XI. European Stroke Conference
Geneva, Switzerland
29 May - 1 June 2002

Haemorrhage
Date: 30.5.2002   Time: 13:45-13:55 -  Room: 2
Chair: Y. Yonekawa,Switzerland ; M.Brown, UK

01
Cerebral amyloid angiopathy is an independent risk factor for intracerebral haemorrhage
M.A.Ritter    K. Hegedüs    R. Szepesi    L. Csiba    E.B.Ringelstein    D. W.Droste                            
 

University of Münster, Germany, University of Debrecen

GERMANY

Introduction: Cerebral amyloid angiopathy (CAA) has been reported as a cause of ICH in elderly patients. The role of CAA as a general risk factor for ICH has not been evaluated. We investigated whether CAA is a general risk factor for ICH in a post-mortem study. Methods: 95 brains from the Neuropathology Department of the University of Debrecen (47 with ICH and 48 hypertension- matched controls without ICH) were evaluated. Samples from four different regions and the bleeding site were taken. Thin sections were stained with HE and with Kongo Red for the presence of CAA. ICH was classified as lobar or central according to CT- and/or gross macroscopic appearance. Charts were reviewed for typical risk factors of ICH. Results: Hypertension was prevalent in 46/47 patients with ICH and in 46/48 patients without ICH. 18/47 ICHs were located in the cerebral lobes (38%) and centrally in 29/47 (62%) patients. 11/47 patients with ICH had CAA compared to 3/48 patients without ICH. 5/18 patients with lobar ICH had CAA, but only 6/28 with central ICH. After adjustment for other risk factors by multiple logistic regression, CAA was significantly more frequent in the ICH group than in the controls (p=0.01, OR 6.9, 95% CI 1.6-29.9). The association between lobar ICH and CAA was stronger (p=0.012, OR 9.8, 95%CI 1.6-58.4), but still significant in patients with central ICH (p=0.037, OR 5.9, 95% CI 1.1-30.7). Discussion: CAA is an independent risk factor for ICH even in a population with a high prevalence of otherwise typical risk factors of ICH. Our results show that risk factors are additive. Assessment of the location of ICH on imaging studies does not allow to exclude CAA as an important contributing factor.

Haemorrhage
Date: 30.5.2002   Time: 13:55-14:05 -  Room: 2
Chair: Y. Yonekawa,Switzerland ; M.Brown, UK

02
NEUROLOGICAL DETERIORATION AFTER DEEP INTRACEREBRAL HEMORRHAGES
S. Abilleira    J. Álvarez-Sabín    J.  Montaner    C.A.Molina    M. Quintana    J. Castillo                            
 

Hospital Vall d'Hebron. Barcelona

SPAIN

Background: Neurological deterioration (ND) after intracerebral hemorrhage (ICH), mainly related to progression of mass effect, may lead to greater brain injury. We aimed to study the relationship between MMP-9, TNF-alpha, ICAM-1, and glutamate measured within 24 hours after onset, to development of ND after spontaneous ICH. Methods: Patients with deep ICH less than 24 hours of stroke onset, and who survived the first three days were studied. A baseline (<24 hours), and a follow-up visit (days 3-6) were performed. Neurological status was recorded at both visits with the use of CSS and GCS. ND was defined when CSS decreased 1 or more points between 2 visits. Blood pressure (BP), temperature and glycemia were recorded, and CT scans were performed at both visits. MMP-9, TNF-alpha, ICAM-1, and glutamate were measured in blood samples withdrawn at baseline visit. Results: Seven patients out of 31 patients included (22.6%) developed ND. ND did not associate with age, gender, the presence of vascular risk factors, or radiological findings. TNF-alpha, ICAM-1, and glutamate did not show an association with ND, but it was significantly related to higher MMP-9 concentrations (132.15+/-132.7 ng/ml vs. 249.04+/-80.6 ng/ml; p=0.036). A strong trend in association was found between lower dyastolic BP on admission and ND (99.58+/-18.46 mm Hg vs. 85.71+/-17.42 mm Hg; p=0.052). Multivariate analysis identified MMP-9 concentration on admission (>202 ng/ml) as an independent predictor of ND (OR= 17; 95% CI= 1.29-223.13). Conclusions: High MMP-9 levels in the first 24 hours after stroke onset are involved as one of the mechanisms related to ND in deep hemorrhages.

Haemorrhage
Date: 30.5.2002   Time: 14:05-14:15 -  Room: 2
Chair: Y. Yonekawa,Switzerland ; M.Brown, UK

03
Incidence and outcome of adult brain AVM hemorrhage in the Northern Manhattan Stroke Study
C. Stapf    D.L.Labovitz    H.C.Schumacher    H. Mast    JP. Mohr    R.L.Sacco                            
 

The Neurological Institute, Columbia University

USA

Objective: Brain AVMs represent a potential source of intracranial hemorrhage (ICrH) but prospective population-based incidence data on AVM hemorrhage are lacking. We investigated the incidence of first-ever AVM hemorrhage in adults based on population data from the Northern Manhattan Stroke Study (NOMASS). Methods - NOMASS is a prospective, population-based, stroke incidence survey collecting all hospitalized and non-hospitalized cases with first-ever (incident) stroke over age 20 in a ZIP-code defined area. For this study, data on all cases with incident ICrH occuring between July 1, 1993 and June 30, 1997 were used. Patients with ICrH due to trauma, tumor, or intracranial vascular malformations other than a previously unknown AVM were excluded. Results: Of the 207 patients diagnosed with a first-ever ICrH, 3 cases (1.4%) with an underlying brain AVM were identified. The crude incidence rate for first-ever AVM hemorrhage was 0.55 per 100,000 person-years (95% CI 0.11 to 1.61). Within 30 days after the hemorrhage, all 3 AVM patients survived with 2 being discharged home and 1 to a rehabilitation facility; of the non-AVM patients 62 (30%) died, 32 (16%) were placed in a nursing home, 25 (12%) required rehabilitation, and 71 (35%) were discharged home. Conclusion: Our results support prior epidemiologic findings from retrospective surveys. Prospective population-based studies on AVM hemorrhage, morbidity, and mortality are needed to confirm the data.

Haemorrhage
Date: 30.5.2002   Time: 14.15-14:25 -  Room: 2
Chair: Y. Yonekawa,Switzerland ; M.Brown, UK

04
DECLINE IN SUBARACHNOID HEMORRHAGE MORTALITY. DIFFERENT EXPLANATIONS IN MEN AND WOMEN
B. Stegmayr    K. Asplund                                                        
 

Medicine/Public Health and Clinical Medicine

SWEDEN

Background and Purpose: Results emerging from the WHO MONICA Project show that northern Sweden has one of the highest incidence rates of subarachnoid hemorrhage (SAH) among the participating populations. The incidence is about twice as high as in other populations in Europe. The aim of this study was to study trends in incidence and 28-day case fatality in SAH over the last 15 years. Methods: Since 1985, all suspected SAHs in northern Sweden have been validated, using the same strict MONICA criteria. The total population is half a million, living in a sparsely populated area of 154,000 km2. SAH has been monitored in age group 25-74 years in both men and women. During the period 1985-99, 369 men and 557 women had SAH. Results: The age standardized incidence decreased in men from 21 to 13 per 100,000 and year (p-value for trend= 0,005). In women the annual incidence ranged from 19 to 33 per 100,000 with no significant time trend (p=0.8). In total, 134 men and 199 women died within 28 days after the onset. Across all years, case fatality (CF) was 36% in men and 38% in women (p=0.9). In men, no trend over the years was seen, but in women the 28-day CF declined from 46% to 25% the first compared to the last year (p-value for trend =0.001). The only population risk factor trend that could explain the diverging SAH incidence trends was that of smoking; this declined to a low prevalence in men (12% in 1999) but remained high in women (20%). Discussion: The decline in SAH mortality has different explanations in men (declining incidence) and women (declining case fatality). The diverging incidence trends parallel those in smoking in the male and female populations. The different trends in case fatality need to be explored in further in detail.

Haemorrhage
Date: 30.5.2002   Time: 14:25-14:35 -  Room: 2
Chair: Y. Yonekawa,Switzerland ; M.Brown, UK

05
SMALL INTRACEREBRAL BLEEDINGS : TO TREAT OR NOT TO TREAT
B. Chandra                                                               
 

Airlangga University Surabaya

INDONESIA

Large intracerebral hemorrhages (ICH), more than 60 cc are usually consulted to the neurosurgeon,but small ICH (less than 30 cc) are treated medically.The author has set up a double blind placebo controlled trial with this small ICH. All patients (P) who came to the university hospital of the author were asked to participate.The trial started January 1,1995 and ended January, 1 2001.An informed consent was obtained. Only P who came to the clinics within 6 hours after the 1st symptom of stroke were admitted.A CTscan was performed in all P and magnetic resonance imaging in some. The diagnosis of ICH was based on the clinical and the CT scan.P with cerebellar hemorrhage and P with hemorrage into the pons were not included. 310 P were randomized into two grous. One of which received 2,1 cc (=0,4 mg) of a nimodipine infusion ( NI ) per hour intravenously as a coinfusion for 10 days with Ringerlactatesolution (Rls).The other group received isotonicsaline solution (ISS)as a co-infusion with a Rls.The doctor, nurse and P did not know, which ampules contained NI and which contained ISS, because both were identical.Both groups received 2,5 mg ramipril each day. Random assignment of P to treatment was carried out by the pharmacist. Opening the code showed that 156 P had received NI and 154 P ISS.A significant difference favoring the nimodipine treatment was seen in terms of functional outcome (FO) BarthelIndex(p<0,05).NeurologicEvaluation (NE) by the NIH stroke scale (p<0,05) and cognitive function by the MiniMentalStateExamination (p<0,05). Conclusion: The trial suggest that the used of low dose NI in small ICH will significantly improve FO and NE.

Haemorrhage
Date: 30.5.2002   Time: 14:35-14:45 -  Room: 2
Chair: Y. Yonekawa,Switzerland ; M.Brown, UK

06
Neurologic Outcome in Endovascular Embolization Therapy for Brain Arteriovenous Malformations (AVMs)
H.C.Schumacher    R.M.Lazar    C. Stapf    R.S.Marshall    A. Hartmann    H. Mast    J.P.Mohr    J. Pile-Spellman              
The Columbia AVM Study Group

Stroke Center. Columbia Presbyterian Medical Center.

USA

Background: To determine neurologic outcome after endovascular embolization therapy for patients with brain arteriovenous malformations (AVM). Methods: We analyzed a series of 338 consecutive, prospectively enrolled patients from the Columbia AVM Database treated by endovascular embolization with N-butyl-cyanoacrylate from May 1992 to December 2001. Superselective Wada testing was performed in 90.5% of the procedures by injection of sodium amytal and/or lidocaine followed by a standardized neurological/neuropsychological examination. The modified Rankin Scale (mRS) was used for coding severity of new neurological deficits post-embolization, and we counted mRS³3 as a disabling deficit. If more than one complication occurred in a given patient, only the worst event was tallied. Results: The 338 patients underwent a total of 776 embolization sessions (mean 2.3±1.8 sessions/patient; range 1–11). The mean number of total embolized vessels per pt. was 4.3±3.8 (range 1–29). New neurological deficits occurred in 78 (23.1%) of patients post-procedure. In 29 (8.6%) these deficits were transient, subsiding within 48 hours. However, 49 (14.5%) patients had deficits persisting >48 hours. Of these, 29 (8.6%) had non-disabling deficits, due to either brain infarction in 26 (7.7%), or intracranial hemorrhage in 3 (0.9%). Another 20 (5.9%) had persistent disabling deficits from either brain infarction in 14 (4.1%), or intracranial hemorrhage in 6 (1.8%). Only two (0.6%) died after developing disabling deficits post-embolization. Discussion: Most neurological complications after embolization in our series were due to brain infarction. Efforts to reduce complication rates should therefore focus on vessel selection, improvement of functional testing procedures prior to embolization, and periprocedural anticoagulation and blood pressure management.

Haemorrhage
Date: 30.5.2002   Time: 14:45-14:55 -  Room: 2
Chair: Y. Yonekawa,Switzerland ; M.Brown, UK

07
PREDICTIVE FACTORS OF EARLY GROWTH OF INTRACEREBRAL HEMORRHAGE
Y. Silva    R. Leira    J. Tejada    J. Castillo    M. Martinez-Seijo    A. Dávalos                            
 

Hospital Doctor Josep Trueta

SPAIN

Purpose and Methods: We studied potential predictors of early growth of the volume of intracerebral hemorrhage (ICH) in a large multicenter study that included 234 patients (71+-11 y, 55% male) with primary hemispheric ICH of less than 12 hours' duration (6.1+-3.2 h). More than 60 clinical, biochemical and neuroimaging variables were collected prospectively on admission. Patients had a neurological evaluation and a CT scan performed at baseline and at 48+-6 hours. A relevant early growth of the ICH volume was defined as an increase greater than 33% between the two CT exams. Predictive factors of ICH enlargement, and the independent effect of early growth on mortality and dependency (modified Rankin score >2) at 3 months, were analyzed by logistic regression analyses. Results: 35 (15%) patients showed an early growth >33% of ICH. Bivariate and multivariate analyses did not identify significant and independent predictors of early growth. Early growth was associated with a higher mortality (OR, 2.0; 95%CI, 1.02-4.1) and dependency (OR, 2.9; 95%CI, 1.05-8.1) after adjusting for initial ICH volume and Canadian Stroke Scale on admission. Conclusions: Early growth of ICH is associated with poorer outcome. However, this study has not identified useful clinical predictors of enlarging ICH.

Haemorrhage
Date: 30.5.2002   Time: 14:55-15:05 -  Room: 2
Chair: Y. Yonekawa,Switzerland ; M.Brown, UK

08
SERUM METALLOPROTEINASE-9 CONCENTRATIONS AND BRAIN INJURY IN INTRACEREBRAL HEMORRHAGES
A. Dávalos    J. Alvarez-Sabin    C. Kase    R. Leira    Y. Silva    J. Montaner    J. Castillo                     
 

Hospital Doctor Josep Trueta

SPAIN

Edema and cellular death in the tissue surrounding intracerebral hemorrhage (ICH) have been associated with high levels of inflammatory molecules in blood. Since the expression of matrix metalloproteinases (MMP) also play an important role in the development of secondary effects after ICH we sought to investigate the relationship of MMP-9 to brain injury after ICH. Methods: We prospectively studied 124 consecutive patients with spontaneous ICH admitted within 24 hours of stroke onset who survived a 3 month follow-up. The volumes of the initial ICH, peripheral edema on days 3 to 4, and the residual cavity at 90 days were measured on CT. MMP-9, TNF-alpha, IL-6, and ICAM-1 were measured in blood samples obtained on admission. Stroke severity and neurological outcome were evaluated with the Canadian Stroke Scale (CSS). Results:MMP-9 concentration correlated significantly with the relative volume of peri-hematoma edema (r= .91, p<0.0001), and was its strongest predictor (r=.83) after adjusting for the volume of ICH, stroke severity, and inflammatory molecules on admission (all r<.2). However, ICH volume (r=.56) and IL-6 (r=.56), but not MMP-9 levels, were significantly and independently associated with the volume of the residual cavity left after ICH absorption (all p<0.001). Poor neurological outcome at three months (CSS<7) was observed in 53 patients (43%). Baseline stroke severity (p<0.001) and IL-6 concentrations (p<0.001) were the only factors independently associated with poor outcome. These same results were observed when lobar (n=58) and deep (n=66) ICHs were analyzed separately. Conclusions: High plasma levels of MMP-9 within 24 hours of ICH onset are correlated wiyh the magnitude of the subsequent perihematoma brain edema, but have no other detrimental effects.

Haemorrhage
Date: 30.5.2002   Time: 15:05-15:15 -  Room: 2
Chair: Y. Yonekawa,Switzerland ; M.Brown, UK

09
Influence of location of aneurysm on outcome following subarachnoid haemorrhage
M.L.Hackett    C.S.Anderson    K. Jamrozik    A.C.Lee                                          
 

Faculty of Medical and Health Sciences, The University of Auckland

NEW ZEALAND

Subarachnoid haemorrhage (SAH) is the least frequent stroke subtype, but is distinguished by being more common in adults of working age and by a high case fatality. We present data on survival and health-related quality of life (HRQoL) for SAH from a large, population-based study that identified all cases of SAH in four Australasian cities during 1995-1998. The large number of cases also permitted a meaningful examination of the relationship between the anatomical features of the haemorrhage and outcome. A total of 432 cases of first-ever SAH were registered. 242 (56%) cases were alive at follow-up (mean 1.2 years), with follow-up data presented from 158 cases with confirmed aneurysmal SAH who completed the SF-36. Most (76%) patients had an aneurysmal SAH with a Hunt and Hess grade of 3 or less. Among the 340 who had surgery, clipping was the most common procedure (41%). The 28-day case fatality was 39% overall, but where an aneurysm was identified, early survival varied significantly with site of the lesion, from 82% for PCA aneurysms to 58% for MCA aneurysms which were significantly more likely to exceed 5mm in diameter. Lesion location was an important predictor of poor HRQoL. On average, patients with an MCA lesion reported lower scores on the SF-36, particularly in role limitations due to physical problems, compared to patients with lesions at other sites. In conclusion, our study provides precise and unbiased estimates of survival from a first-ever bleed and can help clinicians managing such cases to provide patients and their families with a more detailed prediction of the likely outcome in the short- and medium-term. Aneurysms in the MCA territory tended to be larger, more lethal, and to cause greater long-term impairment and disability among survivors.