted neurologists with the aim to compose a guideline for classifying such events. Methods- Neurologists with a special interest in stroke and great experience in stroke research filled in a questionnaire and audited 5 case vignettes. Henceforth, we made a proposal for classifying cause of death after stroke, on which all participants commented. Results- Twenty-nine neurologists from 14 countries participated in the study. There was no agreement on the importance of the interval between stroke and death, on the degree of disability after stroke, on the co-existence of an infection and on the discharge destination. Consequently there was a large variation in classifications of the case vignettes. However, from these different points of view we were able to create a subsequent proposal for classifying the cause of death after stroke. The main criteria were time since stroke (cut off at 1 month) and best Rankin grade after the stroke (cut off at 3). All but two of the participating neurologists agreed with the proposal. Discussion- There is great variation in the way neurologists spontaneously classify causes of death in patients who die after they suffer a stroke. With our proposed criteria, the work of auditing committees in clinical research may be simplified.

Risk factors of stroke     Poster Session III
Date: Saturday, 28 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

31
Anti-annexin V Ab in Acute Cerebral Infarction
K.-O.Lee    K.-Y.Lee    W.-J.Kim    K.-S.Song                                          
 

Yonsei University College of Medicine

SOUTH KOREA

Background: Antiphospholipid antibodies (aPLs) are a heterogeneous group of immunoglobulins directed against negatively charged phospholipids, phospholipid-protein complexes, or plasma protein. The presence of aPLs has been associated with vascular occlusive events. Among them lupus anticoagulant (LA) and anti-cardiolipin antibody (aCL) are commonly used as a screening test. Anti-annexin V Ab, one of the other aPLs, has been reported in the thrombotic event in other disorder such as systemic lupus erythematosus. In this study, we investigate the positive rate of anti-annexin V Ab in acute cerebral infarction patients. Methods: The subjects consisted of 128 acute cerebral infarction patients and 40 young age normal control. Anti-annexin V Ab was tested using enzyme immunoassay in acute cerebral infarction and control groups. LA and aCL were tested only in acute cerebral infarction group by the usual screening methods. Results: The positive rate of anti-annexin V Ab in acute cerebral infarction group was 18.0% (23/128), whereas no one showed positivity in control group. The positive rates of LA and aCL were 7.0% and 13.3% in acute cerebral infarction group. Among the 23 patients with anti-annexin V Ab positivity, only five patients showed positive response in LA or aCL. Discussion: Anti-annexin V Ab is prevalent in acute cerebral infarction patients and usually not combined with LA or aCL positivity. It may be a useful screening tool in addition to the LA and aCL in detecting the antiphospholipid antibody syndrome, especially in acute cerebral infarction. A further study will be needed to define the possible role of anti-annexin V Ab, which leads to the thrombosis or vascular occlusion.

Acute stroke: treatment concepts Oral Session 1B    
Date: Friday, 27 May 2005   Time: 17:05 - 17:15 -  Room: Sala Italia
Chair: J.L. Marti-Vilalta, Spain and A. Gass, Switzerland/Germany

18
Acute Stroke Treatment with Systemic Thrombolysis in Patients over 80 Years
B. Dimitrijeski    H.C.Koennecke    A. Wasczcuk    A. Villringer    A. Hartmann                                   
 

Charite-Campus Benjamin Franklin

GERMANY

Background: The effectiveness of acute stroke treatment with recombinant tissue plasminogen activator( r-tPA) within 3 hours after onset of stroke has been proven for patients up to age 80. However, information on patients aged over 80 years are scarce. Methods: From January 1998 until December 2004, a total of 181 patients were treated in our hospital systemically with r-tPA using the NINDS study protocol and additional CT exclusion criteria from ECASS. During prospective follow-up, neurological Status was assessed at admission, discharge, and after 3 months using the Rankin scale. After informed consent, patients over age 80 years were treated when their comorbidity was low and their overall functional status was considered good. Results from the treatment group in the NINDS trial and patients treated with r-tPA in our hospital in the same time period with age under 80 years were used to compare neurologic outcome. Results: From January 1998 to December 2004, 26 patients with age over 80 years (mean age 84 years, range 81-90 years, mean baseline NIHSS 13, 73% women) were treated with systemic thrombolysis. Functional outcome after 3 months is shown in Figure 1. Symptomatic intracranial hemorrhage occurred in 3% in the patients under 80 years, compared with 4% in the older patients (p=0,72). Conclusion: In our small study of elderly patients >80 years, the benefit of stroke treatment with systemic thrombolysis seems to be small. The risk for symptomatic intracranial hemorrhage was not significantly increased.

 
http://www.esc-archive.eu/bologna05/b_graphic/t_1018.htm

Etiology of stroke Oral Session 1A    
Date: Thursday, 26 May 2005   Time: 12:00 - 12:10 -  Room: Sala Maggiore
Chair: I. Henriques, Portugal and J. DeReuck, Belgium

07
Lacunar Infarct Predominate among Stroke Patients With a Strong Family History of Stroke
H. Lövkvist    B. Hallström    P. Höglund    A.-C.Jönsson    U. Kristoffersson    H. Luthman    B. Petersen    B. Norrving    A. Lindgren       
 

Lund University, Faculty of Medicine, department of clinical sciences

SWEDEN

Background: Stroke patients have an increased prevalence of stroke or TIA among first degree relatives compared with control subjects. However, a possible association between specific types of ischemic stroke and a strong family history of stroke or TIA needs further evaluation. Methods: From the population based Lund Stroke Register in Sweden, a consecutive group of 606 stroke patients participated in this study. All individuals reporting a strong family history of stroke (defined as reporting at least 3 relatives with stroke or TIA) were identified. We also determined OCSP subtype for the first 231 ascertained patients with cerebral infarct and all patients with a strong family history of stroke. Results: There were 34 stroke patients (5.6% from the total of 606) reporting at least 3 relatives with stroke. They had a median age of 66 years, whereas the remaining 572 stroke patients had a median age of 76 years (p=0.001). Among the 34 stroke patients with a strong family history of stroke, one had intracerebral hemorrhage and additionally one had subarachnoid hemorrhage while the remaining 32 were suffering from cerebral infarct. Lacunar infarcts were more common in the group reporting a strong family history (17/32) compared with an unselected group of cerebral infarct patients (73/231; OR=2.45; 95% CI 1.16-5.18). This difference remained significant even after using multiple logistic regression controlling for age (three age groups, cutpoints at 65 and 75 years; OR=2.45; 95% CI 1.13-5.31). Conclusion: Stroke patients reporting strong familial history of stroke or TIA are younger and more often affected by lacunar infarct compared with a general population of ischemic stroke patients.

Experimental studies     Poster Session II
Date: Friday, 27 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

04
Ultrasound enhanced surface thrombolytic activity of human cerebral endothelial cells
Z. May    G. Pánczél    G. Szilágyi    C. Óváry    L. Simon    N. Szegedi    Z. Nagy    J. Skopál              
 

National Stroke Center, Budapest

HUNGARY

Background: It has been demonstrated both by in vitro experiments and clinical studies that ultrasound (US) insonation enhances thrombolysis. Since previous studies focused on ultrasound- cloth interactions, in our experiments we intended to investigate the physiological changes of the endothelial cells induced by the insonation. Methods: Cultured human brain microvessel endothelial cells were insonated with 2 MHz, 0.1 W/cm2 and 175kHz frequency, 0.1 W/cm2 energy US beam. Cell necrosis induced by the insonation was investigated using propidium-iodid staining. Changes of the mitochondrial membrane transport were studied with JC-1 labeling. In the presence of 12 ug/ml concentration of rtPA the effect of US on rtPA induced cell surface thrombolytic activity was detected. Using in situ ELISA the amount of bound rtPA on the cell surface, and annexin-II receptor density were measured. Results: No significant increase in the number of necrotic cells could be detected as a consequence of the US insonation. Treatment with 175 kHz frequency US beam resulted significant increase of the mithochondrial membrane transport. In the presence of rtPA significant increase could be observed in endothelial cell surface thrombolytic activity following insonation (p=0.0001). US increased both rtPA binding (p<0.01), and annexin-II receptor density (p<0.01) on the cell surface. Discussion: Our experiments show that US insonation activates human brain endothelial cells: increases mithochondrial membrane transport, enhances rtPA induced cell surface thrombolytic activity, rtPA binding and annexin-II receptor density . These results suggest that endothelial cell activation might be an additional factor in the thrombolysis enhancing effect of ultrasound.

Acute stroke: treatment concepts     Poster Session I
Date: Thursday, 26 May 2005   Time: 7:30- 8:30 -  Room: Padiglione(Pavilion)
Chair:  

11
The Efficacy of Nitric Oxide in Stroke (ENOS) trial: baseline characteristics of the first 301 patients
L. Gray    N. Sprigg    M. Willmot    U. Ferentzi    C. Weaver    P.M.W.Bath                            
ENOS Investigators

Institute of Neuroscience, University of Nottingham, UK

UNITED KINGDOM

Background: Acute high blood pressure is associated independently with a poor outcome after stroke. No large trials have assessed the effect of altering BP during the acute phase of stroke. Additionally no data exist as to whether prior antihypertensive treatment should be continued or stopped temporarily. Methods: ENOS is an international, randomised, parallel-group, blinded, controlled, collaborative trial in 5000 patients with acute stroke investigating the safety and efficacy of lowering blood pressure with transdermal glyceryl trinitrate (GTN), a nitric oxide donor, and of stopping or continuing prior antihypertensive therapy. Randomisation and data collection are performed online over a secure internet site. This analysis describes the baseline characteristics of the first 301 patients recruited into the trial. Results: Recruitment started in July 2001 and by December 2004 301 patients had been recruited from 19 centres across 5 countries. 142 patients had been recruited into the stop or continue part of the trial. The independent Data Monitoring Committee have recommended that the trial should continue after each of four safety assessments. Conclusions: ENOS is already the largest trial of a nitric oxide donor in acute stroke. The international recruitment confirms the feasibility of the trial, including using the internet for randomisation and data collection. The baseline data are representative of those in many stroke services. We are seeking new centres to join the trial.

 
http://www.esc-archive.eu/bologna05/b_graphic/t_1021.htm

Cerebral haemorrhage and SAH Oral Session 1A    
Date: Saturday, 28 May 2005   Time: 10:10 - 10:20 -  Room: Sala Topazio
Chair: S. Davis, Australia and L. Caplan, USA

11
Antiplatelet Use after Intracerebral Hemorrhage
A. Viswanathan    S.M.Rakich    C. Engel    R. Snider    J. Rosand    S.M.Greenberg    E.E.Smith                     
 

Massachusetts General Hospital

USA

BACKGROUND and PURPOSE: Survivors of intracerebral hemorrhage (ICH) are often at risk for both recurrent ICH and ischemic cardiovascular disease. We sought to determine whether antiplatelet (APA) use after ICH increases risk of recurrent ICH. METHODS: We reviewed data from consecutive survivors of ICH enrolled in a single center prospective cohort study; 92% had complete APA information. Survivors were followed by telephone interview at 3 and 6 months and every 6 months thereafter; recurrent ICH and post-index APA use and duration were recorded. We used Cox proportional hazards models with APA exposure as a time dependent variable to assess the effect of APA on recurrent ICH, stratified by lobar and deep ICH location. RESULTS: Recurrent ICH was more common in survivors of lobar ICH compared with survivors of deep hemispheric (basal ganglia or thalamic) ICH (cumulative 2-yr rate 34% vs. 10%, p<0.001). APA were prescribed in 21% (36/175) of ICH survivors (19/100 lobar, 17/75 deep hemispheric), most commonly for prevention of ischemic heart disease. APA use was associated with a statistically insignificant decrease in ICH recurrence in survivors of lobar ICH (HR 0.6, 95% CI 0.2-1.6) with little change after adjustment for apolipoprotein E genotype and number of hemorrhages on baseline MRI scan (HR 0.8, 95% CI 0.3-2.5). APA use was associated with a statistically insignificant increase in ICH recurrence for survivors of deep ICH (HR 1.4, 95% CI 0.1-16.0). CONCLUSIONS: APA use is relatively common following ICH but does not appear to be associated with increased risk of ICH recurrence. These data suggest that APA use might be safe in selected ICH survivors at risk for ischemic cardiovascular disease.

Epidemiology of stroke Oral Session 1A    
Date: Thursday, 26 May 2005   Time: 11:10 - 11:20 -  Room: Europauditorium
Chair: B. Pieschowski-Jozwiak, Poland and P. Rothwell, UK

02
Large subcortical infarctions: risk factors, clinical symptoms and (long-term) prognosis compared to cortical and small deep infarctions
P.H.A.Halkes    L.J.Kappelle    A. Algra                                                 
DTT Study Group

University Medical Center Utrecht

THE NETHERLANDS

Background-Large subcortical infarcts should be distinguished from small deep 'lacunar' infarcts, caused by small vessel disease and from cortical infarcts. They are localised in the same region as small deep infarcts, but are larger and usually caused by large vessel disease or cardioembolism. We studied risk factors, clinical symptoms and stroke recurrence in a large series of patients with large subcortical, cortical and small deep infarctions. Methods-From 3150 patients who participated in the Dutch TIA Trial (DTT), patients with a single clinically relevant supratentorial infarction on the CT scan were selected. Infarcts were classified as large subcortical, cortical or small deep. Data were obtained from the DTT (mean follow-up 2.6 years) and the extended follow-up in LILAC (up to 17 years). Results-659 patients were found to have a single symptomatic ischaemic lesion on CT scan (120 subcortical, 328 small deep, 211 cortical). Patients with a subcortical infarct tend to have a risk pattern similar to that of patients with a small deep infarct. Clinical symptoms of the subcortical infarcts can be similar to those of the small deep as well as to those of the cortical infarcts. After a mean follow-up of 7.7 years, 134 patients suffered a recurrent stroke, 46 (22%) of patients with a cortical infarct at baseline, 25 (21%) of patients with a large subcortical infarct at baseline and 63 (19%) of patients with a small deep infarct. Discussion-Patients with transient or minor disabling stroke associated with a large subcortical infarct do not substantially differ from patients with a small deep infarct or a cortical infarct with respect to clinical features and prognosis, but have a vascular riskfactor pattern that is more common in patients with smalll vessel infarct

Longterm outcome of stroke     Poster Session I
Date: Thursday, 26 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

05
Prevalence of pain in stroke survivors declines with time
A.-C.Jönsson    I. Lindgren    B. Hallström    B. Norrving    A. Lindgren                                   
 

Clinical Sciences

SWEDEN

Background: Prevalence of pain in stroke patients has been reported in several follow-up studies. However, prevalence of pain and its temporal changes after stroke in population-based groups has been less studied. Methods: From the prospective population-based Lund Stroke Register, 297 stroke survivors were followed up after 4 months and 16 months (median). We asked the patients to assess their perceived intensity of pain, if any, using the visual analogue scale (VAS) with zero indicating no pain and 100 indicating worst possible pain during the past 24 hours. In this report, pain is defined as VAS score ≥ 40, corresponding to moderate-severe pain. We examined if the prevalence and intensity of pain changed between the two follow-ups and if the pain was related to stroke in the patients' opinion. Results: Of the 297 patients, 91(31%, 45 men/46 women) reported pain at follow-up I (VAS median 60). Site of pain was upper limbs 60% (19% combined with other sites), lower limbs 34% and other sites 21%. In the patients' opinion, their pain was stroke-related in 50%. At follow-up II, significantly fewer patients (59=20%, 29 men/30 women; p <0.001) reported pain, whereas the intensity was significantly more severe (median VAS score 70; p <0.001. Site of pain was 47% upper limbs (14% combined with other sites), 37% lower limbs and 25% other sites. Patient-reported causes of pain were stroke-related in 37% at follow-up II (p <0.001 compared with follow-up I). Conclusions: Pain after stroke is common, but the prevalence tends to decrease with time in survivors. However the severity of pain may increase with time. In the patients' opinion the stroke-related pain decreased from about half to about a third of the patients reporting moderate-severe pain.

Heart and brain (cardiac disorders and stroke)     Poster Session II
Date: Friday, 27 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

02
Ischemic stroke mimicking acute myocardial infarction, a diagnostic dilemma
I. van der Bilt    D. Hasan    F. Visser                                                 
 

VU University Medical Center/ dep. Cardiology

THE NETHERLANDS

A 63-year-old man was found in a comatose state, with generalized seizures. His medical history consisted of hypertension, but no heart disease. The Glasgow Coma Score was E1M4V1. The intial CT-scan was normal. Routine electrocardiography (ECG) (figure 1) showed ST-elevations. Echocardiographic wall motion abnormalities (SWMA), and biochemical signs of myocardial damage were present. Because of suspected myocardial infarction, coronary angiogram was performed, which was normal. A repeat CT revealed ischemic stroke. 9 days later the ECG and echo were normal. Myocardial injury defined as ECG changes, SWMA, and biochemical signs of myocardial damage, may occur following acute neurological events. Without appropriate tests, the ECG changes, SWMA, and elevated troponins, may be easily mistaken for coronary insufficiency. This case illustrates the diagnostic and therapeutic pitfalls of neurocardiac injury. Anticoagulation because of suspected myocardial ischemia may lead to hemorrhagic transformation of the stroke area. The pathophysiology of this cardiac injury remains unclear. Evidence is cumulating that sympathetic stimulation, through the nerve terminals, induces an excess catecholamine release in the myocardium. Studies on epidemiology and pathophysiology of neurocardiogenic injury in acute neurological disorders are limited, although reports are emerging. Troponins and NT-pro-BNP are known to be elevated following ischemic stroke. Data on how these markers for myocardial damage can be interpreted, are conflicting. It has been posed that these biochemical tests can be used as a predictor for death and prognosis. Increased mortality related with elevated Troponins has been suggested, but could not be confirmed in a recent study in patients with acute isschemic stroke.

http://www.esc-archive.eu/bologna05/b_graphic/g_1026.htm
 

Management and economics     Poster Session II
Date: Friday, 27 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

11
Are we treating Transient Ischaemic Attack (TIA) with the due urgency it deserves?
I.U.Din    D. Rees    M. Robathan    B. Richard    P. Khanna                                   
 

Nevill Hall Hospital, Department of Adult Medicine

UNITED KINGDOM

Background:The Royal College of Physicians RCP published guidelines on management of Transient Ischaemic Attack TIA. Risk of developing a stroke following TIA is highest in the first few days. Active urgent intervention within seven days of TIA can lead to a huge benefit. We audited our TIA mangement results against these national guidelines and made recommendations to improve the services in the District General Hospitals DGH in United Kingdom Methods:Retrospective Audit of 54 randomly selected patient case notes who attended the TIA Outpatient Clinic in the last one year. Results: 54 patients between ages 25-85 mean 67.4 were included in the study. 70% revealed a definite diagnosis of TIA/Stroke. 3% of these patients were seen within the therapeutic window of 2 weeks. The subset of TIA ± Stroke 38/54 were further studied. 28/38 had carotid doppler only 1 within 3 weeks of event. 20/38 had CT head 7 within 1 week. All Cardiovascular risk factors had appropriate intervention.28/38 had carotid doppler tests of whom 5/38 had stenosis (3patients >50% stenosis). 3 patients underwent successful endarterectomy, none within 2 weeks of event. Discussion: There is a need for education of the public and better co-ordination between Primary/Secondary care physicians and neuroradiologist. This means improved refferal systems adequate numbers of clinical experts and dedicated Neurovascular clinics. This will be an important service development and have significant financial impact. Recommendation to be made to RCP to develop a National Sentil Audit of TIA management.This will highlight the importance of active urgent intervention of TIA in order to reduce the incidence of stroke in the general population.

 
http://www.esc-archive.eu/bologna05/b_graphic/t_1027.htm

Brain imaging Oral Session 1A    
Date: Friday, 27 May 2005   Time: 11:30 - 11:40 -  Room: Sala Bianca (B)
Chair: J. M. Wardlaw, UK and J. Röther, Germany

04
Non-invasive measurement of brain temperature in acute ischaemic stroke with MR spectroscopy - relationship to infarct and penumbra.
B. Karaszewski    J.M.Wardlaw    I. Marshall    V. Cvoro    K. Wartolowska    P.A.Armitage    M.E.Bastin    K. Haga    M.S.Dennis       
 

Division of Clinical Neurosciences (DCN), University of Edinburgh, UK

POLAND

Background: Pyrexia, common following acute ischaemic stroke, is associated with severe stroke and poor outcome, but the relationship to temperature within the stroke lesion is unknown. With MR proton spectroscopic imaging (MRSI), we measured regional brain temperature (temp.) in patients with acute ischaemic stroke, and related it to other imaging (e.g. DWI and PWI) data. Methods: 33 patients with acute ischaemic stroke had MR DWI (tensor), PWI (contrast bolus) and single slice MRSI within 24 hrs of stroke. Voxels on DWI were coded "definitely" or "possibly hyperintense" (DH or PH respectively), "infarct outer edge" (IE), "ipsi-" or "contra-lateral normal" (INL or CNL respectively) blind to all other data. We calculated regional brain temp. from MRSI data (chemical shift of water relative to N-acetylaspartate) and compared it to PWI/DWI values on co-registered images, and other lesion characteristics. Results: Temp. in regions (mean of patient means, °C) were: DH 37.3; PH 37.6; IE 37.7; INL 37.2; CNL 37.3. Ischaemic (DH) temp. were 0.36° and 0.42° higher (mean) than normal tissues (CNL and INL respectively) (p<0.00001), PH was (mean) 0.37° higher than DH (p<0.00001), and "potential penumbral" tissues (PH, IE) were hottest. Greater temp. difference between ischaemic lesion (DH) and normal tissue (CNL) was associated with: smaller DH/PH lesions, good CBF in and around the DWI lesion and lesions with any DWI/PWI mismatch. Discussion: Regional brain temp. can be measured non-invasively with MRSI. This could be used to monitor trials of interventions, e.g. anti-inflammatory agents and hypothermia. Apparently higher temperatures in "potential penumbra" may reflect more intense release of inflammatory mediators, raised metabolism and/or hyperaemia in still viable tissue.

Chronic conditions and recurrences     Poster Session III
Date: Saturday, 28 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

01
Secondary Stroke Prevention With Ximelagatran in Patients With Atrial Fibrillation and Prior Stroke - a Pooled Analysis of SPORTIF III and V Clinical
P.T.Akins    H.A.Feldman    R.G.Zoble    D. Newman    S.G.Spitzer    P.Y.-A.Ding    H.-C.Diener    G.W.Albers              
 

Mercy Stroke Center, Sacamento, CA, USA

USA

Background: In patients with atrial fibrillation (AF), a prior stroke or transient ischaemic attack (TIA) is the strongest risk factor for recurrent stroke. Ximelagatran was compared to warfarin in patients treated in SPORTIF III and V trials with prior stroke/TIA. Combination aspirin/anticoagulation was compared to anticoagulation alone for primary event rates and bleeding rates. Methods: Patients with prior stroke/TIA (21%) were identified from pooled data in the SPORTIF III and V trials. Primary outcome was the rate of all strokes (ischaemic+haemorrhagic) and systemic embolic events (SEE); secondary outcomes included major and minor bleeding rates. Results: Primary outcome rate in patients with prior stroke/TIA was ximelagatran (2.83%/y) and warfarin (3.27%/y; P=0.625). Without prior stroke/TIA the rate was ximelagatran (1.31%/y) and warfarin (1.26%/y; P=0.852). Combination treatment with low-dose aspirin (≤100 mg) plus anticoagulation was associated with higher primary event rates (P=0.096) (ximelagatran 2.51%/y; ximelagatran/aspirin 3.80%/y; warfarin 2.87%/y; warfarin/aspirin 4.33%/y). Aspirin use remained an independent predictor of stroke/SEE in a multivariate analysis. Combination aspirin/anticoagulation was also associated with increased rates of major/minor bleeding (P<0.0001) (warfarin 36.1%/y; warfarin/aspirin 72%/y; ximelagatran 33.4%/y; ximelagatran/aspirin 49%/y) and major bleeding (P=0.0006) (warfarin 1.5%/y; warfarin/aspirin 4.95%/y; ximelagatran 2.35%/y; ximelagatran/aspirin 5.09%/y). Discussion: In patients with AF and prior stroke/TIA, ximelagatran provided comparable stroke prevention to warfarin with similar bleeding risks. Aspirin combined with anticoagulation was associated with significantly higher bleeding rates and higher primary event rates.

Genetic disorders     Poster Session II
Date: Friday, 27 May 2005   Time: 7:30 - 8:30 -  Room:  
Chair:  

05
SNP polymorphism of MMP-2 gene is associated with lacunar strokes
M. Fatar    M. Stroick    M. Griebe    S. Thiel    P. Bugert    T. Bettecken    T. Meitinger    M. Steffens    T. Wienker    M.G.Hennerici
 

Universitätsklinikum Mannheim, University of Heidelberg

GERMANY

Background: In recent years different SNP polymorphisms and their association with different cerebrovascular diseases were examined. We present for the first time SNP polymorphism in the MMP-2 gene which are associated with lacunar strokes. Methods: Cerebrovascular patients (n=225) from our stroke unit and vascular outpatient clinic were recruited. Controls were obtained from the local blood bank (n=57) and the ophthalmology clinic (n=85). Patients were classified into acute territorial stroke, lacunar stroke, intracranial haemorrhage or carotid artery stenosis without acute infarction, confirmed by MRI, CCT and ultrasound evaluation. All participants had given informed consent for genetic analysis according to local ethic committee guidelines. DNA was analysed by MALDI-TOF analysis. Results: All samples were at the Hardy-Weinberg Equilibrium and mean call rate was 98.7 %. Out of 12 SNP polymorphisms in the MMP-2 gene, which were examined - 3 SNPs were found to be significantly associated with lacunar strokes (p<0.01). All other cerebrovascular subgroups showed no association with any of the SNPs studied. Conclusion: Our data demonstrates for the first time at least 3 SNPs of the MMP-2 gene with significant association with lacunar strokes. Whether these genotypes are a risk factor, not only for lacunar strokes but also vascular dementia has to be further verified.

Experimental studies Oral Session 1A    
Date: Thursday, 26 May 2005   Time: 12:10 - 12:20 -  Room: Sala Topazio
Chair: L. Hirt, Switzerland and S. Blecic, Belgium

08
GCF2 transcription factor is up-regulated in brain during ischemia
J. Mallolas    O. Hurtado    M. Castellanos    J. Serena    J. Castillo    Y. Silva    P. Lorenzo    I. Lizasoain    A. Dávalos    M.A.Moro
 

Fundació Dr Josep Trueta. Hospital de Girona Dr Josep Trueta

SPAIN

Background and Purpose: GC-binding factor 2 (GCF2) is a transcriptional repressor that decreases activity of several genes. GCF2 is expressed as a 4.2 Kb mRNA in most human tissues showing the highest expression level in peripheral blood leukocytes and lowest expression in brain and testis. After vascular injury, such as mechanical injury of vascular endothelial cells in culture or after balloon injury of rat carotid artery wall, a sustained induction of GCF2 expression is found. Our aim was to clarify whether GCF2 could be a transcriptional regulator of gene expression in cerebral ischemia. Methods: GCF2 expression was studied by immunoblotting using a specific anti-GCF2 antibody, in homogenates of ipsilateral cortices and striata from rats sacrificed 2, 24 and 48 h after a permanent middle cerebral artery occlusion (MCAO) or sham procedure. Results: Whereas GCF2 expression in samples from sham animals was not detected, MCAO increased GCF2 expression in both cortex and striatum. Time course studies showed that GCF2 expression was increased at all times examined. Discussion: GCF2 is a transcriptional repressor overexpressed in ischemic brain with a putative role in regulating expression of genes involved in cerebral ischemia, either by direct transcriptional repression of genes, such EAAT1, or by repressing transcription factors like AP-2. Thus, GCF2 could be a new therapeutic target in acute ischemic stroke.

http://www.esc-archive.eu/bologna05/b_graphic/g_1031.htm
 

Longterm outcome of stroke Oral Session 1A    
Date: Friday, 27 May 2005   Time: 11:00 - 11:10 -  Room: Sala Topazio
Chair: L. Pantoni, Italy and A. Massaro, Brazil

01
Long term outcome of carotid angioplasty or stenting versus endarterectomy: Final results from CAVATAS
L. Coward    R. Featherstone    M.M.Brown                                                 
for the CAVATAS Investigators

Institute of Neurology, University College London

UNITED KINGDOM

Introduction The Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS) completed randomisation in 1997. An analysis at mean follow up of 1.96 years published in 2001showed similar early rates of stroke after randomisation between endovascular treatment (angioplasty or stenting) and endarterectomy (surgery), but long term outcome was uncertain. Follow up was therefore continued for a minimum of 5 years. Methods 504 patients with carotid stenosis suitable for surgery were randomised to endovascular treatment (N=251) or surgery (N=253). 78% of endovascular patients received simple balloon angioplasty and 22% were stented. Patients were followed up with ultrasound where available. Analysis was by intention to treat. Results Survival analysis was performed at 8 years after randomisation. Median follow up was 60.7 months in the surgical group and 60.2 months in the endovascular group. There was no significant difference in the 8 year rate of ipsilateral stroke lasting more than 7 days, including treatment related events (15.4% surgical group versus 16.7% endovascular group P=0.69). The rate of fatal or disabling stroke in any territory did not differ significantly (8.9% in the surgical group and 10.4% in the endovascular group P=0.53) [Figure 1]. Restenosis of the treated artery to more than 50% was more common after endovascular treatment than after surgery (55.6% versus 28.9% P<0.0001 Chi square test). Conclusion Both endovascular treatment and endarterectomy are associated with high long term rate of restenosis. Despite this, the rate of stroke after randomisation to either treatment remains low 8 years after treatment. Endovascular treatment, even without stent insertion, appears as effective as carotid endarterectomy in preventing long term stroke.

http://www.esc-archive.eu/bologna05/b_graphic/g_1032.htm
 

Longterm outcome of stroke     Poster Session I
Date: Thursday, 26 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

09
Predicting long-term independency in ADL after MCA stroke: Does MRI information add in prediction next to clinical information?
S. Schiemanck    G. Kwakkel    M. Post    T. Witkamp    J. Kappelle    A. Prevo                            
 

Rudolf Magnus Institute of Neuroscience, University Medical Center Utrecht, The Netherlands

THE NETHERLANDS

Objective: Does neuro-imaging information next to clinical information has surplus value in prediction of ADL-independency one year poststroke? Methods: Two predictive models were evaluated (logistic regression analysis) for 75 first-ever ischemic MCA stroke patients in the Netherlands; Model 1 consisting of clinical variables (stepwise forward model) and model 2 with added neuro-imaging variables (enter model). Independent variables: stroke severity (National Institutes of Health Stroke Scale), consciousness (Glasgow Coma Scale), urinary continence, demographic variables (age, sex, partner, educational level), and clinical instruments: sitting balance (Trunk Control Test), motor functioning (Motricity Index), activity limitations (Barthel Index (BI)). Neuro-imaging variables determined on conventional MRI scans: number of days of MRI scan poststroke, lesion volume, cortical localization (cortex/subcortex), hemisphere, white matter lesions, hemorrhagic component. As dependent variable, independency in activities of daily living (ADL) after one year poststroke was defined as 19 and 20 points on the BI. Results: Model 1 consisting of clinical variables (age, total Motricity Index and urine continence) had an area under the curve (AUC) of the Receiver Operating Curve (ROC) of 0.90. Model 2 with entered significant neuro-imaging variables next to clinical variables: (number of days of MRI scan poststroke, white matter lesions, hemorrhagic component, hemisphere, logarithmic volume) had an AUC of 0.93. Conclusions: Clinical information in the second week poststroke stroke is a good predictor for independency in ADL assessed with the BI one year poststroke. Neuro-imaging variables from conventional MRI scans do not have surplus value in the prediction of ADL on the longterm.

Acute stroke: treatment concepts     Poster Session I
Date: Thursday, 26 May 2005   Time: 7:30- 8:30 -  Room: Padiglione(Pavilion)
Chair:  

05
Safety, tolerability and pharmacodynamics of allopurinol in acute stroke patients: a pilot study
C. Harrow    S. Muir    K. Lees    M. Walters                                          
 

University of Glasgow

UNITED KINGDOM

Background Elevated serum urate concentration is associated with poor outcome after stroke. The potential benefit of urate lowering with allopurinol in stroke patients has not been explored, and the optimal dose in this population is unknown. Methods We did a randomised, double blind placebo-controlled trial to investigate the safety, tolerability and urate lowering effect of high (300mg od) and low (100mg od) doses of allopurinol in patients within 3 days of ischaemic stroke. Urate concentration was measured at baseline, then at 1 and 6 weeks. NIHSS scores, further vascular events and adverse effects were recorded. ANOVA was used to analyse the biochemical and NIHSS data. Results 50 patients (50% male) were recruited (n= 17, 17 and 16 for high (H), low (L) and placebo (P) groups respectively). Mean (SD) age and baseline NIHSS of all participants were 70 (12) yrs and 3.2 (1.7) respectively. Groups were well matched with regard to age, gender, NIHSS, baseline urate and stroke aetiology. 2 (12%) patients withdrew from (P) (1 GI upset and 1 potential drug interaction). 1 patient (6%) withdrew from both (L) (GI upset) and (H) (potential interaction). Compared to placebo, % reduction in urate concentration was significantly greater in (H) but not (L) at 7 days (-32% (20), -18% (28), and -1.6% (19) in H, L and P respectively (p=0.005)). The difference was sustained and unchanged at six weeks. There was no difference in NIHSS between groups at any timepoint. Conclusion Allopurinol 300mg was well-tolerated and lowered urate in stroke patients. The effect of 100mg allopurinol on urate did not differ significantly from placebo. 300mg allopurinol should be used in future stroke secondary prevention trials. Potential drug interactions may affect recruitment into such trials.

Management and economics     Poster Session II
Date: Friday, 27 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

14
Adding to the Patients' Burden: A Multinational Investigation of Time- and Travelling Costs in Attending Anticoagulation Clinics
S. Jowett    S. Bryan    I. Mahé    D. Brieger    J. Carlsson    B. Kartman    M. Nevinson                     
 

University of Birmingham, Health Economics Facility, Health Services Management Centre

UNITED KINGDOM

Background: Anticoagulation is used in patients with atrial fibrillation to reduce the risk of ischaemic stroke but the therapy requires regular monitoring. We determined the time- and travelling costs incurred by patients when attending anticoagulation clinics. Methods: A subset of anticoagulation patients in the randomized controlled trial SPORTIF III (patients from Australia, France, Portugal, Spain, Sweden, and UK) completed a questionnaire. Type of monitoring used (primary or secondary care) was in line with the typical approach to monitoring in each country. Patients were asked to indicate the type of transport used to get to and from the clinic, and to estimate travelling expenses. In addition, patients were asked to estimate total travelling time to and from the clinic, time spent at the clinic, and to confirm if they were currently employed, and if they had to give up time from work to attend the clinic. Time cost of companions was also taken into consideration. Cost per patient was calculated. A 2003 price year was used and costs are presented in Euros (€). Results: Questionnaires for a total of 381 patients were analysed, with the majority of patients from Sweden (n=130) and UK (n=101). Mean costs varied widely between countries ranging from €8.47 for French patients (primary care) to €37.51 for Portuguese patients. For all countries except France, time costs (i.e. value of lost working and leisure time) were the main driver of costs. Discussion: Patients incur considerable costs when visiting their anticoagulation clinic. Taking into account that the average patient attends their clinic approximately 10 times a year, the results demonstrate that including time- and travelling costs is important when considering the cost-effectiveness of anticoagulation.

Chronic conditions and recurrences     Poster Session III
Date: Saturday, 28 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

06
The Recurrent Stroke Quality and Epidemiology study (RESQUE). A multicenter study of stroke recurrence, its causes and consequences
A. Lindgren    B. Leijd    T. Leoo    K. Leire    P. Kaur    M. von Arbin                            
On behalf of the RESQUE investigators

Clinical Sciences,University Hospital, Lund

SWEDEN

Background: Much interest has been focused on first-ever stroke, whereas the characteristics of patients with recurrent stroke have been less extensively studied. In this multicenter study we examine patients with recurrent stroke and their risk factors and treatment before the recurrent stroke. Methods: We aim at enrolling 1000 consecutive patients with recurrent stroke, treated at stroke units at 19 different Swedish hospitals. Type of recurrent stroke is assessed using the TOAST criteria. Information about risk factors is collected from the clinical examination, patient history and laboratory tests. We register medical treatment before and after the recurrent stroke as well as reasons for changing or keeping ongoing treatment. Outcome after recurrent stroke is evaluated measuring activities of daily life function with Barthel or Katz index at hospital discharge. Results: Patient recruitment began in the end of 2004. On January 20, 2005 there are 19 hospitals active in recruitment of patients and 75 patients have been included. We plan to include all 1000 patients in the study before the end of 2005. Conclusion: The RESQUE study will provide important information about a large number of patients with recurrent stroke. More details will be presented at the ESC meeting.

Meta-analysis and review papers Oral Session 1A    
Date: Thursday, 26 May 2005   Time: 11:50 - 12:00 -  Room: Sala Azzura
Chair: J. E.Rinkel, The Netherlands and P. Sandercock, UK

06
Effect of Anticoagulant Therapy With Ximelagatran or Warfarin on Cardio- and Noncardioembolic Stroke in Patients With Nonvalvular Atrial Fibrillation
J.S.Teitelbaum    R. von Kummer    K. Gjesdal    A. Kristinsson    G. Gahn    G.W.Albers                            
 

Montreal Neurological Institute and Hospital, Montreal, Quebec, Canada

CANADA

Background: Atrial fibrillation (AF) is responsible for about 15% of ischaemic strokes. Cardiogenic embolism is the most common stroke mechanism among high-risk patients with AF. Warfarin has a greater impact on prevention of cardioembolic than on noncardioembolic stroke. In the SPORTIF III and V trials, the oral direct thrombin inhibitor ximelagatran was as effective as warfarin in reducing the rate of all stroke and systemic embolic events in high-risk patients with nonvalvular AF. We compared the effect of warfarin vs ximelagatran on rates of cardioembolic and noncardioembolic stroke. Methods: In SPORTIF III and V, 7329 patients with AF and 1 or more additional risk factors for stroke were randomized; 126 ischaemic strokes occurred on treatment. Strokes were classified into subtypes according to predetermined (TOAST) criteria based on blinded event assessment. Adverse events and stroke outcomes were assessed according to stroke subtype. Results: Annual rates were low for both cardioembolic (0.39-0.47) and noncardioembolic ischaemic stroke (0.37-0.57) and not significantly different between treatment groups. Of all ischaemic strokes, 33.9% (ximelagatran) and 34.3% (warfarin) were of probable cardioembolic origin. More cardioembolic than noncardioembolic strokes were fatal (P<0.01). Patients with cardioembolic stroke had a significantly higher rate of poor outcome (fatal or disabling stroke, MI, or death from any cause) than all other groups combined (P<0.02). Discussion: In the SPORTIF III and V studies of patients with AF, the efficacy of warfarin and ximelagatran appeared similar for prevention of both cardioembolic and noncardioembolic strokes. Overall outcome and survival were significantly worse following a cardioembolic stroke.

Acute stroke: treatment concepts Oral Session 1A    
Date: Friday, 27 May 2005   Time: 11:50 - 12:00 -  Room: Sala Italia
Chair: D. Toni, Italy and P. Trouillas, France

06
Functional outcome after intracerebral hemorrhage is improved by therapy with human processed lipoaspirate mesenchymal stem cells in rats
M. Stroick    M. Griebe    M. Fatar    F. Giesel    K. Bieback    S. Kern    C. Zechmann    I. Marwedel    W. Back    M.G.Hennerici
 

Department of Neurology, Klinikum Mannheim, University Heidelberg

GERMANY

Cell transplantation is widely used to reduce behavioural deficits after focal cerebral damage in animals. We hypothesize that processed lipoaspirate mesenchymal stem cells (PLA-MSCs) migrate to an intracerebral hemorrhage (ICH) after iv. application and can be visualized by in vivo MRI tracking and species specific markers histologically. Experimental ICH was induced by stereotactic administration of collagenase into the striatum of 20 adult rats. After one day rats were randomly assigned into control or treatment group. Treatment group received 3x106 adipogenic MSCs by intravenous injection in the tail vein while control animals received a placebo injection with Ringer solution. The functional outcome was monitored with the Rota-Rod Test (a motor performance task) which was performed daily in the training period 3 weeks before and 10 times over 4 weeks after ICH induction. Morphometric analysis of the hemorrhage and immunhistochemical analysis (GFAP, NeuN) was performed consecutive. The Rota-Rod baseline value was 23.1+/- 3 rpm and decreased to 7.3 +/- 3 rpm on day 1 after ICH induction proving an adverse effect of the hemorrhage. However, there was a highly significant improvement in functional outcome for the MSC treated group to 17.5 +/- 2 rpm after 4 weeks compared to only 11.5 +/-4 rpm in controls (p<0.01). This is the first report using human adipose tissue-derived mesenchymal stem cells as a highly effective treatment to improve functional outcome after ICH. Analysis of brain sections will reveal whether differentiation of infused MSC was causative for the therapeutic effect. Initial in vitro results with gadolinium liposomes in MSCs are promising concerning in vivo tracking for further experiments.

Acute stroke: complications and early outcome Oral Session 1A    
Date: Thursday, 26 May 2005   Time: 12:10 - 12:20 -  Room: Sala Italia
Chair: N. Bornstein, Israel and F. Aichner, Austria

08
Predictors of symptomatic parenchymal hemorrhages in patients treated with intravenous t-PA: a multi-center study
J. Martí-Fàbregas    Y. Bravo    J. Díaz-Manera    J.-L.Martí-Vilalta    M. Blanco    M. Castellanos    N. Pérez de la Ossa    J. Roquer Lastname9=Obach    V. Obach    J. Maestre
 

Hospital de la Santa Creu i Sant Pau

SPAIN

Background. Few studies have evaluated the risk factors for symptomatic parenchymal hemorrhage (PH) in patients treated with t-PA outside clinical trials. Moreover, the definitions of PH have varied among different studies. Methods. We retrospectively reviewed a multi-center database of prospectively included patients with the following data: demographics (age,sex); vascular risk factors; time to treatment; dose; baseline NIHSS, body temperature and blood pressure; baseline platelet count and glycemia; TOAST classification; antiplatelet treatment; use of antihypertensive treatment before or after t-PA; early signs of ischemia on baseline CT; protocol violations; criteria (NINDS, ECASSII, SITS-MOST). Symptomatic PH was defined as 1)PH-1 or PH-2 type (according to ECASS criteria); 2) Appears within the first 36 hours after t-PA infusion; 3) Increase >3 points in NIHSS score attributable to PH. Statistics: Bivariate analyses (t-test, contingency tables) and logistic regression analysis. Results. We studied 347 patients treated at 7 centers. Mean age was 6810.9 years, and 56% were men. Median baseline NIHSS was 15 and 87% patients were treated within 3 hours. PH was detected in 28 patients (8%), but was symptomatic in only 8 patients (2.3%). Variables statistically associated with PH in bivariate analyses were: Previous Transient Ischemic Attack, early CT signs of ischemia, dense middle cerebral artery sign and protocol deviation. In the multivariate analysis, early CT ischemic signs (OR 9.9, CI 1.1-84.3, p=0.03) and protocol deviation (OR 6.9, CI 1.5-31.2, p=0.01) were independent predictors of symptomatic PH. Discussion. The frequency of symptomatic PH was 2.3%. Risk factors were early CT ischemic signs (10-fold risk) and deviations from the protocol (7-fold risk).

Clinical Trials Oral Session 1A   Poster Session III
Date: Saturday, 28 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

03
AVASIS: An open randomized trial comparing Aspirin versus Oral Anticoagulants in patients with symptomatic stenosis of the middle cerebral artery
J. Martí-Fàbregas    D. Cocho    R. Belvís    Y. Bravo    M. Millán    A. Rodríguez-Campello    M.      J.-L.Martí-Vilalta              
AVASIS study (Spanish Stroke Project)

Hospital de la Santa Creu i Sant Pau

SPAIN

Background. The best antithrombotic treatment for patients with intracranial stenosis is unclear. We report the results of an open, randomized, multi-centre trial that compared aspirin (ASA) and Oral Anticoagulants (OA) in the secondary prevention of vascular events in patients with symptomatic stenosis of the middle cerebral artery (MCA). Methods. Inclusion criteria: 1)Transient Ischemic Attack (TIA) or cerebral infarct (CI) in the MCA territory; 2)MCA stenosis demonstrated by conventional angiography or at least two non-invasive examinations (Transcranial Doppler, Magnetic Resonance Angiography or Computed Tomography Angiography); 3)Exclusion of 50% stenosis of the ipsilateral carotid artery, cardioembolic and aortic embolic sources (including transesophageal echocardiography), and any uncommon etiology. Patients were randomized to receive ASA 300mg/day or coumarin (INR 2-3). The combined primary end-point was: non-fatal CI, non-fatal acute myocardial infarct, vascular death and major hemorrhage (cerebral or systemic). Patients were followed-up for a minimum of 1 year and a maximum of 3 years and the evaluation of the primary end-point was not blind. Statistics: Contingency tables and 2 test. Results. We included 28 patients (14 in each group), age 67 ± 9.9 y, 66.6% were men. At inclusion, 70% were CI and 30% were TIA. After a mean follow-up of 710 ± 323 days, the recurrence of CI was 0% in both groups. No end-point was reported in the ASA group (0%), but 2 in the OA group (14.3%, 1 acute myocardial infarct and 1 intracerebral hemorrhage), and this difference was not statistically significant (p=0.48). Discussion. This small study suggests that ASA is more effective than Oral Anticoagulants to prevent vascular events in symptomatic stenosis of the MCA.

Experimental studies Oral Session 1B    
Date: Thursday, 26 May 2005   Time: 17:25 - 17:35 -  Room: Sala Topazio
Chair: P. Wester, Sweden and V. Skvortsova, Russian Federation

20
Agreement between different platelet function tests in detection of aspirin non-responsiveness
L. Silver    P. Harrison    H. Segal    K. Blasbery    C. Furtado    P. Rothwell                            
 

Stroke Prevention Research Unit, Department of Clinical Neurology, University of Oxford

UNITED KINGDOM

Background: Recent studies suggest that patients who fail to respond to aspirin (ASA) therapy may be at increased risk of ischaemic vascular events. The availability of simple to use point of care (POC) platelet function tests now potentially allows aspirin non-responsiveness to be identified in routine clinical practice. However, there are very few data on whether the different tests produce consistent results. We therefore compared two POC tests (PFA-100 device and the Ultegra-RPFA ASA test) with conventional light transmission aggregometry (LTA). Methods: Platelet function was assessed by all 3 tests in 100 consecutive patients receiving low dose ASA therapy after TIA or ischaemic stroke. Results: The incidence of ASA non-responsiveness was 17% by the RPFA test and 22% by the PFA-100, compared to only 5% by LTA (i.e. as defined with both Arachidonic Acid and ADP). Agreement between both the RPFA test and the PFA-100 and Arachidonic Acid induced LTA was poor: kappa = 0.16 (95% CI: -0.08 - 0.39), p=0.11 and kappa = 0.09 (-0.12 - 0.30), p=0.32 respectively. Agreement between the two POC tests was also poor: kappa = 0.14 (-0.08 - 0.36), p=0.15. Only 2% of patients were aspirin non-responders by all 3 tests. Conclusions: The prevalence of apparent ASA non-responsiveness was higher with both the POC tests than with LTA. However, agreement between the tests was poor and very few patients were ASA non-responsive by all 3 tests. Aspirin non-responsiveness is therefore highly test-specific and large prospective studies will be required to determine the prognostic value of each of the separate tests.

Epidemiology of stroke     Poster Session III
Date: Saturday, 28 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

08
A population-based study of the prevalence of aspirin non-responsiveness after acute vascular events
C. Lovelock    L. Silver    P. Harrison    H. Segal    P. Rothwell                                   
 

Stroke Prevention Research Unit, Department of Clinical Neurology, University of Oxford

UNITED KINGDOM

Background: Aspirin reduces the risk of recurrent vascular events by 15-20% after ischaemic stroke and acute coronary syndromes. Platelet function tests identify some patients as "aspirin non-responsive" but the clinical significance of this is unclear, particularly whether there is any association with aspirin failure or aspirin dose. Methods: We studied consecutive patients with TIA (n=115), ischaemic stroke (n=222), and acute coronary syndromes (ACS, n=191) in a population-based incidence study. Citrated (3.2%) blood was tested with PFA-100, a “point of care” high-shear platelet function test. Aspirin non-responsiveness was defined as the absence of a prolonged closure time within a Collagen/Epinephrine cartridge (<164secs) in patients taking regular aspirin (75-300mg). Collagen/ADP (CADP) cartridges were also tested Results: Of the 528 patients studied (296 male, mean age=71), 125 (23.7%) were aspirin non-responsive. Non-responsiveness was unrelated to age, sex, type of presenting event, severity of presenting event (NIH score in strokes; troponin level in ACS), duration of treatment, or prior aspirin treatment (i.e. “aspirin failure”), but was more prevalent in patients taking low dose aspirin (119/479 on ≤75mg versus 6/49 ≥150mg, p=0.035). Non-responsive patients also had shortened median CADP closure time (74 versus 94 secs, p<0.001) and increased mean levels of VWF antigen (203iu/dl versus 178iu/dl, p<0.001) and fibrinogen (4.48mg/ml versus 3.90mg/ml, p<0.001). Conclusion: About a quarter of patients with acute vascular events are aspirin non-responsive by the PFA-100. Non-responsiveness is strongly associated with increased VWF and fibrinogen levels, and possibly with aspirin dose, but is unrelated to “aspirin failure” or the severity of presenting events.

Experimental studies Oral Session 1A    
Date: Thursday, 26 May 2005   Time: 12:40 - 12:50 -  Room: Sala Topazio
Chair: L. Hirt, Switzerland and S. Blecic, Belgium

11
Influence of citrate concentration and in-vitro addition of aspirin on apparent aspirin non-responsiveness using the PFA-100
L. Silver    P. Harrison    H. Segal    K. Blasbery    C. Furtado    P. Rothwell                            
 

Stroke Prevention Research Unit, Department of Clinical Neurology, University of Oxford

UNITED KINGDOM

Background: The PFA-100 is the point of care test of platelet function that is most widely used to identify patients who do not appear to respond to aspirin therapy. However, the sensitivity of this test may be confounded by patient non-compliance, under-dosing, or the concentration of citrate used in blood sampling. Method: Citrated blood (3.2% and 3.8%) was collected from patients taking daily aspirin (75-300 mg) after TIA, ischaemic stroke, or myocardial infarction. The samples were tested using Collagen Epinephrine (CEPI) cartridges. An aspirin non-response was defined as the absence of a prolonged closure time with the CEPI cartridge. In non-responsive patients, 1ml of blood was further incubated with 100µM aspirin for 30 minutes at 37°C prior to retesting with another CEPI cartridge. Results: Of 546 patients studied, 114 were identified as being non-responsive by PFA-100 with samples collected in 3.2% citrate and were retested following incubation with ASA. Of these samples, only 39 (34.2%) remained non-responsive on re-testing. 91 of the 114 patients also had a sample taken simultaneously into 3.8% citrate, of whom only 28 (30.8%) were also aspirin non-responsive with this higher concentration. Conclusion: Aspirin non-responsiveness as detected by the PFA-100 is very sensitive to the citrate concentration used in blood sampling. The reduction in apparent non-responsiveness with the addition of aspirin in vitro is probably due to under-dosing or non-compliance with aspirin therapy. The high levels of aspirin non-responsiveness reported in some previous studies of the PFA-100 should be interpreted in the light of these observations.

Brain Imaging – new developments     Poster Session III
Date: Saturday, 28 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

11
Magnetisation transfer imaging of white matter hyperintensities in the elderly: results from the Austrian Stroke Prevention Study
F. Fazekas    S. Ropele    C. Enzinger    G. Faton    A. Seewann    R. Schmidt                            
 

Department of Neurology, Medical University Graz

AUSTRIA

Background: White matter hyperintensities (WMH) are a frequent phenomenon of the ageing brain and have been associated with microangiopathy. The severity of tissue changes which are associated with these abnormalities and possible distant effects cannot be adequately determined by conventional magnetic resonance imaging (MRI). Methods: We performed magnetization transfer imaging in 198 neurologically asymptomatic participants of the Austrian Stroke Prevention Study (mean age 70, age range 62-87 years) using a 1.5T scanner. Regional analysis of the magnetization transfer ratio (MTR) maps was performed in regard to WMH and predefined areas of normal appearing white matter (NAWM). Fluid attenuated inversion recovery MRI was used to grade lesion severity and for lesion volume measurements. Results: The MTR of WMH was always significantly lower than that of normal appearing white matter (NAWM) with an overall relative reduction of about 10% and decreased significantly with increasing scores of WMH severity (p=0.02) and WMH volume (r=-0.24, p=0.0016). NAWM MTR was not different between subjects with very few and extensive WMH. The WMH volume was associated with NAWM MTR in the frontal lobe but not in other regions of the brain. Discussion: The tissue damage associated with WMH is quantifiable with magnetization transfer imaging. It is relatively mild and increases with lesion size. Overall there appear to be no related MTR changes in the NAWM except for the frontal lobe.

Recovery and rehabilitation     Poster Session I
Date: Thursday, 26 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

15
New idea of Cognitive rehabilitation for the patients with ideational apraxia by caused cerebral hemorrhage
K. Ikeda    S. Miyamoto    S. Morioka    Y. Kataoka    K. Kobayashi    K. Tsuduki                            
 

Kochi School of Allied Health and Medical Professions Rehabilitation

JAPAN

[Introduction] We report a cerebral hemorrhage patient showing ideational apraxia who were applied Cognitive Therapeutic Exercise as a cognitive rehabilitation. [Cases] A cerebral hemorrhage patient (9 months from the onset) were 80 year-old man and showed a ideational apraxia caused by left subcortical hemorrhage. Main symptoms were a significant decreased spontaneity and sensory aphasia without paralysis. MRI images revealed extensive hemorrhage from the left parietal to the occipital lobe. Physical therapy started 2 days after hospitalization. Rehabilitation was introduced because he could not accept instructions of therapists, or imitate their activities. For conversion of sensory information, “visual left/right interspace matching” was firstly performed as a challenge. At the beginning, the approach did not work well, but he gradually learned to do it. The training advanced to “object identification by means of touch”. Four months has passed since the initiation of training, he has improved to the level where he can understand instruction of therapists and imitate their simple activities. [Discussion] Since the cerebral hemorrhage was ,limb-kinetic apraxia, ideomotor apraxia, and ideational apraxia are all expected to occur. The symptom of the patient was judged as the category of ideational apraxia. Generally, rehabilitation for apraxia is entirely-focused only on indentification of goods or repetition of operational activities, symptoms rarely improve. Recently we have considered apraxia as a disorder of information conversion among heterogeneous senses and advocated cognitive rehabilitation. The performed challenges might promote improvement in conversion of sensory information in our case. In the process of training, disorder of control function was considered to be improved by encouraging cognitive process and kinetic process and then the favorable activities were obtained. Therefore, this must be important for future approaches to apraxia.

Acute stroke: treatment concepts     Poster Session I
Date: Thursday, 26 May 2005   Time: 7:30- 8:30 -  Room: Padiglione(Pavilion)
Chair:  

01
Descriptive Analysis of tPA use for Stroke in the Registry of the Canadian Stroke Network
J. Nadeau    S. Shi    J. Fang    M. Kapral    F. Silver    M. Hill                            
 

University of Toronto

CANADA

Background: Thrombolytic therapy with recombinant tissue plasminogen activator (tPA) has been shown to be cost-effective and safe. Thrombolysis for stroke with tPA is now a standard of care in North America. However, it is only used on a small percentage of patients. Methods: The Registry of the Canadian Stroke Network was a consent-based stroke registry comprising 21 hospital sites across Canada. Using the thrombolysis data in phase 1 and 2 of the Registry, we sought to give a descriptive analysis of tPA use and its outcomes. Results: A total of 4107 patients were diagnosed with ischemic stroke in phase 1 and 2 of the Registry, of which 8.9% were treated with tPA. The method of tPA treatment was 85.8% IV, 9.0% IA and 5.2% IV/IA. Patients had a median onset-to-treatment time of 167 minutes [IQR 140-188]. Approximately a quarter (25.1%) of eligible candidates (time from onset <150 minutes) were treated with tPA. In-hospital mortality was 11.6%. Canadian Neurological Scale score and glucose level were predictive of mortality. The symptomatic hemorrhage rate (phase 2 only) was 4.3%. Mortality at 6-month follow-up was a further 8.5%. The mean Stroke Impact Scale-16 score at 6 months was 73.2, indicating above average patient physical function. Conclusions: Stroke is an increasingly treatable illness, and with the advent of integrated "stroke teams" in Canada, stroke care and thrombolysis use is improving. Phase 1 and 2 data from the Registry closely describes the state of thrombolysis in Canada. Further study on thrombolysis is necessary for Canada to continue improving stroke care.

Epidemiology of stroke     Poster Session III
Date: Saturday, 28 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

04
Secondary prevention and undertreatment in 16,901 cerebrovascular patients worldwide: Data from the REACH Registry
J. Roether    P.G.Steg    D.L.Bhatt    M. Alberts    A. Hirsch    C.-S.Liau    J.-L.Mas    E.M.Ohman    P.W.F.Wilson    S. Uchiyama
For the REACH Registry Investigators

Universitat-Klinikum Hamburg Eppendorf

GERMANY

Patients with cerebrovascular disease (CVD, defined as stroke/TIA), are likely to have ³1 risk factors (RF) and be at risk for future atherothrombotic events. The prevalence of risk factors and manifestations of atherothrombosis, therapeutic management and achievement of therapeutic goals were assessed through a worldwide registry of vascular disease. Baseline results are presented for CVD patients. Method: The REACH Registry is an international prospective observational registry that has recruited ñ62,800 outpatients in 43 countries. Recruited subjects were all considered at risk of atherothrombosis either because of multiple risk factors (³3 risk factors) or because of documented CVD, coronary artery disease (CAD) or peripheral arterial disease (PAD). Baseline characteristics, use of medication and adherence to guidelines were analyzed. Result: 16,901 patients with stroke (71%) or TIA (51%) were included. Almost half of these patients (48%) had a history of vascular disease in other areas: CAD (38%) and/or PAD (19%). CVD patients had evidence of atherothrombosis in 1 (52%), 2 (38%) or 3 (9%) locations. The use of various medications in CVD patients compared to multiple risk factor patients was as follows: antiplatelet agents 82% vs 57%, oral anticoagulation 18% vs 6%, lipid-lowering agents 64% vs 82%, antihypertensives 89% vs 93%, (all pá0.001). The success of achieving therapeutic goals is shown below. Conclusion: Patients with CVD in the REACH Registry had high rates of concomitant vascular disease in other locations. Therapeutic goals set by international guidelines, e.g. blood pressure and dyslipidemia, are not achieved in many CVD patients worldwide, despite the use of antihypertensives and statins. Secondary prevention with antiplatelelet agents is common.

 
http://www.esc-archive.eu/bologna05/b_graphic/t_1047.htm

Recovery and rehabilitation Oral Session 1A    
Date: Thursday, 26 May 2005   Time: 17:25 - 17:35 -  Room: Sala Azzura
Chair: P. Langhorne, UK and M. Brainin, Austria

08
NEUROMUSCULAR MICROSTIMULATION FOR SHOULDER SUBLUXATION IN PERSONS WITH STROKE
S. Bagg    J. Creasy    F. Richmond    G. Loeb                                          
 

Queen's University / Dept of Physical Medicine and Rehabilitation

CANADA

Background & Purpose: Glenohumeral subluxation is a common complication of stroke which can be painful and impede functional recovery. This is a preliminary report on a prospective randomized controlled trial that examines the effectiveness of a new technique to treat this problem with intramuscular stimulation. Methods: BIONsTM are individually addressable single channel, electrical stimulators that can be injected into muscle through a 12 guage needle. They receive power and command signals from an externally worn radio-frequency transmission coil. Twelve patients with a flaccid upper extremity (3 - 12 weeks post onset) have been accrued to date. The supraspinatus and middle deltoid muscles are stimulated 3 times daily (15 to 30 minute sessions) for 6 weeks. Control patients receive conventional physical therapies for 6 weeks, and are offered BIONTM therapy if subluxation persists. Results: Patients receiving BIONTM therapy have found the stimulation device to be easy to use and quite comfortable. The implanted BIONsTM have stable thresholds (1-10 mA at 200 us pulse width). Patients receiving intramuscular stimulation experience at least 50 % reduction of glenohumeral subluxation (quantified on X-ray), and a more modest increase in muscle thickness (measured with ultrasound). Muscle strength and fatigue resistance also was noted to increase over the stimulation period. Figure 1 shows the results observed in subject 1. Discussion: BIONsTM appear to offer a low-risk, reliable and cost effective technology for delivering therapeutic electrical stimulation that can be self-administered by the patient. Shoulder subluxation can be prevented or reversed by TES with these devices. We plan to recruit a total of 30 patients in order to complete this study.

http://www.esc-archive.eu/bologna05/b_graphic/g_1048.htm
 

Interesting cases     Poster Session I
Date: Thursday, 26 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

06
Reversible hypertensive encephalopathy mimicking brainstem glioma
C.M.Pleizier    M.C.Visser                                                        
 

VU Medical Centre

THE NETHERLANDS

A 45-year old man without a relevant past medical history was admitted to an ophthalmologist because of progressive loss of vision since about six months. Fundoscopy showed retinopathy and bilateral papillary edema. Because of the suspicion of raised intracranial pressure an MRI-scan of the head was performed, showing different signal intensity in the brainstem without hydrocephalus; no gadolinium-enhanced lesions could be detected. (Figure) The patient was admitted to our hospital for further analysis of this space-occupying lesion. Apart from severe headache and progressive loss of vision he reported nausea and vomiting, especially in the morning. On examination we saw a lean man who look ashen without neurological symptoms. Blood pressure 220/115 mm Hg. Assessment by an ophthalmologist revealed bilateral papillary edema, peripapillary bleeding and exsudate, resembling malignant hypertension and hypertensive retinopathy grade four. Further investigation showed anemia and severe renal failure. These findings and the specific characteristics on MRI (T2 weighted images showing diffuse hyperintensity, mostly in posterior areas indicating vasogenic edema) we concluded to hypertensive encephalopathy of the brainstem. After treatment of hypertension a dramatic improvement of headache and nausea appeared. MRI-examination of the brain about one month after treatment, showed almost no abnormalities. Diffusion weighted images and spectroscopy were normal. Reversible brainstem hypertensive encephalopathy was diagnosed. His renal failure remained, unfortunately. This case illustrates that hypertensive encephalopathy may mimick brainstem glioma and that the lesions are reversible after treatment.

http://www.esc-archive.eu/bologna05/b_graphic/g_1049.htm
 

Risk factors of stroke Oral Session 1A    
Date: Friday, 27 May 2005   Time: 11:30 - 11:40 -  Room: Sala Maggiore
Chair: H. Mattle, Switzerland and J. Lodder, The Netherlands

04
Early risk of recurrent stroke after TIA or minor stroke is highly predictable at presentation
M. Giles    Z. Mehta    P. Rothwell                                                 
 

Stroke Prevention Research Unit, Radcliffe Infirmary, Oxford University

UNITED KINGDOM

Background: Risk of stroke is high in the first days and weeks after TIA or minor stroke. Recent research shows that patients with carotid stenosis or ischaemic lesion(s) on DWI have a high early risk, but there are few data on the predictive value of simple clinical characteristics prior to investigation. Initial identification of very high or very low risk individuals would be invaluable for triage. Understanding which clinical characteristics are strongly associated with early recurrence would also be valuable in informing public education campaigns. Methods: We studied early (7,30 & 90 days) risk of stroke after TIA or minor stroke (NIH score ≤3) in a population based study of all individuals presenting over 2 years. Results: Complete follow-up of all 354 patients (165 minor strokes & 189 TIAs) identified 61 recurrent strokes at 90 days. Predictors of stroke were highly consistent at 7, 30 and 90 days, and so results are presented for 90-day risk. Patients with motor weakness (HR=5.2; 95%CI=1.9-14.5, p=0.002) and patients with speech (dysarthria or dysphasia) disturbance without weakness (HR=2.8; 0.83-9.2, p=0.09) tended to be at higher risk than patients with neither. Early risk increased with initial blood pressure. For example, DBP≥90mmHg was associated with a doubling in risk (HR=2.1, 1.2-3.7, p=0.017). No prior antiplatelet therapy was also significantly associated with increased risk (HR=1.85, 1.1-3.2, p=0.023). Stratification of patients by the number of these risk factors present identified major heterogeneity of risk (p=0.0003), ranging from 0% in those with no risk factors to 36% in those with three or more. Conclusion: Early risk of recurrent stroke is highly predictable at presentation, with implications for both triage and public education.

Risk factors of stroke Oral Session 1A    
Date: Friday, 27 May 2005   Time: 11:20 - 11:30 -  Room: Sala Maggiore
Chair: H. Mattle, Switzerland and J. Lodder, The Netherlands

03
“Aspirin failure” is associated with a low early risk of recurrent stroke after TIA or minor stroke
M. Giles    Z. Mehta    P. Rothwell                                                 
 

Stroke Prevention Research Unit, Radcliffe Infirmary, Oxford University

UNITED KINGDOM

Background: Occurrence of stroke or TIA in patients already receiving aspirin is often defined as “aspirin failure”. Some guidelines recommend addition of a second antiplatelet agent in this situation. However, the clinical correlates of “aspirin failure” are uncertain, particularly the prognosis. We aimed to determine the early risk of recurrent stroke following TIA or minor stroke in patients with and without prior aspirin treatment in a population based study. Methods: All patients with TIA and minor stroke presenting over 2 years were studied. Follow up was complete and all recurrent strokes within 90 days were recorded. Baseline clinical data, including medication before and after the event and vascular risk factors, were collected. Patients on warfarin were excluded. Results: Of 331 patients studied, 190 were on no prior antiplatelet agent, 141 were on aspirin (6 with another antiplatelet agent and 2 were on non-aspirin antiplatelet therapy alone). 58 had recurrent strokes within 90 days. Antiplatelet therapy (usually aspirin alone) was initiated at first assessment in all patients on no prior aspirin. However, although patients on prior antiplatelet therapy were older (mean age 77 vs 71, p<0.001) and more likely to have a history of hypertension, diabetes, MI, angina, previous TIA or stroke, or vascular intervention (all p<0.05), their risk of recurrent stroke was lower than those not on prior antiplatelet therapy: aspirin alone (HR= 0.51; 95%CI=0.29-0.90, p=0.016); any prior antiplatelet therapy (HR= 0.48; 0.27-0.86, p=0.01). Subsequent changes in antiplatelet treatment did not explain this effect. Conclusion: Rather than being a high-risk group, “aspirin failures” have a relatively a low risk of recurrent stroke.

Experimental studies Oral Session 1B    
Date: Thursday, 26 May 2005   Time: 17:05 - 17:15 -  Room: Sala Topazio
Chair: P. Wester, Sweden and V. Skvortsova, Russian Federation

18
Hemodynamic Evaluation of Embolic Trajectory in an Arterial Bifurcation: Implications for Embolic Stroke
D. Bushi    Y. Grad    S. Einav    B. Nishri    O. Yodfat    D. Tanne                            
 

Dept. of Biomedical Eng. Tel Aviv University, Ramat Aviv Tel Aviv, Israel

ISRAEL

Background and purpose: Despite the importance of embolism as a major cause of brain infarction, little is known about the hemodynamic factors that govern the path emboli tend to follow. Our aim was to study the hemodynamic parameters that govern the distribution of embolic particles in an arterial bifurcation. Methods: In-vitro experiments were conducted using suspensions of sphere shaped particles (0.6, 1.6 and 3.2 mm) in water-glycerin mixture, using steady and pulsatile laminar flow regimes in a Y-shaped bifurcation model [identical branching angles (theta1=theta2=45o) with one outlet diameter wider then the other (D1=6mm, D2=4mm); Reynolds number 500]. Results: The experimental results under steady flow with naturally buoyant particles, using six Q1/Q2 ratios and the three sizes of particles and shown in the Figure. Further experiments under pulsatile flow and assessing the effect of particle buoyancy revealed that the tendency of high particle to branch diameter ratios to preferentially enter the wide bifurcation branch further increases under these conditions. Conclusion: The particle to branch diameter ratio affect the distribution of particles in a bifurcation, beyond the flow rate ratios between the two branches. The tendency to preferentially enter the wide bifurcation branch increases for high particle to branch diameter ratios, and this tendency is augmented under pulsatile flow conditions and by the density ratio between particles and fluid. These findings have important implications for understanding the hemodynamic mechanism underlying embolic stroke.

http://www.esc-archive.eu/bologna05/b_graphic/g_1054.htm
 

Epidemiology of stroke Oral Session 1A    
Date: Thursday, 26 May 2005   Time: 11:20 - 11:30 -  Room: Europauditorium
Chair: B. Pieschowski-Jozwiak, Poland and P. Rothwell, UK

03
The Incidence of Stroke in the U.S. is Not Changing Over Time: A Population-Based Study
D. Kleindorfer    B. Kissela    J. Khoury    D. Woo    M. Flaherty    K. Alwell    R. Miller    J. Szaflarski    R. Shukla    J.P.Broderick
 

University of Cincinnati College of Medicine

USA

Introduction: Stroke incidence in the U.S. remained stable in the 1980s, while rates in other populations such as Oxfordshire, England declined. In the 1990s, several advances were made in stroke prevention and treatment, but it is not known if trends in stroke incidence changed accordingly. We present the first data regarding temporal trends in stroke incidence and stroke subtypes between 1993/94 and 1999, within a population of 1.3 million with a significant proportion of African Americans (AA). Methods: Hospitalized cases of stroke were ascertained at all local hospitals by screening ICD-9 codes in 7/93-6/94, and in 1/99-12/99, as well as prospective screening of ED admission logs, review of coroner's cases, and review of all outpatient hospital clinics and public health clinics. A sampling scheme was used in physician’s offices and nursing homes. All potential cases were confirmed by physician review. Strokes of all ages were included. Incidence rates were adjusted to the 2000 U.S. population. Results: There were a total of 1972 first-ever strokes in 1993/94, and 2028 in 1999. The incidence of first-ever hospitalized stroke, ischemic/hemorrhagic stroke, and subtypes of ischemic stroke remained constant. AAs had a higher incidence of all stroke, ischemic stroke, and ICH in both study periods (data not shown). Addition of strokes in the out-of-hospital settings increased the incidence of all first-ever stroke slightly in 1999 (197 in ’99 vs 186 in ’93, p = .03), although this could be due to improvements in ascertainment methodology. Discussion: The incidence of stroke has improved little within our population in the 1990’s, and the proportion of subtypes is also stable. Continued monitoring of trends is necessary to see if improved prevention will be realized in future time periods.

 
http://www.esc-archive.eu/bologna05/b_graphic/t_1055.htm

Cerebral haemorrhage and SAH     Poster Session II
Date: Friday, 27 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

06
Neuroendocrine changes after acute, spontaneous, supratentorial intracerebral hemorrhage
B. Goetz    T. Bertsch    C. Wolpert    M.G.Hennerici    S. Schwarz                                   
 

Universitätsklinikum Mannheim,University of Heidelberg

GERMANY

Background: Unlike in stroke and brain trauma, neuroendocrine changes after acute supratentorial intracerebral hemorrhage have not been systematically investigated yet. Methods: We prospectively studied 15 patients (8 women, 7 men, mean age 68 years, median NIH-SS 10) with intracerebral hemorrhage throughout the first 5 days. On day 1, 3 and 5, we analysed the 24h urine concentrations of catecholamines. Adrenocorticotropic hormone (ACTH) and cortisol levels were analysed at 8:00, 16:00 and 24:00. Continuous Holter-ECG and blood pressure monitoring were performed. Results: Compared to patients with an NIH-SS<10, in patients with an NIS-SS10, initial cortisol (39,3+/-22,1pg/mmol vs. 15,7+/-6,7pg/mmol; p<0,01) and ACTH (144,7+/-266,8pg/mmol vs. 9,3+/-9,4pg/mmol; p<0,05) levels were elevated. In general, adrenalin, noradrenaline and dopamine production was not markedly elevated throughout day 5 despite massively raised blood pressure. In two patients who died during the study period, noradrenaline and adrenalin were highly elevated. The development of severe cardiac arrhythmias in five patients was not consistently associated with high catecholamine levels. Patients with a good outcome at 90 days (modified Rankin Scale [mRS] 0-3) had lower initial cortisol levels (17,7+/-8,4pg/mmol) than those with a poor outcome (mRS 4-6; cortisol 40,4+/-23,7pg/mmol; p<0,05) Conclusions: Patients with NIH-SS-scores 10 have markedly elevated cortisol and ACTH levels. Elevated cortisol levels at presentation are associated with poor outcome (mRS 4-6). Although blood pressure was mostly massively raised, catecholamine production was not remarkably elevated, possibly indicating that factors other than circulating catecholamines may contribute to usually present sympathetic activation.

Brain imaging     Poster Session I
Date: Thursday, 26 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

04
Perfusion Weighted MRI is Valuable in Identifying Persisting Vessel Occlusion in Acute PICA Ischemia
T. Thiel    K. Szabo    R. Kern    M. Griebe    C.-H.Lie    M.G.Hennerici    A. Gass                     
 

Universitätsklinikum Mannheim,University of Heidelberg

GERMANY

Background: In acute stroke of the internal carotid artery territory, the extent of affected tissue can be further characterized by demonstration of vessel occlusion on MR angiography (MRA) and the extent of hypoperfusion on perfusion weighted MRI (PWI). The ability of MRA to demonstrate posterior circulation branches of the vertebral and basilar artery is limited. This study analyzes the combined value of DWI, PWI and MRA in acute PICA stroke. Methods: From a prospectively collected stroke center data registry with over 3000 stroke patients, 275 were diagnosed with acute brainstem or cerebellar infarction. Of those 49 patients had acute PICA stroke, 16 of whom received an extensive MRI stroke workup including DWI and PWI, and extra- and transcranial color-coded duplex sonography (TCCD). Results: PWI showed hypoperfusion in the PICA territory in 9/16 demonstrating persistent vessel pathology. Six of these patients showed lack of flow signal of vertebral artery (VA) and/or PICA on MRA, whereas on corresponding TCCD, only 4 patients had a clearly pathologic flow signal in the VA. From the 7/16 patients with normal PWI, 2 cases had lack of signal of VA and/or PICA on MRA. Conclusions: In patients with acute PICA stroke, the persistent vessel pathology of the VA or PICA cannot be reliably demonstrated with MRA and ultrasound. The high contrast visualisation with a combination of DWI and PWI helps to achieve the diagnosis of persistent vessel pathology and identifies the extent of the abnormalities and tissue at risk for infarction.

http://www.esc-archive.eu/bologna05/b_graphic/g_1058.htm
 

Brain Imaging – new developments Oral Session 1A    
Date: Friday, 27 May 2005   Time: 12:20 - 12:30 -  Room: Sala Bianca (B)
Chair: J. M. Wardlaw, UK and J. Röther, Germany

09
Assessment Of Slow Diffusion Component Changes In Acute Stroke By Q-Space Analysis
K. Szabo    R. Grüner    R. Kern    M. Griebe    J. Hirsch    M. Günther    M.G.Hennerici    A. Gass              
 

Universitätsklinikum Mannheim, University of Heidelberg

GERMANY

BACKGROUND Experimental evidence suggests, that the slow diffusion component depicts intracllular/intraaxonal water molecules rather than the extracellular fraction. We developed and implemented advanced DWI MR sequences and analysis strategies for slow diffusion component analysis along the lines suggested by Assaf and Cohen. High b-value DWI and q-space analysis were performed in acute stroke patients to study the sensitivity and imaging information when compared to conventional DWI and other contrasts. METHODS Standardized MRI was performed in 20 patients with acute stroke and 6 normal controls on a 1.5 T Siemens SONATA system including DW (6 directions, 14 b-values range: b=0-8182s/mm2). Q-space analysis derived quantitative maps of the probability-for-zero-displacement were analysed. RESULTS All acute stroke lesions were detected on high b-value DWI. However exact lesion delineation differed depending on anatomical lesion location. While cortical ischemic lesions were demonstrated well because of the low probability for zero displacement in normal cortical tissue, in acute subcortical lesions delineation was difficult due to similar signal from areas of densely packed white matter with a physiologically high slow diffusion contribution. Both acute lesions and healthy white matter showed prominent slow diffusion components. CONCLUSIONS High b-value q-space analysis of diffusion MRI allows a more thorough visualisation of diffusion characteristics adding quantitative information on the slow diffusion component. It maps out white matter with very high contrast and is sensitive to acute stroke lesions not yet visible on T2-weighted MRI. However lesion to background discrimination in white matter areas is more difficult than at b=1000s/mm2.

http://www.esc-archive.eu/bologna05/b_graphic/g_1059.htm
 

Risk factors of stroke     Poster Session III
Date: Saturday, 28 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

38
Doubts on the immediate relation between non-valvular atrial fibrillation and acute stroke
E. Grips    O. Sedlaczek    M. Kablau    M. Stroick    C.-E.Dempfle    M.G.Hennerici                            
 

Department of Neurology, Universitätsklinikum Mannheim, University of Heidelberg

GERMANY

The benefit of primary and secondary prevention in non-valvular atrial fibrillation (NVAF) is well established. However, immediate causal circumstances of embolic events remain obscure. Based on medical history and simple lab testing we re-evaluated potentially active cardio-embolic stroke mechanisms confined to NVAF. Methods: Patients admitted to our stroke unit were prospectively examined for valid data on medical history and NVAF as the conclusive source of the acute embolic event as evidenced by standard stroke work up including MRI. Standardised history taking focused on duration and therapy of NVAF and circumstances related to the stroke. Results: Of 107 patients in 37 the acute stroke was preceding the diagnosis of NVAF. Of the 70 patients with established NVAF, in 17 the diagnosis was pre-documented yet the exact onset unknown; in 20 patients onset of NVAF was <5, in 23 between 5 and 10 and in 10 cases >10 up to 23 years (ns). Initial blood testing for inflammation showed elevated levels of CRP in all patients (known: 13.3 +/- 21.4 vs. newly diagnosed NVAF: 10.0 +/- 15.0mg/l, ns.) with only 24 % of all patients presenting with clinical infections. Age at the time of stroke was different in the known and newly diagnosed patients: 78.4 +/- 7.8 vs. 74.1 +/- 11.3 years, p<0.03 as well as in males (73.8 +/- 9.8 years) and females (79.6 +/- 8.1 years, p< 0.001). Conclusion: The even distribution of latencies of NVAF and first ever clinical stroke confirms the lack of a causal immediate relationship - rather in all patients sub-clinical signs of infection could be evidenced. This favours the view of NVAF as a persistent condition of only mild enhanced risk of stroke with potential increase only if activated through further mediators such as inflammatory processes.

Experimental studies Oral Session 1B    
Date: Thursday, 26 May 2005   Time: 16:45 - 16:55 -  Room: Sala Topazio
Chair: P. Wester, Sweden and V. Skvortsova, Russian Federation

16
Hyperbaric oxygen (HBO) reduces postischemic blood-brain barrier damage and edema.
R. Veltkamp    D.A.Siebing    L. Sun    S. Heiland    K. Bieber    H. Marti    S. Schwab    M. Schwaninger              
 

University Heidelberg

GERMANY

Background: We examined the potential of HBO to reduce postischemic blood-brain barrier (BBB) damage and edema. Methods: Rats and mice underwent occlusion of the middle cerebral artery (MCAO) for 2h. Forty min after filament introduction, animals were placed in a HBO chamber and breathed either 100% O2 at 3.0 atmospheres absolute (ata; HBO group) or at 1.0 ata (control) for 1 h. In rats, stroke MRI was performed 15 min after MCAO, and after 15 min, 3, 6, 24, 72 h of reperfusion. Volume of T1w postcontrast enhancement and an interhemispheric quotient of mean gray values in T1w images were calculated for estimation of BBB damage. In ischemic mice, BBB permeability for Na-Fluorescein was measured fluorometrically after 24 h of reperfusion. Results: Increased BBB permeability on postcontrast T1w images had a biphasic pattern. HBO reduced volume of BBB damage on postcontrast T1w images (p<0.05 for 6, 24, 72 h). The quotient of mean gray values was significantly lower in HBO treated animals at all time points: at 15 min of reperfusion: 1.73±0.11 (control) vs. 1.57±0.07 (HBO); at 3 h: 1.74±0.07 vs. 1.60±0.06; at 6 h: 1.77±0.07 vs. 1.62±0.06; at 24 h: 1.79± 0.10 vs. 1.60±0.05; at 72 h: 1.81±0.10 vs. 1.62±0.07. In mice, mean interhemispheric quotient (ischemic/nonischemic) of relative fluorescence units was significantly larger in control (1.56±0.50) than in HBO (1.11±0.16) treated mice. HBO also significantly reduced brain edema as estimated on T2w images at 72 h after MCAO and on histological sections.

Brain imaging     Poster Session I
Date: Thursday, 26 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

03
Prognostic value of early CT -signs in ESTAT: Haemorrhagic Transformation and Functional Outcome
O. Sedlaczek    A. Schwartz    M.G.Hennerici                                                 
for the ESTAT Investigators

Department of Neurology, Universitätsklinikum Mannheim, University of Heidelberg

GERMANY

Stroke treatment depends on adequate CT evaluation including signs of early ischemia. In contrast to the Stroke Treatment with Ancrod Trial patients with early stroke signs should have been excluded in the European Stroke Treatment with Ancrod Trial (ESTAT). To examine this approach the rate of haemorrhagic transformation (HT) and functional outcome assessed by Barthel-index (BI) on day 7 from the largest ever acute stroke trial were reviewed. Methods: Exclusion criteria for ESTAT included bleeding on screening-CT, Scandinavian stroke score >40, severe hypertension, fibrinogen <100 mg/dL and stroke onset later than 6 hours. Patients were randomized to placebo (n=618) or Ancrod (n=604) to reach and maintain a fibrinogen level of 40-70mg/dL. Early CT-signs of ischemia such as hypodensity, effacement of sulci, swelling of the affected hemisphere were reviewed by the blinded central imaging panel. Control CTs performed at day 7 were re-reviewed to compare functional outcome and late infarcts with the presence of early CT-signs. Results: Among the 1222 patients 1190 screening and 1113 follow-up CTs were evaluated. Signs of evolving infarcts were detected in 228 patients (19.1%): 119 in the placebo and 109 in the verum group. In the follow-up CTs HT was found in 236 patients, 61 of whom had presented with early infarct signs: in patients treated with Ancrod HT was more frequent (33% vs. 21%, p<0.05). BI was worse in patients with signs of evolving infarcts (41 vs. 53 p<0.01). HT tended to correlate with a worse BI in both the placebo (22, p<0.08) and the verum groups (29, p<0.06). Conclusion: Early CT-signs are associated with both a significantly worse functional outcome and increased risk for HT in the spontaneous course of acute stroke and when treated with ancrod.

Imaging: new methods and applications Oral Session 1A    
Date: Thursday, 26 May 2005   Time: 12:40 - 12:50 -  Room: Sala Bianca
Chair: M. Forsting, Germany and F. Fazekas, Austria

11
Feasibility of contrast-enhanced transcranial pulse-inversion harmonic ultrasound for the assessment of supratentorial intracerebral hemorrhage
R. Kern    M. Kablau    C. Sick    S. Thiel    M.G.Hennerici    S. Meairs                            
 

Universitätsklinikum Mannheim; University of Heidelberg

GERMANY

Introduction: Transcranial pulse-inversion contrast harmonic ultrasound imaging (PICHI) can be used to assess normal and abnormal brain perfusion. However, this method has not yet been evaluated in patients with spontaneous intracerebral hemorrhage (ICH). Methods: We investigated twelve patients (6 w., 6 m., mean age 71 y.) with supratentorial ICH, as diagnosed by cranial CT. Another five patients were excluded due to insufficient insonation conditions. PICHI was performed bilaterally from the temporal approach both before and after intravenous administration of the echocontrast agent SonoVue®. If ICH was detected with ultrasound, lesion volume was calculated by measuring its maximum extent in 3 axes perpendicular to each other. Volume data were then compared to lesion size on CT. Results: ICH were located subcortical in 9 patients, 3 patients had lobar ICH (1 frontal, 2 parietal). Using ultrasound, ICH could be visualized in 8/9 patients with subcortical, but only in 1/3 with lobar extension. Typical sonographic findings were (1) presence of an echogenic mass without contrast agent, and (2) focal absence of contrast agent arrival within the lesion after contrast agent injection. Mean lesion size measured with PICHI correlated well to lesion size on CT (32 vs. 34.4 cm3). Conclusions: The combined application of PICHI with and without echocontrast agents allows discrimination of ICH from surrounding tissue due to focal absence of contrast arrival in the primary echogenic lesion. This enables superior estimation of lesion size, which may be of importance for bedside monitoring ICH patients. However, the detection of ICH with ultrasound can be difficult or impossible in patients with insufficient insonation conditions, or with lobar type of ICH.

http://www.esc-archive.eu/bologna05/b_graphic/g_1066.htm
 

Brain Imaging – new developments Oral Session 1A    
Date: Friday, 27 May 2005   Time: 12:00 - 12:10 -  Room: Sala Bianca (B)
Chair: J. M. Wardlaw, UK and J. Röther, Germany

07
Assessment of Cerebral Perfusion in Acute Stroke by Arterial Spin Labeling MRI
R. Kern    M. Guenther    K. Szabo    M. Griebe    M.G.Hennerici    A. Gass                            
 

Universitätsklinikum Mannheim; University of Heidelberg

GERMANY

Introduction: Arterial spin labeling (ASL) MRI provides information on cerebral perfusion by consecutive readout of labeled blood captured in arteries or in the microvasculature. In this study, we used ASL with a novel single-shot 3D readout technique to evaluate the extent and severity of hemodynamic alteration in acute stroke patients. Methods: Thirty-six patients (14 w., 22 m., mean age 59 y.) with acute hemispheric stroke (31 MCA, 5 PCA) were examined according to a standard MRI protocol including time-of-flight angiography (TOF-MRA), diffusion-weighted imaging (DWI) and dynamic susceptibility perfusion MRI analyzed on time-to peak maps (TTP). Micro-vascular perfusion (CBF) and bolus arrival time (BAT) were measured in ASL time series using multiple TI ranging from 250 ms to 2500 ms, and were analyzed in regions of interest. In addition, a non contrast-enhanced dynamic angiography (DynAngio) providing time-resolved images of the inflow of blood into the arterial tree was obtained. Results: CBF and micro-vascular BAT measurements using ASL were feasible in 34/36 patients. In these, hypoperfused areas could all be located with ASL corresponding to TTP. The extent of the perfusion deficit was smaller compared to the area visible on TTP in 8 patients. Vessel obstruction was confirmed in 33/36 cases with DynAngio compared to TOF-MRA. Conclusions: ASL was feasible in acute stroke patients demonstrating areas of reduced CBF, matching findings of DWI and TTP. Although a quantitative technique, areas of very low CBF are difficult for ASL (and TTP). The combination of ASL perfusion and DynAngio is promising since it allows assessment of hemodynamic impairment in both macro- and micro-vascular compartments without contrast agents.

http://www.esc-archive.eu/bologna05/b_graphic/g_1067.htm
 

Experimental studies     Poster Session II
Date: Friday, 27 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

09
Direct detection of oxidative stress after rtPA thrombolysis in severe stroke. Preliminary study.
G. Szilágyi    Zs. May    Gy. Pánczél    I. Gubucz    J. Skopál    Z. Nagy                            
 

National Stroke Center, Department of Vascular Neurology, Semmelweis University

HUNGARY

Introduction: During the last decade the most prevalent revascularisation technique in acute stroke was thrombolysis with IV rt-PA. During the reperfusion, great amount of reactive oxygen species (ROS) generate, indicating the cell damage. The change of the total antioxidant capacity is reflect to the ROS-load. In this study we investigate the ROS production during and after the rt-PA thrombolysis in MCA territorial ischemic stroke. Methods: We collected venous blood samples repeatedly up to 7 days after the lysis from 16 patients, who had been thrombolysed in our Institute. The blood samples were centrifuged and the total antioxidant capacity was measured using the carbamid peroxid method. In each cases, blood flow was measured by transcranial doppler US (TCD) in the MCA of the affected side before lysis and 2 days later on. Final infarct size was determined on CT scan at the 7th day. Results: Patients were selected into 3 groups on the basis of lesion size and the successful recanalisation: group A: normal flow by TCD and small ischaemic lesion on 7th day (n=6), group B: normal flow and territorial lesion (n=5) and group C: no reperfusion detected by TCD and large territorial lesion (n=5). The antioxidant capacity of blood samples were the following: the take off values at the 0 hr were 33,1-37,7% in all groups (Fig.). Antioxidant capacities in the 3 groups were different. The maximal decrease in the antioxidant capacity was 5,8% in the group A, 14,4% in the group B and 14.9% in the group C. The antioxidant capacity has been restored in all groups about at the sixth days. Discussion: The ischaemic brain injury resulted in an oxidative load into the circulating blood. Our preliminary data suggest a correlation between antioxidant capacity and the size of lesion.

http://www.esc-archive.eu/bologna05/b_graphic/g_1068.htm
 

Acute stroke: complications and early outcome     Poster Session II
Date: Friday, 27 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

02
A previous therapy with antiplatelet agents is not associated with stroke severity in patients with acute ischemic stroke/TIA
S. Greisenegger    S. Tentschert    M. Weber    J. Ferrari    W. Lang    W. Lalouschek                            
 

Universitaetsklinik fuer Neurologie/Medizinische Universitaet Wien

AUSTRIA

Background: Altough the efficacy of antiplatelet agents (APA) in the secondary prevention of ischemic stroke is clear, their role concerning stroke outcome is controversial. Methods: Within a multi-centre cross-sectional study, nested in a cohort we analyzed the relation between a prior therapy with APA and stroke severity in 1643 patients with acute ischemic stroke or TIA. Clinical severity of the vascular event was evaluated by the National Institutes of Health Stroke Scale on day 1 (NIHSS1) and after 1 week (NIHSS2). By means of variance analysis we analyzed a possible association of APA with stroke severity and interactions between APA and covariates that influenced stroke severity. Results: 475 patients (29%) received aspirin prior to the cerebrovascular event, 51 patients (3%) ticlopidine or clopidogrel and 26 patients (1,6%) aspirin combined with extended release dipyridamole. 1091 patients (66%) did not take any antiaggregant medication. A prior therapy with APA was neither associated with NIHSS1 and NIHSS2 nor with the difference of NIHSS1-NIHSS2. In a dual variance analysis we did not find significant interactions between APA and other parameters (gender, hypertension, diabetes, smoking, previous stroke/TIA, coronary heart disease, thrombolysis, etiology, atrial fibrillation, median leucozyte count, median serum glucose) that influenced stroke severity at the defined time-points. Also inclusion of age as interfering variable into the model did not change the results significantly. Discussion: Our results do not indicate that a prior therapy with APA is associated with a better outcome in acute ischemic cerebrovascular events. There were no interactions found with other parameters that influenced stroke severity.

Acute stroke: complications and early outcome Oral Session 1B    
Date: Thursday, 26 May 2005   Time: 17:05 - 17:15 -  Room: Sala Italia
Chair: M. Brown , UK and M. Kaste, Finland

18
The Effect of Dysphagia and Subsequent PEG feeding on Short term outcome following Acute Stroke
R. Kumar    J. Monaghan    D. McDowell    A. Sharma                                          
 

University Hospital Aintree

UNITED KINGDOM

Background: Previous studies have suggested that patients requiring percutaneous endoscopic gastrostomy(PEG) insertion due to persistent dysphagia following stroke have a worse outcome. However, these studies have not taken into account the fact that patients requiring PEG insertion were likely to have suffered more severe strokes. Methods: The present study looked at all stroke patients admitted to a University hospital over a two year period. The patients were split into three groups for the purpose of analysis - 1. Never Dysphagic (n = 577), 2. Transient Dysphagics (n = 316) and 3. Persistent Dysphagics requiring PEG insertion (n = 62). Results: Cox survival analysis revealed that the significant predictors of survival were - Age(hazard ratio[HR], 1.05; 95% CI 1.02-1.07), Incontinence (HR 2.91;95% CI 1.53-5.52), Previous Stroke (HR 1.83; 95% CI 1.19-2.82) and Dysphagia (HR 2.75; 95% CI 1.47-5.16). Both transient and persistent Dysphagia were significant predictors of short term mortality. Kaplan Meier survival curves showed significantly lesser survival for both the dysphagic grous compared to the non dysphagic group (p<0.01). PEG insertion by itself did not predict survival(HR O.70; 95% CI 0.41-1.22). Significantly more persistent dysphagic patients(42%) were discharged to new institutional care than transient dyshagic(25%) and never dysphagic(8%) patients. Discussion: The present study suggests that persistent and even transient dysphagia are independent predictors of short term mortality and and discharge to institutional care after stroke. Although PEG feeding is predictive of discharge to institutional care, it does not account for higher mortality once the recognised predictors of poor outcome like stroke type and severity are taken into account.

Genetic disorders Oral Session 1A    
Date: Saturday, 28 May 2005   Time: 9:40 - 9:50 -  Room: Sala Maggiore
Chair: H. Markus, UK and H. Chabriat, France

08
Lack of association between IVS6+79G/A polymorphism of proteinZ and stroke.
V. Obach    X. Muñoz    M. Revilla    P. Garcia de Frutos    N. Sala    A. Chamorro                            
 

Hospital Clinic.

SPAIN

Background: Protein Z (PZ) is a vitamin K–dependent plasma protein synthesized by the liver, whose structure is similar to coagulation factors VII, IX, and X and protein C. PZ down-regulates coagulation by enhancing the inhibition of FXa although its physiological role is still uncertain. Association between plasma levels of PZ and stroke has been reported with divergent findings. In a recent study, the allele A of the IVS6+79G/A polymorphism of PZ has been associated with ischemic stroke in young German patients. The A allele was also associated with low PZ plasma levels in control subjects. We investigated whether the prevalence of this single nucleotide polymorphism (SNP) differed between patients with ischemic or hemorrhagic stroke and healthy controls. Methods: The genotype for the PZ IVS6+79G/A SNP (alleles A and G) was evaluated in 554 patients with ischemic (n=393) or hemorrhagic (n=161) stroke, and in 127 controls using PCR amplification and Hpa I digestion. Results: PZ IVS6+79G/A genotype distribution is shown in the table. No significant differences were found between stroke and control subjects even when stroke subtypes were analyzed. Furthermore, this polymorphism was not associated with any of the vascular risk factors. Conclusions: PZ IVS6+79G/A SNP is not associated with stroke in patient older than 50 years of age in Spanish population.

 
http://www.esc-archive.eu/bologna05/b_graphic/t_1073.htm

Cerebral haemorrhage and SAH Oral Session 1A    
Date: Saturday, 28 May 2005   Time: 8:50 - 9:00 -  Room: Sala Topazio
Chair: S. Davis, Australia and L. Caplan, USA

03
Impact of intraventricular haemorrhage on outcomes after recombinant activated factor VII treatment in patients with acute intracerebral haemorrhage
T. Steiner    D. Schneider    S. Mayer    N. Brun    K. Begtrup    J. Broderick    S. Davis    M. Diringer    B. Skolnick       
for the Novoseven ICH Trial Investigators

University Of Heidelberg, Hedelberg, Germany

GERMANY

Background: Intracerebral haemorrhage (ICH) is the deadliest form of stroke and no treatments are currently available. Studies of recombinant activated factor VII (rFVIIa) have shown efficacy in the treatment of patients with ICH. Objective: Analyses of the effect of intraventricular haemorrhage (IVH) on neurological outcomes in patients with ICH receiving rFVIIa treatment and the effect of therapy on the growth of IVH. Methods: Patients with spontaneous ICH confirmed by CT scan within 3 hours of symptom onset were randomised to placebo or rFVIIa (40, 80, or 160 microg/kg) within 1 hour of the baseline scan. Neurological endpoints included the Glasgow Coma Scale, National Institute of Health Stroke Scale, and modified Rankin scale (mRS). Results: 399 patients (placebo, N=96; 40 microg/kg, N=108; 80 microg/kg, N=92; 160 microg/kg, N=103) were included in the analysis. IVH was present in 154 (39%) patients. mRS scores at Day 90 improved in rFVIIa-treated patients both with and without IVH. Overall outcomes for patients with IVH, however, were consistently worse in patients with IVH compared to patients without IVH, regardless of treatment. Change in total haemorrhage volume from baseline to 24 hours in patients with IVH was 31% in placebo-treated patients compared to 16%, 14%, and 13% in patients receiving 40, 80, and 160 microg/kg rFVIIa (p=0.0156). Conclusions: Patients with IVH had consistently worse outcomes at 90 days compared to patients without IVH. rFVIIa reduced haemorrhage growth in patients with IVH to the same extent as patients without IVH at baseline.

Management and economics     Poster Session II
Date: Friday, 27 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

03
Use of antiplatelet therapy after ischemic stroke in routine clinical care. The German Stroke Register Study Group
P.U.Heuschmann    K. Berger    B. Misselwitz    M. Biegler    K. Kuehn-Walz    P. Hermanek    A. Ferbert    K. Lowitzsch    J. Rother    P.L.Kolominsky-Rabas
German Stroke Registers Study Group (ADSR)

Institute of Epidemiology and Social Medicine

GERMANY

Background and Purposes: Antiplatelet therapy after ischemic stroke or TIA is considered as one of the most effective strategies for secondary stroke prevention and should be initiated in eligible patients already during hospitalisation. We investigated frequency and predictors of use of any antiplatelet therapy for secondary stroke prevention within a pooled analysis of German stroke registers. Methods: Patients after ischemic stroke or TIA admitted to hospitals cooperating within the German Stroke Register Study Group (ADSR) between 2000 and 2002 were analyzed. The ADSR is a network of regional stroke registers, combining data from 225 academic and community hospitals throughout Germany. Multivariate logistic regression was used to investigate the impact of demographics, comorbidities and neurological deficits on frequency of any antiplatelet therapy. Results: A total of 76.493 patients after ischemic stroke or TIA were registered within the ADSR network between 2000 and 2002. Mean age was 67.9 years, 54.7% were men. 87.7% of eligible patients received any antiplatelet therapy during hospitalisation or at discharge. Antiplatelets were used more frequently in older patients (p<0.0001) and in patients with less severe strokes (p<0.0001). Patients without comorbidities (p<0.0001) and patients discharged to a nursing home (p<0.0001) or to a rehabilitation unit (p<0.0001) were less likely to receive antiplatelets. An independent increase in use of antiplatelets was observed in the three year study period (p<0.001). Conclusions: Although antiplatelet therapy for secondary stroke prevention was frequently used in Germany an independent increase in its use could be documented during the three years of observation.

Acute stroke: treatment concepts Oral Session 1A    
Date: Friday, 27 May 2005   Time: 12:40 - 12:50 -  Room: Sala Italia
Chair: D. Toni, Italy and P. Trouillas, France

11
DEVELOPING BENCHMARKS FOR STROKE REHABILITATION IN ONTARIO, CANADA
S. Bagg    W. Hopman                                                        
 

Queen's University / Dept. of Physical Medicine & Rehabilitation

CANADA

Background: Stroke rehabilitation is critical in enabling survivors to maximize their functional abilities and independence. Organized stroke rehabilitation has been found to reduce mortality and long term institutionalization for individuals recovering from severe stroke. Given that rehabilitation resources are limited, it is essential to identify patients who will benefit most from this intervention. For groups of patients with common measurable baseline characteristics, it may be possible to use benchmarking comparisons to gain further insight into factors associated with optimal recovery. This study used the Functional Indepence Measure - Functional Related Group (FIM TM - FRG) classification system to develop benchmarks for persons recovering from stroke in a Canadian rehabilitaiton facility.. Methods: 561 patients admitted to the rehab unit with their first stroke between January 1994 & Dec 1999 were stratified (by stroke severity and age) into the 9 categories of the FIM-FRG system. Length of stay, FIM gain, discharge FIM and discharge location were calculated. Results: Mean wait time to rehab admission was 29.7 days. Mean length of stay was 49 days. Mean admission and discharge FIM scores were 78.1 and 103.1 respectively. 17 % of all patients were discharged to nursing homes. 60 % of FRG 2 (patients over 75 years old with severe motor and cognitive impairments) required nursing home care. Greatest FIM gains were noted in patients with severe physical disability (figure 1) except FRG 2, which confirms the negative influece of severe cognitive impairment on functional recovery. Discussion: Utilizing these benchmarks can assist in the process of developing realistic rehab goals. National standards may ensure more equal access to appropriate services.

http://www.esc-archive.eu/bologna05/b_graphic/g_1076.htm
 

Experimental studies     Poster Session II
Date: Friday, 27 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

23
Vinpocetin enantiomer's effect on gene expression of human brain capillary endothelial cells in hypoxia-reoxygenation condition
L. Dénes    P. László    G. Bugovics    K. Tihanyi    I. Spisák    Z. Bori    G. Szilágyi    Z. Nagy              
 

Dept.Vascular Neurology, Semmelweis University, Hung. Natl. Inst. Psychiatry & Neurology

HUNGARY

Background. Hypoxia induced changes of gene expression and their pharmacological modification in human brain capillary endothelial cells (HBEC) still not documented. In the present study we used oligonucleotid arrays to asses 18000 transcripts of HBEC treated with vinpocetin (G.Richter) and their isomers as well a derivative (RGH1088) as drug candidates after 2-2hrs hypoxia and reoxygenation. Methods. HBEC were isolated and cultured (Nagy et al. 1995) and hypoxic insult had been created with Argon method for 2 hrs and the cells strait treated with agents tested either 10µM or 0,1 µM of concentration for 2hrs. The microarrays were scanned with GSI Luminomix scanner. Results. Hypoxia/reoxygenation induced a roboust upregulation of 146 transcripts (at >3 times level) and a modest increase of 106 transcripts were detected. Besides the well documented genetic changes by hypoxia, ion channel genes and plasticity genes expressions have been increased significantly. After by hypoxia repressed gene expressions were highly increased by vinpocetin treatment: caspase 2, apoptosis related cystein protease, lung type-I cell membrane-associated potein (hT1a-2), glutamate decarboxylase (GAD1). and a moderate increase was detected in plasticity genes: synaptophysine, synaptobrevine, synaptotagmine, synaptosomal-associated protein. All the tested molecules have a neuroprotective effect. CisV (at dose of 10-7M ) has the strongest (p<0,01) inductive effect compared to others (p<0,05).Vinpocetin and cisV reUsing hypoxia to study the effects of compounds have a neuroprotection. After hypoxia cisV (at 10-7M ) has the strongest (p<0,01) inductive effect compared to other molecules (p<0,05). Vinpocetin, cisV normalized the hypoxia induced pp38 and the opposite enhanced effects by transV and RGH1088. Conclusion We described the changes on transcripts induced by hypoxia in human brain endothelial cells and their modification due to Vinpocetin and enantiomers (Supported by Richter 282/2004)

Interesting cases     Poster Session I
Date: Thursday, 26 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

21
FIBROMUSCULAR DYSPLASIA OF THE BASILAR ARTERY, ARTERIAL DISSECTION AND SILENT OCCLUSION
L. Benavente    S. Calleja    J.M. M.Fernandez    J. Garcia-Garcia    J. Salas-Puig    C.H.Lahoz                            
 

Hospital Universitario Central de Asturias

SPAIN

BACKGROUND: Historically, basilar artery (BA) occlusive disease has been considered to convey a poor prognosis and a high mortality rate. In contrast, two recently published prospective studies have shown a mortality rate around 2.3-4%. BA is most commonly affected by atherosclerosis, but may also be affected by embolisms, dissections, aneurysms, and other conditions like fibromuscular dysplasia (FMD). We present a patient with a basilar FMD which evolved into an arterial dissection followed by an asymptomatic occlusion of the BA. CASE REPORT: A 47-year-old male was admitted after suffering a transient episode of ataxic gait and dysarthria. Transcranial Doppler showed a stenotic flow in BA with distal embolic signals. MR angiography demonstrated an isolated FMD of the BA causing a >50% stenosis. No parenchimal lesions were shown, and oral anticoagulation was initiated. Nine months later, despite the patient being asymptomatic, a control MR angiography showed a dissection which evolved into a complete occlusion of the BA. Its distal portion was filled via a reverse flow from both posterior communicating arteries. Anticoagulation was stopped. DISCUSSION: FMD of the BA is a rare and usually asymptomatic disease. Several complications have been associated with FMD, including dissections, mural aneurysms and thrombus formation, but the usual clinical presentation is a stenosis-related ischemic stroke. Intracranial artery dissections may be further complicated by subarachnoid hemorrhage. Many authors have recommended anticoagulant therapy for FMD, though it may increase the risk of bleeding in case of dissection. BA occlusion, as this case shows, not always conveys a poor prognosis. This is determined, at least in part, by the presence of good collateral circulation.

Vascular imaging Oral Session 1A    
Date: Thursday, 26 May 2005   Time: 17:35 - 17:45 -  Room: Sala Bianca
Chair: R. Baumgartner, Switzerland and J. Norris, UK

09
Visualization of Intracranial Cortical Vascular Territories by Regional Arterial Spin Labeling MRI
M. Guenther    R. Kern    K. Szabo    M. Griebe    M.G.Hennerici    A. Gass                            
 

Department of Neurology, Universitaetsklinikum Mannheim, University of Heidelberg

GERMANY

Introduction: Visualization of the different intracranial vascular territories is usually obtained by using angiographic techniques. However, due to the difficulties to visualize the distal vascular bed with any angiographic technique it is difficult to infer the cortical borders of vascular territories. Arterial spin labeling (rASL) MRI provides information on cortical cerebral perfusion and by using a regional arterial spin labeling (rASL) approach there is potential to visualize cortical perfusion of the anterior and posterior circulation separately, which we explored in this study. Methods: Ten young healthy normal controls were examined according to a standard MRI protocol including time-of-flight angiography (TOF-MRA), anatomical T1- and T2-weighted MRI. In addition, rASL time series with multiple inflow times ranging from 250 ms to 2500 ms were acquired and were analyzed in regions of interest for micro-vascular perfusion (CBF) and bolus arrival time (BAT). An improved readout module was used (single-shot 3D-GRASE) which reduced the total measurement time for this rASL time series to 6 min on a clinical 1.5T MR scanner. Color coding was used for visualization of differentially labeled blood volumes. Results: Colored rCBF maps demonstrated the cortical vascular perfusion pattern providing a sharp delineation of MCA and PCA territories in all subjects (see Fig.1). Conclusions: Improved visualization of the cortical borders of vascular territories is feasible with rASL. Complete information on temporal behavior and vascular origin of local perfusion can be gained. This is a first step to provide better anatomic information on cortical perfusion.

http://www.esc-archive.eu/bologna05/b_graphic/g_1079.htm
 

Experimental studies     Poster Session II
Date: Friday, 27 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

26
A new neuroprotective drug candidate prevents cell injury induced by hypoxia/reoxygenation (by Benzofuran-propilaminopentan/BPAP)
L. Dénes    Z. Bori    G. Szilágyi    A. Gál    Z. Nagy                                   
 

Vascular Neurology of Semmelweis University, Natl. Inst. Psychiatry &Neurology

HUNGARY

Background BPAP/benzofuran derivative (Fujimoto Pharm.Corp.) is a new agent, has neuroprotective effect even at low dosis (10-14–10-12M, femto-pico mol). Deprenyl is a member the group of endogen enhancer substances (Knoll et all, 2002). The antiapoptotic effect of Deprenyl has been documented in our laboratory. In this study we investigated the effect of both agents. Methods On PC12 cell cultures and human brain capillary endothelial (HBE) cells we tested the cytoprotective effect and the possible mechanism of this drug candidate. The effects of compounds were registered between broad scale of dosis (1fM-10 M). Mitochondrial membrane potential and oxygen free radicals were determined with JC1 and CeCl staining by confocal microscope. Alamar Blue assay was designed to measure the proliferation of cells (0, 2, 4, 21 hours). Results After hypoxia/reoxygenation BPAP and Deprenyl not just maintained but significantly upregulated the metabolism of the cells compared to the control of both cell types. Hypoxia induced reduction prevented by both agents at high doses p<0,001 (10-4M, 10-5M) and at very low doses p<0,05 (10-11M, 10-12M). BPAP induced mitochondrial membrane integrity visualized and calculated by JC1 staining in confocal microscope. Deprenyl and BPAP supress a decline of m that suggested a cytoprotectiv mechanism reflected to the events of mitochondrium. Conclusion Both compounds were effective in neuroprotection at very low and high concentrations. The two phenomena still not full elucidated different mechanisms.

Acute stroke: early management and stroke units     Poster Session II
Date: Friday, 27 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

06
Process and Outcome Quality is superior in Stroke Units compared to General Wards
A. Haass    P. Kostopoulos    K.H.Grotemeyer    A.J.Grau    W. v. Arnim                                   
 

University of Saarland, Germany

GERMANY

Background: Quality control is a valuable tool to investigate and improve process and outcome quality. Stroke patients are treated in general wards or in specialized stroke units (SU). We compared process and outcome quality in these two settings to identify strengths and weaknesses of either system. Methods: In the states of Rhineland-Palatinate and Saarland (4 and 1 million inhabitants, respectively) data of acute stroke patients were collected prospectively in a stroke database. In 2001- 2002, 15 Neurology departments including 8 SU and 19 departments of Internal Medicine including 3 SU participated with a total of 19,000 patients (about 66% of all expected strokes in the two states). In the study presented here, we assessed process quality based on the use of diagnostic procedures (CCT, vessel and heart ultrasound), clinical competence (RINGELSTEIN and TOAST classification) and duration of hospital stay. Outcome quality was measured by the treatment outcome (Barthel-Index). We used a scale of 4x10 points to weight the parameters. Results: In departments with SU process and outcome quality were significantly better than in departments without SU. Specifically, the use of diagnostic procedures and clinical competence were 39 % and 33 % better, respectively. The duration of hospital stay was 41 % shorter and the treatment outcome of patients admitted to the hospital within 6h and with disturbances of the macrocirculation was 24 % better. Overall, departments with SU had a 32 % better process and outcome quality than departments without SU. Discussion: This quality control study of a large number of patients and participating hospitals shows that process and outcome quality are superior in departments with SU compared to departments without SU.

Brain Imaging – new developments     Poster Session III
Date: Saturday, 28 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

04
Correlation of Dynamic MR-Angiography with Flow Velocity on TCD Sonography in Normal Controls and Patients with Internal Carotid Artery Stenosis
M. Griebe    K. Szabo    M. Guenther    R. Kern    O. Sedlaczek    M.G.Hennerici    A. Gass                     
 

Universitaetsklinikum Mannheim, University of Heidelberg, Mannheim

GERMANY

BACKGROUND: Arterial spin labelling (ASL) techniques have been shown to be useful in the assessment of cerebral haemodynamics. Possible applications include non-contrast agent perfusion measurements and a dynamic angiography (DynAngio). Using a Look-Locker approach, volumes are captured at different time intervals after labelling, displaying the inflow of the labelled blood bolus in the large vessels at several time points. We compared this technique to transcranial Doppler (TCD) blood velocity measurement in normal controls and patients with internal carotid artery (ICA) stenoses. METHODS: 12 middle cerebral arteries (MCAs) of 6 normal controls and 6 MCAs of 3 patients with unilateral ACI stenosis were examined. For the DynAngio sequence, 36 phases of inflow with a temporal resolution of 36ms and an in-plane resolution of 0.52mm were acquired on a clinical 1.5T scanner. Blood flow velocity was calculated from the covered distance of the vessel signal and the difference of the inflow time between the phases. These were compared to the mean blood flow velocities as detected by TCD. RESULTS: In all subjects, the DynAngio technique showed the inflow of the labelled blood bolus with acceptable quality (see Fig.1, displaying 9 out of 36 phases). TCD measures and DynAngio calculated MCA velocities correlated for both controls and ICA patients (r=0.89, p<0.0001; see Fig.2, red squares depicting MCAs at side of ICA stenosis). DISCUSSION: The DynAngio technique is useful in assessing MCA haemodynamics, providing additional functional information like blood flow velocity. The calculated values are within the range of standard ultrasound measurements. Thus, it combines the advantages of MRI techniques and quantitative TCD, linking the results of the different methods nicely.

Imaging: new methods and applications Oral Session 1A    
Date: Thursday, 26 May 2005   Time: 11:50 - 12:00 -  Room: Sala Bianca
Chair: M. Forsting, Germany and F. Fazekas, Austria

06
Bio-effects of transcranial Doppler visualised by serial MR-arterial spin labeling
O. Sedlaczek    M. Gunther    H. Bäzner    A. Gass    M.G.Hennerici    M. Daffertshofer                            
 

Department of Neurology, Universitätsklinikum Mannheim, University of Heidelberg

GERMANY

Bio-effects of ultrasound have been suggested to enhance thrombolysis in acute stroke patients. However, reported techniques applying 2MHz conventional transcranial Doppler (TCD) frequency/amplitude characteristics have not been evidenced any significant sonothrombolytic effect in vivo. Arterial spin labeling (ASL) is an emerging MR-technique in non contrast agent dependent cerebral perfusion measurements. The aim of our pilot study was the detection of perfusion-alterations associated to 2-MHz -TCD-monitoring in stable stroke patients. Methods: 5 women with recent symptoms of cerebral ischemia were investigated during regular stroke-work-up including HITS monitoring (focused beam depth: 52/57 mm) for 40 minutes followed by MR-ASL-measurements (TR=3000ms, TI1=1800ms,FOV 190 mm, 64x64 matrix, 10 acq., 24 slices). Specific in our pilot-study was the unilateral application of insonation and the immediate MR investigation thereafter. Post-processing: SPM 99 with motion-correction, and spatial smoothing (6mm). Only images after slice-selective inversion were chosen (not the untagged images, serving as negative control). The images acquired immediately after the end of TCD-monitoring were analysed against those acquired after 20minutes and 24 hours using boxcar standard procedures of SPM99. Significant threshold was set at p<0.01. Results: In 4 / 5 patients a significantly unilaterally increased perfusion was seen. TCD-dependent altered perfusion was mainly detected along the cortical layer adjacent to the insonation but extended (3/5) up to the basal ganglia. Comment: Our data provide evidence that ultrasound applied at frequencies permitting transcranial application exerts bio-effects detectable by means of serial ASL-perfusion measurements reflecting hyperperfusion.

Interesting cases     Poster Session I
Date: Thursday, 26 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

15
Central respiratory dysfunction following vertebral artery dissection
O. Lanczik    K. Szabo    O. Lecei    S. Thiel    M.G.Hennerici                                   
 

Universitätsklinikum Mannheim, University of Heidelberg

GERMANY

Background: Vertebral artery dissection (VAD) is a major cause of cerebral ischemia in young patients. A central respiratory failure complicating VAD, even weeks after initial symptoms, is an exceptional finding recently observed. Patient: A 42-year old carpenter was admitted two hours after onset of nausea and unsteadiness of gait. He reported suffering from neck pain since one week after having painted the ceiling in a typical posture. Neurological examination revealed incomplete Wallenberg´s syndrome with spontaneous nystagmus to the right, Horner´s syndrome on the left and dissociative sensory loss for the left face as well as for the contralateral limbs. Initial MRI demonstrated a typical ischemic lesion in the left dorsolateral medulla oblongata and a vessel wall haematoma in the left VA. One hour later, he developed hemiplegia and hemihypaesthesia on the left and an acute central respiratory failure with a breathing rate of 4/minute, requiring intubation. Follow up MRI verified new ischemic lesions extending from the left dorsolateral medulla oblongata into the anterolateral part (anterior spinal artery territory) as well as into the posterior quarter (posterior spinal artery territory) of the left spinal cord. Within 1 week he achieved spontaneous respiration and improvement of the hemiplegia/hemihypaesthesia. Conclusion: This is the first case of combined brainstem and spinal cord stroke in succession due to VA dissection causing central respiratory failure as a severe complication by affecting nuclei responsible for the control of spontaneous respiration which are part of the lateral segment of the reticular formation. Therapeutic implications are tremendous since increased awareness and subsequent early mechanical ventilation is potentially life saving.

http://www.eurostroke.org/b_graphic/g_11087.htm
 

Acute stroke: complications and early outcome Oral Session 1A    
Date: Thursday, 26 May 2005   Time: 12:40 - 12:50 -  Room: Sala Italia
Chair: N. Bornstein, Israel and F. Aichner, Austria

11
Prognostic significance of Interleukin- 6 in acute brain ischemia
Y. Schwammenthal    R. Tsabari    T. Reshef    R. Schwartz    D. Orion,    J. Chapman    Y.A.Mekori    D. Tanne              
 

Sheba Medical Center, Tel Hashomer, Israel

ISRAEL

Background -Inflammation plays a critical role in the pathogenesis of atherothrombosis. The purpose of this study was to assess the association of plasma levels of inflammatory markers and severity and outcome of acute brain ischemia. Methods-Patients presenting with acute brain ischemia were assessed systematically by serial NIH stroke scale (NIHSS) scores and by the modified Rankin Scale (mRS). Patients with evidence of infectious or inflammatory disease were excluded. Frozen plasma samples collected within 36 hours of symptom onset were evaluated with conventional, highly-sensitive ELISA kits for levels of interleukin-6 (IL-6), interleukin-10 (IL-10), intercellular adhesion molecule-1 (ICAM-1) and CD40 ligand (CD40L). Results-Seventy three patients were included (36% women, mean age 63 years). IL-6 levels were associated with increasing age, body temperature and WBC counts. IL-6 concentration at baseline was positively correlated with stroke severity [mean±SD of 2.7±2.4 pg\ml for NIHSS 0-5 (n=44), 6.1±5.9 for NIHSS 6-15 (n=15) and 9.4±6.4 for NIHSS>15 (n=13; p<0.0001)]. IL-6 was associated with functional outcome at discharge [mean±SD 2.9±3.6 for mRS 0 (n=11), 3.3±3.4 for mRS 1-2 (n=39), 4.5±3.2 for mRS 3-4 (n=11) and 11.2±6.8 for mRS 5 or death (n=11; p<0.0001)]. No correlation between concentrations of soluble IL-6, IL-10, ICAM-1 and CD40L could be detected, nor any association between any of the other inflammatory markers tested and stroke severity or outcome. In logistic regression analyses, IL-6 levels were associated with stroke severity (NIHSS > 10; adjusted OR= 1.34, p=0.001) and with poor functional outcome (mRS > 2; OR =1.19; p=0.007; per one pg\ml change). Conclusions–Increased plasma levels of the inflammatory marker IL 6 are associated with worse neurological deficits and poorer functional outcome in patients with acute brain ischemia. Plasma markers of inflammation may assist in risk stratification of patients with acute ischemic stroke.

New clinical trials Oral Session 1A    
Date: Saturday, 28 May 2005   Time: 11:27 - 11:39 -  Room: Europauditorium
Chair: S. Davis, Australia and C. Warlow, UK

02
Effects of Repinotan in Patients with Acute Ischemic Stroke: Phase IIb modified Randomized Exposure Controlled Trial (mRECT)
P. Teal    P. Lyden    M. Kaste    S. Davis    W. Hacke    M. Fierus                            
 

University of British Columbia, Vancouver, British Columbia, Canada

CANADA

Background: Repinotan hydrochloride (BAY x3702) is a serotonin (5-HT)1A receptor full agonist with demonstrated efficacy in animal models of transient and permanent middle cerebral artery occlusion (Bode-Greuel et al, 1990; Horvath et al, 1997; Horvath and Augstein, 1997). Methods: A double-blind, placebo-controlled, parallel group, multi-center study to evaluate the efficacy, safety, tolerability, and pharmacokinetic/pharmacodynamic effects of a targeted exposure of intravenous repinotan. A total of 681 patients with an ischemic thromboembolic hemispheric stroke were randomized 1:1, to placebo or repinotan. Study drug infusion had to be initiated within 4.5 hours from the onset of ischemic symptoms. Study drug was infused at a rate of 0.104 mg/h for 2 hours, followed by 0.052 mg/h for 70 hours. At 6 and 12 hours, repinotan plasma levels were determined in a blinded fashion, and the dose reduced if appropriate to achieve the target concentration range. Recombinant tissue plasminogen activator (rt-PA) was permitted as standard medication. The primary intention-to-treat outcome was a Barthel Index (BI) score > 85 at 3 months post-treatment. Results: The study was well balanced for baseline variables. There were 127 (37.1%) patients with successful response in the repinotan treated group vs 143 (42.4%) in the placebo group. This difference was not statistically significant (Cochran-Mantel-Haenszel p-value=0.149). The death rate was similar in both treatment groups: 71 (20.7%) on repinotan and 67 (19.9%) on placebo. Of the repinotan treated patients, 149 (43.4%) experienced at least one serious adverse event, in comparison to 136 (40.4%) of the placebo group. Conclusion: Repinotan failed to show clinical benefit in patients with acute ischemic stroke.

Vascular imaging Oral Session 1A    
Date: Thursday, 26 May 2005   Time: 17:05 - 17:15 -  Room: Sala Bianca
Chair: R. Baumgartner, Switzerland and J. Norris, UK

06
The “carotid ring sign” on angio-CT is accurate to differentiates acute from chronic carotid occlusion
P. Michel    S. Binaghi    M. Gonzalez-Delgado    D.C.Bezerra    M.D.Reichhart    R. Meuli    J. Bogousslavsky                     
 

Centre Hospitalier Universitaire Vaudois

SWITZERLAND

Background: Currently, there is no reliable method to differentiate acute from chronic carotid occlusion, although this may be helpful in treatment selection in patients with cerebral or retinal ischemia. Methods: Between 2001 and 2004, we examined 72 patients with 89 spontaneousely occluded extracranial internal carotid arteries with CT-angiography (CTA). All occlusions were confirmed by another method (DS-angiography, Doppler or MRA). They were classified as “probably acute” (imaging within 1 week of presumed occlusion) and “probably chronic” (imaging > 4 weeks), based on circumstantial clinical and radiological evidence. A neuroradiologist and neurologist blinded to clinical information determined the site of occlusion on axial sections of the CTA. They also looked for a) a hypodensity within the carotid artery (thrombus), b) contrast within the carotid wall (vasa vasorum), c) the size of the occluded carotid, and d) the “carotid ring-sign” (defined as presence of a) or b) or both. Results: Of the 90 carotids, 24 were excluded because of insufficient circumstantial evidence to determine timing of occlusion, 4 because of insufficient image quality, and 3 because of subacute timing of occlusion. Among the remaining 45 acute and 13 chronic occlusions, interrater agreement for the site of proximal occlusion was kappa = 0.88, for distal occlusion 0.45, and for the “carotid ring-sign” was 0.90. Sensitivity was 92%, specificity 88%, and accuracy 89% of the “carotid ring sign” for acute carotid occlusion. Conclusions: The “carotid ring-sign” accurately differentiates acute from chronic carotid occlusion. This information may be helpful in studying ischaemic symptoms and selecting treatment strategies in patients with carotid occlusions.

Brain Imaging – new developments     Poster Session III
Date: Saturday, 28 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

01
Perfusion-CT during transient global amnesia
P. Michel    M.D.Reichhart    P. Browaeys    R. Meuli    J. Bogousslavsky                                   
 

Centre Hospitalier Universitaire Vaudois, Neurology Service

SWITZERLAND

Objective: Medial temporal lobe abnormalities are occasionally observed on diffusion-weighted (DWI) MRI and on functional imaging in patients with transient global amnesia (TGA). We used perfusion CT (PCT) to study these patients during the actue phase. Methods: Over a 3 year period, patients satisfying clinical criteria for transient global amnesia underwent acute perfusion CT while anterograde amnesia was still present. Patients with additional clinical features suggesting TIA or stroke were excluded. In 10 of the patients, a DWI-MRI was obtained within 14 days after the TGA. Results: Over a 3 year period, 21 patients with TGA underwent acute PCT with a mean latency of 5.2 hours (range: 45 minutes to 9 hours) from symptom onset. 3 patients were excluded because PCT slices did not include the medial temporal lobes (n=2) or because of movement artefacts (n=1). Among the 18 remaining patients, 17 PCTs were normal. One 42 year old man showed hypoperfusion in bilateral lenticulostriate territories as well as in the left insular and fronto-opercular cortex. On acute perfusion-weighted MRI one hour later, left insular cortex hypoperfusion was still present, and DWI was normal. Among the 10 patients with DWI-MRI within 14 days, one 62 year old lady with a normal PCT showed small bilateral anterior corpus callosum lesions. No cause for the ischaemia was identified except hypertension. Conclusion: Most patients with TGA do not have abnormalities on acute perfusion-CT. One patient with bilateral basal ganglia and left opercular and insular hypoperfusion but no stroke was identified. Another patient with a normal PCT was found to have an acute small corpus callosum stroke on subacute DWI-MRI.

Behavior and mood Oral Session 1A    
Date: Friday, 27 May 2005   Time: 16:45 - 16:55 -  Room: SalaAzzura (1st floor)
Chair: J. Ferro, Portugal and L.Pantoni, Italy

04
Detecting Depression in Long-term Stroke Survivors
K. Chatterjee    D. Barer    S. Fall                                                 
 

Department of Stroke Medicine, Queen Elizabeth Hospital, Gateshead

UNITED KINGDOM

Background Despite the high incidence of post-stroke depression and its adverse effects on functional recovery, little is known about the performance of potential postal screening tools. We aimed to assess the feasibility of postal screening and to compare the diagnostic efficiency of 3 instruments, the General Health Questionnaire (GHQ-12), Dartmouth COOP chart or Yale depression question. Methods A questionnaire including GHQ-12, COOP and Yale was sent to patients living at home at least 9 months after a stroke. Respondents were then interviewed at home by a trained investigator, blind to postal questionnaire results, using standard DSM-IV criteria to diagnose major depression. Appropriate screening thresholds were defined for the GHQ (2-3) and COOP (1-2) by a prespecified rule. Scale performance was compared using diagnostic odds ratios (DOR) and areas under the receiver operating curves (AUROC). Results The response rate to first mailing was 62%, increased to 87% in a subset by repeated mail and telephone contact. All responses contained usable information on all 3 scales. 176 patients were interviewed and 42(24%) found to have major depression. All three scales had adequate sensitivity but only moderate specificity at the screening thresholds. The GHQ had the highest DOR and a significantly better AUROC than theYale (p<0.05) (Table). All scales performed less well in more disabled patients. The GHQ performed better than COOP in those with left hemisphere damage. Combining two or more scales did not significantly improve diagnostic accuracy. Discussion A single postal assessment may be adequate to rule out depression in stroke survivors. Single questions such as the Yale, though simple, might not be as useful as a multi-item scale such as GHQ-12.

 
http://www.esc-archive.eu/bologna05/b_graphic/t_11094.htm

Imaging: new methods and applications Oral Session 1A    
Date: Thursday, 26 May 2005   Time: 12:10 - 12:20 -  Room: Sala Bianca
Chair: M. Forsting, Germany and F. Fazekas, Austria

08
Subcortical Vascular Encephalopathy - Assessment Of Slow Diffusion Component Changes By Q-Space Analysis
A. Gass    K. Szabo    R. Grüner    R. Kern    M. Griebe    J. Hirsch    M. Günther    M.G.Hennerici              
 

Department of Neurology, Universitätsklinikum Mannheim, University of Heidelberg

GERMANY

BACKGROUND Experimental evidence suggests, that the slow diffusion component depicts intracllular/intraaxonal water molecules rather than the extracellular fraction. We developed and implemented advanced DWI MR sequences and analysis strategies for slow diffusion component analysis along the lines suggested by Assaf and Cohen. High b-value DWI and q-space analysis were performed in patients with chronic subcortical, mainly white matter lesions to study the sensitivity and imaging information when compared to conventional DWI and other contrasts. METHODS Standardized MRI was performed in 15 patients with typical vascular subcortical white matter and basal ganglia lesions and 6 normal controls were investigated on a 1.5 T Siemens SONATA system including DW (6 directions, 14 b-values range: b=0-8182s/mm2). Q-space analysis derived quantiative maps of the probability-for-zero-displacement were analysed. RESULTS Low probability for zero displacement maps provide very high contrast of white matter vs. gray matter structures showing prominent slow diffusion components in normal white matter. Chronic subcortical tissue change show loss of the slow diffusion component even in areas of questionable signal abnormality and in normal appearing white matter on T2-weighted images highlighting the high sensitivity of high b-value diffusion weighted MRI. CONCLUSIONS High b-value q-space analysis of diffusion MRI allows a more thorough visualisation of diffusion characteristics adding in quantitative on the slow diffusion component. Chronic subcortical tissue change shows loss of the low diffusion component indicating microstructural damage.

http://www.esc-archive.eu/bologna05/b_graphic/g_11095.htm
 

Vascular surgery and PTCA Oral Session 1A    
Date: Saturday, 28 May 2005   Time: 9:40 - 9:50 -  Room: Sala Bianca
Chair: A. Guekht, Russian Federation and D. Schneider, Germany

02
A population-based study of delays in carotid imaging and endarterectomy after TIA and stroke and the risk of otherwise preventable recurrent stroke
J. Fairhead    Z. Mehta    P. Rothwell                                                 
 

Department of Clinical Neurology, Oxford University

UNITED KINGDOM

Background: In light of evidence that benefit from carotid endarterectomy (CEA) is greatest when performed within two weeks of a presenting TIA or stroke and falls rapidly thereafter, we determined the delays to carotid imaging and CEA in Oxfordshire, UK, and the consequences for the effectiveness of stroke prevention. Methods: We identified all patients undergoing carotid imaging for ischaemic retinal or cerebral TIA or stroke in two populations: the population of Oxfordshire, UK (n=680,772) from 01/04/02 - 31/03/03; and the Oxford Vascular Study (OXVASC) sub-population (n=92,000) from 01/04/02 - 31/03/04. We determined the times from presenting event to referral, scanning and CEA (Oxfordshire population) and the risk of stroke prior to surgery in patients with ≥50% symptomatic carotid stenosis (OXVASC population). Results: Among 853 patients who had carotid imaging in Oxfordshire population, median (IQR) times from presenting event to referral, scanning and CEA were 9 (3-30), 33 (12-62) and 100 (59-137) days respectively. 85 patients were found to have 50-99% symptomatic stenosis, of whom 49 had CEA. Only 3 (6%) had surgery within two weeks of their presenting event and only 21 (43%) within 12 weeks. The risk of stroke prior to CEA in the OXVASC sub-population with ≥50% stenosis was 21% (8-34%) at two weeks and 32% (17-47%) at 12 weeks, half of which strokes were disabling or fatal. Conclusion: Delays to carotid imaging and CEA after TIA or stroke in the UK, which are similar to those reported in several other countries, are associated with very high risks of otherwise preventable early recurrent stroke.

Acute stroke: complications and early outcome     Poster Session II
Date: Friday, 27 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

29
Is Age Alone Predictive of Stroke Outcome?
H.G.M.Shetty    K. Khanna    JA.Francis                                                 
 

Regional Stroke Unit, Cardiff Royal Infirmary, Wales, UK

UNITED KINGDOM

Background The objective of this study was to investigate whether age alone is a true prognostic factor of stroke outcome. Methods This is a retrospective cohort study of 274 patients admitted to the Regional Stroke Unit, Cardiff Royal Infirmary, Wales, between March 2002 and March 2004. Data was obtained from the routinely maintained ward database. 219 patients were deemed eligible. Patients with missing data and those with a terminal illness were excluded. The patients were divided into three groups: those less than 70 years (71 patients), those 70 to 80 years (79 patients) and those greater than 80 years (69 patients). The mean age of the patients was 73.53 years. The outcome measures were i) Barthel index on discharge, ii) change in Barthel index from admission to discharge, iii) destination of discharge. Results Statistical software SPSS version 11.5 for windows was utilised for statistical analyses and graphical representations. Three cross-tabulations were undertaken and for each, a chi-squared test was performed rendering p-values for the categorical data. No significant correlation was found between age of stroke patient and discharge Barthel index (p-value = 0.110); similarly no significant correlation was discovered when age was compared to unit change in Barthel score (p-value = 0.103). Age did appear to have a small but significant prognostic influence on destination of discharge (p-value = 0.030). Discussion Age does not appear to predict adverse functional status on discharge or the degree of change in functional status during the rehabilitation period. However, age of stroke patient does appear to have a weak but significant influence on destination of discharge. This may be explained by patients’ social and environmental factors. These results support the view that patients should not be denied access to stroke rehabilitation units because of advanced age.

New clinical trials Oral Session 1A    
Date: Saturday, 28 May 2005   Time: 12:27 - 12:42 -  Room: Europauditorium
Chair: S. Davis, Australia and C. Warlow, UK

07
PreliminaryResults of SAINT-1 Trial
K.R.Lees    J. Zivin    T. Ashwood    A. Davalos    S. Davis    H.C. Diener    J. Grotta    P. Lyden    A. Shuaib    W. Wasiewski
For the SAINT-1 Study Group

Glasgow SAINT-1 Study Group

UNITED KINGDOM

Oral presentation!

Experimental studies Oral Session 1A    
Date: Thursday, 26 May 2005   Time: 12:30 - 12:40 -  Room: Sala Topazio
Chair: L. Hirt, Switzerland and S. Blecic, Belgium

10
Comparison of changes in gene and protein regulation between human and rat models of stroke: Identification of novel markers of inflammation and apoptosis
N. Mitsios    J. Krupinski    M. Slevin    M. Saka    J. Gaffney    P. Kumar    S. Kumar    M. Sullivan              
 

Manchester Metropolitan University

UNITED KINGDOM

Therapeutic trials, often using molecules isolated following analysis of stroke development in animal models, have failed to demonstrate significant improvements in recovery in man. In this study, we have used Atlas 1.2 microarrays to compare gene expression between patients suffering from large vessel ischaemic stroke, and a rat model of middle cerebral artery occlusion. Our initial results demonstrated a significant difference in the total numbers of genes affected, and the time-course of gene expression between the two. RT-PCR and Western blotting were used to confirm de-regulated expression of novel genes and proteins found in human stroke. Using immunohistochemical analysis, we have identified increased neuronal expression of high mobility group protein-1 (HMG-1), cyclin-dependent kinase-5 (CDK-5), protein activated kinase-1 (PAK-1), mixed lineage kinase-3 (MLK-3) and prion protein (PrP). Increased expression of CDK-5 and PrP also occurred in microvessels from the peri-infarcted region. In conclusion, our results demonstrate notable differences in the activation of signalling pathways potentially involved in determination of the pathophysiological development of infarct between human disease, and a conventional rat model. This work highlights the importance of analysis of human material in the search for novel therapeutic agents, which may be useful in the treatment of stroke.

Acute stroke: treatment concepts     Poster Session I
Date: Thursday, 26 May 2005   Time: 7:30- 8:30 -  Room: Padiglione(Pavilion)
Chair:  

02
Conservative medical treatment and intravenous thrombolysis in acute stroke from carotid-T occlusion
M.T.Wunderlich    E. Stolz    G. Seidel    T. Postert    G. Gahn    U. Sliwka    M. Goertler                     
for the Duplex Sonography in Acute Stroke (DIAS) Study Group

Departments of Neurology, Universities of Magdeburg, Giessen, Luebeck, Bochum, Dresden and Jena

GERMANY

Background: We aimed to analyse the course of early recanalization and corresponding functional outcome in patients with an acute occlusion of the carotid-T who were treated conservatively or underwent intravenous thrombolysis. Methods: 42 patients with an acute occlusion of the carotid-T within 6 hours were recruited from consecutive admissions to a neurological department participating in the Duplex Sonography in Acute Stroke (DIAS) study. All patients underwent a standardized admission and follow-up procedure. Colour-coded duplex sonography was performed on admission, 30 minutes after thrombolysis, and at 6 and 24 hours after onset of symptoms. Recanalization of the carotid-T was classified as complete, partial and absent. Functional outcome was rated with the modified Rankin Scale (mRS) at 3 months as favourable (mRS 0 to 2) or poor (mRS 3 to 6). Results: Within 6 hours, complete or partial recanalization occurred in 1 of 27 patients treated conservatively and in 6 of 15 thrombolysed patients. Intravenous thrombolysis predicted early recanalization also after adjustment for age, sex, cardioembolic stroke aetiology and time to treatment (adjusted odds ratio [OR], 39.7; 95% confidence interval [CI], 2.0 to 801.7; P = 0.016). An early recanalization was the only selected predictor of a favourable outcome (OR, 13.6; 95% CI, 1.0 to 179.0; P = 0.047) at regression analysis and was achieved in 3 thrombolysed patients but in none with conservative medical treatment. Discussion: In patients treated conservatively, functional outcome is poor and early recanalization rarely occurs. The latter can be achieved by intravenous thrombolysis with a rate comparable to that found at an intra-arterial approach without major intracranial bleeding complications. Early recanalization is associated with a better functional outcome.

Chronic conditions and recurrences     Poster Session III
Date: Saturday, 28 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

04
Ipsilateral Ventriculomegaly in Unilateral Carotid Stenosis
S.C.Hong    Y.B.Kim    J.Y.Ahn    K.Y.Park    P.W.Chung    S.J.Lee    C.S.Chung    K.H.Lee    B.J.Kim       
 

Hanil General Hospital

SOUTH KOREA

Background : Chronic cerebral hypoperfusion alone may produce cerebral atrophy even in the absence of apparent ischemic changes or infarcts. Method : To test this hypothesis, we studied 24 subjects with unilateral proximal carotid stenosis (right: 14, left: 10) more than 70% (NASCET method) but without infarcts on MRI in the cerebral hemisphere, and 27 age- and sex-matched controls. Cerebral atrophy was assumed if ventriculomegaly was present without a cotrical sulci effacement. The lateral ventricle volume was measred and then the laterality index (LI: left - right / left + right x 100 ) was computed (+ value represents larger left ventricle). Result : LI of patients and controls showed normal distribution (Shapiro-Wilk, p > 0.05) and their mean values were 3.56 +/- 4.59 in the control, 8.30 +/- 6.62 in the left carotid, and 1.49 +/- 7.39 in the right carotid groups. LI of control differed from that of left (p = 0.019) or right carotid group (p = 0.01). Discussion : Our results suggest a unilateral carotid stenosis can produce ipsilateral cerebral atrophy even without an apparent infarcts or ischemic changes.

Management and economics     Poster Session II
Date: Friday, 27 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

06
ISCHEMIC STROKE AND ATHEROMA. RESULTS OF THE DETECT STUDY
D. LEYS    F. WOIMANT    J. FERRIERE    C . BAUTERS    P.J.TOUBOUL    M. GUERILLOT    M.A .HERRMANN    P. PRIOLLET              
On behalf of the DETECT investigators

University of Lille. Roger Salengro Hospita.

FRANCE

Background: cerebral infarction (CI), myocardial infarction (MI), peripheral artery disease (PAD) and aortic atheroma (AA) are the main clinical manifestations of atherothrombosis. Objective: to determine the breakdown of other locations of atherothrombosis in patients with atherothrombotic CI. Method: prospective, observational, multicenter survey, conducted between February 2003 and July 2004 in patients with atherothrombotic ischemic stroke admitted in neurological departments in France. Results: 753 patients were included (men: 74%; mean age: 69.5 years). Vascular risk factors were present in 96% of them (arterial hypertension: 69%; dyslipidemia: 41%; smoking: 28%; diabetes mellitus: 26%; obesity: 11%). Previous coronary events had occurred in 26% (MI: 14%; stable angina pectoris : 11%; unstable angina: 3%; silent ischemia : 3%). Previous cerebral events had occurred in 31% (transient ischemic attacks: 18%; CI: 16%; intra-cerebral hemorrhage: 1%; undetermined: 1%). PAD was already known in 15% (5% were at stage III or IV). A search for asymptomatic locations was positive in 46% of patients (coronary: 23%; PAD: 20 %; AA: 16%). Conclusion: almost 2/3 of patients with recent atherothrombotic CI have other locations of atherothrombosis. This finding suggests that a systematic search for these other locations should be recommended.

Acute stroke: complications and early outcome Oral Session 1A    
Date: Thursday, 26 May 2005   Time: 11:10 - 11:20 -  Room: Sala Italia
Chair: N. Bornstein, Israel and F. Aichner, Austria

02
POST-THROMBOLYTIC PARENCHYMAL HEMATOMAS AND HEMORRHAGIC INFARCTS HAVE DISTINCT BIOLOGICAL SIGNIFICANCES
P. TROUILLAS    M. HANSS    L. DEREX    N. NIGHOGHOSSIAN    S. CAKMAK    M. HERMIER    M. DECHAVANNE    F. CHAPUIS              
 

Cerebrovascular Unit, Lyon, FRANCE

FRANCE

Background Little is known about the coagulation factors in patients with post-thrombolytic hemorrhagic infarcts (HI) and parenchymal hematomas (PH). Methods Consecutive patients were included in the Lyon rt-PA protocol, treated by rt-PA 0.8 mg/kg and followed up (Trouillas etal, 1996, 1998). Early bleedings (within 24 hours) were diagnosed on the ECASS anatomo-radiological basis, (PH=PH1+PH2; HI=HI1+HI2). The fibrinogen and Fibrin(ogen) Degradation Products were assessed at entry, at 2 and 24 hours after the start of thrombolysis. Thirty three clinical and 11 CT radiological variables were studied. Results One hundred fifty seven patients were studied: 11 patients had early parenchymal hematomas (7%), 31 had early hemorrhagic infarcts (19.7%) and 115 had no bleeding (73.2%). Early PH (<24H) had a significant increase of FDP at 2 hours after thrombolysis (median 60mg/L, 95% CI 10-500 vs 10 mg/L, 95% CI 10-30, p<0.04). In logistic regression, FDP at 2 hours was a powerful predictor of parenchymal hematomas : OR 2.5, CI 1.09-5.8; an increase of FDP >200 mg/L multiplicated the odd of parenchymal hematoma by 4.95 (IC 1.09-22.4). Early HI (<24H) had different predictive factors: no fibrinogenolysis parameter was involved, while clinical severity at entry and CT early symptoms were definite factors. Early PH were predictive of a bad prognosis at 3 months (p=0.001), while HI were not. Conclusion- There is a clear distinction between post-thrombolytic PH and IH (<24H). Early PH appear as both "malignant" and exclusively due to an attack of circulating fibrinogen with explosive increase of FDP at 2 hours, ie an Early Fibrinogen Degradation Coagulopathy (EFDC). Conversely, early HI are benign and not linked to fibrinogen factors, but to clinico-radiological factors potentially indicative of the deepness of ischemia. In summary, parenchymal hematomas are mainly due to a coagulopathy and hemorrhagic infarcts to an ischemic vasculopathy. This distinction is in keeping with the data of the literature, which demonstrated in the ECASS1 and ECASS2 studies that PH are linked to rt-PA while HI are not.

Acute stroke: complications and early outcome Oral Session 1A    
Date: Thursday, 26 May 2005   Time: 11:50 - 12:00 -  Room: Sala Italia
Chair: N. Bornstein, Israel and F. Aichner, Austria

06
Blood Pressure and Clinical Outcomes In Acute Ischemic Stroke from the Shanghai Stroke Trial
Q. Dong    Y. Yan    X. Han    L. Wang    Z.C.Lu                                   
 

Department of Neurology,Huashan Hospital,Fudan University

GHANA

Objective: To explore the association of systolic (SBP) and diastolic (DBP) blood pressure during acute ischemic stroke with subsequent clinical outcomes. Methods: The data including 225 patients from the Shanghai Stroke Trial (anticoagulant/control group) with confirmed acute anterior circulation ischemic stroke and fulfillment of follow-up was analyzed. A single casual SBP/DBP was recorded within 48 hours of stroke onset, before any dehydrator was administered. Potential prognostic factors were checked. Clinical outcomes were evaluated: (1) death resulting from any cause within 14 days; (2) death or dependency (BI 0~55) at >=3 months. Results: 84% (189/225) of patients had high BP during the acute phase of ischemic stroke, if the JNC-7 definition of hypertension was used. In univariate analysis, hypertension known prior to stroke was associated with high SBP (P<0.0001) and high DBP (P<0.0001); conversely, age was related to low DBP (P=0.006). The relationships between high SBP,high DBP and early death were observed in the uni- (SBP: Odds Ratio[OR] 1.027, 95%Confidence Interval[CI] 1.001~1.054,P=0.040;DBP: OR 1.044,95%CI 1.002~1.087,P=0.038) but not in the multivariate analysis. The lowest frequency of death or dependency at >=3 months occurred in patients with a SBP of 141~150mmHg. And if this level was used as a reference point, both low (OR 5.803,95%CI 1.440~23.381,P=0.013) and high (OR 7.491,95%CI 2.074~27.052,P=0.002) SBP increased the risk of poor late outcome. The multivariate regression analysis showed that this U-shaped relationship was independent. No association of DBP during acute stroke and late outcome was seen. Conclusions: High BP was common in acute ischemic stroke. The link betweenhigh BP during the acute period and poor early outcome was confirmed, but whether this was independent was unclear. DBP was not associated with late prognosis. However, both high (<=140mmHg) and low (<150mmHg) SBP were confirmed as independent late prognostic factors.

Cerebrovascular autoregulation     Poster Session I
Date: Thursday, 26 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

06
Cerebrovascular Effects of Cilostazol in Patients with Atherosclerotic Disease
S.F.Ameriso    R. Lagos    L.M.Ferreira    L. Fernandez Cisneros    L.R.La Mura                                   
 

Institute for Neurological Research-FLENI

ARGENTINA

BACKGROUND Cilostazol is a potent selective inhibitor of phosphodiesterase-3 of proved efficacy in intermittent claudication. It has antiagreggant effect and produces vasodilatation in several vascular territories. This drug has been approved in some countries for the prevention of stroke recurrence. Limited data in patients with cerebral infarcts suggest improvement in cerebral blood flow. Cerebral vasodilatation can be assessed using transcranial Doppler with CO2 challenge. The percentage increase in middle cerebral artery blood flow velocity (MCA-BFV) during hypercapnia is called cerebral vascular reserve (CVR) and indicates dilatation of distal vessels. The objective of the present study was to assess changes in CVR after oral administration of cilostazol. We intended to advance in the knowledge of the effects of the drug on the cerebral circulation. METHODS We recruited a group of patients with risk factors for atherosclerosis before they received cilostazol 100 mg twice daily for intermittent claudication. CVR was assessed by measuring bilateral MCA-BFV during normoventilation and after 3 minutes of breathing 8% CO2. One average value was obtained from each subject. CVR was measured the day before cilostazol first dose, at 1 month, and 3 to 6 months later. RESULTS We examined 9 subjects (8 males and 1 female) aged 67.6+/-8.4 years. One patient had had a minor stroke. All subjects had hypertension, 5 had diabetes, 4 were smokers, 5 had high cholesterol levels, and 4 had coronary artery disease. CVR was 54.4+/-14.4% at baseline, and increased to 64.2+/-18.6% after one month (p<0.05), and to 67.1+/-13.3% 3 to 6 months later (p<0.01). DISCUSSION Our study suggests that cilostazol increases CVR in patients with atherosclerotic disease.

New clinical trials Oral Session 1A    
Date: Saturday, 28 May 2005   Time: 12:03 - 12:15 -  Room: Europauditorium
Chair: S. Davis, Australia and C. Warlow, UK

05
The Results of the Joint Analysis of Two Phase II Trials on Desmoteplase in Acute Ischemic Stroke with Treatment 3 to 9 Hours after Stroke Onset
W. Hacke                                                               
Werner Hacke for the DIAS and DEDAS Steering Committees and investigators

University of Heidelberg, Germany

GERMANY

Background: The European/Australasian based Desmoteplase in Acute Stroke (DIAS) study demonstrated dose dependent beneficial effects on reperfusion and 90 day clinical outcome in acute ischemic stroke patients treated with intravenous (IV) desmoteplase (DSPA) 3 to 9 hours after ischemic stroke onset. The US twin study DEDAS confirmed the results only for the 125µg/kg DSPA dose whereas the 90µg/kg dose appeared less effective than in DIAS. However, a number of MRI protocol violations compromised the interpretation of this finding. A joint analysis of both trials, adjusted for several co-variates, explores the robustness of the efficacy data in the intention to treat (ITT) population and the per protocol cohort of both trials. Methods: DIAS and DEDAS were placebo controlled, double blind, multicenter and multinational MRI-based dose finding phase II safety and preliminary efficacy studies. Altogether 142 acute ischemic stroke patients within 3 to 9 hours of stroke onset were randomized. The joint analysis includes all patients treated with either placebo, 90µg/kg or 125µg/kg (N=94). Main efficacy endpoints were the rate of reperfusion (measured by a reduction of the PWI deficit >/= 30% or a reopening of the affected vessel 4-8h after treatment) and positive clinical outcome after 90 days (combined endpoint defined as reduction by >/= 8 points or scoring 0-1 on NIHSS and mRS 0-2 and BI 75-100). A multiple logistic regression model including the co-variates baseline NIHSS, interaction between age and baseline NIHSS, age, baseline glucose and time from onset was applied for reperfusion and positive clinical outcome. Results: Safety: Only one symptomatic intracranial hemorrhage (sICH) occurred in both studies (ITT, 90µg/kg tier of DIAS). The combined sICH rate for the doses of 90µg/kg and higher was 1.7% (1/59). Mortality was generally low: 5.7% (2/35) on placebo, 6.9% (2/29) on 90µg/kg and 3.3% (1/30) on 125µg/kg. Efficacy: The reperfusion rates were: Placebo: 23.5% (8/34), 90µg/kg: 34.6% (9/26), 125µg/kg 62.1% (18/29). Positive clinical outcomes at day 90 were: Placebo 22.9% (8/35), 90 µg/kg 37.9% (11/29) and 125 µg/kg 60.0% (18/30). The adjusted odds ratios (ORs) for the positive clinical outcome over placebo were: 90µg/kg: 1.73 (0.49; 6.05); 125µg/kg: 6.20 (1.85; 20.76). The clinical outcome in particular in the 90µg/kg group was substantially improved in the per protocol subset (Adjusted OR: 2.95 (0.75; 11.61). Conclusion: There was a very low rate of sICH in the doses investigated. Both reperfusion and clinical outcome were substantially and significantly improved with 125µg/kg IV DSPA compared to placebo. The outcome with the 90µg/kg dose in the ITT is affected by the high rate of MRI protocol violators. The per protocol analysis shows a trend for efficacy. The results need to be confirmed in a larger patient population but suggest that 125µg/kg DSPA is safe and effective while for the 90µg/kg dose the interpretation is less conclusive. DIAS2 will test both dosages in a larger Phase IIb/III-trial.

Clinical Trials Oral Session 1A   Poster Session III
Date: Saturday, 28 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

05
Are we selecting the same category of patients for routine stroke thrombolysis as we did for previous randomised controlled trials?
N.G. Wahlgren                                                               
 

Neurology

SWEDEN

Background and aims: Safe Implementation of Thrombolysis in Stroke (SITS) International Stroke Thrombolysis Register (SITS-ISTR) is an Internet-based, international monitoring registry for auditing the safety and efficacy of routine therapeutic use of thrombolysis in acute ischaemic stroke. SITS-MOST is an observational safety monitoring study required by EMEA (European Medical Evaluation Agency) for EMEA affiliated countries embedded within the SITS-ISTR. We aimed to analyse whether patients recruited in SITS-ISTR (inclusive SITS-MOST) are comparable with patients treated in the randomised controlled trials (RCTs). Methods: In total 3599 patients data have been entered in SITS-ISTR from 262 centres in 22 countries during 1st January 2003 to 31st December 2004. Of these 3599 patients, baseline data were confirmed for 3277 and included in the analyses. In SITS, following data are collected: baseline and demography, time delays, baseline stroke severity (NIH score), baseline imaging studies, follow-up NIH score and imaging, global outcome at 24 hours and 7 days, modified Rankin Score at 3 months together with details of any adverse drug reactions such as haemorrhages. Results: SITS-ISTR The mean age was 67 (median 70, range 10-95) years, 42% females, mean time (hours: minutes) from stroke onset to treatment (OTT) was 2:32 (median, 2:25, range, 0:15 to 13:50) and mean NIHSS 13.3 (median 13, range 0-40), mean blood glucose 130.8 mg/dl (n=2001) and 7.1 mmol/l (n=1096). 248 patients (7.6%) were more than 80 years old, OTT was greater than 3 hours for 179 (5.5%) patients. 95% patients were functionally independent (Modified Rankin score 0-2) before stroke onset, 62% with known previous hypertension, 17% with diabetes, 35% with hyperlipidaemia, 22% current and 23% previous smokers, 26% with atrial fibrillation, 9% congestive heart failure, 31% were on aspirin alone, 34% were on any antiplatelet therapy (aspirin, dipyridamole, clopidogrel, other), 49% received antihypertensives (5% intravenous) and 1.7% received anti-coagulation before thrombolysis. Discussion and conclusions: Compared to RCT:s routine treated patients were of similar age and gender proportion. Routine patients were slightly more severe at baseline. Fewer patients were treated within 90 minutes and beyond 180 minutes. A higher proportion of patients were on aspirin before stroke onset.

Acute stroke: markers in early diagnosis     Poster Session II
Date: Friday, 27 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

02
Taste Disorders in Acute Stroke: A prospective Obervational Study on Taste Disorders in 102 Stroke Patients
J.G.Heckmann    C. Stößel    C.J.G.Lang    T. Hummel    B. Neundörfer                                   
 

Department of Neurology, University of Erlangen-Nuremberg

GERMANY

Objective: To assess whether and how frequent taste disorders in unselected first ischemic stroke patients occur and to search for associations. Methods: A one-year prospective observational study at a stroke unit of university level. For the assessment of gustatory function we used a standardized, validated test kit, the “taste strips”. In addition we assessed olfactory function, swallowing, stroke localization, comorbidities, and the patients’ medication. Results: 102 patients (45 women, 57 men; mean age 63.3+/-12.8 years) with first-ever stroke who were conscious and medically stable were enrolled; 30.4% of all patients revealed impairment of gustatory function, and 5.5% of all patients exhibited a lateralised impairment of taste (right-left difference > 30%). Taste dysfunction was associated with male sex (OR 5.6, CI 1.7-17.7; p=0.004), NIHS-score (OR1.3, CI 1.1-1.5, p=0.013), coexisting swallowing disorder (OR 0.2, CI 0.05-0.9, p=0.044), and total anterior circulation syndrome (according OCPS-criteria) (OR 4.9, CI 1.4-17.1, p=0.014. No association was detected with factors such as age, prehospital activity status, medication, underlying disease, diabetes, smoking, alcohol intake, stroke type, and smell function. In 14 patients follow-up was performed which showed significant improvement of taste sensitivity (p=0.0001). In 4 of these patients the lateralised taste dysfunction resolved completely.

New clinical trials Oral Session 1A    
Date: Saturday, 28 May 2005   Time: 11:15 - 11:27 -  Room: Europauditorium
Chair: S. Davis, Australia and C. Warlow, UK

01
Diazepam to improve acute stroke outcome; results of the EGASIS trial (Early GABA-ergic Activation Study In Stroke): a randomised, double-blind, placebo-controlled trial
J. Lodder    L.vRaak    A. Hilton    E. Hardy    A. Kessels                                   
the EGASIS Study Group

dept Neurology,University Hospital,Maastricht

THE NETHERLANDS

Background and Purpose Diazepam is a GABA-ergic drug that may be neuroprotective in acute stroke. Animal experiments and a clinical study sustain this hypothesis. We tested whether diazepam improves clinical outcome at three months in predefined subgroups. Methods 880 patients, randomised within 12 hours of acute stroke, received diazepam 10 mg or placebo by rectiole, as soon as possible, followed by 10 mg tablets twice daily at 12 hour intervals for three days (total six doses). Primary outcome was independence (Rankin score < 3) at three months; secondary outcome was complete recovery (Barthel index >/= 95 or Rankin score>/= 1). Intention-to-treat, safety, efficacy, and predefined subgroup analyses were performed. Results Intion-to-treat analyses on all 849 patients with full follow-up (50.4% on diazepam) yielded an odds ratio (OR) of 1.14, 95% CI 0.87-1.49 for primary endpoint, and an OR of 1.26 (0.90-1.76) for complete recovery, both favouring diazepam. Adjusted analyses for all stroke patients (N=843) yielded an OR of 1.20 (0.87-1.65), and 1.25 (0.89-1.74), respectively; for all infarct patients (N=748) ORs were 1.31 (0.93-1.85) and 1.46 (1.02-2.09; P=0.037), respectively. OR point estimates were higher for infarct patients treated within 3 hours (N=132) than for those treated later (N=616). Diazepam treatment significantly improved primary outcome in cardioembolic infarct patients (N=200): OR 2.26, 95% CI 1.07-4.76, P=0.032, and complete recovery: OR 2.65, 95% CI 1.06-6.59, P=0.037. About one third of ischemic stroke, and half of hemorrhage patients had "any adverse event", without difference between treatment groups. Conclusions Diazepam treatment is safe in acute ischemic stroke, and improves outcome in cardioembolic stroke. Proving efficacy in all ischemic stroke patients requires a larger trial.

Interesting cases     Poster Session I
Date: Thursday, 26 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

09
Hemiballism as repetitive transient event – is this a recidivant TIA? A case report
A.M.Pavlovic    J. Zidverc-Trajkovic    M. Mijajlovic    D.M.Pavlovic    Z. Jovanovic    N. Sternic                            
 

Institute of Neurology, Belgrade

YUGOSLAVIA

Background. Hemiballism is usually a result of infarction in basal ganglia and pathways. However, hemiballism as a transient ischemic attack (TIA) is rarely seen. We report a case of recidivant hemiballism with clinical characteristics of repetitive TIAs. Methods. A case report. Results. A 79-year-old man with mild hypertension experienced 6 episodes of involuntary movements and tingling of left arm and leg without other complaints during 5 year period. Symptoms lasted 5 to 10 minutes and disappeared completely. Two episodes were observed by neurologist and corresponded to left-side hemiballism leaving no deficit. The last episode lasted one hour and left persistent hemiparesis and hemihypaesthesia. Electroencephalography showed no abnormalities. Magnetic resonance imaging revealed lacunar infarction in lateral thalamus on the right side and mild confluent periventricular ischemic changes. During six-month follow-up episodes did not reoccur. Discussion. Our patient is a rare case of transient episodes of hemiballism with characteristics of repetitive TIA. Although rarely reported, recidivant TIAs can be manifested as episodes of transient hemiballism.

Risk factors of stroke     Poster Session III
Date: Saturday, 28 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

43
Intima-media thickness and pulsatility index correlate with severity of cerebrovascular lesions
A.M.Pavlovic    Z. Jovanovic    M. Mijajlovic    J. Zidverc-Trajkovic    D.M.Pavlovic    N. Sternic                            
 

Institute of Neurology

YUGOSLAVIA

Background: Increased intima-media thickness in common carotid artery (IMT-CCA) is a marker of atherosclerotic changes on large and blood vessels in general, and risk factor for cerebrovascular disease (CVD). Intracranial pulsatility index (IPI) is a marker of brain small blood vessels resistance and structural changes due to cerebral atherosclerosis. The aim of our study is to determine impact of these two complementary non-invasive atherosclerosis markers on CVD of different severity. Methods: Carotid color-triplex (ESAOTE Technos MP 700C) and transcranial Doppler (Nicolet EME legend TC 22) examinations were performed on CVD patients successively examined in Neurovascular Laboratory of the Institute of Neurology in Belgrade in period 1.12.2003. – 1.7.2004. IMT-CCA and IPI were determined. Patients were divided in four subgroups according to CVD severity: asymptomatic carotid stenosis (ACS), transient ischemic attack (TIA), ischemic stroke (IS) and vascular white matter lesions with multiinfarcts (WML/MI). Results: Group comprised of 295 patients, 166 (56.3%) men, 129 (43.7%) women, mean age 62+/-11 years. There were 69 (23.39%) patients in ACS subgroup, 66 (22.37%) in TIA, 47 (15.93%) in IS and 113 (38.31%) in WML/MI. Group mean IMT-CCA was 1.09+/-0.29 mm. Mean IMT-CCA in subgroups was: 1.15+/-0.28 mm in ACS, 1.01+/-0.28 mm in TIA, 1.14+/-0.34 mm in IS and 1.1+/-0.28 mm in WML/MI. Statistical analyses showed significant difference between subgroups ACS-TIA, IS-TIA and WML/MI-TIA at the level of p<0.05. Mean IIP was 1.07+/-0.027 and there was statistically significant difference between subgroups WML/MI and TIA (p=0.044) while there was a trend between TIA and ACS (p=0.071). Discussion: Patients with TIA had the lowest IMT-CCA and IIP which could indicate that atherosclerosis was not the leding factor in this subgroup. There was significant correlation between both IMT-CCA and IIP and CVD severity.

Behavior and mood     Poster Session II
Date: Friday, 27 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

06
LATERALITY OF SYMPTOMS IN PATIENTS ADMITTED TO A STROKE UNIT WHO HAD A DISCHARGE DIAGNOSIS OF A PSYCHIATRIC CONDITION
C.OSantos    L. Caeiro    J.M.Ferro    R. Albuquerque    M.L.Figueira                                   
 

Serviços de Neurologia and Psiquiatria, Hospital de Santa Maria

PORTUGAL

Background: Some psychiatric conditions produce symptoms that can mimic a stroke, leading to the admission of patients to a stroke unit. If such symptoms were more frequent on one side of the body, this would help its clinical recognition. The aim of the present study was to test the hypothesis that these symptoms are more frequent on the left side of the body. Methods: We reviewed the discharge summaries of patients who were admitted to a stroke unit, from May 1996 to December 2003, who had a discharge diagnosis of somatoform disorder and/or anxiety disorder, according to DSM-IV criteria and without recent stroke, according to the WHO definition. We retrieved data concerning the side of the body of their presenting symptoms. Results: We included 32 patients with a mean age of 41 years (26 women and 6 men). Twenty-five patients had a diagnosis of somatoform disorder and 7 had a diagnosis of anxiety disorder. Eleven patients presented symptoms on the left side of the body and 14 patients on the right side. There were no statistical significant differences between patients with left-sided symptoms and with right-sided symptoms concerning demographic variables, discharge psychiatric diagnosis, type of the symptoms, vascular risk factors and neuroimaging data. Discussion: The present study did not confirm the left side preponderance of the symptoms in patients presenting a stroke-like psychiatric disorder. Clinical implication: left-sided laterality of symptoms cannot be used as a tool to establish a psychiatric diagnosis in patients with acute lateralised neurological symptoms mimicking a stroke.

Recovery and rehabilitation     Poster Session I
Date: Thursday, 26 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

08
Neuromuscular electrostimulation of paretic muscles in acute stage of stroke
R.M.Umarova    M.M.Tanashyan    L.A.Chernikova    M.V.Krotenkova                                          
 

Institute of Neurology

RUSSIAN FEDERATION

Background and Purpose. The overuse of paretic limb immediately after ischemia could lead to infarct expansion. To our mind, rehabilitation should obtain such intensity of afferentation from paretic limb which will stimulate motor cortex without additional damage of acute ischemia lesion. The purpose of our work was to assess if neuromuscular electrostimulation (NES) of paretic muscles obtains the adequate afferentation intensity for acute stroke patients. Methods. 15 patients with acute ischemic stroke and symptoms of upper extremity paresis were included within the first 48 hours from symptom onset. The basic group consisted of 11 patients received NES of the paretic wrist and fingers extensors in median time 22 [10; 37] hours after stroke onset in addition to conventional therapy. NES was made 20 min twice a day during 3 weeks. Control group received only conventional therapy. All patients were studied with MRI including diffusion- (DWI) and perfusion – weighted (PWI) MRI at the first hours (pretreatment), 5, 21 days and 3 months after stroke onset. Results. None from the basic group had hand’s flexor spasticity. It was a tendency for better motor recovery of paretic arm in basic group versus control. MRI data showed that NES didn’t disturb normal evolution of acute ischemic lesion that was seen in dynamic DWI. Perfusion characteristics didn’t deteriorate in basic group versus control. Discussion. The improved correlation of extensor and flexor muscle tones enhanced the motor capabilities in the basic group. The fact of infarct expansion absence and cerebral perfusion worsening indicate that local NES of paretic muscles doesn’t lead to additional brain damage. NES obtains such afferentation from paretic limb that stimulate motor recovery without ischemic lesion expansion at acute stroke patients. The study should be continued.

Vascular imaging Oral Session 1A    
Date: Thursday, 26 May 2005   Time: 16:45 - 16:55 -  Room: Sala Bianca
Chair: R. Baumgartner, Switzerland and J. Norris, UK

04
Diffusion – and perfusion – weighted MRI is helpful in acute stroke diagnosing
R.M.Umarova    M.M.Tanashyan    M.V.Krotenkova                                                 
 

Institute of Neurology

RUSSIAN FEDERATION

Withdrawn!

Brain imaging     Poster Session I
Date: Thursday, 26 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

07
CT Perfusion Helps Decision Making For Thrombolysis When There Is No Clear Time of Onset
K.D.Hellier    J.L.Hampton    N.P.Higgins    N.M.Antoun    D.J.Day    J-C. Baron    E.A.Warburton                     
 

Addenbrooke's Stroke Service Department of Neuroscience

UNITED KINGDOM

Background: 25% of all strokes are noted on waking when the time of onset is unclear, reducing the number of patients who could benefit from thrombolysis. We present two cases where the combination of the clinical deficit, information from CT and CT perfusion imaging were used to make the thrombolysis decision Case Histories: Case 1: A 58 year-old woman was heard falling down beside her bed at 7.40am. She had a right hemiparesis and aphasia. CT showed a hyperdense left middle cerebral artery (MCA) and subtle hypodensity of the left basal ganglia. CT perfusion showed very decreased flow to the left basal ganglia with less severe hypoperfusion to the rest of the left MCA territory. She was given intra-arterial thrombolysis and then mechanical agitation and suction thrombectomy, which restored flow. She recovered over a few days and was discharged home well. Repeat CT showed a left basal ganglia infarct. Subsequent history showed that the final time to reperfusion was 7 hours post-stroke. Case 2: A 72 year-old man was found leaning against a post outside the emergency department with a right hemiparesis and aphasia. CT showed a dense left MCA. CT perfusion showed a large area of reduced perfusion in the left MCA territory. He was given intravenous thrombolysis and his power and speech recovered over the next few hours. Transcranial doppler showed reperfusion. He was discharged well within a week. Repeat CT showed no abnormality. Subsequent history showed that the thrombolysis had been given 2 hours post-stroke. Conclusion: Current guidance on thrombolysis post stroke excludes its use where time of onset is unknown. Where the expertise is available, the addition of perfusion CT to the CT scan and clinical examination can increase the potential number of patients able to receive thrombolysis. Using these techniques we were successfully able to reperfuse two patients who would otherwise have been unable to benefit from thrombolysis.

Acute stroke: complications and early outcome     Poster Session II
Date: Friday, 27 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

08
ARE TRIGLYCERIDES AN INDEPENDENT PREDICTOR FOR SURVIVAL IN PATIENTS WITH ACUTE STROKE?
S. Voyaki    A. Stavrianou    A. Haralabopoulos    T. Loukopoulos    L. Matzaris    V. Tsiodra    C. Keramidas                     
 

3rd Medical Dept of General Hospital of Athens

GREECE

Aim of the study was the investigation of triglycerides (Tg) as possible predictor factor for poor outcome in patients with acute stroke. Methods : We studied patients hospitalized for at least one week in our Dept. All underwent a brain CT-scan at entry or within 48 hours after acute stroke. Only patients with neurological deficit and ischaemic infarct were included. A specialist neurologist examined and recorded the Scandinavian Scale score (SSs) appropriately in admission and at days 3 and 7 during hospitalization. Lipids (fasting) other biochemical parameters and blood pressure were measured at entry. Patients under hypolipidemic treatment, those with familial hypercholesterolemia, nephrotic syndrome, cirrhosis, malignancies and thyroid diseases were excluded. Results: We included 489 patients ( 202M/287W, aged 61-98 years old ). Their lipid profil was as follows: TChol: 191±49.8mg/dl, Tg: 119±53mg/dl, HDL:48.3±14.3mg/dl, LDL:114±42mg/dl. There were no differences between the two sexes in Tg levels. Among 489 patients 160 ( 32.7% )had DM, 220 (45%) hypertension and 179 ( 36.6% ) previous cardiovascular complications. Diabetics had higher Tg levels in comparison to non diabetics ( 136.1±60.6mg/dl vs 113.1±49.4mg/dl, P=0.000). Among 489 patients 320 (65.4%) improved their neurological deficit, 95 (19.4%) remained stable, 68 (13.9%) died during their hospitalization. Patients with poor outcome had lower Tg in comparison to those who survived ( 106.6±45.7 vs 121.5±53.8mg/dl, P=0.039). In a univariate analysis Tg was inversely correlated with Age (r=-0.24, P=0.000), but positively correlated with Pulse pressure ( r=0.19, p=0.025). In a multiple regression analysis, after correction for all possible cofactors Tg were found strong predictor of poor outcome (P=0.019). Conclusions : Low triglycerides in admission strongly predicts higher mortality in patients with acute stroke.

Acute stroke: complications and early outcome     Poster Session II
Date: Friday, 27 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

22
SERUM CREATININE LEVELS AS A PROGNOSTIC FACTOR OF SURVIVAL IN ELDERLY PATIENTS HOSPITALIZED WITH ACUTE STROKE.
S. Voyaki    A. Efstratopouos    M. Meikopoulos                                                 
 

3rd Medical Dept. of General Hospital of Athens

GREECE

Aim of the present study was the investigation of serum creatinine levels(Scr) and all possible cardiovascular risk factors as determinants for poor outcome in elderly patients with acute stroke. Methods : We studied 221 patients ( 104M/117F), hospitalized with acute stroke in our Depts. All patients underwent a brain CT-scan at entry or within 48 hours after stroke. Only patients with neurological deficit and ischaemic infarct were included. All events ( fatal and non fatal ) which occurred within the hospitalization period for acute ischaemic stroke were recorded. All possible cardiovascular risk factors were recorder, Scrt and other biochemical parameters were measured. Results :The mean age was 81.8±5.2 ( ranged 74-100 years old) and Scrt : 1.2mg/dl (0.4-7.3). At entry 178 patients (80.5%) had normal renal function (Scrt<1.4mg/dl), 26 ( 11.7%) mild renal dysfunction (RD)(Scrt: 1.4-2mg/dl), 11 patients (7.7 %) moderate RD (Scrt >2.0 and <4.0 mg/dl) and 6 (2.7%) severe RD (Scrt>4.0mg/dl). 113 (51%) were hypertensives under treatment, 55 patients (24.8%) had diabetes mellitus (DM), 64 (28.9%) CHD, 58 ( 26.2%) previous stroke and 38 (17.9%) atrial fibrillation. Patients with DM had higher Scrt levels in comparison to patients without DM (1.43±0.49 vs 1.12±0.48, p=0.000). Among 221 patients with acute stroke 39 (17.6%) died, 55 (24.8%) remained with neurological deficit and 127 (57.4%) improved. The 39 patients with poor outcome were older in comparison to patients who discharged ( 83.3±5.6 vs 81.4±5.1, P=0.045) and had higher Scrt levels ( 1.69±1.6mg/dl vs 1.14±0.53mg/dl, P=0.000). In a multivariate analysis after correction for all other cardiovascular risk factors the serum creatinine was the main determinant for poor outcome ( P=0.003). Conclusions : We conclude that in patients with acute ischaemic stroke, the serum creatinine levels at entry are a significant determinant for the outcome during the hospitalization period.

Longterm outcome of stroke     Poster Session I
Date: Thursday, 26 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

13
LONG-TERM PROGNOSIS AND QUALITY OF LIFE AFTER FIRST-EVER STROKE
D. Smajlovic    B. Kojic    O. Sinanovic    A. Burina    R. Hodzic                                   
 

University Clinical Centre Tuzla, Bosnia and Herzegovina

BOSNIA-HERZEGOVINA

Background. The aim of the study was to analyze the 5-year prognosis and quality of life after first-ever ischemic stroke and intracerebral hemorrhage. Methods. In this study 836 patients were analyzed with a first-ever stroke admitted at the Department of Neurology Tuzla, Bosnia and Herzegovina, from January 1st 1997 to December 31st 1998. Of these 613 (73.3%) were ischemic strokes and 223 intracerebral hemorrhages (26.7%) Subarachnoid hemorrhages were excluded. After hospitalization surviving patients examined periodically, and a final examination was performed 5 years after the stroke. Results. During the first month, the mortality rate was significantly higher in intracerebral hemorrhage than in ischemic stroke (58% vs. 28%, p<0.001). The first year survived 60% patients with ischemic stroke, and 38% with intracerebral hemorrhage. After 5 years, 188 (31%) patients with ischemic stroke and 53 (24%) with intracerebral hemorrhage were alive (p=0.5). Among 30-day survivors (n=535) surviving rate after 5 years was significantly higher in patients with intracerebral hemorrhage (57% vs. 42.5%, p=0.01). Predictors of 5-year mortality were older age and hypertension for both types of stroke, heart diseases for ischemic stroke and diabetes for intracerebral hemorrhage. Both the Rankin scale (1.8+/-1.5 vs. 2.6+/-1.2, p<0.001) and “Questionnaire on Quality of Life After Stroke” (p<0.001) 5 years after stroke were better in patients with intracerebral hemorrhage. Conclusion. Long-term prognosis after first-ever ischemic stroke and intracerebral hemorrhage is similar. However, among 30-day survivors the 5-year survival and quality of life is better in patients with intracerebral hemorrhage.

Vascular surgery and PTCA     Poster Session II
Date: Friday, 27 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

06
Clinical features of ruptured unilateral vertebral artery dissecting aneurysm: Unique subgroup of severe subarachnoid hemorrhage
J. Moroi    H. Hadeishi    M. Sasaki    J. Satomi    M. Sawada    N. Kobayashi    A. Kawashima    A. Suzuki    N. Yasui       
 

Research Institute for Brain and Blood Vessels - Akita

JAPAN

Purpose: The present prospective analysis was undertaken to review our experiences in the treatment of subarachnoid hemorrhage (SAH) due to ruptured unilateral vertebral artery (VA) dissecting aneurysms. Method: We investigated clinical features and outcome of 14 patients (9 men and 5 women, mean, 51.4 years) with ruptured unilateral VA dissecting aneurysm treated in our institute since 1991 to April 2004. Results: At the time of hospitalization, according to World Federation of Neurological Surgeons (WFNS) grading, 7 patinets are included to grade IV or V. Subsequent bleeding was recognized in 7 patients (50.0%). By initial or subsequent bleeding, 10 patients (71.4 %) were classified WFNS IV or V, and 7 patients (50 %) suffered respiratory arrest. Computed tomography demonstrated severe subarachnoid hematoma in all patients and acute hydrocephalus in 13 patients (93 %). In all case, the origin of posterior inferior cerebellar artery was not involved in VA dissection and basilar artery was perfused enough via contralateral unaffected VA. Four patients were treated with direct proximal clipping, 9 with endovascular coil embolization of parent VA, the rest one patient was not treated due to poor condition. The observation period was for 6-105 months (mean, 26.7) months. Nine patients were good recovery, 2 was moderately disabled in Glasgow Outcome Scale (GOS). Discussion: In these patients with this type of SAH, semicoma and respiratory arrest are frequently observed but temporary in most cases. Our investigation suggests that comatose patient with ruptured unilateral VA dissection has enough possibility to have favorable outcome, if treated properly.

Acute stroke: complications and early outcome     Poster Session II
Date: Friday, 27 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

25
PULMONARY COMPLICATIONS IN ACUTE INTRACEREBRAL HEMORRHAGES; A TIME FOR ACTION
B.V.MARAMATTOM    E.M.MANNO    S. WEIGAND    E.F.M.WIJDICKS                                          
 

MAYO CLINIC, ROCHESTER, MINNESOTA

USA

Introduction; Pulmonary complications frequently occur after acute intracerebral hemorrhage (ICH). Studies from patients with acute ischemic stroke suggest a frequency of 3-11%, but comparable data in ICH patients is unavailable. These complications are important as they influence the natural history of ICH and decisions regarding continuity of care. Consequently we sought to analyze the frequency, types and clinical predictors of pulmonary complications in acute ICH. Materials and methods; One hundred and forty-four (144) consecutive patients with spontaneous and anticoagulation induced ICH between January 1999 and October 2003 were analyzed for pulmonary complications. Results; Twenty eight percent (28%) of patients developed pulmonary complications in hospital. These included Aspiration pneumonitis or pneumonia in 19%, Neurogenic pulmonary edema in 6%, Cardiogenic pulmonary edema in 2% and symptomatic pulmonary embolism in 1% of patients. Pulmonary events increased the hazard ratio for mortality (3.21, 95% CI, 1.5-6.84). They were more frequent as the GCS score decreased. The hazard ratio of pulmonary complications was five at a GCS < 8 and three for patients with a GCS of 9-14. Pulmonary events occurred early in the course of ICH (all before 10 days) with 63% detected on the day of ictus itself. Conclusions; After acute ICH, pulmonary complications occur in almost a third of patients in the hospital and increase morbidity and mortality. After ICH, they are 2-3 times more frequent than in acute ischemic stroke. Although they are often considered inevitable, aggressive management can potentially improve outcomes in ICH. Prospective studies in ICH should focus on this major complication.

Acute stroke: treatment concepts     Poster Session I
Date: Thursday, 26 May 2005   Time: 7:30- 8:30 -  Room: Padiglione(Pavilion)
Chair:  

13
15-months of experience with recombinant tissue plasminogen activator (rt-PA) in Warsaw: A study of patient eligibility.
A. Kobayashi    I. Sarzynska-Dlugosz    M. Mazurkiewicz    A. Czlonkowska                                          
 

2nd Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland

POLAND

Systemic rt-PA for ischemic stroke treatment was registered in Poland in November 2003 and introduced at our Department in October 2003 according to Safe Implementation of Thrombolysis in Stroke Study (SITS) criteria and also within the limits of the International Stroke Trial: Thrombolysis (IST-3). The aim of the study is to evaluate eligibility of patients for rt-PA patients since treatment introduction. A survey of the database of stroke patients admitted at our Department from October 1st 2003 to December 31st 2004. Rt-PA treatment was administered according to SITS criteria –and eligibility for IST-3 was assessed adjusted for inclusion and exclusion criteria. A total of 347 stroke patients were admitted within 7 days of onset. 317 were ischemic, 58 of whom (18.3%) were admitted within 2 hours of onset (taking in account a 1-hr. door-to-needle time). 45 (77.6%) were aged under 80, 45 (77.6%) had NIHSS score under 23. 50 (86.2%) had INR over 1.5. None of the patients admitted within 2 hours had thrombocytopenia nor hypo or hyperglycaemia. 32 (10,1%) out of all admitted ischemic stroke patients were treated with rt-PA. IST-3 is a randomised, placebo controlled, open-label trial on the efficacy of rt-PA administered within 3 to 6 hours of stroke onset and also within 3 hours not meeting other SITS criteria (age, severity). 75 (23.7%) of patients were admitted within 2 to 6 hours. Altogether 29 (9.2%) were randomised. Our 15 month experience with systemic thrombolysis reveals that in can be administered to 10% of all ischemic stroke patients according to SITS criteria. Extension of treatment criteria can enable rt-PA treatment in up to a further 10%. Therefore further evaluation of rt-PA treatment efficacy and safety is needed. Improvement of emergency services and social education can also increase the number of patients admitted early to hospital.

Interesting cases     Poster Session I
Date: Thursday, 26 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

03
Left posterior spinal artery stroke due to ipsilateral vertebral artery dissection
D. Ulbricht    M. Kruger                                                        
 

Service de Neurologie, Centre Hospitalier Emile Mayrisch

LUXEMBURG

Introduction: Ischemic stroke of the spinal cord is rare outside the setting of aortic surgery. Posterior spinal artery (PSA) stroke is very rare, and presents with signs of the posterior cord, leading to sensory loss in the affected segment and below, and little motor and bladder dysfunction. Case report: a 48 year-old man was admitted for dysesthesia of the distal extremities in a stock-and-gloving pattern and unsteady gait. Tactile and pain sensation were slightly diminished and position and vibration sense were abolished, much more on the left than on the right body half, without clear segmental level. Tendon reflexes were exaggerated, Claus’ sign was positive the left, and there was slight distal paresis of his left hand and foot and urinary retention. He had left painless Horner’s syndrome, but no other pain. His past medical history was unremarkable but for inactive Bechterew’s disease. Technical work-up was normal except for cervical magnetic resonance imaging demonstrating high signal in T2-weighted imaging in the left posterolateral spinal cord reaching from level C2-7. There was hyperintensity in the wall of the vertebral artery confirming dissection with preserved flow on Doppler ultrasound. A tetraparesis was transient, but crurally accentuated left sensory ataxia with central pain, and urinary retention persisted. Three months after, the patient was able to walk without aid, and was devoid of urinary trouble, but kept left sensory ataxia, and resumed his everyday activities. Discussion: this presentation of stroke in the PSA territory is unusual for several reasons: (1) the initial complaint of the patient was suggestive of infect-related acute polyneuritis or myelitis than (2) of vertebral artery dissection, which presented painless. The clue to vascular pathology was Horner’s syndrome. The probable mechanism of stroke was obstruction of the posterior spinal artery at its origin from the left vertebral artery by hematoma of the arterial wall. The short-term outcome was excellent.

Behavior and mood Oral Session 1A    
Date: Friday, 27 May 2005   Time: 16:35 - 16:45 -  Room: SalaAzzura (1st floor)
Chair: J. Ferro, Portugal and L.Pantoni, Italy

03
Dissociative or Conversion Disorder in the Acute Stroke Unit mainly involving suspected young stroke sufferers
M. Mamun    T. Guha                                                        
 

Medway Maritime Hospital Stroke Unit, Department of Adult Medicine

UNITED KINGDOM

Background: Many young (<45 Y), and occasional middle aged (45 – 65 Y) and older (> 65 Y) adults get admitted to acute stroke unit with apparent focal neurological deficits which on further evaluation proves to be functional in origin (Dissociative or Conversion disorder). Data for these patients including prognosis are sparse. In the age of instant thrombolytic therapy a rapid and accurate diagnosis is essential to avoid harm to this small but potentially vulnerable group. Methodology: We prospectively evaluated all such patients admitted to an 8-bedded acute stroke unit over a period of one year (January – December 2004). The setting is a district general hospital in the southeast of England (U.K.) with a catchment population of 400,000. Results: Out of 314 patients admitted to the Unit, seven patients (2.2%) were diagnosed to have dissociative disorder. None were suspected to have functional symptoms when referred or assessed by the admitting physician. They were mostly young and male (five were < 45 Y, 4 male), one middle aged (51 Y) and one elderly (78 Y). Common presentations were mild degree of paraesthesia and weakness, but a few had dense hemi / monoplegia. None had any previous psychiatric history and all denied illicit drug use. However, most had notable stress factors. All improved slowly, but some had further symptoms / readmission. All imaging investigations were unremarkable. Follow-up ranged up to a year, but none returned to gainful employment despite psychiatric input and rehabilitation. Conclusion: A high degree of suspicion is required particularly in young patients to detect inconsistencies in signs and symptoms. Although the degree of deficits may be minimal, many continue to have disabling symptoms. More research using functional imaging technique, and development of effective psychotherapy and practical support system are required to help this group back to their normal functioning.

Behavior and mood Oral Session 1A    
Date: Friday, 27 May 2005   Time: 17:25 - 17:35 -  Room: SalaAzzura (1st floor)
Chair: J. Ferro, Portugal and L.Pantoni, Italy

08
Predictors of post-stroke dementia. Results of a hospital-based study in Poland
A. Klimkowicz-Mrowiec    T. Dziedzic    A. Slowik    A. Szczudlik                                          
 

Department of Neurology, Jagiellonian University, Medical College, Cracow, Poland

POLAND

Objective: Dementia affects approximately 20-30% stroke survivors three months after stroke. Identification of clinical determinants of post-stroke dementia (PSD) is important in terms of cost evaluation and indications for possible prevention. The goal of this study was to determine the risk factors of PSD in a cohort of consecutive stroke patients in Poland. Subjects and Methods: A standard stroke evaluation including neurological, cognitive and functional assessment as well as neuroimaging examination was conducted on admission in consecutive 250 patients with ischemic/hemorrhagic stroke. Patients with pre-stroke dementia (Pre-SD) were excluded from the study. After 3 months survivors completed a comprehensive neuropsychological examination. The DSM-IV definition for diagnosis of dementia was used. Results: Dementia was diagnosed in 22.6 % of stroke patients 3 months after stroke. Patients with PSD were significantly older, more frequently suffered from ischemic heart disease and diabetes, more often had a history of myocardial infarction, and had a more severe neurological deficit on admission as measured by Scandinavian Stroke Scale (SSS). These patients had also significantly more severe brain atrophy and more often leukoaraiosis on CT scan than patients without PSD. In logistic regression analysis age (OR 1.08, CI 95% 1.04-1.14, P<0.001), diabetes mellitus (OR 2.67, CI 95% 1.06-6.57, P=0.03), and more sever neurological deficit (OR 0.92, CI 95% 0.89-0.96, P<0.001) remained independently associated with PSD. Conclusions: Age, neurological deficit and diabetes mellitus are the most important determinant of PSD in the population of stroke patients in Poland.

Epidemiology of stroke Oral Session 1A    
Date: Thursday, 26 May 2005   Time: 12:10 - 12:20 -  Room: Europauditorium
Chair: B. Pieschowski-Jozwiak, Poland and P. Rothwell, UK

08
Continued Improvements in short-term survival after stroke: experience from population-based studies in Auckland, New Zealand over 20 years.
K.N.Carter                                                               
for the Auckland Regional Community Stroke (ARCOS) Study Collaborative group

The Univeristy of Auckland

NEW ZEALAND

Background and purpose: Survival, the most fundamental measure of the stroke outcome, is influenced by case mix variables as well as medical care and treatment. There is conflicting data regarding trends in short-term case fatality ratios across studies, and therefore uncertainty regarding the impact of improved stroke care and declines in stroke severity in populations. . This study aimed to determine trends in early case fatality after stroke across three population-based stroke incidence studies in Auckland, New Zealand, conducted over a 20 year period. Methods: The three Auckland Regional Community Stroke (ARCOS) studies used uniform standard definitions and case finding procedures, and are recognized as meeting certain ‘ideal’ criteria for stroke incidence studies. All first-ever and recurrent strokes in people (aged >/=15 years) were identified in the population of Auckland during similar 12 month calendar periods in 1981-82, 1991-92, and 2001-02. Kaplan-Meier analysis and the log-rank test were used to investigate trends in 28-day case fatality. Results: Overall, 1030 first-ever strokes (after adjustment for sampling) were registered in 1981-82, 1305 in 1991-92, and 1423 in 2002-03. 28 day case fatality declined significantly from 32% (95% CI 29% - 35%), to 23% (95% CI 21% - 25%), and then 19% (95%CI 17% - 21%) after first ever stroke, across the three studies. Even after adjusting for stroke severity, as measured by level of consciousness at stroke onset, the trend was for improved stroke survival over time. Conclusions: These data show significant declines in early case fatality for stroke over 20 years, which can be attributed both to declines in the incidence of stroke, the severity of the strokes occurring and to success in acute stroke care.

Cerebral haemorrhage and SAH Oral Session 1A    
Date: Saturday, 28 May 2005   Time: 10:00 - 10:10 -  Room: Sala Topazio
Chair: S. Davis, Australia and L. Caplan, USA

10
Impact of early surgery after aneurysmal subarachnoid hemorrhage
M. van der Jagt    D. Hasan    D.WJ.Dippel    H.WC.Bijvoet    C.JJ.Avezaat    P.J.Koudstaal                            
 

Neurology

THE NETHERLANDS

Background - It is unclear which patients after aneurysmal subarachnoid hemorrhage (SAH) benefit from early aneurysm surgery (<72 hours) when endovascular treatment cannot be performed. Methods - Two consecutive series of patients (group A, n=172 and group B, n=121) admitted within 72 hours after aneurysmal SAH were studied between 1989 and 1998. Medical therapy and management of cerebral complications were standardized. In group A, aneurysm surgery was planned on day 12. In group B surgery was performed early (<72 hours) in patients with Glasgow Coma Scale 14 or 15. Logistic regression analysis was used for outcome analysis (Glasgow Outcome Scale at 3 months), adjusted for differences in prognostic variables between cohorts. We separately analyzed patients admitted with favorable prognostic factors (GCS >12 and cisternal blood score </=18). Results - In group B, early aneurysm surgery was performed in 39% of patients. Unexpectedly, early surgery did not reduce the rebleeding rate in group B versus group A. Cerebral ischemia developed significantly more often in group B. Outcome improved significantly in patients with favorable prognostic factors on admission in group B versus group A (risk of death: RR=0.30, 95% CI=0.21-0.44, by logistic regression, and chance of good outcome (GOS 4&5), group B vs A, RR=2.16, 95% CI=1.7-2.75). None of the patients with favorable prognostic factors treated with surgery in group B died. In both group A and B, the most important cause of death was rebleeding. Discussion - We found that only patients with favorable prognostic factors on admission benefit from early aneurysm surgery. These findings may help in the selection of patients for early surgery when endovascular treatment is not suitable.

Stroke and diabetes     Poster Session II
Date: Friday, 27 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

04
The impact of diabetes mellitus on carotid atherosclerotic macroangiopathy.
B. Dumitriu    C. Popa                                                        
 

Department of Neurovascular Emergency

ROMANIA

BACKGROUND The importance of diabetes mellitus in induction of the atherosclerotic changes in carotid arteries,the cuantification of the intensity and of the extension of the atheromathous lesions by Doppler ultrasound assessment. METHODS We have enrolled 441 consecutive patients along two years.They were divided in 2 groups:222 nondiabetic patients that were admitted in our Department with acute cerebral infarct or transient ischemic attack(TIA) or lacunar stroke in carotid territory and 219 diabetics group regardless they have presented or not acute ischemic stroke;all of them have undergone Doppler ultrasound and Duplex scanning. RESULTS The diabetic group with macroangiopathy has presented compared with nondiabetic group more frequent comune carotid artery topography of atheromathous plaques(25,7% and 15,3%) and more associate plaques on subclavian,vertebral and intracranial carotid(p=0,0169)The diabetic patients with stroke or TIA have had more obstructive carotid lesions compared with diabetics without stroke(p=0,01992<0,02)The unstable and complicated plaques were more frequent present in nondiabetic group compared with diabetic group(p=0,03263)The diabetics with stroke have presented more unstable and complicated plaques compared with diabetics without stroke(p=0,00652<0.01) DISSCUSIONS The great frequency of unstable plaques with attached thrombus in diabetics with atrial fibrilation suggests that the obstruction of the carotid artery in these cases could be due of cardioembolism.The intensity and extension of carotid atheromathosis and the presence of associate lesions were more severe in diabetics with ischemic stroke compared with diabetics without acute cerebral infarct.

Dementia/cognition     Poster Session III
Date: Saturday, 28 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

02
Cognitive Decline and Risk of Silent Brain Infarction
O.J.Kim                                                               
 

Pochon CHA University

SOUTH KOREA

Background : Silent brain infarction(SBI) on MRI is common in elderly people, and is associated with various risk factors such as age, hypertension, etc. We investigate whether SBI is associated with cognitive function. Methods : 521 patients performed MRI were included. All patients are neurologically normal and have no previous history with stroke, depression and definite cognitive dysfunction including dementia. Korean Mini-Mental State Examination (K-MMSE) was used to evaluate cognitive function. The patients were divided into two: control group (CG; n=196) and SBI group (SG; n=325) according to MRI findings. Results : The number of persons below 24 on MMSE score is 8(4.1%) in CG and 82(25.2%) in SG (p<0.05). The average of MMSE score is 28.47 in CG and 25.49 in SG (p<0.05). The significant differences on MMSE score between CG and SG is shown in the patients over 50 year old. Discussion : Our results suggest that SBI may play a role in the pathogenesis of cognitive decline in elderly people. If a normal elderly patient has a low score in K-MMSE, MRI is recommended to find SBI. And then, early identification of SBI may lead to effective prevention of future stroke and vascular dementia.

Acute stroke: early management and stroke units     Poster Session II
Date: Friday, 27 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

01
The abnormal pattern of diurnal blood pressure variation in acute stroke is not a transient phenomenon
G. Tsivgoulis    E. Manios    K. Spengos    K. Xinos    V. Peppes    I. Revela    K.N.Vemmos                     
 

University of Athens

GREECE

Background: Elevated systolic (SBP) and diastolic (DBP) blood pressure levels are well-recognized following acute stroke and BP tends to decrease spontaneously the first week of ictus. A reduced nocturnal BP fall has also been reported in the acute stroke stage. We sought to evaluate changes in the circadian BP pattern during and after the acute phase of stroke. Methods: 24-hour BP-monitoring was performed in 242 first-ever acute (<24 hours) stroke patients on days 1 and 7 after symptom onset. Stroke risk factors, clinical and radiological characteristics were documented. Patients who received antihypertensive medication during the first week of stroke were excluded. The degree of nocturnal BP dip was calculated as: [(mean daytime values- mean nightime values)/ mean daytime values] x 100. BP changes in relation to time were assessed by repeated-measures ANOVA, while multiple linear regression analyses were used to determine which factrors influence the extent of the nocturnal BP dip. Results: A significant fall in 24-hour SBP [12.9mmHg (95%CI:11.8-15.0); p<0.001] and DBP [6.0mmHg (95%CI:4.7-7.3); p<0.001] was documented during the first week. No significant changes were detected in the magnitude of the nocturnal SBP [2.3% (95%CI:1.6-3.0) vs 2.2% (95%CI:1.4-3.1); p=0.907] and DBP dip [2.8% (95%CI:2.0-3.7) vs 3.9% (95%CI:2.9-4.9); p=0.271]between day 1 and day 7 of ictus. The magnitude of the nocturnal SBP and DBP dip was significantly (p<0.001) and inversely correlated with history of hypertension and the levels of 24-hour SBP and DBP respectively both during the first and seventh day of ictus Conclusion: In contrast to BP elevations that tend to settle spontaneously the first week following stroke, the abolished pattern of diurnal BP variation is not a transient phenomenon. This finding implies that nondipping status may constitute a direct cause of stroke or a permanent consequence of brain damage.

Meta-analysis and review papers Oral Session 1A    
Date: Thursday, 26 May 2005   Time: 12:00 - 12:10 -  Room: Sala Azzura
Chair: J. E.Rinkel, The Netherlands and P. Sandercock, UK

07
Can parametric statistical methods be used to analysis and present ordinal Barthel data in trials of post-stroke interventions?
F.J.Song    C.J.Jerosch-Herold    I. Harvey    M. Drachler    R. Holland    K. Mares                            
 

University of East Anglia, Norwich, UK

UNITED KINGDOM

Background: There are arguments against the use of parametric statistical methods for analysing ordinal data in trials. The objectives of this studies are to review statistical methods used for the presentation and analysis of an ordinal scale -the Barthel Index (BI)- in trials of post-stroke interventions; and to assess the robustness and power of different statistical methods for analysing Barthel scores. Methods: Randomised trials (RCTs) of post-stroke interventions published from 1995 to 2004 in two journals (Stroke and Clinical Rehabilitation) were scrutinized about methods used for the presentation and analyses of BI scores. Monte Carlo simulations were conducted to compare the Type I errors and statistical power of the rank sum test, t-test, dichotomisation, and ordinal regression. Findings: 156 RCTs of poststroke interventions were included. The central tendency of BI scores was measured by median values in 47 trials, by mean values in 36 trials, and by both in nine trials. Nonparametric methods were used in 47 trials, and parametric methods used in 18 trials for the statistical analysis of BI scores. The proportion of trials that used parametric methods increased from 11% during 1995-1999 to 24% during 2000-2004. The results of the Monte Carlo simulations demonstrated the t-test has similar Type I errors and statistical powers to those of the rank sum test under all the assumed circumstances. Under the many circumstances, the possible maximal power of dichotomisation and ordinal regression is often much lower than that of the t-test or rank sum test. Conclusions: The parametric statistical method is robust and as powerful as the nonparametric method in the analysis of Barthel scores. To facilitate comparison and meta-analysis, mean values and corresponding standard deviations (or standard errors) of Barthel scores should be routinely reported in trials of post-stroke interventions.

Risk factors of stroke     Poster Session III
Date: Saturday, 28 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

14
The FABP2 gene polymorphism, serum fatty acids and the risk of stroke.
M. Carlsson    I. Nilsson    P. Wanby    I. Gustafsson    P. Palmquist    L. Brudin                            
 

Department of Clinical Chemistry

SWEDEN

Background: Epidemiological studies have shown an inverse relationship between intake of n-3 fatty acids and the risk of cerebrovascular disease (CVD). Two common genetic variants, A54 and T54, of the intestinal fatty acid-binding protein gene (FABP2) have different in vitro binding affinities for long-chain fatty acids. In vivo studies have shown that the T54-encoding allele of the FABP2 gene is associated with increased postprandial lipaemia and, recently, an association with the T54 variant and stroke was reported. The present study aimed at determining differences in fatty acid composition of serum phospholipids, which reflects dietary intake of fatty acids (FAs), in stroke patients compared with controls. We also investigated whether the FABP2 gene variant alters serum fatty acid composition. Methods: Fatty acid composition of serum phospholipids was determined from fasting serum samples and compared between 58 patients with acute CVD and 29 healthy controls. The patients were genotyped for the A54T variant. Results: CVD patients had higher proportion of saturated FAs (P=0.01) and lower proportions of total monounsaturated (p=0.03) and total diunsaturated (p=0.001) FAs vs. controls. No differences were observed between CVD patients and controls as concerns total triunsaturated or total polyunsaturated FAs. The CVD patients had lower proportion of the n-3 FA eicosapentaenoic acid (EPA), than the controls (p=0.003) but the n-3 FA docosahexaenoic acid (DHA) was not significantly different. Patients with TT or TA genotypes of the FABP2 gene had higher proportion of the saturated FAs C16:0 (p=0.02) and C18:0 (p=0.04) and lower proportion of C20:0 (p=0.002), C22:0 (p=0.06) and C24:0 (p=0.01) compared with patients with AA genotype. Discussion: Our findings suggest that the FABP2 T54 allele in combination with dietary fat profile influence the risk of CVD.

Genetic disorders     Poster Session II
Date: Friday, 27 May 2005   Time: 7:30 - 8:30 -  Room:  
Chair:  

07
FACTOR V LEIDEN A1691G, METHYLENETETRAHYDROFOLATE REDUCTASE C677T AND PROTHROMBIN G20210A MUTATIONS WITH LIGHTCYCLER IN CEREBRAL ISCHEMIC INFARCTS
A.Z.Boloman     A. Akyol    N. Kiylioglu    G. Kadikoylu    A. Erturk    A. Ozkul    S. Batun                     
 

Adnan Menderes University Department of Neurology 09100 Aydin / Turkey

TURKEY

The objective of this study was to determine the role of the FVL A1691G, prothrombin PG20210A, and MTHFR C677T mutations in the pathogenesis of stroke and particularly in certain pathogenic subtypes of infarct. Twenty four patients with cerebral ischemic infarct and 53 healthy controls were enrolled in the study. Among 24 cerebral infarct patients we found 9 (%15) heterozygote prothrombin (G20210A) point mutations, 2 (%8.3) heterozygote FVL A1691G mutations, 8 (%33.3) heterozygote MTHFR C677T mutations, and 2 (%8.3) homozygote MTHFR C677T mutations. In the control group 2 (%3.7) heterozygote FV Leiden mutations, 13 (%24.5) heterozygote, 2 (%3.7) homozygote MTHR (C677T) mutations were detected. As a result in our study we found out that among cerebral infarct patients FVL A1691G and MTHFR C677T gene mutation is more frequent when compared to control group. In ischemic infarcts to determine the hereditary thrombophilia may effect the therapeutic approaches. We believe that there is a need a larger and uniform studies in patients with cerebral infarct to understand the relation of importance and hereditary thrombophilia.

Stroke and diabetes Oral Session 1A    
Date: Saturday, 28 May 2005   Time: 9:00 - 9:10 -  Room: Sala Azzura
Chair: P. Michel, Switzerland and J. Bamford, UK

04
To be or not to be diabetic. Therapeutic implications in acute stroke.
B. Fuentes    E. Díez-Tejedor    J. Castillo    A. Dávalos    A. Gil-Nuñez    J. Vivancos    J. Egido                     
 

Stroke Proyect. Cerebrovascular Diseases Study Group. Spanish Society of Neurology.

SPAIN

Introduction: Several studies have found the deleterious effect of hyperglycemia in acute stroke, and that this effect is higher in non diabetic patients. Our goal is to analyse the possible influence of previous history of diabetes in the corrective treatment of hyperglucemia in acute stroke in-patients. Methods: GLIA study is a multicentre, prospective study to determine the glucose level associated to poor outcome adjusting for other known prognostic variables. Acute IS patients (<24 h) were included and capillary glucose, blood pressure, body temperature and Canadian Stroke Scale (CSS) were determined each 8 h within the first 48 h. Outcome at 3 months was evaluated by means of CSS and Modified Rankin Scale. Interim analysis from GLIA Study has been developed to evaluate the applied therapies to correct hyperglycemia and the possible existence of differences regarding the previous history of diabetes. Results 270 acute stoke in-patients. 39,6% had capillary glucose levels >150 mg/dl within the first 48 h, 43,9% of whom had no previous history of diabetes. Hyperglycemia corrective treatment (insulin or antidiabetic drugs) was used in 91,7% of known diabetic patients but only in 55,3% of those with no history of diabetes, but up to 50% of them were indeed not-known diabetic patients. To have no previous history of diabetes was an independent predictor factor to no received hyperglycemia corrective treatment (OR 8,8 (95%IC 3,0-26,1). Conclusions Acute stroke patients without previous history of diabetes have eight times higher risk to no receive any corrective treatment for hyperglycaemia although in a high percentage they are true diabetic patients. Prognostic implications of this fact should be analysed in further prospective studies.

Risk factors of stroke Oral Session 1A    
Date: Friday, 27 May 2005   Time: 12:10 - 12:20 -  Room: Sala Maggiore
Chair: H. Mattle, Switzerland and J. Lodder, The Netherlands

08
Family History in Ischemic Stroke Before 70 Years of Age. The Sahlgrenska Academy Study on Ischemic Stroke (SAHLSIS).
K. Jood    C. Ladenvall    A. Rosengren    C. Blomstrand    C. Jern                                   
 

Institute of Clinical Neuroscience, Sahlgrenska Academy, Göteborg University, Göteborg, Sweden

SWEDEN

Background and purpose: Results from twin and family history studies of ischemic stroke suggest that future molecular genetic studies should focus on strictly defined stroke subtypes and younger cases. Accordingly, we investigated stroke subtypes, vascular risk factors and family history in a large study of patients with ischemic stroke onset before 70 years. Methods: Six hundred consecutive white participants with ischemic stroke (18-69 years) and 600 age- and sex- matched controls were examined for vascular risk factors and family history of stroke and myocardial infarction (MI). Stroke subtype was defined using Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria. Results: Family history of stroke was associated with overall ischemic stroke (multivariate odds ratio (OR) 1.70; 95% CI 1.29-2.23), large vessel disease (LVD) (OR 1.88; 95% CI 1.02-3.44), small vessel disease (SVD) (OR 1.79; 95% CI 1.13-2.84), and cryptogenic stroke (OR 1.70; 95% CI 1.13-2.56), but not with cardioembolic stroke. Family history of MI was strongly associated with LVD (OR 3.25; 95% CI 1.74-6.07), whereas no significant association were observed for other subtypes. Conclusion: Family history of stroke is an independent risk factor for ischemic stroke with onset before 70 years. For the first time, we report this association not only for LVD and SVD, but also for cryptogenic stroke, implying that future studies of the genetics of ischemic stroke should target these three subtypes.

Risk factors of stroke Oral Session 1A    
Date: Friday, 27 May 2005   Time: 11:50 - 12:00 -  Room: Sala Maggiore
Chair: H. Mattle, Switzerland and J. Lodder, The Netherlands

06
Combined effects of homocysteine and c-reactive protein on the extent and progression of early carotid atherosclerosis. The INVADE study
D. Sander    H. Bickel    H. Gnahn    B.  Conrad                                          
INVADE study group

Dept. of Neurology, TU Munich, Germany

GERMANY

Homocysteine and c-reactive protein (CRP) are risk factors for the development of atherosclerosis and vascular events. Whereas CRP has been accepted as an independent risk factor, the role of homocysteine has not been unequivocally clarified so far. We investigated the joint effects of both parameters on early carotid atherosclerosis and major vascular events (a composite of myocardial infarction, stroke, and vascular death). We analyzed the data of INVADE (Intervention project on cerebrovascular diseases and dementia in the community of Ebersberg, Bavaria), a prospective and population-based study conducted in 3532 subjects older than 55 years (mean, 68 years, 41% male). In addition to several common risk factors, measurements of carotid intima-media-thickness (IMT), hsCRP, and homocysteine were performed at baseline and after 2 years of follow-up. Median levels of hsCRP and homocysteine were 2.0 mg/l [IQR 1.0, 3.6] and 6.5 umol/l [IQR 5.0, 8.5] respectively. There was a significant effect of homocysteine (p=0.038) but not hsCRP on baseline IMT after adjustment for other risk factors. IMT progression was most enhanced after 2 years of follow-up in the subgroup with both homocysteine and hsCRP in the top half as compared to the group with both parameters in the bottom half according to median (0.03 [0.015; 0.043] vs. 0.01 mm/year [0.004; 0.012]; p=0.008) even after adjustment for several conventional risk factors. In the subgroup with low hsCRP (<2 mg/l), elevated homocysteine (>6.5) was not associated with an increased IMT progression (0.012 vs. 0.010 mm/year; p=0.78), whereas subjects with elevated hsCRP showed a significant enhanced IMT progression if homocysteine was elevated (0.034 vs. 0.014 mm/year; p=0.009). Subjects with homocysteine and hsCRP levels in the top half have an increased risk for new vascular events (HR: 1.5 [1.15; 1.92]; p=0.009; Cox proportional hazard regression). The effects of homocysteine on sub-clinical carotid atherosclerosis are significantly enhanced in the presence of inflammation, indicated by hsCRP. In contrast, in subjects with low hsCRP values according to median (< 2 mg/l), elevated homocysteine values were not associated with an enhanced progression of early carotid atherosclerosis. These findings may in part explain the negative results of homocysteine lowering trials on clinical endpoints.

Acute stroke: complications and early outcome     Poster Session II
Date: Friday, 27 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

19
Patterns of Acute Stroke Care in Poland and Germany
J. Pniewski    P.U.Heuschmann    J. Glahn    I. Gorczyca    M. Heise    R. Wozniak    O. Busse                     
 

Dpt. Neurology CSK MSWiA, Warsaw, Poland; University of Muenster; Dpt. Neurology, Minden, Germany

POLAND

Background: Data are lacking about differences in acute stroke management between Eastern and Western European countries. Aim of the study was to compare patterns of acute stroke care and early outcome between two community hospitals in Poland and Germany. Methods: Consecutive patients after ischemic stroke admitted in the year 2002 to the Department of Neurology CSK MSWiA in Warsaw, Poland (PL) and Department of Neurology in Minden, Germany (G) were analyzed. Both are community hospitals and provide services for acute stroke care in. Data were collected within the Northwest German Stroke Register. Results: 305 patients (pts) with ischemic stroke were hospitalized in PL and 525 in G. Pts in PL were older compared to G (71.6 y vs. 68.0 y), more often in coma (5.6% vs. 2.5%) or somnolent (18.0% vs. 9.3%) and demonstrated more comorbid conditions (hypertension 76.7% vs. 68.6%, atrial fibrillation 30.2% vs. 15.4%). A lower percentage of pts in PL was admitted within 3h after stroke onset (12.1% vs. 18.9%). Regarding the frequency of diagnostic procedures, MRI (12.5% vs. 35.8%) Doppler sonography (73.7% vs. 97.5%) and echocardiography (41.6% vs. 72.2%) were performed less frequent in PL. Thrombolytic therapy (0.3% vs. 8.2%) as well as low dose heparin (39.7% vs. 51.8%) were used less often in PL. Patients in PL suffered more often from complications (pneumonia 10.2% vs. 6.5%, urinary tract infection 29.2% vs. 9.3%). No differences were found in the median length of stay in hospital. Pts in PL were discharged less often to rehabilitation unit (10.8% vs. 23.8%); more pts died in hospital in PL (8.9% vs. 3.6%). Conclusion: Substantial differences in patient characteristics, acute stroke management, early complications and early outcome were found between Poland and Germany.

Clinical Trials     Poster Session III
Date: Saturday, 28 May 2005   Time: 7:30 -8:30 -  Room: Padiglione(Pavilion)
Chair:  

01
Continuation of aspirin therapy despite aspirin resistance is associated with higher mortality. A two-year follow up in 921 ischemic stroke and cardiovascular patients
E. Pongrácz    G. Stef    G. Kerecsen    F. Poór    E. Seres    L. Németh    I. Préda    R.G.Kiss              
 

Central Hospital of Home Office, Budapest

HUNGARY

Background:Tailored, sustained antiplatelet therapy is a common task in ischemic vascular medicine.Laboratory and/or clinical definition of antiplatelet drug resistance for the clinician and methods for routine screening for the laboratory were studied.Threshold of the measurable inhibition was postulated as mean of max. platelet aggregation % -2xSD of 150 untreated control patients.Turbidimetric routine inhibition assay method was used on a Carat TX4 platelet aggregometer.Aspirin treated patients were considered resistant to aspirin if results of their maximal aggregation was higher than the postulated threshold value.Epinephrine and collagen were used to evaluate aspirin monotherapy(maximal aggregation beyond threshold to any of these two inducers considered aspirin resistant:collagen 64%,epinephrine 59%).Arachidonic acid was used as a control of drug compliance of aspirin. Results:Out of 921 ischemic stroke and cardiovascular patients taking aspirin(100-325mg) alone for secondary prevention,22%(204) showed drug resistance.All 921 patients were followed for 24 months.Antiplatelet drug of choice was left to physician’s discretion.9% (62 of 717) of aspirin responders and 12%(24 of 204) of aspirin resistants died during the follow up.Aspirin resistant patients were evaluated in terms of their antiplatelet drug therapy after their platelet response was measured.103 of them received continuous antiplatelet monotherapy with careful periodic control.48 of 103 aspirin resistants remained on aspirin, 23%(11) died.55 of 103 were changed to thienopyridine(30 received 500 mg ticlopidine, 25 others took 75 mg clopidogrel daily),4%(2) died,(p<0,01). Conclusions:Aspirin resistance can be detected by a blood test.The phenomenon of aspirin resistance represents a higher mortality risk among ischemic stroke and cardiovascular patients taking aspirin for secondary prevention.In case of antiplatelet drug resistance,changing to other class of antiplatelet drug can be lifesaving.

Meta-analysis and review papers Oral Session 1A   Poster Session II
Date: Friday, 27 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

04
User involvement in stroke research: rationale, examples and prospects.
N. Fudge    C. Wolfe    C. McKevitt                                                 
 

King's College London

UNITED KINGDOM

Background Throughout Europe there is recognition of the need to encourage the involvement of patients and the public as active research partners with professionals. This is thought to improve research quality but recent systematic reviews found little evidence of the impact of user involvement. We reviewed recent user involvement literature to establish current status of, and prospects for, user involvement in stroke research. Methods Electronic databases (1999-2004) were searched using the key words consumer, patient/user, involvement/participation, research. Inclusion criteria: English language; peer-reviewed publication. We excluded theoretical papers. Two authors read papers, using a matrix to record level of involvement; evaluation of impact; evidence outcomes. Results 70 papers were included. 1 paper reported involving users to develop a randomised control trial of thrombolysis for acute ischaemic stroke. Other studies relevant to stroke research included: cardiovascular disease (2), diabetes (4), rehabilitation (2), older people’s health (4) and research to reduce smoking/improve diet (2). Reasons for involving users were: improves design and conduct of research and trials; facilitates recruitment and retention; increases relevance of research outcomes; improves dissemination and implementation of results; increases lay knowledge and fosters mutual education between users and professionals. Discussion Few studies have reported actively involving stroke service users. Since there are many areas of uncertainty in stroke prevention and management, involving users in research would lead to research questions and service developments informed by user priorities and perspectives. This may improve services and outcomes.

Longterm outcome of stroke Oral Session 1B    
Date: Friday, 27 May 2005   Time: 16:35 - 16:45 -  Room: Sala Maggiore
Chair: JP Mohr, USA and E. Özdemir, Türkey

15
Male gender, NIHSS on admission and initial DWI lesion volume are predictors of favourable outcome after IV-thrombolysis with tPA within 6 hours of symptom onset.
G. Thomalla    J. Fiehler    T. Kucinski    C. Weiller    H. Zeumer    J. Röther                            
 

University Hospital Hamburg-Eppendorf

GERMANY

Objective: We analysed our database of acute middle cerebral artery (MCA) stroke patients studied by stroke-MRI for predictors of a favourable outcome after IV-thrombolysis with tPA < 6 h. Methods: Stroke MRI including diffusion weighted imaging (DWI) and perfusion weighted imaging (PWI) was performed in all patients with acute middle cerebral artery stroke arriving < 6 h. IV-thrombolysis with tPA was performed within 6 hours according to ECASS II criteria, and after 3-6 hours based on stroke MRI findings. Neurological deficit was assessed using the National Institutes of Health Stroke Scale (NIHSS). Outcome was assessed 90 days after stroke using the Modified Rankin Scale (MRS). Favourable outcome was defined as MRS 0-1. DWI and PWI lesion volumes were defined using standardized window settings, and PWI/DWI mismatch was calculated. Results: Within a 4 years period, 96 patients were examined by a complete stroke MRI protocol and treated with IV-tPA <6 h. Of these, 46 (48%) patients reached a favourable outcome. Patients with a favourable outcome were more likely to be male (72% vs. 52%, p=0.023), were younger (median 61 vs. 64 years, p=0.039), presented with a lower NIHSS on admission ( 12.5 vs. 16.5, p<0.001), had smaller initial DWI lesions (17 vs. 37 ml, p=0.001) and a higher PWI/DWI mismatch ratio (8,8 vs. 5,0, p=0.017). There was no difference between both groups regarding side of infarction, onset to treatment time or PWI lesion volume. Logistic regression identified male gender (p=0.004), NIHSS on admission (p=0.009) and DWI lesion volume (p=0,032) as independent predictors of favourable outcome. Conclusions: Patients with acute MCA stroke are more likely to reach a favourable outcome after intravenous thrombolysis with tPA <6h if they are male, show a less severe deficit and present with smaller DWI lesions in the acute stroke MRI. These results may influence the selection of patients for IV-tPA beyond the 3 hour time window.

Rare stroke conditions (experimental and clinical)     Poster Session I
Date: Thursday, 26 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

02
CEREBRAL AUTOSOMAL DOMINANT ARTERIOPATHY WITH SUBCORTICAL INFARCTS AND LEUCOENCEPHALOPATHY (CADASIL): THE FIRST FAMILY IN GREECE
M. Vikelis    M. Xifaras    C. Sarafoglou    G. Gekas    D.D.Mitsikostas                                   
 

Nikea General Hospital, Department of Neurology, Nikea, Greece

GREECE

Background: Cerebral autosomal dominant arteriopathy with subcortical infarcts and leucoencephalopathy (CADASIL) is an inherited autosomal dominant arterial disease characterized by migraine, ischemic events and progressive cognitive impairment and has been shown to be due to mutations in the notch 3 gene. Worldwide, more than 200 families with CADASIL from many ethnic populations have been identified. We present two patients (members of the same family) with CADASIL, which has not been previously reported from Greece. Case Reports. A 55-year-old woman with progressive cognitive decline and a past history of migraine with aura was referred for assessment. Her mother and grandmother had a history of similar illness, resulting in death before the age of 60. Her MRI brain scan showed extensive hyperintensities within subcortical and deep white matter on T2-WI. Genetic studies of the notch 3 gene detected a heterozygous Arg169Cys (CGC/TGC) mutation in the protein coding sequence of exon 4, confirming the diagnosis of CADASIL. Her 30-year-old son had a history of migraine with aura and although his neurological examination and brain MRI scan was normal, genetic studies revealed the presence of the same heterozygous mutation. The family pedigree includes 22 individuals from four generations. Two individuals (our patient and her son) were affected as determined by clinical manifestations and genetic testing and two additional individuals (our patient’s mother and grandmother) probably have been affected based on historic information from relatives. Discussion: CADASIL is an inherited arterial disease, commonly overlooked or misdiagnosed. Although numerous families with CADASIL have been reported, its prevalence remains unclear. Early diagnosis of CADASIL is important for prognosis of symptomatic patients and counseling of asymptomatic family members who may be at risk but also for the establishment of patient cohorts for observational studies and therapeutic trials.

Acute stroke: complications and early outcome     Poster Session II
Date: Friday, 27 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

06
Life-threatening orolingual angioedema during alteplase treatment of acute ischemic stroke.
S. Engelter    F. Fluri     C. C. Buitrago-Téllez    S. Marsch    A.J.Steck    S.  Rüegg    P. Lyrer                     
 

Neurological Clinic University Hospital Basel,

SWITZERLAND

Background: The clinical significance of orolingual angioedema during i.v. alteplase in acute ischemic stroke is unknown. Objective (1), to alert to the potentially life-threatening complication of orolingual angioedema, (2), to present imaging data of the tongue which exclude lingual hematoma. (3), to estimate the frequency of orolingual angioedema, among (i) all stroke patients treated with alteplase and among (ii) the subgroup of those with concurrent use of angiotensin-converting-enzyme inhibitors (ACEi). Methods: Single center, databank-based observational study among 120 consecutive patients with i.v. alteplase for acute ischemic stroke. Combined analysis with a recent study focusing on ACE-inhibition. The main outcome variables were frequency of orolingual angioedema and the Peto odds ratio (OR) of angioedema for “concurrent use of ACEi” across both studies. Results. Orolingual angioedema was observed in 2 of 120 patients (1.7%, 95%CI 0.2 – 5.9%). CT–scan showed orolingual swelling but no bleeding. One of 19 (5%) patients taking ACEi experienced orolingual angioedema, while 18/19 (95%) did not. In patients without concurrent ACEi, one of 101 (1%) had orolingual angioedema. The combined analysis of the Basel and the Calgary data resulted in a Peto OR of 37 (95%-CI 8–171) for patients taking ACEi (p<0.001). Conclusion: Orolingual angioedema triggered by alteplase for acute ischemic stroke can be life-threatening and should not be considered a negligible rarity. Close monitoring of all alteplase-treated stroke patients seems mandatory. Those who currently take ACE-inhibitors should have the most careful monitoring. Orolingual hematoma as differential diagnosis can be excluded by CT-scan.

Vascular imaging Oral Session 1A    
Date: Thursday, 26 May 2005   Time: 16:55 - 17:05 -  Room: Sala Bianca
Chair: R. Baumgartner, Switzerland and J. Norris, UK

05
CT-angiography in acute ischemic stroke. Do we get additional information about short and long-term outcome?
M.A. Ritter    T. Poeplau    R. Dittrich    R. Dziewas    D.G.Nabavi                                   
 

Department of Neurology, University Hospital of Münster

GERMANY

Background: We assessed whether CT-angiography (CTA) in patients with ischemic stroke independently from clinical admission status predicts infarction on control imaging and functional outcome after three months. Methods: 151 consecutive patients with clinically suspected ischemic stroke presenting within 12 h from symptom onset (median 1h) received CTA of the intracranial arteries. Stroke severity was determined using the NIHSS. Reconstructed CTAs were investigated for presence and site of stenosis or occlusion. Control imaging was performed 24-48 hours after symptom onset. Patients were interviewed after 3 months to determine outcome using the modified Rankin scale (mRS). Dependency was defined as mRS scores >/=3. Single factor and multiple regression analyses were performed for different subgroups of pathologic CTA findings in correlation with occurrence of infarction and dependency at follow up. Results: Median time to admission was 1 hour. Mean NIHSS on admission was 9.6 (±6.6). Only 61/151 patients (40%) had vessel pathologies on CTA congruent with clinical symptoms. However, infarction was later demonstrated in 127/151 patients (84%). We found significant correlations between pathological vessel status on CTA and presence of infarction on control imaging and of dependency at three months follow-up (each p<0.001). After adjustment for age (>/=/<65y), sex, therapy, NIHSS (>/=/<10), and time to presentation (>/=/<3 h) only “any pathology on CTA” remained weakly predictive of brain infarction (p=0.04) in multivariate logistic regression analysis. M1-occlusion occlusion was not independently predictive of infarction or dependency (OR 3.3, 95%CI 0,4-29,1; p=ns). Only NIHSS-scores >/=10 on admission were highly predictive of dependency at follow-up in all calculated models (p<0.001). Conclusions: CTA does not offer independent additional value to determine long-term prognosis after acute stroke. Brain infarction occurs frequently even in cases with unremarkable CTA.

Acute stroke: treatment concepts Oral Session 1A    
Date: Friday, 27 May 2005   Time: 11:20 - 11:30 -  Room: Sala Italia
Chair: D. Toni, Italy and P. Trouillas, France

03
Thrombolysis in stroke patients aged 80 years and older in Switzerland
S. Engelter                                                               
Swiss Survey of Intravenous Thrombolysis for Acute Stroke

Neurological Clinic University Hospital Basel, Switzerland

SWITZERLAND

Background: Intravenous thrombolysis with recombinant tissue plasminogen activator (rtPA) applied within 3 hours is efficacious in acute stroke patients. However, little information is available about rtPA-treatment in very elderly patients who were either excluded or underrepresented in the randomized controlled rtPA-trials. Methods: In a multicenter Swiss cohort study, all patients aged 80 years or more (n=38) were compared with those <80 years old (n=287) concerning the rate of favorable outcome (mRS 0-1), death (all causes), and intracranial hemorrhage 3 months after rtPA for acute stroke. Furthermore, the significance of the variable “age” was estimated by stepwise logistic regression. Results: After 3 months, 32% of the elderly versus 12% of the younger patients had died (p<0.01). The risk of intracranial hemorrhage (symptomatic/fatal) did not differ significantly between older (13%, 5%) and younger (8%, 3%) patient groups. Favorable outcome occurred in 29% of the elderly and in 37% of the younger counterparts (p>0.1). Age, NIH Stroke Scale score, time to lysis, glucose level, history of coronary heart disease, hypertension, and atrial fibrillation were factors predicting poor outcome in univariate analyses. In a stepwise logistic regression, age, hypertension, and atrial fibrillation were no longer significant. Conclusion: Stroke patients aged 80 years or older receiving rtPA bear a higher mortality risk than younger patients. However, the likelihood of favorable outcome is similar. Stroke severity, time to lysis, glucose level and history of coronary heart diseases were more relevant outcome predictors than age. Stroke patients at very old age should not be deprived from rtPA-treatment based exclusively on their age.

Behavior and mood Oral Session 1A    
Date: Friday, 27 May 2005   Time: 17:15 - 17:25 -  Room: SalaAzzura (1st floor)
Chair: J. Ferro, Portugal and L.Pantoni, Italy

07
The frequency of depressive symptoms following stroke: a systematic review of observational studies
M.L.Hackett    C.M.Yapa    V. Parag    C.S.Anderson                                          
 

The University of Auckland

NEW ZEALAND

Background: Stroke is an important contributor to depression and other neuropsychiatric disorders. However, uncertainty remains over the frequency, the natural history and the impact of depression on patient outcomes, largely due to complexities in study designs and assessment of mood in the setting of stroke. Methods: We undertook a systematic review of observational studies of stroke (published before June 2004), with prospective and consecutive recruitment that attempted to quantify the burden of depressive symptoms following stroke. Data were identified from searches of 12 electronic databases and grouped by type (population-, hospital- and community-based studies) and time of assessment (</= 4 weeks, > 4 weeks to </= 6 months, and > 6 months) following stroke. Pooled estimates with 95% confidence intervals (CI) were calculated. Results: Data were available from 51 studies (reported in 96 publications) conducted between 1977 and 2002. While the frequency of depressive symptoms varies across individual studies, pooled estimates indicate that between one quarter and one third of stroke survivors experience depression. Much of the variation in individual study results may be explained by the variation in participant characteristics and the method of mood assessment. Only a small proportion of survivors appear to experience depressive symptoms, for longer than a year, and few seem to receive effective management of the illness. Physical disability is associated with depressive symptoms but the direction of causality is unclear. Discussion: A high proportion of stroke survivors experience depressive symptoms at any time after stroke, raising the potential justification for routine screening for symptoms after stroke, but also a pressing need for predictive variables to be identified to better target therapy in high risk individuals.

Epidemiology of stroke     Poster Session III
Date: Saturday, 28 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

05
Clinical profile of non-cardioembolic ischemic stroke in Qatar: analysis of risk factors including echocardiographic parameters
D. Deleu    A.A.Hamad    S. Kamran                                                 
 

Hamad Medical Corporation

QATAR

Background: The dramatic change in lifestyle in the Arabian Gulf countries posses a major health problem, with increasing risk for stroke. The purpose of this hospital-based study was to analyze the risk factors (RF), echocardiographic variables, stroke subtypes and outcome of patients admitted with non-cardiogenic ischemic stroke (NCIS) in Qatar. Method: The data of 455 patients, admitted with NCIS at HMC (the only stroke-admitting facility in Qatar) over 2001 were retrospectively reviewed. Only patients with a complete work-up (including brain CT scan or MRI, carotid doppler, and echocardiography) were included. The WHO criteria for stroke classification were used. All relevant data were collected from the patients' case records. Data are expressed as means+/-SD, and means were compared by using t-test or chi-square test. Level of significance was 0.05. Results: From the 455 patients, 303 matched the inclusion criteria: 48% Qatari and 52% non-Qatari. The mean age was 61.1+/-12.1 yrs with a sex ratio of 2.7 (M/F). Lacunar hemispheric stroke represented 68% of all strokes. The median RF was 3: hypertension (69%), dyslipidemia (57%), diabetes (50%), obesity (30%) and prioir stroke (24%). Diabetes, particularly in female, was significantly higher in Qataris. The ejection fraction (EF) (59.3+/-10.2%) correlated negatively with age, presence of ventricular wall motion abnormalities (26% of patients) and the number of RFs. In addition, EF was significantly lower in patients with previous stroke (24% of patients). Significant carotid artery stenosis was observed in 14% of patients. Stroke recurrence was reported in 10% of patients, while the 30 day case-fatality rate was 5%. Discussion: The overall distribution of NCIS did not differ from Western countries or other Gulf countries. Different from these studies however is that, dyslipidemia instead of diabetes has become the second most important risk factor in NCIS. This may be partly due to racial-ethnic differences.

Interesting cases     Poster Session I
Date: Thursday, 26 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

22
Clinical features of the Capsular Warning Syndrome
J. LEE    S.J.LEE    J.H.KIM    S.G.BAIK    M.Y.PARK    J.S.HAA                            
 

Yeungnam University College of Medicine

SOUTH KOREA

Background: Capsular warning syndrome(CWS) is characterized by recurrent, stereotypic, motor or sensory deficit, and absence of cortical signs. We describe clinicoanatomic correlations with magnetic resonance imaging(MRI) and magnetic resonance angiography(MRA) and possible pathomechanisms of ischemia in patients with CWS. Methods: CWS was defined as 3 or more transient ischemic attacks(TIAs) representation of pure motor or sensorimotor stroke without any cortical sings. We collected clinical, MRI, and MRA data on patients who presented CWS. Results: 10 patients(8 men and 2 women) with mean age of 52.5 years(between 33 to 70 years) were corresponded to CWS for 15 months. 5 patients showed pure motor deficits and 5 showed sensorimotor deficits. CWS presented as 3-16 TIAs lasting from 5 and 60 minutes with a mean duration of 12 days(between 1 and 40 days). Hypertension in 6 patients and smoking history in 5 patients were found as risk factors. We could not find sources of coronary heart disease and cardioembolism on echocardiography in all patients. 2 patients developed silent infarction in the left putamen and striatocapular area on the follow-up images, respectively. Leg weaknesses were checked after recurrent TIAs on arriving in 2 patients who were treated with acupunctures. 5 patients had normal MRA findings. Proximal middle cerebral artery stenoses were checked in 4 patients and proximal internal carotid artery severe stenosis in one. 8 patients were treated with intravenous heparin, and symptoms were stopped within one day in 6 patients. Discussion: We have been known CWS is associated with a high risk of imminent lacunar infarction, nevertheless lesser than half patients developed infarction in our case. We recognized that the hemodynamic mechanism in a penetrating or parent arteries is important pathophysiolosy in CWS, but effectiveness with heparinization suggest microembolisms also contribute to the pathomechanism of CWS.

Behavior and mood Oral Session 1A    
Date: Friday, 27 May 2005   Time: 17:55 - 18:05 -  Room: SalaAzzura (1st floor)
Chair: J. Ferro, Portugal and L.Pantoni, Italy

11
Prevalence, Time-Course and Determinants of Post-Stroke Depression
J.W.Sturm    S. Whyte    T. Desborough    D. Crimmins    C. Levi    R. Markus    B.S.Townend                     
 

Stroke Unit, Gosford Hospital, Gosford, NSW, Australia

AUSTRALIA

Background Post-stroke depression (PSD) has been associated with increased mortality, disability, and length of hospital stay. It is likely that the early identification of PSD or its determinants could bring better outcomes through earlier treatment. However, the prevalence, time-course and determinants of depression within the first few weeks after stroke require further investigation. Methods 138 consecutive patients admitted to Gosford Hospital were assessed within 5 days of stroke onset, and at 1 and 3 months post-stroke. Baseline data included demographics, co-morbidities, stroke subtype, pre-stroke disability (Modified Rankin Scale, MRS), and cognition (Informant Questionnaire Code, MMSE). At baseline, 1 and 3 month interview assessments were made of physical impairment (NIHSS), disability (Barthel Index, MRS), mood (Hospital Anxiety Depression Scale), cognition (MMSE), social support (Multidimensional Scale of Perceived Social Support), and quality of life (Assessment of Quality of Life instrument). Results The prevalence of PSD within 5 days and at 1 and 3 months post-stroke was 4.8%, 16.1% and 21.0% respectively. PSD was found to be independently associated with mortality and poorer quality of life at 3 months post-stroke. Multivariate regression analyses revealed the independent determinants for PSD at 0-5 days (first ever stroke, pre-morbid disability, any post-stroke complication, social support, and prior smoking or alcohol use); 1 month (Barthel Index score, social support, and current use of anti-depressants) and 3 months (MRS score, social support, and current use of anti-depressants). Discussion PSD is common, increases in prevalence over the initial weeks post-stroke, and is associated with poorer outcomes. Disability is known to be associated with PSD and antidepressant use probably reflects severity of depression. The influence of social support on mood needs further investigation.

Interesting cases     Poster Session I
Date: Thursday, 26 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

19
A case of middle cerebral artery occlusion in ovarian hyperstimulation syndrome
B. Krupka    A. Bartkova    J. Dostal    V. Krcova    P. Otruba    R. Herzig    D. Sanak    I. Vlachova    P. Kanovsky       
 

Dpts. of Neurol., Gyn. and Obstetrics, and Haematooncology, Univ. Hosp., Olomouc, Czech Rep.

CZECH REPUBLIC

Background: Ovarian hyperstimulation syndrome (OHSS) is the most serious complication of sterility treatment. OHSS is characterized by ovarian enlargement, ascites, electrolyte imbalance, hypovolaemia and haemoconcentration. Case: A 31-year old female who underwent pharmacological treatment of sterility suffered from acute ischaemic stroke due to the right middle cerebral artery (MCA) occlusion. Left hemiparesis occurred suddenly within a few days after embryo-transfer. Magnetic resonance (MR) - diffusion weighted imaging showed infarction in the right basal ganglia and MR angiography (MRA) revealed occlusion of the main trunk of the right MCA. Haemodilution and anticoagulation therapy seemed to be effective. 24 hours after stroke onset MRA showed MCA recanalization. Neurological deficit gradually almost completely resolved. The patient delivered 2 healthy infants at the term. Discussion: This case demonstrates that the recently introduced ovulation induction and reproductive techniques can be a newly recognized cause of cerebral stroke in otherwise healthy female subjects.

Genetic disorders Oral Session 1A    
Date: Saturday, 28 May 2005   Time: 9:30 - 9:40 -  Room: Sala Maggiore
Chair: H. Markus, UK and H. Chabriat, France

07
CONNECTION BETWEEN GENE POLYMORPHISMS OF REGULATORS OF APOPTOSIS (PARP-1, AIF, P53) AND THE VOLUME OF BRAIN INFARCTION IN ATHEROTHROMBOTIC ISCHEMIC STROKE
V.I.Skvortsova    I.M.Shetova    P.A.Slominsky    A.Yu.Botsina    K.V.Koltsova    T.V.Tupitsina    S.A.Limborska                     
 

Dep.of Fundamental and Clinical Neurology, Russian State Medical University

RUSSIAN FEDERATION

Purpose. The aim was to study the connection between gene polymorphisms of poly (ADP-ribose) polymerase-1 (PARP-1), apoptosis inducing factor (AIF) and p53 with the brain infarction volume (BIV) in patients with atherothrombotic ischemic stroke (IS). Methods. Rsa-I PARP-1, Bcl-1 AIF and Bam HI RFLP p53 diallelic polymorphisms were studied in 96 patients with IS from Moscow population. Presence of restriction site for all polymorphisms was marked as (+), absence as (–). Poly ADP-ribose (PAR) levels were assessed in CSF on days 1 and 3 using ELISA technique. MRI with the manual morphometry and “Osiris” morphometric hardware (by the University of Geneva) were applied 24 h after IS onset and on days 3, 7 and 21. Results. A close association between RsaI PARP-1 and Bam HI p53 polymorphisms and BIV on days 3 and 7 after IS onset was found. The predominance of the big-size infarctions (>90 cm3) was revealed in patients with (–/–) RsaI PARP-1 genotype vs. (+/–) (p<0.001) and (+/+) (p=0.04) genotypes. According to the NIHSS, (–/–) RsaI genotype was associated with worse outcome on day 21 vs. (+/–) and (+/+) genotypes (p=0.03 and p=0.003, respectively). Bam HI p53 polymorphism was connected with BIV as well. The predominance of small-size infarctions (<40 cm3) was revealed in patients with (–/–) Bam HI p53 genotype vs. patients with (+/–) (p<0.001) and (+/+) (p<0.001) genotypes. According to the Bayesian’s statistics, in patients with (–/–) Bam HI p53 genotype the development of a small-size infarction in IS can be prognosticated with probability more than 65%. High levels of PAR in CSF occurred more often in patients with (+/–) Bam HI p53 genotype vs. other genotypes (р=0.03). The association was found between PAR level in CSF, BIV on day 3 and stroke outcome on day 21: the higher was PAR level, the larger was BIV (r=0.67; p=0.03), and the worse was outcome (r=–0.65; p=0.04). Discussion. This results additionally confirm that apoptosis plays an important role in the formation of ischemic brain lesion in patients with IS and that the drugs with anti-apoptotic properties may prove beneficial in stroke patients.

Epidemiology of stroke Oral Session 1B    
Date: Friday, 27 May 2005   Time: 17:35 - 17:45 -  Room: Europauditorium
Chair: A. Czlonkowska, Poland and T. Truelsen, Denmark

21
Seasonal variation and winter excess in number of admissions and deaths by stroke subtype in Eastern England: database study
P.K.Myint    R.A.Fulcher    S.L.Vowler    O. Redmayne                                          
 

Department of Medicine for the Elderly, Norfolk and Norwich University Hospital, Norwich and Centre for Applied Medical Statistics, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK

UNITED KINGDOM

BACKGROUND The winter excess is variable for different stroke subtypes and many studies conducted in different populations are not generalisable. We investigated the local pattern of stroke admissions and deaths during acute episodes in Eastern England. METHODS We performed a retrospective analysis on stroke registry data collected since late 1996 for 6 seasonal years (1997/98 to 2002/03). We classified seasons and calculated the number of hospital admissions and deaths occurred during corresponding seasons using Curwen's method (Curwen M. Health Trends. 1990/1991); [winter = December- March: Winter excess = admissions/deaths in {winter - ½ (preceding 4 autumn months + following 4 summer months)}]. We stratified the analysis by stroke subtypes based on computerised tomography findings. RESULTS Total number of admissions = 5484 (men = 2488, 45%), total number of deaths = 1585. Table 1 shows the total number of admissions and deaths by seasons. CONCLUSION Non-haemorrhagic and subarachnoid haemorrhage showed persistent winter excess in hospital admissions and deaths in our population. Although this study is limited by the number of cases with undetermined stroke subtypes, the fact that non-CT scan rate is higher in older age group, and the rate of CT is unlikely to be influenced by season suggest that a similar pattern of admissions and deaths showing winter excess in the undetermined group may be largely contributed by non-haemorrhagic stroke subtype.

 
http://www.esc-archive.eu/bologna05/b_graphic/t_19.htm

Management and economics     Poster Session II
Date: Friday, 27 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

13
Ensuring national standards of practice are evidence-based and up-to-date – the National Clinical Guidelines for Stroke. 2nd Edition.
P. Irwin    A.G.Rudd                                                        
The Intercollegiate Stroke Working Party

Royal College of Physicians

UNITED KINGDOM

Background: The growing research evidence in stroke requires guidelines to be continuously updated. Following publication of the Royal College of Physicians stroke guidelines in 2000, the working party responsible continued. An up-date supplement was issued in 2002, and the 2nd edition in 2004. Methods: As with the first edition, the AGREE (Appraisal of Guidelines Research and Evaluation) collaboration www.agreecollaboration.org/ criteria were used. Therefore systematic literature searches and reviews, using the SIGN methods (www.sign.ac.uk/) were conducted, and the guidelines circulated for peer review before final agreement. Dissemination and implementation interventions were key elements in the strategy. Results: New Cochrane reviews and important research had been published in recent years with major implications for practice. Stroke units are still at the heart of care. Recommendations for acute care now include: expedited management of transient ischaemic attack; how thrombolysis should be used; proactive management of physiological parameters; and more aggressive secondary prevention. In rehabilitation, new recommendations highlight possible management strategies for specific cognitive impairments; and when new therapies may be appropriate eg treadmill training, constraint induced movement therapy. Dissemination included the published guidelines and supporting evidence; discipline-specific concise guides; a patient information booklet; and the web version (www.rcplondon.ac.uk/pubs/books/stroke). The new recommendations were promoted at regional multidisciplinary workshops. Discussion: The work involved in keeping guidelines current is considerable, but will continue. The extent to which they are implemented will be measured by the national audit every two years.

Acute stroke: treatment concepts     Poster Session I
Date: Thursday, 26 May 2005   Time: 7:30- 8:30 -  Room: Padiglione(Pavilion)
Chair:  

14
Cerebrolysin in Acute Ischemic Stroke: results of randomized, double blind, placebo-controlled study
V.I.Skvortsova    N.A.Shamalov    L.V.Stakhovskaya    L.V.Gubsky    I.V.Tikhonova    A.S.Smichkov                            
 

Dep. of Fundamental and Clinical Neurology, Russian state Medical University

RUSSIAN FEDERATION

Purpose of this randomized, double blind, placebo-controlled study was to assess the safety and the efficacy of the neuroprotective drug Cerebrolysin in acute ischemic stroke (IS). Cerebrolysin (Cer) is peptidergic drug which in many ways mimics the effects of neuronal growth factors and which has shown promise in earlier experimental and clinical stroke studies. Methods: Thirty-six patients with IS in carotid artery territory were eligible for inclusion in the trial if they were admitted to the clinic within the first 12 h after IS onset. Individual random and blind assignment was performed on patients to receive treatment with Placebo (n=12) or one of two dosages of Cer: 10 ml/d (n=12) and 50 ml/d (n=12) for 10 days with concomitant standard basic treatment in each group. Neurological status was assessed by the NIHSS, the modified Rankin Scale (mRS) and the Clinical Global Impression Score (CGIS), the functional outcome was assessed by the Barthel Index (BI). MRI was conducted at 0.15 T MR-scanner with the using of FLAIR for calculation of the infarction volume (IV) by "Osiris-3.1" software on days 1, 3, 10 and 30. EEG, mapping EEG and 3-dimensional Brain Loc EEG analysis were performed on days 1, 3, 6, 10, 30 after IS onset. Results: Marked side effects or adverse events were absent. The Cer had not provoked any paroxismal activity on EEG. It was revealed the acceleration of clinical improvement (by the CGIS, mRS and BI) in the 50 ml/d Cer group on day 30 (p<0.05 vs. Placebo). The significant reduction in IV was shown in the both Cer groups (p<0.05 vs. Placebo) up to days 3 and 30. Acute pharmacological test revealed the decreasing of the size and spreading of delta and tetha focus in the 50 ml/d Cer group (p<0.05 vs. Placebo). In the 10 ml/d Cer group the increase in power of alpha band was revealed only in the intact hemisphere, while in the 50 ml/d Cer group that was demonstrated in both hemispheres. Conclusion: The trial demonstrated that Cer is safe and well-tolerable in treatment of IS and can exert certain favourable clinical effects, that is accompanied by its significant positive influence on IV and EEG pattern.

Epidemiology of stroke Oral Session 1A    
Date: Thursday, 26 May 2005   Time: 12:40 - 12:50 -  Room: Europauditorium
Chair: B. Pieschowski-Jozwiak, Poland and P. Rothwell, UK

11
Incidence of Ischemic Stroke in Sta. Coloma de Gramenet, Spain.
M.T.ALZAMORA    M. SORRIBES    J. SANCHEZ    A. HERAS    R. MORROS    R. FORES    M.LL.VICHETO      STUDY GROUP ISISCOG              
 

INSTITUT CATALA DE LA SALUT

SPAIN

Background and Purpose We sought to investigate the incidence of ischemic stroke, stroke subtypes, case fatality and disability at 90 days in a prospective 1-year community-based study in an urban area of Barcelona(Sta. Coloma de Gramanet)(January -December 2003). Methods All strokes admitted in the two hospitals or seen by GPs covering this community were recorded.Every patient underwent an in-hospital complete clinical evaluation. Systematic investigations included neuroimaging (CT/MRI) and vascular studies (duplex scan/MR angiography).Stroke subtype was classified following the TOAST criteria, and disability according to the Barthel index (BI).Incidence rates with 95% confidence interval (CI) were calculated for sex and age bands. Results A total of 196 ischemic strokes were registered (107 men/89 women; mean age 74, range 39-98) during study period. Crude annual incidence for first-ever ischemic stroke was 138/100,000 (95% CI, 116-159) and attack rate incidence (new and recurrent strokes) was 169/100,000 (95%CI, 145-192). After age-adjustment to the European population , incidence rate was 128 (95% CI,109-146) per 100,000 inhabitants; in men 160 (130-191) and in women 90 (70-109).The incidence of stroke increased with age. Stroke subtype was lacunar 28.8% (95% CI, 22.1-35.5), atherothrombotic 18.6% (95% CI, 12.9-24.4), cardioembolic 26.6% (95% CI, 20.0-33.1) and undetermined 26.0% (95% CI, 19.5-32.4). Case-fatality at 90 days was 12% (95% IC:7-17), and, among survivors, severe disability was present in 19.4% (BI,<60), moderate disability in 25.2%(BI, 60-90) and mild disability in 55.5%(BI, >90). Conclusions Stroke incidence was high in our community, notably in the older age subgroups, suggesting that rather than declining, stroke is only being postponed until later in life. Low fatality rate could be explained by a general improvement in acute stroke care and registration of milder strokes. Key words: epidemiology, incidence, stroke.

Venous diseases     Poster Session III
Date: Saturday, 28 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

02
PAI-1 4G/4G genotype is a risk factor for cerebral venous thrombosis
C. Lichy    K. Reuner    T. Dong-Si    P. Reismann    J. Genius    A. Grau    C. Grond-Ginsbach                     
 

Department of Neurology University of Heidelberg Germany

GERMANY

Background and Purpose The plasminogen activator inhibitor 1 (PAI-1) is an important inhibitor of endogenous fibrinolysis. The 4G/4G genotype of a 4G/5G polymorphism in the promoter of the PAI-1 gene has been shown to be associated with increased plasma levels and with risk of peripheral venous thrombosis. We investigated whether the 4G/4G genotype is also a risk factor for cerebral venous thrombosis (CVT), a rare but life threatening condition affecting mainly young women. Subjects and methods We performed a case-control-study including 17 consecutive patients with spontaneous CVT and 184 age- and sex-matched controls randomly selected from the population of the same region in South Germany. CVT was diagnosed by pathognomonic findings in MRI or angiography. In all subjects, the PAI-1 4G/5G polymorphism genotype was determined by allele-specific PCR amplification. Further, all participants underwent a standardized interview on established risk factors for CVT and genotyping for FV Leiden and the prothrombin G20210A polymorphism. For comparison of genotype distribution between groups, Fisher's two-sided test was used. Results Nine out of 17 patients (53%) and 40 out of 184 controls (22%) were found to be homozygous for the 4G allele of the PAI 4G/5G polymorphism. This translates into an odds ratio of 4.05 (95%CI 1.47-11.18; p=0.0076) for CVT in carriers of the 4G/4G genotype. Homozygosity for the PAI-1 4G/5G polymorphism was the strongest risk factor among all variables investigated in this study. The PAI-1 genotype distribution in controls was consistent with that described in healthy European populations by other studies. Conclusion In our study, the 4G/4G genotype of the PAI-1 4G/5G gene polymorphism was significantly associated with a high risk for CVT. This finding warrants confirmation by a larger multi-centric approach, especially to detect potential interactions with other prothrombotic genetic variants.

Meta-analysis and review papers Oral Session 1A    
Date: Thursday, 26 May 2005   Time: 11:30 - 11:40 -  Room: Sala Azzura
Chair: J. E.Rinkel, The Netherlands and P. Sandercock, UK

04
Botulinum Toxin in the Treatment of Spasticity of the Upper Limb: a Systematic Review of the Literature
T. Sycha    K. Elwischger    E. Auff    E. Fertl                                          
 

Department of Neurology, Medical University of Vienna

AUSTRIA

Background Botulinum toxin (BTX) has been used for the management of focal spasticity since several years, but data on treatment outcomes in upper limb spasticity (ULS) are scarce. With this systematic review we set out to assess the efficacy of botulinum toxins versus systemic myotonolytic agents, functional therapy, placebo, or no treatment in reducing spasticity and secondary limitations of function. Methods We searched the bibliographic databases MEDLINE, EMBASE, and the Cochrane Library from 1985 up to May 2004. We also reviewed the reference lists from identified articles and booklets of scientific congresses in the field of neurology. Randomised controlled trials (RCTs) testing any dose of BTX for ULS caused by stroke, traumatic brain injury or multiple sclerosis, and describing functional improvement and subjective pain assessment as either the primary or a secondary outcome, were included in this review.All trials were quality scored and two independent reviewers extracted data. Main results Within 112 relevant citations we identified ten RCTs dating from 1996 to 2004. Nine RCTs reported on BTX type A, including 413 patients suffering from chronic post-stroke ULS and 37 patients with other reasons for chronic ULS. There was a single RCT testing BTX type B in chronic post-stroke spasticity of the upper limb. No RCT addressed the question of early versus late initiation of BTX treatment after stroke. For nine RCTs the control condition was intramuscular injection of placebo, for one RCT a different dilution of the same BTX dose. Pre – post modified Ashworth scores were measured in all studies. Reviewers' conclusions There is substantial scientific evidence for the efficacy of BTX-A in the reduction of chronic ULS caused by stroke. However, there is still more work to be done in terms of optimal timing of BTX treatment after stroke, and in ULS caused by other cerebral disorders.

Acute stroke: complications and early outcome     Poster Session II
Date: Friday, 27 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

11
PROTECT - Prophylaxis of Thromboembolic Complications in Acute Ischemic Stroke with Certoparin
H.C.Diener    E.B. Ringelstein    R. von Kummer    H. Landgraf    I. Rektor    A. Csanyi    D. Schneider    J. Klingelhöfer    J. Brom    G. Weidinger
 

Dep. of Neurology, University Hospital Essen, Germany

GERMANY

Background: Venous thromboembolic complications (VTE) are a major cause of morbidity and mortality after acute ischemic stroke. Without thromboprophylaxis, deep vein thrombosis (DVT) occurs in approximately 70% of patients and up to 5% suffer a fatal pulmonary embolism (PE). Methods: PROTECT was a multicenter, randomized, double-blind trial comparing certoparin (1x3000 U anti-factor Xa/day s.c.), a low-molecular-weight heparin, with unfractionated heparin (UFH, 3x5000 U/day s.c.). Treatment was started within 24 hrs after onset of stroke symptoms and lasted for 12-16 days. Stroke severity was defined by a score on the National Institute of Health Stroke Scale between 4 and 30. Patients had mild-severe paresis of a leg. The objective was to show non-inferiority of certoparin to UFH for the prevention of thromboembolic complications in acute ischemic stroke. Efficacy endpoint was a composite outcome consisting of proximal DVT screened by repeat duplex scan, non-fatal PE or death related to VTE during treatment. Endpoints were centrally verified. Results: Overall 272 patients were randomized to certoparin and 273 to UFH. The per-protocol analysis revealed a rate of 7.0% of patients with VTE in the certoparin group vs. 9.7% in the UFH group, thereby proving the non-inferiority (p=0.0011), which was confirmed by intent-to-treat analysis (p=0.0008). Fatality rates during treatment were identical in both treatment groups (2.6%). CT scan was performed at trial entry, after 7 days and on clinical deterioration. Major bleeding occurred in 3 patients of the certoparin group (1.1%) compared to 5 patients of the UFH group (1.8%). Discussion: PROTECT has proved that certoparin is at least as efficacious and safe as UFH for prevention of VTE in patients with acute ischemic stroke.

Vascular imaging – new developments     Poster Session I
Date: Thursday, 26 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

07
Duplex scanning value in the early diagnosis of cervical vertebral arteries dissections. A case control study.
C. Alecu    J.M.de Bray    X. Ducrocq    J.O.Fortrat    F. Dubas    H. Vespignani                            
 

CHU Nancy

FRANCE

Background and purpose: Duplex scanning (DS) diagnostic value for the cervical vertebral dissection (CVAD) is still discussed. The aim of this study was to search if some ultrasonographical aspects can be specific for this diagnosis. Method: Two experienced sonographists compared retrospectively the DS examinations of 24 early certain CVAD patients and 24 age, centre and gender controls, with search of nine items considered in the descriptive studies as suggestive for the diagnosis (intimal flap, tapering occlusion, eccentric residual channel, localized ectasis, biphasic signal, low/absent diastolic velocity, systolic slowdown, systolic notch, lack of atheromatous changes). Results: Lack of atheromatous changes was the most common sign in CVAD (p<.003). An extended stenosis with eccentric residual channel and/or localized ectasis, significantly more frequent in CVAD in simple analysis (p<.02), without false positive, was not significant after Yates correction (p=0.065). Conclusion: This series does not find specific signs of CVAD, but suggest the value of eccentric residual channel and localized ectasis aspects for the early DS CVAD diagnosis.

Epidemiology of stroke     Poster Session III
Date: Saturday, 28 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

25
Regional differences in stroke care delivery in Poland depend on size of the city.
M. Mazurkiewicz    M. Niewada    A. Kobayashi    A. Czlonkowska                                          
 

2nd Department of Neurology

POLAND

National Stroke Prevention and Treatment Program was one of health programs in Poland. The first step analysis of data collected in the Program Registry revealed that there are significant differences in stroke care delivery in participating units. This work is to establish, whether regional gaps in stroke care delivery in Poland depend on the size of the city . Data in the Registry were collected on stroke risk factors, time and state on admission, drugs and medical procedures implemented and outcomes during 2001 and 2002. 26 centers, which reported more than 200 patients and at least 50% of stroke patients admitted in observation period, were analyzed. They were divided in two groups: units from large cities (over 100 thousand inhabitants) and from rural areas (under 100 thousand inhabitants) and than compared. There were 11 large cities (17 centers- 6 from Warsaw) and 9 small (9 centers). Total number of 10 141 stroke patients were recorded in the Registry. 3650 were hospitalized in small city and 6301 in large city centers. There were no differences in gender and mean age between the groups. There were differences in prevalence of risk factors, time from stroke onset to admission (47% in small and 40% in large cities were admitted under 6 hours). Patients from small cities had a mean of 3,5 Rankin score on admission, and those in large cities had 3,2. CT scan on admission was performed in 19% of cases in small and in 35% of cases in large cities. Large city patients also had rehabilitation more often after stroke (81% vs 74%). There are significant differences in stroke risk factors prevalence and in stroke care delivery between large and small centers. Despite the differences situation should be improved in both large and small cities.

Epidemiology of stroke     Poster Session III
Date: Saturday, 28 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

09
Vulnerability of extreme old age to excess inpatient mortality due to stroke in colder weather
P.K.Myint    R.A.Fulcher    S.L.Vowler    O. Redmayne                                          
 

Department of Medicine for the Elderly, Norfolk and Norwich University Hospital, Norwich and Centre for Applied Medical Statistics, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK

UNITED KINGDOM

BACKGROUND We investigated the mortality from stroke following admission to a District General Hospital in colder weather. METHODS We analysed a hospital stroke register (catchment population = 568,000) for 6 seasonal years (1997/98-2002/03) using Curwen's method (Curwen M. Health Trends 1990/91); winter deaths [winter = December- March: Winter excess = deaths in {winter - ½ (preceding 4 autumn months + following 4 summer months)}]. We performed stratified analysis by (1) quartiles of patients' age and (2) seasonal year. Deaths were counted as occurring during the season corresponding to admission rather than death. RESULTS Total number of deaths = 1721 out of 5484 stroke admissions. Table 1 shows the winter excess in deaths due to stroke/its complications by quartiles of age. Table 2 demonstrates the winter excess of inpatient death by seasonal year. CONCUSION Winter excess in inpatient mortality due to stroke is variable. However, increasing age appeared to be related to an increased number of deaths associated with a winter admission. Extreme old age appears to be an important factor contributing to mortality from stroke associated with a winter admission.

 
http://www.esc-archive.eu/bologna05/b_graphic/t_20.htm

Longterm outcome of stroke Oral Session 1B    
Date: Friday, 27 May 2005   Time: 16:45 - 16:55 -  Room: Sala Maggiore
Chair: JP Mohr, USA and E. Özdemir, Türkey

16
Tandem carotid artery/middle cerebral artery occlusion: the prognosis depends on the site of the carotid artery occlusion
J. Eggers    H. Canguer    G. Seidel                                                 
 

Neurology, University Hospital of Schleswig-Holstein, Campus Luebeck

GERMANY

Background: An additional occlusion of the ipsilateral internal carotid artery (ICA) has been reported to worsen the prognosis in case of acute middle cerebral artery (MCA) occlusion (tandem ICA/MCA occlusion). We evaluated whether the site of ICA occlusion, proximal or distal, has an impact on the prognosis. Methods: Acute ischemic stroke patients were examined by extracranial and transcranial duplex sonography for the presence of MCA and ipsilateral ICA occlusion. In case of ICA occlusion the site of the occlusion was defined based on extracranial ultrasound findings as proximal (prICA), distal occlusion/severe stenosis (dICA) or none occlusion of the ICA. The patients were followed-up regarding ICA and MCA recanalization and clinical course up to 3 months. Results: A total of 79 patients with acute ischemic stroke due to occlusion of the main stem segment of the MCA (MCA-M1) were studied (mean NIHSS 17.3±3.6, mean age 61.9±11.8 ys). An additional prICA was found in 19 cases (24.1%) and an additional dICA in 12 (15.2%) cases. A subgroup of 57 received intravenous thrombolysis with tissue plasminogen activator (TPA), and 19 patients of these additionally continuous insonation of the MCA-M1 for ultrasound enhanced thrombolysis (US+TPA). The National Institutes of Health Stroke Scale (NIHSS) at baseline, after 1 and 4 days were significantly lower in patients with prICA compared to the patients with MCA-M1 occlusion alone or dICA. After 3 months, favourable outcome (mRS of 0,1) was significantly more frequent in prICA (31.6% vs. 4.8%, p=0.003) than the other patients and was less frequent in dICA compared solely to prICA (p=0.007). This was also true for the subgroups undergoing TPA and US+TPA. Conclusion: Patients with a tandem prICA/MCA-M1 occlusion have a lower baseline NIHSS and recover better than patients with acute MCA-M1 occlusion alone or additional dICA. This might be due to improved collateral flow or ischemic tolerance induced by pre-existing arteriosclerotic ICA stenosis or occlusion. Bad outcome in tandem ICA/MCA occlusion is affiliated only with distal ICA occlusion.

Chronic conditions and recurrences     Poster Session III
Date: Saturday, 28 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

02
Disturbances of hormones of renin-angiotensin, hypothalamic-pituitary-adrenal and thyroid axes in patients with chronic brain ischemia
I.A.Platonova    I.V.Ostrovtsev    T.V.Tvorogova    V.I.Skvortsova                                          
 

Department of Fundamental and Clinical Neurology, the Russian State Medical University, Moscow

RUSSIAN FEDERATION

Background and Purpose: Prospective studies have shown that neuroimmunoendocrine system is the main regulatory meta-system for all physiological and pathological processes. Nowadays a vital role of neuroendocrine response to acute brain injury is well known. The purpose of this investigation was to evaluate role of endocrine changes in pathogenesis of chronic brain ischemia (CBI). Methods: The study was performed in 39 patients with CBI caused by atherosclerotic encephalopathy, who had no endocrine, autoimmune and inflammatory disorders. A healthy control group consisted of 20 age- and sex-matched persons having neither plaques nor stenosis of the carotid arteries by duplex examination. Concentrations of thyroid-stimulating hormone (TSH), free triiodothyronine (fT3), free thyroxine (fT4), renin, aldosterone, cortisol and adrenocorticotropic hormone (ACTH) were studied in blood plasma by radioimmune assay. Results: We found the statistically significant lower renin activity as well as a tendency to higher level of cortisol in blood plasma of patients with CBI vs control (p=0.03; p=0.062, respectively). The significant lower plasma level of TSH and tendency toward lower plasma concentrations of fT3 and fT4 were revealed in patients with CBI vs control group (p=0.04; p=0.12; p=0.09, respectively). There was also a strong negative correlation between levels of fT3 and fT4 in examined patients (r= -0.71; p=0.036). Conclusion: The data establish that endocrine changes are involved in the development of CBI. As pro-inflammatory cytokines are triggers of similar endocrine reactions in acute stroke, we can speculate about participation of inflammatory factors in development of revealed hormonal changes in patients with atherosclerosis encephalopathy who had no other disorders.

Experimental studies Oral Session 1B    
Date: Thursday, 26 May 2005   Time: 16:35 - 16:45 -  Room: Sala Topazio
Chair: P. Wester, Sweden and V. Skvortsova, Russian Federation

15
Semax and PGP increase BDNF expression in ischemized rat’s brain
I. Platonova    V. Dergunova    A. Stavchanskii    A. Botsina    T. Tvorogova    E. Shaykhutdinova    S.  Limborska    V. Skvortsova              
 

Dept of Fundamental and Clinical Neurology, Russian State Medical University

RUSSIAN FEDERATION

Background: It was revealed that expression of brain-derived neurotrophic factor (BDNF) was increased by Semax administration (synthetic fragment of adrenocorticotropic hormone – ACTH 4-10) in rats’ cultured glial cells. Purpose: To analyze the effect of Semax and its C-terminal fragment Pro-Gly-Pro (PGP) upon BDNF expression within cerebellum and forebrain cortex of the rats subjected to global brain ischemia. Methods: After 15 min of global ischemia the animals (n=36) were subjected to intraperitoneal injection of Semax (100 mg/kg in 0.5 ml of 0.9% NaCl) or PGP (37,5 mg/kg in 0.5 ml of 0.9% NaCl) or 0.5 ml of 0.9% NaCl only. Sham-operated animals were used as a control group. Animals were decapitated 30 min /1 h / 2 h after the operation. BDNF mRNA expression level was assessed in forebrain cortex and cerebellum by semi-quantities PCR. BDNF PCR signals were normalized to the corresponding RT product GAPDH signal. BDNF and GAPDH PCR signals were analyzed for two cDNA samples of each rat. Results: The ischemized rats treated with 0,9% NaCl did not demonstrate the difference between BDNF expression levels within forebrain cortex or cerebellum vs control group (p>0.05). At the same time, expression level of BDNF within investigated regions of the animals treated with Semax and PGP was significantly increased (p<0.01 vs control in all comparisons) with maximum of expression at 30 minutes after occlusion. Conclusion: Previously trustworthy effects of Semax on mechanisms of local inflammation, abundant NO synthesis and oxidative stress were detected in experimental models of cerebral ischemia. Here we demonstrated that other positive contribution of Semax is mediated by the rise of BDNF production in ischemized rat’s brain, and PGP keeps its neuroprotective properties.

Risk factors of stroke     Poster Session III
Date: Saturday, 28 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

13
Effects of Stroke Risk Factors and Etiology on C-Reactive Protein Increase in Acute Ischemic Stroke
D. Shin    Y. Lee    S. Jeon                                                 
 

Department of Neurology, Gil Medical Center, Gachon Medical School

SOUTH KOREA

BACKGROUND: The role of inflammation in the pathogenesis of ischemic stroke is unclear. C-reactive protein(CRP) in acute stroke may reflect the ischemia lesion itself or the cormobid risk factors for stroke. The aim of the study was to identify the association between CRP and the risk factors and the etiology for stroke and early stroke outcome. PATIENTS AND METHOD: Out of 980 consecutive acute stroke patients, 750 cases uncomplicated by infection. CRP test material was obtained within 24 hours of stroke onset. Stroke severity was assessed by the National Institutes of Health stroke scal (NIHSS) on admission and 7 days, 1 month. Analysis was based on TOAST classification and novel risk factors for stroke; hypertension, diabetes mellitus(DM), hyperlipidemia, cigarette smoking, heart disease, previous stroke history. RESULT: The CRP level increased significantly higher in the patients with hypertension, hyperlipidemia, smoking than those with DM and, also with large artery disease than with cardioembolism and small artery occlusion. The recurrent stroke patients had higher CRP levels than the patients with first-ever stroke. There was no difference in CRP distributions between the patients with and without early clinical worsening. CONCLUSION: The level of CRP increase within the first 24 hours in the patients with stoke was contributed by the pre-existing risk factors for stroke and etiology.

Acute stroke: markers in early diagnosis     Poster Session II
Date: Friday, 27 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

12
HEADACHE AND NECK PAIN : THE WARNING SYMPTOMS OF SPONTANEOUS INTERNAL CAROTID AND VERTEBRAL ARTERY DISSECTIONS
A. Pieri    R.A.Valiente    M.M.Alves    G.S.Silva    M.S.Rocha    A.A.Gabbai    A.R.Massaro                     
 

Federal University of São Paulo/Escola Paulista de Medicina

BRAZIL

Introduction:Headache is one of the main complaints of patients seeking medical attention in the emergency room. This prevalent symptom can herald the onset of many cerebrovascular diseases, including spontaneous internal carotid and vertebral artery dissections (IC/VAD). Methods:We studied the main clinical features of headache and neck pain through a comprehensive protocol to determine the patterns of headache and the clinical presentation in patients with IC/VAD evaluated at Hospital São Paulo, from Jan 2001 to May 2004. Results: Among 46 patients with IC/VAD, headache occurred in 78% of patients. Of those 36 patients, 25 presented vertebral dissection (VAD) and 11 internal carotid dissection (ICD). The mean age of our patients was 41 years and most of them were white (83%). Males predominated in the VAD group (p=0.05) accounting for 68% of the patients. The majority of patients had no past history of the modifiable stroke risk factors, however, smoking and alcohol abuse were found in 53% and 36%, respectively. Oculosympathetic paresis was present in 13 patients. The mean delay to the ischemic events was 2.9 days (3.4 days CAD; 2.7 days VAD; range 1 hour to 1 week). A history of previous migraine was found in 60% of patients. The location was also significantly different (p<0,001) between CAD and VAD. VAD usually presented with a focal subocciptal and ipsilateral pain mimicking SAH. Conclusion: A high degree of suspicion is essential for diagnosis of IC/VAD and may help to early recognition and possible treatment, hopefully prior to an ischemic event. This is particularly important in young white patients with few vascular risk factors and with no past history of a similar focal severe ipsilateral headache or neck pain in addition to a oculosympathetic paresis.

Experimental studies     Poster Session II
Date: Friday, 27 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

11
Nicotinic receptors in the dorsal facial area regulate blood flow of the common carotid artery in the cat.
J.S.Kuo                                                               
 

Institute of Pharmacology and Toxicology Tzu Chi University

TAIWAN

Background: Glutamate-stimulation of the dorsal facial area (DFA) in the medulla increases blood flows of the common carotid artery (CCA) (Kuo et al., 1987) and various brain regions (Kuo et al., 1995) in the cats. Purpose: We attempted to determine the involvement of nicotinic acetylcholine receptor (nAChR) subtypes in the DFA for regulation of the CCA blood flow. Methods and Results: Microinjections at doses of 10, 20, 40, 80, and 160 nmol of nicotine (a non-selective nAChR agonist) or choline (a selective α7- nAChR agonist) into the DFA elicited a dose-dependent increase in the CCA blood flow. Nicotine (40 nmol)-induced increases in the CCA blood flow were dose-dependently attenuated by prior microinjections of 0.02, 0.04, and 0.08 nmol α-bungarotoxin (an α7-nAChR antagonist), 0.025, 0.05, and 0.1 nmol methyllycaconitine (an α7-nAChR antagonist), 1.0, 2.0, and 4.0 nmol mecamylamine (a relatively selective α3β4-nAChR antagonist) and 0.25, 0.5, and 1.0 nmol dihydro-β-erythroidine (a relatively selective α4β2-nAChR antagonist) in the DFA. Choline (80 nmol)-induced increases in the CCA blood flow were dose-dependently attenuated by pretreatment, at the same dose ranges as above, of α-bungarotoxin and mecamylamine, but not by pretreatment of dihydro-β-erythroidine in the DFA. Microinjections of muscarinic agonists, 10 nmol muscarine and 20 nmol methacholine, did not affect the basal nor the nicotine-induced increase in the CCA blood flow. Discussion and Conclusion: Functional α7, α4β2, and α3β4 subunits of the nAChR appear to be present on the DFA neurons. Activations of these receptors increase the CCA blood flow. The present findings do not preclude the presence of nAChRs subunits other than α7, α3β4, and α4β2. Muscarinic receptors, if any, on the DFA are not involved in regulation of the CCA blood flow. The putative roles of various subtypes of nAChRs in the DFA may be important in regulation of the CCA and possibly the cerebral blood flows.

Risk factors of stroke     Poster Session III
Date: Saturday, 28 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

41
The study of relationship between Lipoprotein(a),CRP and fibrinogen with stroke
S.A.Sadreddini    A.A.Abolfathi    A. Lakian                                                 
 

The study of relationship between Lipoprotein(a) CRP and Fibrinogen with stroke

IRAN

Summary: Background: stroke is a leading cause of morbidity and mortality in most developed nations. Various risk factors have been known are associated with stroke. The aim of this study was to find out among different risk factors which one is mostly prevalent. Methods: this study was performed as descriptive and analytical. Prospectively about the patients with stroke admitted in neurology wards during 2002-2003 years. 100 Ischemic stroke (IS) patients consist of 46 man and 54 women with mean age of 67 ± 15 and 100 age and sex matched apparently healthy subjects were studied. Plasma levels of C. Reactive protein (CRP); fibrinogen, platelet counts, Lipoprotein(Lp (a)) High Density Lipoprotein cholesterol(HDL-C), Law Density Lipoprotein cholesterol (LDL-C), total cholesterol (TC) and Triglycerides(TG). Were measured in patients and controls Background disease was also investigated in the patients. Results: mean plasma levels of LP (a), TC, TG, CRP and LDL-C were significantly higher in IS groups compared with controls (p< 0.05). But these were no significant deference for HDL-C and platelets count (p > 0.05). The prevalence of background disease in IS patients were hypertension (78%) hyperlipidemia (62%) Cardiovascular disease (38%) type 2 Diabetes Mellitus (24%), smoking (20%) and previous stroke (18%). Conclusion: It was concluded that hypertension was the most prevalent background disease in IS patients. It was also found that although there is close relationship in incidence of IS with level of LP (a), TC, TG, LDL-C and CRP but regarding to cut off point frequency of at least fibrinogen, CRP, LP (a), Platelets count from patient to patient was variable. Key words: Stroke, lipid profile, LP (a), CRP, Platelet count, fibrinogen, background disease.

Clinical Trials Oral Session 1A   Poster Session III
Date: Saturday, 28 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

02
THROMBOTRIPSY STUDY – CASE CONTROL STUDY
D. Skoloudik    M. Bar    O. Skoda    D. Vaclavik    G.M.von Reutern    J. Allendoerfer    P. Hradilek                     
NAIS study collaborators

University Hospital Ostrava BMA Ostrava Hospital Pelhrimov Asklepios Kl. Bad Salzhausen

CZECH REPUBLIC

In the study we want to document safety and efficacy of acceleration of thrombolysis by ultrasound (thrombotripsy) in acute stroke patients using TCCS and 2 MHz probe. Methods: During 30 months 52 pts with acute occlusion of M1- or M2-MCA were treated by TCCS thrombotripsy. 15 pts received also systemic thrombolysis, 6 pts high dose heparin and 31 pts had aspirin only. Diagnostic TCCS was performed after arrival to the hospital, 1 hour after starting therapy, at 6th and at 24th hour after stroke onset. TCCS results we divided into complete, partial or no recanalization of intracranial arteries. In all patients we recorded all adverse events. Control group with the same inclusion and exclusion criteria was chosen from NAIS study database. Chosen controls had the same location of occlusion, initial NIHSS, therapy except thrombotripsy, time to therapy, age and gender as cases. Results: 52 pts in thrombotripsy group and 52 controls was chosen to comparison (mean age 62 y, mean NIHSS 14,5, 8 ICA-MCA occlusions, 25 M1- and 19 M2-MCA occlusions). In both groups 15 pts received rtPA. In trombotripsy group we detected significantly higher number of recanalized arteries at 6th hour (73% vs. 10% pts). Improvement of NIHSS during first 7 days was not significantly different (-5,7 vs -5.0 points) but in Rankin score there was significant improvement at day 90 (Rankin 2.44 vs. 3.15). At day 90 in thrombotripsy group 59.2% pts had Rankin 0-2 vs. 34.6% pts. in control group (p<0.01) . 4 pts in thrombotripsy group had severe complications, 2 pts symptomatic hemorrhage (3.9%) and 2 pts symptomatic brain oedema. Conclusion: Thrombotripsy seems to be an effective therapeutic procedure for acceleration of recanalization MCA occlusion within 6 hours after stroke onset with significant improvement of outcome at 3 months.

Acute stroke: complications and early outcome Oral Session 1B    
Date: Thursday, 26 May 2005   Time: 16:45 - 16:55 -  Room: Sala Italia
Chair: M. Brown , UK and M. Kaste, Finland

16
SERUM CREATININE LEVELS AS A PROGNOSTIC FACTOR OF SURVIVAL IN ELDERLY PATIENTS HOSPITALIZED WITH ACUTE STROKE.
A.D.Efstratopoulos    S.M.Voyaki    M.A.Meikopoulos                                                 
 

General Hospital of Athens " G. Gennimatas"

GREECE

Aim of the present study was the investigation of serum creatinine levels and all possible cardiovascular risk factors as determinants for poor outcome in elderly patients with acute stroke. Methods : We studied 221 patients ( 104M/117F), hospitalized with acute stroke in our Depts. All patients underwent a brain CT-scan at entry or within 48 hours after stroke. Only patients with neurological deficit and ischaemic infarct were included. All possible cardiovascular risk factors were recorder. Serum creatinine (Scrt) and other biochemical parameters were measured. Results :The mean age was 81.8±5.2 ( ranged 74-100 years old) and Scrt : 1.2mg/dl (0.4-7.3). At entry 178 patients (80.5%) had normal renal function (Scrt<1.4mg/dl), 26 ( 11.7%) had mild renal dysfunction (Scrt: 1.4-2mg/dl), 11 patients (7.7 %) had moderate renal dysfunction( Scrt >2.0 and <4.0 mg/dl) and 6 (2.7%) severe renal dysfunction (Scrt>4.0mg/dl). 113 (51%) were hypertensives under antihypertensive treatment, 55 patients (24.8%) had diabetes mellitus (DM), 64 (28.9%) had CHD, 58 ( 26.2%) previous stroke and 38 (17.9%) atrial fibrillation. Patients with DM had higher Scrt levels in comparison to patients without DM (1.43+/-0.49 vs 1.12+/-0.48, p=0.000). The hospitalization period was 7.9+/-6.3 days. Among 221 patients with acute stroke 39 (17.6%) died, 55 (24.8%) remained with neurological deficit and 127 (57.4%) improved. The 39 patients with poor outcome were older in comparison to patients who discharged ( 83.3+/-5.6 vs 81.4+/-5.1, P=0.045) and had higher Scrt levels ( 1.69±1.6mg/dl vs 1.14+/-0.53mg/dl, P=0.000). In a multivariate analysis after correction for all other cardiovascular risk factors the serum creatinine was the main determinant for poor outcome ( P=0.003). Conclusions : We conclude that in patients with acute ischaemic stroke, the serum creatinine levels at entry are a significant determinant for the outcome during the hospitalization period.

New clinical trials Oral Session 1A    
Date: Saturday, 28 May 2005   Time: 12:27 - 12:42 -  Room: Europauditorium
Chair: S. Davis, Australia and C. Warlow, UK

07
Preliminary Results of SAINT-1 Trial
K.R.Lees    J. Zivin    T. Ashwood    A. Davalos    S. Davis    H.C. Diener    J. Grotta    P. Lyden    A. Shuaib    W. Wasiewski
For the SAINT-1 Study Group

SAINT-1 Study Group

UNITED KINGDOM

Oral presentation!

Vascular imaging – new developments     Poster Session I
Date: Thursday, 26 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

05
Ultrasounds vs. histological assessment of fibrous cap thickness in carotids
M. Pusztaszeri    J.A.Lobrinus    P. Ruchat    J. Bogousslavsky    G. Devuyst                                   
 

Centre Hospitalier Universitaire Vaudois,(CHUV)

SWITZERLAND

Background : Fibrous cap thickness (FCT) may be implicated in unstable plaque pathology. The reliability of ultrasounds in assessing FCT and to correlate it to clinical symptoms of stroke is still debated. The goal of our study was to correlate ultrasounds FCT with histological FCT of internal carotid artery stenoses in symptomatic and asymptomatic patients. Methods : We assessed agreement between ultrasounds obtained FCT values and those measured histologically in 14 patients (7 symptomatic; 7 asymptomatic) who underwent carotid endarterectomy for stenoses over 70%. Imaging of ICA stenoses was performed by B-mode with a large band (5-12MHz) linear probe and served for analysis on a new semiautomatic ultrasounds system based on boundary detection by dynamic programming. Results: Agreement between histology and ultrasounds [mean difference % (limits of agreement)] was excellent for mean FCT [-1.4% (-5.8% to 3.1%)] and maximal FCT [-1% (3.2% to 1.3%)] and fair for minimal FCT [-3.4% (-15.3% to 8.1%)]. Ultrasounds showed that symptomatic plaques had thinner fibrous cap. The obtained values for ultrasounds mean, minimal and maximal FCT were lower in symptomatic compared with symptomatic patients. The decision threshold of 0.65mm (mean FCT) demonstrated the best correct classification rate of 82.8%. Positive and negative predictive value were respectively 75% and 88.2%. Conclusions: FCT measurement of carotid atheromas using ultrasounds is feasible. There is a good correlation between histological and ultrasounds FCT assessment. Discrimination of symptomatic from asymptomatic plaques using mean ultrasounds FCT values is good.

Interesting cases     Poster Session I
Date: Thursday, 26 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

13
Agenesis of the right carotid artery associated with Klippel-Feil syndrome. Case report.
M. Braga    P. Canovaro    M. Pederzoli    S. Beretta    G. Casati    P. Bazzi    M. Ferrarini    V. Crespi              
 

Ospedale Civile di Vimercate Department of Neurology

ITALY

Background The Klippel-Feil syndrome is one of the spinal malformations characterised by fusion of the cervical vertebrae. It is well known that the malformation can cause some neurologic disorders and that is associated to vascular abnormalities. However, agenesis of right internal carotid associated with the Klippel-Feil syndrome is extremely rare. Case report A 49 years-old woman came to our attention for recurrent transitory ischemic attacks presenting with weakness of left limbs associated with sensory abnormalities. Personal history was unremarkable and intelligence was normal. Neurological examination at the admission demonstrated mild left hemiparesis and tactile hypoesthesia at the left hemisoma. Brain magnetic resonance and magnetic resonance angiography demonstrated absence of the right internal carotid and the middle cerebral artery was filled from the basilar artery. Fusion of C3 and C4 vertebral bodies was also documented at magnetic resonance imaging and confirmed at spinal contrast enhanced CT scan. The day after the admission the neurological examination became normal. Ticlopidin was then started. Discussion Literature of vascular abnormalities in association with Klippel-Feil syndrome takes the form of anecdoctal reports. Aortic coartation, vertebral artery dissection, aneurysms, persistent trigeminal artery, abnormal origin of internal carotid are described. An unusual association of carotid internal agenesis and Klippel-Feil syndrome is reported with a literature review.

Cerebral haemorrhage and SAH Oral Session 1A    
Date: Saturday, 28 May 2005   Time: 8:40 - 8:50 -  Room: Sala Topazio
Chair: S. Davis, Australia and L. Caplan, USA

02
Follow-up screening after subarachnoid hemorrhage: frequency and determinants of new aneurysms and enlargement of existing aneurysms
M.J.H.Wermer    ICvan der Schaaf    BKVelthuis    A Algra    E Buskens    GJERinkel                            
for the ASTRA study group

University Medical Center Utrecht

THE NETHERLANDS

Background – Patients who survive after subarachnoid hemorrhage (SAH) may be at risk for new aneurysms. We studied the yield of screening in these patients and assessed risk factors for formation of new aneurysms and enlargement of aneurysms that were already present at time of the SAH. Methods - We screened 610 patients with CT-angiography (CTA) who had been admitted between 1985 and 2001 for SAH and in whom the ruptured aneurysm had been treated by clipping. Risk factors were evaluated by Cox regression analyses. Results – We detected 129 aneurysms in 96 (16%) of the 610 patients (mean follow-up 8.9 years). From the 129 aneurysms 24 (19%) were located at the clip from the previous operation and 105 (81%) were located at a new site. The CTA/angiogram at the time of SAH was available for review in 59 of the 105 new located aneurysms. Nineteen of the 59 aneurysms were de novo (32%) and 40 (68%) were in retrospect already visible. In addition to these 40 in retrospect present aneurysms, 22 other aneurysms were already known to be present. Of the 62 aneurysms that were followed over time, the original CTA/angiogram was available for review in 53. Of these 53 aneurysms 13 (25%) had enlarged. Risk factors for formation and enlargement of aneurysms were multiple aneurysms at time of SAH (HR 3.6, 95% CI 1.3-9.8), current smoking (RR 4.2, 95% CI 1.7-10.5) and a history of hypertension (RR 2.3, 95% CI 1.1-5.0). Discussion – Intracranial aneurysms should not be considered as a single event in a lifetime but rather as a continuous process. Patients with a previous SAH have a high risk for new aneurysm formation and enlargement of untreated aneurysms. Screening these patients might be beneficial, especially in patients with a high risk. The risks and benefits of screening however should be carefully weighed, for example in a decision model.

Cerebrovascular autoregulation     Poster Session I
Date: Thursday, 26 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

05
Cerebral Vasoreactivity by Transcranial Doppler and Brain SPECT in Patients with Unilateral Carotid Stenosis
J.H.Rha    J.K.Kim    Y.S.Shim                                                 
 

Inha University Hospital Neurology

SOUTH KOREA

Background and Purpose: Cerebral vasoreactivity (CVR) is known to be impaired in the area of insufficient hemodynamic circulation, but available information for its clinical interpretation is scanty. We tried to find the relationship of CVR with parameters such as stenosis degree, collateral pattern, and clinical outcome. Methods: This study was conducted prospectively in 37 consecutive patients with angiographically proven, hemodynamically significant, unilateral carotid stenosis. Relative change of cerebral blood flow (mean flow velocity) before and after acetazolamide challenge was calculated by transcranial Doppler (TCD), and the result was compared with single photon emission computed tomography (SPECT). The degree of stenosis and the pattern of collateral flow were estimated and classified by the conventional angiography. The presence of the cerebral infarct was decided by brain magnetic resonance image (MRI). Result: The CVR of middle cerebral artery (MCA) and internal carotid artery (ICA) was significantly decreased in the ipsilateral side to the carotid stenosis (p<0.05). The CVR impairment was more severe when cerebral infarct was already developed (p<0.01). There was a significant correlation between the degree of carotid stenosis and the CVR (p<0.01). In the area of impaired CVR by SPECT, the estimated CVR by TCD was significantly lower (p<0.05), even to the negative value, implying that there is actually steal phenomenon in that area. Conclusions: TCD is useful tool for the assessment of CVR, which can clue diverse clinical information from stenosis degree and collateral flow to clinical outcome. Acetazolamide challenge can actually decrease cerebral blood flow in the area of impaired CVR. So acetazolamide challenge should be performed very cautiously when there is a severe carotid stenosis because there is a possibility of developing hemodynamic stroke.

Experimental studies     Poster Session II
Date: Friday, 27 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

19
Thrombin as a mediator of ischemic neuronal death
M. de Castro Ribeiro    J. Badaut    M. Price    M. Meins    J. Bogousslavsky    D. Monard    L. Hirt                     
 

Neurology, CHUV, Lausanne

SWITZERLAND

Thrombin is a serine protease with dual effects on cell death and survival: It mediates apoptotic cell death at high concentrations in cultured astrocytes and hippocampal neurons and induces neuroprotection at low concentrations in the same cells. Recent evidence indicates that thrombin plays a role in ischemic cell death, as rats subjected to middle cerebral artery occlusion were protected by the intracerebral injection of hirudin, a selective thrombin inhibitor. We are using an in vitro approach to further characterise the mechanisms involved. Organotypic hippocampal slice cultures were subjected to a 30 minute oxygen (10%) and glucose (1mmol/L) deprivation (OGD). 24 hours after OGD, there was a marked increase in thrombin immunoreactivity on Western blots, showing for the first time that OGD leads to the activation of prothrombin into thrombin. We could also demonstrate that this ischemia induced activation of thrombin plays an important role in ischemic neuronal death, as both recombinant hirudin and protease nexin-1, an endogenous cerebral thrombin inhibitor, significantly prevented neuronal death, when administered after OGD. Using this in vitro approach we are currently characterising the role of thrombin as a mediator of ischemic neuronal death.

Heart and brain (cardiac disorders and stroke) Oral Session 1A    
Date: Friday, 27 May 2005   Time: 11:30 - 11:40 -  Room: SalaAzzura (1st floor)
Chair: G. Di Pasquale, Italy and J.-L.Mas, France

04
Prevalence of coronary heart disease (CHD) in stroke patients admitted to inpatient neurorehabilitation
P. Frommelt    A. Roll    H. Grötzbach                                                 
 

Asklepios Klinik Schaufling

GERMANY

Background Stroke and CHD are diseases with a considerable degree of comorbidity. Most papers report a prevalence of CHD in patients with ischemic stroke between 25 and 35 %. These reports are mostly based on research in which the diagnosis of CHD is based on standard assessments. Few reports differentiate between types of strokes in relation to CHD. The present study refers to a sample of stroke patients consecutively admitted from acute hospitals to inpatient neurorehabilitation. Methods The sample consists of 1340 consecutive ischemic stroke patients. The diagnosis of CHD, myocardial infarction (MI) and hypertension were based on the discharge reports from the referring hospitals. The classification of stroke refers to the Oxfordshire Community Stroke Project (OCSP). Results The ischemic strokes were distributed among the subtypes: 5.7 % total anterior circulation syndromes (TACS), 50.7% partial anterior circulation syndromes (PACS), 28.5 % vertebrobasilar syndromes (VBS) and 4.2 % lacunar syndromes (LACS). In the total sample the prevalences of CHD and MI were 16,3 % and MI 5,7 %. In the subgroups the prevalences for CHD and MI were: In TACS 19.5 % and 6.5 %, in PACS 16.5 % and 5.2 %, in VBS 14.4 % and 6.5 %, in LACS 19.6% and 0%. The prevalence of hypertension in the total stroke sample was 74.6 %. Discussion The prevalence of CHD and MI was lower than in most of the previous reports. In the small group of 56 patients with lacunar stroke there were no MI although the rate of CHD was similar to the other subgroups. We have no explanation for this discrepancy. It should be stressed that these data were collected in routine clinical practice and not in a controlled research protocol. Preliminary further research supports the hypothesis that the prevalence of CHD would be considerably higher when a systematic screening is applied.

Experimental studies     Poster Session II
Date: Friday, 27 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

07
Edema formation and brain aquaporin expression after transient middle cerebral occlusion in mice
M. de Castro Ribeiro    L. Hirt    J. Bogousslavsky    L. Regli    J. Badaut                                   
 

Department of Neurology and Neurosurgery, CHUV, 1011 Lausanne, Switzerland

SWITZERLAND

Cerebral edema contributes to morbidity and death associated with ischemia. Aquaporin1, 4 and 9 have been identified as the three main water channels in the brain, but their role in the water movements in edema formation and resolution is still unclear. To clarify this role, we have compared the time course of the expression of AQP1,4, and 9 with the edema formation after a transient focal brain ischemia. This investigation was realised on mouse brain slices after focal transient ischemia(30min) induced by occlusion of the middle cerebral artery. Brain sections were stained by antibodies against AQP1,4,9, GFAP and MAP2 at 1h,6h,24h,48h and 7days after the occlusion. The edema was evaluated by measuring the swelling of the ischemic hemisphere on haematoxylin-eosin stained slices. The levels of expression of AQPs were quantified in the core and in the border of the lesion(“penumbra”) delimited on MAP2-stained slices. The brain swelling was maximal at 1h(8.4%±3) and at 48h(10.1%±2.5) after the ischemia. AQP1 did not show a modification after ischemia. AQP4 expression on astrocytic endfeet was increased 1h(117%±20,P<0.05) after occlusion and returned to the basal level at 24h(95%±16). In the penumbra, 48h after the occlusion, the AQP4 expression was increased on the whole astrocyte(112%±10,P<0.05). AQP9 showed an induction with 24±6 positive astrocytes versus 5±1 in the contralateral hemisphere. This expression was increased with time, with 69±24 positive astrocytes at 7days. The variations of the level of AQP4 were correlated in time with the variations in brain swelling, in contrast with the AQP9 expression that increased gradually with time. This study suggests that AQP4 could play a major role in the edema formation. AQP9 could be implicated in the elimination of the lactate or glycerol excesses.

Acute stroke: treatment concepts Oral Session 1B    
Date: Friday, 27 May 2005   Time: 17:15 - 17:25 -  Room: Sala Italia
Chair: J.L. Marti-Vilalta, Spain and A. Gass, Switzerland/Germany

19
Differential response to thrombolysis among patients with tandem ICA/MCA occlusions
M. Rubiera    C.A.Molina    M. Ribó    J.F.Arenillas    E. Santamarina    R. Huertas    R. Delgado    J. Montaner    J. Álvarez-Sabín       
 

Neurovascular Unit Vall d´Hebron Hospital

SPAIN

Tandem ICA/MCA occlusion (TIMO) has been associated with a poor response to iv tPA. However, whether the relative resistance to thrombolysis of tandem lesions varies depending of the location of MCA clot remains uncertain We studied 195 consecutive stroke patients due to MCA occlusion treated with iv tPA. Carotid artery ultrasound (CUS) and TCD examinations were performed in all patients before treatment. TIMO was defined according to validated criteria. Patients were continuously monitored with TCD during 2-h tPA infusion. NIHSS scores were obtained at baseline and 24h. mRS score was used to assess outcome at 3 months. Median pre bolus NIHSS score was 17. On TCD, 136(69%) patients had a proximal and 59(31%) a distal MCA occlusion. Severe carotid artery stenosis (>70%) or occlusion ipsilateral to the MCA occlusion (TIMO) was seen in 37(19%) patients. Age, baseline stroke severity and time to treatment were similar in patients with and without TIMO. Thirteen (33.6%) patients with and 107(68.8%) without TIMO achieved a MCA recanalization at 2-h of tPA bolus (p=0.001). Among patients with TIMO, complete recanalization occurred in 4 (60%) patients with an occlusion located in the distal and in 2 (6.5%) in proximal MCA (p=0.05). In logistic regression model, baseline NIHSS score >15 (OR 2.12 95%IC 1.12-18.9) and the presence of TIMO (OR 5.08 95%IC 1.7-14.6) emerged as independent predictors of poor outcome (MRS score >2) at 3 months. However, the independent contribution of TIMO on poor clinical outcome varied depending on the location of MCA occlusion. TIMO independently predicted poor outcome in patients with proximal (OR 4.3 95%IC 1.32-21.3), but not in those with distal (OR 1.2 95%IC 0.78-18.9) MCA occlusion. TIMO independently predicts poor outcome after iv tPA. However, its impact on poor outcome varies depending on the location of MCA clot.

Management and economics     Poster Session II
Date: Friday, 27 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

07
Resource utilization and costs of acute stroke care in Germany
Y. Epifanov    R. Dodel    C. Haacke    K. Zamzow    M. Schaeg    O. Schoeffski    T. Back                     
 

Klinikum Mannheim, Dept. of Neurology, University of Heidelberg,Department of Neurosciences, University of California, San Diego, USA

GERMANY

Objective: Stroke is among the leading causes of death and disability in developed countries. Stroke care is costly and time-consuming. However, to date the resource utilization and costs of stroke care on regular neurological wards in Germany is widely unknown. This study evaluated the costs for stroke care of different cerebrovascular insults in a German university hospital. Methods and patients: We included 253 consecutive in-patients with the diagnosis of ischemic stroke (IS), intracerebral hemorrhage (ICH) or transient ischemic attack (TIA) that were treated on regular wards in the Dept. of Neurology, Marburg, between 1st January and 30th June 1998. Modified Rankin scale (mRS) was used to assess outcome. Costs of stroke care were calculated from the perspective of the healthcare provider (hospital) by using a bottom-up approach. Resource utilization was compared to stroke unit care as determined in a previous study. Prices of 2002 were used (in Euro). Results: IS was present in 78% (n=196), TIA in 13% (n=34), and ICH in 9% (n=23) of patients. Length of stay was 11.1+/-8.9 (mean+/-SD, IS), 11.1+/-6.5 (TIA), and 16.9+/-15.5 (ICH) days. Mean costs of stroke care were €5210+/-4700 for ICH, €3070+/-2270 for IS, and €3060+/-1580 for TIA (p<0.05). The highest relative costs were due to nonmedical care (34% of total costs), doctors’ fees (23%) and nursing care (9%). Clinical status improved during hospitalization from 3.0+/-1.6 to 2.2+/-1.8 (mRS) (p<0,01). In comparison to stroke unit care, mean costs per stroke/TIA patient on regular neurological wards were 15.6% lower. Conclusion: Acute stroke care on regular neurological wards was approximately 16% less costly than stroke unit treatment which, on the other hand, is known to reduce mortality and improve outcome.

Risk factors of stroke Oral Session 1B    
Date: Friday, 27 May 2005   Time: 17:35 - 17:45 -  Room: Sala Topazio
Chair: A. Carolei, Italy and P.Lyrer, Switzerland

21
Advanced carotid atherosclerosis is a different disease in women and men.
J. Krupinski    M. Miguel    P. Cardona    M.A. Font    L. Badimon    F. Rubio                            
 

Department of Neurology, University Hospital of Bellvitge (HUB), Barcelona, Spain

SPAIN

Background. Clinical and experimental evidence suggest that advanced carotid artery atherosclerosis is a different disease in women and men. Methods. Clinical data were taken from our own Hospital Carotid Endarterectomy Database (143 patients undergoing endarterectomy with stenosis >70%, 117 men and 26 women). We measured inflammatory and prothrombotic molecules (C-reactive protein, fibrinogen, COX-2, intraplaque and plasma D-dimer, matrix metalloproteinases expression and plasma activity, tissue factor levels and activity in plasma and carotid plaque), and correlated it with cerebrovascular risk factor distribution, carotid plaque morphology and echogenecity in men and women. Results. Current smoking status (85% versus 12%, p<0,001) and concomittant peripheral vasculopathy (22% versus 0%, p=0,03) but not hypertension (64% versus 88%, p=0,017) were higher in men than women. Both carotid plaque tissue factor levels (0,76ng versus 6,9ng p<0,001) and its plasma activity (13,0pM versus 24,6pM, p=0,035) were higher in women. Further, intraplaque fibrinolysis as measured by intraplaque D-dimer content were higher in women (4,9 a.u versus 8,9 a.u., p=0,027). There were no differences in other studied parameters. Discussion. This study further suggests, that both cerebrovascular risk factor distribution as well as plaque prothrombotic activity is different in women and men. Women with advanced carotid atheromatosis seem to have higher fibrinolytic and prothrombotic plaque activity.

Epidemiology of stroke     Poster Session III
Date: Saturday, 28 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

02
Incidence and Case-fatality of Stroke Types and Cerebral Infarction Subtypes in Northern Portugal: A Prospective Community-Based Study in Rural and Urban Populations
M. Correia    M.R. Silva    I. Matos    R. Magalhães    M.C.Silva                                   
 

Serviço de Neurologia, Hospital Geral de Santo António

PORTUGAL

Background Differences in stroke incidence between regions could be attributed to differences in the incidence of stroke types and subtypes. This study was designed to determine the incidence of stroke types, cerebral infarction subtypes and case-fatality in rural and urban populations in Northern Portugal. Methods All suspected first–ever-in-a-lifetime strokes occurring between October 1998 and September 2000 in 37290 residents in rural municipalities and 86023 living in Porto were entered a population-based registry. Definitions of stroke types, OCSP cerebral infarctions subtypes and comprehensive sources of information were used for identification of patients, followed-up at 3 and 12 months. Results During a 24-month period, 226 stroke patients in rural and 462 in urban areas were ascertained. The annual incidence rate per 1000 adjusted to the European standard population of cerebral infarction was 1.51 (95%CI, 1.15-1.96) for rural and 1.27 (95%CI, 0.92-1.74) for urban populations, of primary intracerebral haemorrhage was 0.35 (95% CI, 0.20-0.62) and 0.32 (95% CI, 0.16-0.60) respectively for rural and urban populations. The annual incidence of TACI was 0.39 (95%CI, 0.23-0.45) and of LACI was 0.66 (95%CI, 0.46-0.95) in rural areas, and for urban areas it was 0.24 (95%CI, 0.11-0.45) and 0.56 (95%CI, 0.34-0.87) respectively. Case-fatality at 28 days for cerebral infarction was 11.3% (95% CI, 8.8-14.4), for TACI was 30.3% (95% CI, 22.5-39.6) and for LACI 3.3% (95% CI 1.4-6.9); for primary intracerebral haemorrhage it was 30.6 (95% CI, 22.4-40.2).. Conclusions Cerebral infarction, TACI and LACI, accounted for the higher stroke incidence in rural compared to urban Northern Portugal, and for the overall relatively high incidence of stroke in Portugal compared to that reported in other Western Europe countries. The high proportion of LACI cases explains the relatively low 28-day case-fatality.

Risk factors of stroke     Poster Session III
Date: Saturday, 28 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

12
Do retinal arterial changes predict ischemic strokes during follow-up in patients with established atherosclerotic disease?
V.I.H.Kwa    J.J.van der Sande    V.E.A.Gerdes    J. Stam                                          
on behalf of The Amsterdam Vascular Medicine Group

Slotervaart Hospital and Academic Medical Center, Amsterdam, The Netherlands.

THE NETHERLANDS

Background: Retinal arterial changes are associated with cerebral small vessel disease. Pathologic changes in the retinal arteries probably parallel changes in the small cerebral arteries that cause strokes. We investigated whether retinal arterial changes have a predictive value for future ischemic strokes. Methods: 207 Patients with recent ischemic stroke (n=65), recent myocardial infarction (n=65), or peripheral arterial disease (n=77) were included. The presence of retinal arterial changes (RAC) at baseline and ischemic strokes during follow-up were registered according to a prospective protocol. Results: Hundred-and-eighty patients (87%) had RAC. During follow-up with a mean duration of 3.5 (sd 1.3) years, 21 patients (10%) had an ischemic stroke. Patients with RAC developed more often ischemic stroke (11%) compared with patients without RAC (7%), but this difference was statistically not significant (p=0.5). In a multivariate regression analysis only previous ischemic strokes were independently associated with ischemic strokes during follow-up (OR 2.9, 95%CI 1.0-8.3). Conclusion: We observed no association between RAC and future cerebral ischemic events in patients with established atherosclerotic disease.

Epilepsy and stroke     Poster Session I
Date: Thursday, 26 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair:  

01
The Epidemiology of Poststroke Epilepsy According to Stroke Subtypes
G. Benbir    B. Ince    M. Bozluolcay                                                 
 

Istanbul University Cerrahpasa Faculty of Medicine Department of Neurology

TURKEY

Cerebrovascular diseases (CVD) represent the most common etiology of secondary epilepsy in elderly patients. The frequency of poststroke epilepsy differs from 2-4%, and there still remain many questions regarding the epidemiology, prevention and management of poststroke epilepsy. In this observational study, 1428 patients (males 52.4%, females 47.6%) between the ages of 32-92 (mean 62.8+13.7) with stroke history admitted to the Stroke Outpatient Clinic of Neurology Department of Cerrahpasa Medical School, Istanbul, Turkey, followed for 1 to 9 years (mean 5,5+2,4 years), between January 1, 1996 and January 1, 2005, were included. 51 patients (males 58.8%, females 41.2%) had poststroke epilepsy (at least two weeks after the stroke). About 2.7% of 1327 patients with ischemic stroke, 12.8% of 86 patients with haemorrhagic stroke, and 26.6% of 15 patients with venous infarctions and intracranial dural sinus thrombosis (IDST) developed poststroke epilepsy. Poststroke epilepsy following venous infartions and IDST constitute the highest ratio when compared to other subtypes of CVD . Among 51 patients with poststroke epilepsy, patients with ischemic, haemorrhagic stroke, and IDST constitute 70.6%, 21.6% and 7.8%, respectively. When all patients with postischemic epilepsy were classified according to TOAST criteria, ischemic strokes were atherosclerotic in 36.2%, cardioembolic in 27.8%, lacunar in 11.1%; other etiologies were present in 11.1%; and the underlying causes were unknown in 13.8%. Poststroke epilepsy developed in 2.7%, 2.6%, and 1.3% of all atherothrombotic, cardioembolic, and lacunar strokes, respectively. The most common arterial territory was middle cerebral artery (63.9%). 61.1% of the cases were localized to the right hemisphere. About 88% of patients are seizure-free with antiepileptic treatment. Much additional work is needed to better understand the pathophysiology of poststroke epilepsy, their prevention, and optimal management.

Dementia/cognition     Poster Session III
Date: Saturday, 28 May 2005   Time: 7:30 - 8:30 -  Room: Padiglione(Pavilion)
Chair: