XIII. European Stroke Conference
Mannheim, Germany
12 - 15 May 2004

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Presentation:Oral  13.05.2004  11:40 - 11:50  Room: Stamitzsaal

GLUCOSE LEVELS IN ACUTE STROKE. GLIA STUDY. PRELIMINARY ANALYSIS ON 250 PATIENTS

E. Diez Tejedor    B. Fuentes  A. Davalos    A. Gil Nuñez   N. Vila    J. Vivancos  J. Egido    J. Castillo    E. Mostacero     
SPAIN

Cerebrovascular Diseases Study Group. Spanish Society of Neurology

Background: It is known the prognostic influence of admission hyperglycaemia in acute stroke, but no prospective studies analysing the glucose levels evolution in the first hours of acute ischemic stroke (IS) and the glucose level associated to poor outcome have been developed. 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. Results: 553 patients included. Data of 250 patients with complete follow up are shown (53% male; mean age: 70,9+/-10,7 y; mean time from onset: 6,5+/-5,7 h).Up to 30% patients had glycaemia > 140 mg/dl in admission and up to 22-40% within the first 48 h. Admission hyperglycaemia was associated with previous metabolic state (Alc Hb) (p=0,001) but not with IS severity. Up to 16% had a non-previously known DM. No hyperglycaemia is found in non-DM patients. ROC analysis point to maximum glucose >153,5 mg/dl as the possible level associated to poor outcome. Conclusions: Hyperglycaemia in acute IS is frequent and related to previous metabolic state (known or not known DM) but not to stroke severity. Capillary glucose >153,5 mg/dl in the first 48 h seems to be associated to poor outcome. The completion of the sample size will get definite conclusions.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

CRYOGLOBULINEMIA AND EXTRACORPOREAL PLASMA THERAPY IN SEVERE ISCHEMIC STROKE (IS)

V. Skvortsova    A.N.Komarov  N.A.Konstantinova                                            
RUSSIAN FEDERATION

Russian State medical University

Background: Cryoglobulines (CG) may participate in autoimmune mechanisms of ischemic brain damage and accompanying hemorheological disturbances. Selective plasmapheresis (SP) appears to be a unique opportunity for correction of cryoglobulinemia. Purpose: To investigate cryoglobulinemia and its prognostic value in severe IS and to assess therapeutic efficacy of SP. Methods: The investigation was performed in 60 patients with severe IS (on admission, the Orgogozo Stroke Scale (OSS) score was less than 50). On the background of the standard therapy (control), 30 patients were treated with SP on days 2,4, and 6 after IS onset. Serum levels of CG were determined by spectrophotometric method on days 1,2,3,7, and 21. Hemorheological properties were determined by Born-o-Brian technique. Results: Increased levels of CG were revealed in all examined patients with IS. On day 1, the level of CG correlated with the OSS score (r=0.6, p<0.01), platelet aggregability (r=0.46, p<0.05), and blood viscosity (r=0.74, p<0.01). Dynamics of CG levels correlated with dynamics of OSS, and NIH SS scores by day 21 (r=0.54, p<0.05, and r=0.65, p<0.05, correspondingly), as well as with the Barthel index on day 21 (r =0.7, p<0.05). SP was safe and not only decreased CG level (by 162 %, p<0.01), but normalized platelet aggregability and blood viscosity (p<0.01 vs. control), as well as improved IS outcome by day 21 (p<0.05 vs. control). Discussion: The phenomenon of cryoglobulinemia is revealed in acute IS, correlates with IS severity and extent of hemorheological disorders, and influences IS outcome. The application of SP in the treatment of severe IS is safe and can exert favourable laboratory and clinical effects.

Presentation:Poster  14 May, 2004  14:00 - 16:00  Room:  

Is Notch3 exon 9 polymorphism a risk factor for cerebral white matter lesions in atherosclerotic patients?

V. I.H.Kwa    J. Stam  B. Verbeeten Jr    P.H.Reitsma                                     
THE NETHERLANDS

Slotervaart Hospital

Background: Cerebral white matter lesions (WML) are associated with hypertension. However, normotensive patients may also have WML. Mutations in the Notch3 gene cause CADASIL with prominent WML. We studied whether certain polymorphisms in Notch3 coding sequences are a risk factor for WML in both normotensive and hypertensive patients. Methods: Patients with symptomatic atherosclerosis (presenting with ischemic stroke, myocardial infarction or peripheral arterial disease) were asked to undergo cerebral MRI´s and determination of the Notch3 coding sequences of exon 9. We choose exon 9, since in this exon the most frequent polymorphism has been found, that leads to amino acid change. The presence of periventricular lesions (PVL) and deep white matter lesions (DWML) on MRI were registered. Results: In 221 patients MRI's and Notch3 exon 9 coding sequences were examined. 66 Patients had an ischemic stroke, 70 a myocardial infarction and 85 peripheral arterial disease. Mean age was 62,0 years (SD 11,7) and 67% were men. Fifty-nine percent was normotensive. Nine patients (4.1%) had CTC instead of CCC at position 1565 on exon 9. This polymorphism was not correlated with WML (p=0.3, Chi-square test). Neither periventricular WML nor deep WML was correlated with notch exon 9 heterogeneity (p=0.9 and p=0.6 respectively). Conclusion: Polymorphism of exon 9 of the Notch3 gene is not a risk factor for cerebral white matter lesions in patients with atherosclerosis.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

Diffusion-Weighted Magnetic Resonance Imaging Patterns in Acute Stroke Patients with Internal Carotid Artery or Middle Cerebral Artery Diseases

D.-K.Jung    W.-H.Cheon  Y.-J.Bae    S.-P.Park   C.-K.Suh                               
SOUTH KOREA

Kyungpook National University Hospital

Background and Purpose: Studies investigating the distinguishing characteristics of diffusion-weighted (DW) MRI in acute stroke between stenosis of ICA or MCA (ICA/MCA) patients and occlusive patients are scanty. Methods: We analyzed DW MRI patterns in 138 consecutive acute cerebral infarction patients with ICA/MCA stenosis (narrowing>50%) or occlusive disease on MR angiography (MRA). The patterns of DW MRI were classified into 4 types: (1) MCA-territorial lesion, (2) subcortical large lesion (diameter>1.5cm), (3) subcortical small lesion (diameter≤1.5cm), and (4) multiple lesions. The involvement of insula, periventricular white matter, basal ganglia, and cortex was also assessed in all patients. Comparisons of these characteristics were made between stenosis of ICA/MCA patients (S-group, n=71) and occlusive patients (O-group, n=67). Results: Multiple lesions (58%) were most commonly seen, followed by MCA-territorial lesion (23.9%), subcortical large lesion (13%), and subcortical small lesion (5.1%). MCA-territorial lesion and insular involvement were more common in patients with O-group than in those with S-group (52.2% vs. 28.2%, p=0.005; 37.3% vs. 11.3%, p=0.001, respectively). Subcortical small lesion was more common in patients with S-group (n=6) than those with O-group (n=1) (p=0.001). Conclusions: This study suggests that MCA-territorial lesion, insular involvement, and subcortical small lesion on DW MRI in acute stroke patients with ICA/MCA steno-occlusive disease are distinguishing characteristics between stenosis of ICA/MCA patients and occlusive patients.

Presentation:Oral  14. 05. 2004  16:40 - 16:50  Room: Stamitzsaal

The EXSTROKE Trial. Physical Activity Before Ischaemic Stroke

T. Truelsen    A. Pedersen  P. Schnohr    G. Boysen                                     
DENMARK

Bispebjerg Hospital

Background: Studies indicate that physical activity (PA) is associated with risk of ischaemic stroke (IS). Analyses are often based on epidemiological studies with follow-up over several years without adjustment for changes. This study provides data on PA in IS patients in the week before symptoms onset. Methods: As part of the EXSTROKE trial patients were asked about their PA during the 7 days before stroke onset using the Physical Activity Scale for the Elderly (PASE). Furthermore, information on overall physical activity in leisure time in the preceding year was obtained by questionnaires from the Copenhagen City Heart Study (CCHS). Cases were matched 1:3 by age, sex, and time of year, to controls from the CCHS, who provided updated data on PA according to both questionnaires. Conditional logistic regression was used. Results: 29 women and 40 men with IS were included. Mean PASE score was 83 (SD 54) in cases while 129 (SD 67) in controls (P < 0.001). Compared with subjects reporting less than 2 hours of PA per week lower stroke risk was associated with weekly moderate PA of 2-4 hours OR=0.14 (95%CI:0.03-0.72), >4 hours moderate PA OR=0.12 (95%CI:0.02-0.59), and intense PA>4 hours OR=0.55 (95%CI:0.05-5.7). For each 25 increase in PASE score risk of IS decreased by 45% (95%CI:0.27-0.59) with no significant difference between men and women (P=0.26). Conclusions: Level of PA was associated with risk of IS using two different scales. Our results suggest that level of PA may be stronger related to risk of stroke than previously reported.

Presentation:Poster  May 13, 2004  14:00 - 16:00  Room:  

Long-term nursing management after stroke

A.-C.Jönsson    I. Lindgren  A. Lindgren                                            
SWEDEN

University Hospital Lund

Background: Stroke is the somatic disease that causes the most extensive needs for health care in Sweden. Follow-up by a multidisciplinary team including specialized nursing care has been reported to be beneficial for stroke patients. Methods: We prospectively included 416 first-ever stroke patients during a one-year period. All survivors were followed up three months (n = 329) and one year (n = 309) after stroke onset. Validated questionnaires were used. Personnel and/or next-of-kin were consulted if patients were unable to communicate. We registered body weight, blood pressure (BP), long-time blood glucose (HbA1c >5,3% indicating possible diabetes), cognitive status (Mini Mental Test, MMT - possible cognitive dysfunction if score ≤ 24/30) and existence of depression (Geriatric Depression Scale - possible depression if score ≥ 6/20). Hypertension was considered to be present if BP was above 140/90. Results: At 3 months after stroke 27 % of the patients had lost>/= 3 kg and 9 % had gained ≥ 3 kg of body weight. After one year BP was measured for 297 patients; 140 (47%) had insufficiently treated hypertension. Among 252 patients without treatment for diabetes; 25 (10%) had a HbA1c value >5,3%. Among 274 patients examined with MMT; 67 (24%) had a score of >/= 24. Possible depression was found in 119 (41%) of 290 patients. Several patients had to be referred to physician, speech therapist, occupational therapist or physical therapist, because of the findings at follow-up. Discussion: Our findings indicate a need for a nursing management program to follow up the patients after stroke. A nurse specialist can also refer the patients to other consultants when needed.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

Endovascular treatment for carotid artery stenosis: a Cochrane Systematic Review of the Randomised Evidence

L.J.Coward    R.L.Featherstone  M.M.Brown                                            
UNITED KINGDOM

Institute of Neurology

Background: Carotid stenosis may be treated endovascularly by balloon angioplasty or stenting. This may be a useful alternative to carotid endarterectomy. The objective of this systematic meta-analysis was to test the hypothesis that the benefits and risks of endovascular treatment and surgery are identical. Methods: We searched the Cochrane Stroke Groups trials register, conducted a search of the published literature, contacted researchers in the field and balloon catheter and stent manufacturers. We selected randomised trials of carotid endovascular treatment compared with carotid endarterectomy in patients with carotid artery stenosis. Results: Two completed trials involving 609 patients were found. In addition two trials were stopped early (242 patients) and a third trial has completed randomisation and 30 day follow up of 307 patients. Four trials are ongoing. Meta-analysis of thirty day safety data from the total 1158 patients found no significant difference in the odds of death or any stroke (odds ratio [OR] endovascular: surgery, 1.26, 95% confidence interval [CI] 0.82 to 1.94), the odds of death or disabling stroke (OR 1.22, CI 0.61 to 2.41) and the odds of death, any stroke or myocardial infarction (OR 0.99, CI 0.66 to 1.48). Endovascular treatment significantly reduced the risk of cranial neuropathy (OR 0.12, CI 0.06 to 0.25). At 1 year following treatment, there was no significant difference in the risks of any stroke or death (OR 1.36, CI 0.87 to 2.13); however there was significant heterogeneity between the trials. Discussion: Data from randomised trials suggests that endovascular treatment has similar major risks as surgery and avoids cranial neuropathy. However, two trials were stopped prematurely because of concern over the safety of carotid stenting. Current evidence does not support a widespread change in clinical practice away from recommending carotid endarterectomy as the treatment of choice for suitable carotid artery stenosis.

Presentation:Oral  14.05.2004  11:30 - 11:40  Room: Beethovensaal I

A detailed histological study of 565 symptomatic carotid plaques: pathological features and clinical correlates

J. Lovett    J. Redgrave  P. Gallagher    P. Rothwell                                     
UNITED KINGDOM

Stroke Prevention Research Unit, Radcliffe Infirmary, Oxford

Background: The pathology of unstable coronary atheroma is well described. However, the relationship between vessel stenosis and risk of acute ischaemic events is very different at the carotid bifurcation and the role of plaque instability is less clear. Previous histological studies have been too small or insufficiently detailed to reliably determine the pathology underlying carotid thromboembolism or to identify clinical correlates. Methods: We performed the largest ever study of plaque pathology, with detailed and reproducible histological assessments of plaques from 565 consecutive patients undergoing endarterectomy for symptomatic severe carotid stenosis, which we related to the nature and timing of presenting symptoms. Results: Cap rupture was present in 56.7%, surface thrombus in 30.1%, large lipid core in 59.6%, inflammatory infiltrate in 66.9%, cap infiltration in 70.8%, frequent foam cells in 41.1%, many new vessels in 33.8%, calcified nodules in 49%, haemorrhage in 63.9%, and AHA grade VI in 49.0%. Histology was similar in patients with hemispheric TIA, stroke and ocular ischaemia. Larger lipid cores (p=0.02), more inflammation (p=0.005), more foam cells (p=0.04), AHA grade VI (p=0.01), less fibrosis (p=0.004) and less calcification (p=0.006) were associated with more recent symptoms. Conclusions: The pathological features reported in acutely symptomatic coronary plaques are present in recently symptomatic carotid plaques, suggesting similar mechanisms of the acute clinical syndromes. Temporal changes in plaque constituents correlate with the fall in risk of ischaemic stroke with time after presenting symptoms, but differences in plaque pathology do not explain the more benign prognosis of ocular vs hemispheric ischaemic events.

Presentation:Poster  14 May, 2004  14:00 - 16:00  Room:  

Scandinavian Stroke Scale Score (SSS) predicts death or dependency in patients with minor stroke

H. Christensen    T. Truelsen  G. Boysen                                            
DENMARK

Bispebjerg Hospital, University of Copenhagen

Background: We investigated if differences in SSS in patients with minor ischaemic stroke were expressed in the risk of death or dependency within 12 months of stroke onset. This may be of importance in clinical trial stratification. Patients and methods: The analysis included 343 patients with acute cerebral infarction (ACI) and SSS of at least 40 points on admission. Diagnosis of ACI was based on CT-scan and clinical findings in all patients. Patients with 40 points or more on the SSS are in general able to walk. Patients were dichotomised above 49 points on the SSS, and death or dependency was defined as 3 – 6 points on the modified Rankin Scale (mRS), 3 and 12 months after stroke onset. The frequencies of death or dependency were compared between groups by x² as well as the risk of mRS > 2 one year after stroke calculated by multiple logistic regression analysis also adjusting for age, gender, arterial hypertension and smoking. Results: The risk of death or dependency was higher in patients with SSS 40 – 49 in comparison to SSS 50 – 58, OR 2.2 CI 95 %(1.4 – 3.5). Three months after stroke 43.7 % of patients with SSS 40 – 49 were dead or dependent in comparison to 25.1 % of patients with SSS > 49, p > 0.001. One year after stroke 47.6 % of patients with SSS 40 – 49 were dead or dependent in comparison to 31.9 % of patients with SSS > 49, p <0.001. Conclusions: The SSS is sensitive to differences in prognosis in minor ischaemic stroke. The observed differences are significant both in clinical and in trial contexts.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

Echocardiography in acute ischemic stroke: does it change therapy?

M. Mateus    T. Tribolet de Abreu  J. Correia                                            
PORTUGAL

Hospital do Espírito Santo-Évora

Background: Stroke, ischemic or hemorrhagic, is the third leading cause of death in most western countries (and first cause of death in Portugal). Cardioembolism might be responsible for 15-20% of ischemic strokes. Although atrial fibrillation can be diagnosed by electrocardiography, the remaining causes of cardioembolic stroke are better diagnosed by echocardiography. Yet, recent recommendations on the management of acute ischemic stroke fail to consider echocardiography as an essential test in all patients. Methods: We evaluated all transthoracic echocardiograms performed on patients with isschemic stroke, without atrial fibrillation, from January 7th 2002 to October 16th 2003. Findings compatible with heart diseases that would indicate anticoagulation as therapy were identified. The Statistical Package for Social Sciences perogram was used to build a database. Results: Of the 435 patients sent for transthoracic echocardiography with ischemic stroke, without atrial fibrillation, 42.8% had findings indicating anticoagulation as beneficial: dilated cardiopathy (24.6%), anterior wall myocardial infarction (8.28%), left ventricular systolic dysfunction with an ejection fraction under 35% (5.52%), mitral valve disease with enlarged left atria (3.68%), intracardiac masses (0.46%), valvular prothesis (0.23%). Conclusions: In our population, transthoracic echocardiography had therapy implications in 42.8% of ischemic stroke patients without atrial fibrillation. Transthoracic echocardiography should be performed in all ischemic stroke patients without atrial fibrillation.

 
http://www.esc-archive.eu/mannheim04/ma_graphics/mt_1027.htm

Presentation:Poster  14 May, 2004  14:00 - 16:00  Room:  

Relation between serum uric acid and risk of long-term stroke in 9900 men – a 23-yr follow-up

U. Goldbourt    N. Koren-Morag  D. Tanne                                            
ISRAEL

Tel Aviv University

The association of serum uric acid (UA) with cardio- and cerebrovascular disease has been a source of controversy. In the CASTEL study UA>6.4 mg/dl was associated with increased risk of stroke, in a large Japanese male railroad workers levels>8.5 experienced doubled stroke mortality; and a milder association was identified in a Chinese cohort. Other investigators proposed a J or U-shape association. We followed up 9909 healthy male civil servants, aged 40-64, over 23 years. Of 3473 deaths, 364 were attributable to stroke as the underlying cause. Fatal stroke showed a U-shaped relationship: in quintiles (up to 3.8, 3.9-4.3, 4.4-4.8, 4.9-5.4 and >5.4 mg/dl) of UA rates were 21,18,15,17, and 20 per 10,000 person years (PY), respectively. Adjusting for age and in particular blood pressure somewhat altered the findings. Stroke mortality hazard ratios (HR) were 1.25, 1.16, 0.95 and 1.13 for quintiles 1,2,4 and 5, respectively, relative to quintile 3 for non-diabetics, whereas for 472 diabetics the respective HRs, based on only 40 fatal strokes, were 3.87, 3.35, 3.45 and 2.80,. Adjustment for smoking and exclusion of men using anti- hypertensive medication made little difference. The effect of adjustment for blood pressure may arise because UA may modify the development of hypertension and its outcome. Coronary heart disease mortality was elevated only in the top quintile of UA (rates of 51, 45, 51, 55 and 71 [95%CI, 63-80] per 10,000 PY). Postulated mechanisms have linked an increased risk with UA levels in the lowest quintiles with possible decreased plasma antioxidant activity, whereas the increased risk at higher levels might reflect the role of uric acid in inducing vascular disease and hypertension. Research on large data sets with sizeable stroke incidence should ill.

Presentation:Oral  14.05.2004  11:40 - 11:50  Room: Beethovensaal II

Initial Tissue-Perfusion in Case of Failed Recanalization: Mismatch Overestimates the Real Penumbra

T. Kucinski    D. Naumann  R. Knab    V. Schoder   S. Wegener    J. Fiehler  A. Majumder    J. Röther    H. Zeumer     
GERMANY

University-Hospital Hamburg-Eppendorf

Background: In acute ischemic stroke, the region of decreased rCBF overestimates the final infarct volume. We hypothesized that surviving tissue with initially decreased rCBF exists even in patients without recanalization. Methods: 19 patients without recanalization at least until day 1 were included. A MRI stroke protocol was carried out at day 0 within 1.7 - 4.7 h (mean 2.8 h) after stroke onset as well as at day 1 and 7. The following lesions were defined: L0 = diffusion restriction at day 0, LG1 = lesion growth until day 1, LG7 = lesion growth until day 7, ST7 = surviving tissue. These lesions were transferred on MRI at day 0 and (relative) time-to-peak, rTTP, mean transit time, rMTT, crebral blood flow, rCBF and volume, rCBV were determined. Results: Median lesion volume at day 0 was 18.2 ml and increased to 39.4 and 43.8 ml at day 1 and 7. Volume of decreased rCBF not progressing to infarction was 148.5 ml (ST7). Mean values of rCBF and rCBV decreased continuously ST7 > LG7 > LG1 > L0 and means of rTTP and rMTT increased in the same pattern. ST7 values of all parameters were significantly different from L0 and LG1, but only rCBV was significantly different between LG7 and ST7, which represents the relevant border between survival or death of tissue. A threshold value of 0.18 CBV decrease for death or survival was determined with a sensitivity of 0.56 and specificity 0.95. Lesion growth was more pronounced in proximal than in distal intracranial vessel occlusions. Discussion The penumbra is generally overestimated by TTP, MTT and even CBF maps. The most conclusive inferences can be drawn from CBV maps. However, lesion growth is also determined by the site of vessel occlusion with distal intracranial carotid artery occlusions showing the greatest progression.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

Perfusion Harmonic Imaging in Acute Middle Cerebral Artery Infarction Predicts Outcome

G. Seidel    K. Meyer-Wiethe  G. Berdien    D. Hollstein   D. Toth    T. Aach                        
GERMANY

University of Schleswig-Holstein, Campus Lübeck

Background: Initial reports indicate that transcranial harmonic imaging after ultrasound contrast agent bolus injection (BHI) can detect cerebral perfusion deficits in acute ischemic stroke. We evaluated parameter images of the bolus washout kinetics. Methods: Twenty-three patients with acute internal carotid artery infarction were investigated with perfusion harmonic imaging (BHI) after SonoVue® bolus injection no later than 40 h after the onset of symptoms. The findings were compared with those of cranial computed tomography (CCT) and clinical course 4 months after stroke. Results: Images of pixelwise peak intensity (PPI) and time to peak intensity (TTP) could be calculated for all patients. Spearman rank correlations of r = 0.772 (p < 0.001) and r = 0.572 (p = 0.008) between PPI and area of infarction in the follow-up CCT as well as outcome after 4 months were obtained, respectively. Discussion: In the early phase of acute ischemic stroke, BHI after SonoVue® bolus injection is a useful ultrasound tool for analyzing cerebral perfusion deficits at the patient's bedside. BHI data correlate with the definite area of infarction and outcome after 4 months.

Presentation:Poster  13 May, 2004  14:00 - 16:00  Room:  

Applicability and relevance of prognostic models for short-term outcome after intracerebral hemorrhage

M.J.Ariesen    A. Algra  H.B.van der Worp    G.J.E.Rinkel                                     
THE NETHERLANDS

University Medical Center Utrecht

Background and Purpose: Several prognostic models for short-term outcome after intracerebral hemorrhage (ICH) have been published. We evaluated their clinical applicability and relevance. Methods: MEDLINE was searched from 1966 to June 2003. Studies were included if they met predefined criteria. Regression coefficients of multivariate models were extracted. Two neurologists independently evaluated the models for applicability in clinical practice. The actual probability of death or poor outcome was calculated for the combination of predictors that provided the highest probability of death or poor outcome. To assess clinical relevance, we calculated the proportion of patients with a ≥ 95% probability of death or poor outcome for each prognostic model in a validation series of 122 patients. To assess the accuracy of the prediction, we calculated the actual 30-day case-fatality in these patients. Results: We identified 19 prognostic models, of which 15 appeared easy to apply. The actual probability of death or poor outcome ranged from 73% to 100% (median 97%). In the validation series, the proportion of patients with a ≥ 95% probability of death or poor outcome ranged from 0% to 43% (median 0%). The 30-day case-fatality in these patients ranged from 75% to 100% (median 94.5%). Conclusions: Most prognostic models are easy to apply and can generate a high probability of death or poor outcome. However, only small proportions of patients have such a high probability of death or poor outcome and 30-day case-fatality is not always correctly predicted. Therefore current prognostic models have limited relevance in clinical practice.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

Cardiac fibroelastoma: a RARE cause or aN INNOCENT bystander in cryptogenic stroke?

B. Piechowski-Jozwiak    T. Karpanayiotides  G. Devuyst    J. Bogousslavsky                                     
SWITZERLAND

Centre Hospitalier Universitaire Vaudois

Background: Fibroelastoma (FE) is the third most common primary cardiac neoplasm with a predilection to cardiac valves, that has the potential for embolization in the cerebral arteries. However, the data on the role of FE in ischemic stroke are scarce. Therefore we assessed the frequency of FE in patients with first-ever cryptogenic stroke included in the Lausanne Stroke Registry. Methods: We reviewed 754 first-ever cryptogenic stroke patients admitted to our community-based primary care center between 1987 and 2001 and selected those with FE confirmed by transesophageal echocardiography (TEE). In all cases we assessed demographics, clinical and TEE findings, topography of infarcts, and clinical outcome. Results: Four patients with FE were identified (0.5% of cases) (2 men; range: 33-42 years); 3 were smokers and 1 had a history of migraine. Three patients had headaches at the onset. Two were somnolent, all had hemiparesis, 1 had upper extremity hemibalism, 1 had motor dysphasia and 3 had hemisensory deficit. Infarcts were localized in the anterior superficial middle cerebral artery territory in 2 and in total middle cerebral artery territory in the other 2 cases. In 2 patients FE was detected on mitral and in 2 on aortic valves. A diagnostic workup was negative except 2 cases in which PFO coexisted and paradoxical embolism was considered a cause of stroke. In other 2 patients FE was considered the only potential source of cerebral embolism. Conclusions: Valvular FE was rare and the causal relationship with ischemic stroke was speculated in only 0.2% in our cryptogenic stroke patients. Considering the long life expectancy of young stroke survivors, the utility of long term anticoagulation in cases with FE remains to be elucidated.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

Spectral and dipole EEG data analysis in patients with acute ischemic stroke

V. Skvortsova    I. Tikhonova  D. Koshurnikov    A. Smychkov   V. Gnezditsky                               
RUSSIAN FEDERATION

Russian State medical University

Background: The nonspecific character of EEG makes it expedient to study individual phenomena to assess prognosis of the functional state of brain in stroke patients. We evaluated focal EEG changes with dipole and spectral data in patients with ischemic stroke on day 1 and day 3 after stroke onset. Methods: 35 ischemic stroke patients (18-m, 17-f, age 69+/-10 years) were studied. 21-let EEG was performed under standard conditions. We evaluated spectral data in alpha, theta, delta band (power: Pd, Pq, Pa, power asymmetry: Ad, Aq, Aa) and dipole data of focal EEG alteration (number of extremumes of focus: Nd, Nq, Na and expansion of focus: Expd, Expq, Expa) by equivalent dipole analysis. Clinical data was evaluated by the NIH scale. Results: Dipole localizations of delta-focus, which were corresponded to MRI infarct zone have been obtained in 76 %. In 51 % of patients we also observed sinusoidal delta with exceeding amplitude in frontal regions. Dipole analysis showed that they originate in basal frontal area, distant from stroke zone. We obtained significant correlations between dipole and clinical data such as Na (r=-0.52) Nd (r=0.65) and Expd (r=0.55) on day 1 and Nd (r=0.60), Expd (r=0.55) on day 3. When MRI volume of infarct exceeded 8.29 cm3, it is always accompanied by EEG focus (p<0.05). On days 1 and 3 such spectral parameters as Pa, Pd and Ad significantly (p<0.01) differed in patients with different severity of stroke by the NIH scale. Moreover, on day 3 dipole parameter Nd (p=0.04) had prognostic value for stroke outcome on day 30. Conclusion: These findings show that dipole and spectral data correlate with clinical state when morphological focus is not formed yet. On day 3 more EEG parameters significantly differed in patients with different stroke severit

Presentation:Poster  May 13, 2004  14:00 - 16:00  Room:  

Functional Outcome and Quality of life among ischemic stroke young patients survivors

A. Arauz    D. Riaño  C. Mader    Y. Aburto   M. López                               
MEXICO

INSTITUO NACIONAL DE NEUROLOGIA

Background and Purpose: The purpose were to evaluated assessments of physical and social functioning in long term stroke survivors patients younger than 45 years old, and to identify variables that predict quality of life Methods: This is a cross-sectional, descriptive correlational design. The modified Rankin scale, Barthel index and Short Form-36 (SF-36) were administered to 100 non-cardioembolic stroke patients. Subjects were interviewed 1 to 5 years after stroke. Independent variables were age, sex, comorbidity, cause, and location of stroke. Multiple regression analysis was used to predict quality of life. Results: The mean age of the patients were 33 +/- 8 years old. 58% of the cases were female. The principal risk factors were hypertension (13%), diabetes 9%, history of ever smoking 26%, alcohol consumption 22%, migraine 10%, and previous stroke 13%. The cause of the stroke were idiophatic in 41%, dissection 26%, hematological in 16%, and others in 17%. The mean Barthel index was 95.33 +/-11.3 (range 20 to 100) with Barthel >/= 85 in 85% of the cases. Rankin score was </= 2= 78%(Rankin 3 to 4 in 11%). Hemorrhagic transformation predicted bad functional outcome (p=0.003). The SF-36 profile categories most affected were emotional, mental health, and vitality with averages values of 59, 65 and 67. Conclusions: Measured by modified Rankin scale and Barthel Index, functional outcome seems to be good. However, the identification of emotional, mental health and vitality as predictors of quality of life suggests the need to assist stroke young patients with support programs.

Presentation:Poster  May 13, 2004  14:00 - 16:00  Room:  

Does persistent hyperintensity on DWI indicate delayed tissue recovery after acute ischaemic stroke?

C. Rivers    J.M.Wardlaw  V. Cvoro    P.J.Hand   P.A.Armitage    M.E.Bastin  M.S.Dennis                   
UNITED KINGDOM

University of Edinburgh

Background: MR diffusion-weighted imaging (DWI) shows hyperintensity in acute ischaemic stroke, which generally becomes iso- or hypo-intense to normal brain by 2 weeks. We noted parts of some infarcts were still very 'hyperintense' even at 1 or 3 months. If this is just 'T2 shine-through', why are only some regions of the infarct affected? We hypothesised that infarct regions remaining hyperintense on DWI had different recovery patterns to the rest of the infarct. Methods: Patients with moderate to severe cortical ischaemic stroke had DWI and perfusion imaging (PWI) at < 12 hrs, 5 and 14 days, 1 and 3 months after stroke. Images were co-registered. DWI hyperintense lesions were outlined. The parts that were 'still bright' at 1 or 3 months were identified blind to all other details: the relative DWI/PWI values extracted and compared with 'not bright' parts and normal brain. Results: Of 33 patients with complete imaging to date, 19 (57.6%) had 'still bright' parts of infarcts at 1 or 3 months or both. In 'still bright' compared with 'not bright' tissue, ADCr was similar (mean 1.24 vs. 1.30, p=NS), but CBFr tended to be lower (mean 0.63 vs. 0.76, p=0.07), and MTTr was shorter (mean 0.91 vs. 1.03, p=0.03). Conclusion: 'Still bright' tissue on DWI at 1 or 3 months is perfused differently to the rest of the infarct, suggesting the effect is a true tissue difference, not just the physical effect of 'T2 shine-through'. Perhaps recovery in 'still bright' tissue is prolonged. Further study is required to see if this relates to clinical recovery patterns.

Presentation:Oral  13.05.2004  16:50 - 17:00  Room: Bruno-Schmitz-Saal

Nitric oxide synthase inhibitors in experimental stroke and their effects on infarct size and cerebral blood flow; a systematic review

M. Willmot    C. Gibson  S. Murphy    P. Bath                                     
UNITED KINGDOM

Nottingham University

Background: Nitric oxide (NO) produced by the neuronal and inducible isoforms of nitric oxide synthase (iNOS, nNOS) is detrimental in acute experimental stroke. NO produced by the endothelial isoform (eNOS) is beneficial. Inhibition of NOS is a candidate treatment for stroke; however, experimental studies have given conflicting results. Methods: Published controlled studies of NOS inhibitors in experimental stroke were identified from EMBASE, PubMed and reference lists. Data on the effect of NOS inhibition on lesion volume (mm3, %) and cerebral blood flow (CBF, %, ml.min-1.g-1) were extracted and analysed using the Cochrane Collaboration Review Manager software. Standardised mean difference (SMD) and 95% confidence intervals (95% CI) are given (* p<0.05). Results: 69 studies (S) were identified. In permanent stroke models the selective inhibitors of nNOS and iNOS reduced total infarct volume; non-selective inhibitors did not affect infarct volume (table) and reduced cortical CBF (SMD -0.59* ml.min-1.g-1, 95% CI -1.09 to -0.09, S=4). In transient ischaemia all types of NOS inhibitor were effective at reducing total and cortical infarct volume, however only the selective inhibitors reduced sub-cortical infarct volume. Non-selective inhibitors had a detrimental effect on total CBF (SMD –0.90 %, 95%CI –1.73, -0.08, S=4). Discussion: Non-selective inhibitors of NOS were ineffective in permanent ischaemia and reduced CBF, perhaps because of co-inhibition of the endothelial isoform of NOS (eNOS). In contrast, selective inhibitors of nNOS and iNOS reduced infarct volume without adversely affecting CBF in both permanent and transient stroke. These agents are candidate treatments for acute ischaemic stroke.

 
http://www.esc-archive.eu/mannheim04/ma_graphics/mt_1044.htm

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

Clinical characteristics in patients with stroke due to patent foramen ovale versus those with cardioembolic stroke

D. Gisler    S. Engelter  C. Gobbi    P. Lyrer                                     
SWITZERLAND

University Hospital Basel

Objective: Patent foramen ovale (PFO) is accepted as stroke etiology in patients with otherwise cryptogenic stroke. Little is known of possible differences in clinical characteristics between patients with stroke due to PFO and cardioembolic (CE) stroke Methods: All consecutive patients with stroke due to PFO documented by echocardiography as the sole identifiable stroke mechanism and those with CE stroke (TOAST criteria) were ascertained for 9 years. We compared age, gender, modifiable risk factors, and clinical stroke syndromes (OCSP classification) of both groups. Results: Among 300 identified patients 125 patients had PFO-strokes and 175 patients had CE-strokes. PFO patients (53 yrs [SD: 15.1]) were significantly younger than CE patients (73 yrs [SD: 11.4], p<0.0001). The gender ratio did not differ between the PFO group (64% men) and the CE group (55% men) (p>0.1). Hypertension (71% versus 29%) and diabetes (21% versus 6%) were more often present in CE patients than in PFO patients (both p<0.001). In turn, smoking occurred more often among PFO patients (45%) than among CE patients (32%; p<0.05). The most frequent stroke syndrome was partial anterior circulation syndrome in both groups. Posterior circulation syndromes occurred more often among PFO patients (31%) than among CE patients (19%; p<0.05), while total anterior circulation syndromes were more frequent in the CE group (21%) than in the PFO group (12%; p<0.05). Conclusion: Patients with strokes due to PFO were younger, were more often smokers and had less often hypertension or diabetes than patients with stroke due to major cardioembolic sources. PFO stroke patients more often had posterior circulation syndromes and less often total anterior circulation syndromes than patients with cardioembolic stroke.

Presentation:Poster  May 13, 2004  14:00 - 16:00  Room:  

Hypothermia and brain-derived neurotrophic factor reduce glutamate synergistically in acute stroke

C. Berger    W.-R.Schabitz  C. Sommer    S. Schwab                                     
GERMANY

University of Heidelberg

Background: Moderate hypothermia and application of brain-derived neurotrophic factor (BDNF) have separately been identified as neuroprotective strategies in experimental cerebral ischemia. To assess their separate and combined effects on striatal glutamate release in the hyperacute phase of stroke, we inserted microdialysis probes into the striatum of rats 2 hours prior to permanent middle cerebral artery occlusion (MCAO). Methods: Rats (N=28) were randomly assigned to one of four treatment strategies commencing 30 min after MCAO: 1. Hypothermia at 33°C. (n=7); 2. Intravenous BDNF infusion (300 µg/kg/h for 2 hours, n=7); 3. Combination of hypothermia und BDNF (n=7), 4. Control group (saline, n=7). Infarct size at 5 hours after MCAO was assessed with the silver-staining method. Glutamate was analyzed every 15 min using cerebral microdialysis until the end of the experiment. Results: Total infarct volume was significantly reduced in the hypothermia (202.7 +/- 3.5 mm3, P=0.0002) and BDNF group (206.5 +/- 6.9 mm3, P=0.0006) as compared to control group (254.4 +/- 9.3 mm3). In the combination group, infarct size was further reduced with overall significance in post hoc tests (157.3 +/- 6.2 mm3, P<0.0001). Postischemic glutamate concentrations in the control group constantly remained significantly higher than in all other treatment groups. At 255 and 270 min after MCAO, striatal glutamate in the combination group decreased significantly more than in animals treated with hypothermia or BDNF alone. Conclusion: Combining hypothermia and BDNF therapy in the acute stage of ischemia has a synergistic effect in attenuating striatal glutamate release and reducing early infarct size.

http://www.esc-archive.eu/mannheim04/ma_graphics/mg_1028.htm
 

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

THE CONSISTENCY OF STROKE UNITS BENEFITS WITHIN YEARS OF RUNNING. AN 8-YEARS EFFICACY ANALYSIS

B. Fuentes    E. Diez Tejedor  R. Merino    P. Martínez   J. Ojeda    F. Rodriguez de Rivera  A. Frank    P. Barreiro            
SPAIN

La Paz University Hospital

Background:The efficacy of Stroke Units (SU) has been amply demonstrated. But to date there are no studies analysing the consistency of their benefits in daily practice along several years of running. Methods:Observational study from the Stroke Data Bank of the Department of Neurology with inclusion of consecutive stroke in-patients since the establishment of the SU (1995) up to 2002 (8 years). Efficacy in terms of length of stay, in-hospital complications, death/dependence and long hospitalisation rates in a yearly basis was analysed and comparisons (Chi-square, t-student) between the different years of SU running and the last year of the Stroke Team (ST)(1994) were made. TIA patients have been excluded in death or dependence and long hospitalisation analysis. Results:3.546 consecutive in-patients included. The consistency of SU efficacy is demonstrated in terms of mean length of stay (11,26 days; p<0,001), in-hospital complications (p<0,001), long hospitalisation (7,7%;p=0,02) and death/dependence rates (33,6%; p<0,001). However, an increase in mortality (higher early death rate) due to a significant increase in the percentage of admissions of severe-ill patients (CSS</=3 or comatose) (23% vs 16%) is detected in 1999-2001. Conclusions:The SU benefits are consistent within time of running with maintenance of SU efficacy in terms of length of stay, death or dependence and long hospitalisation is demonstrated. Severe-ill patients do not get any benefit from SU care. This fact reflexes the importance of the maintenance of strict admission criteria in a SU in order to optimise resources and to keep the SU efficacy up.

Presentation:Poster  May 13, 2004  14:00 - 16:00  Room:  

TREATMENT WITH REPERFUSSION AND NEUROPROTECTION WITH LOW AND HIGH DOSE OF CITICOLINE IN AN EXPERIMENTAL MODEL OF FOCAL CEREBRAL ISCHEMIA. WHICH IS THE BEST?

E. Díez-Tejedor    M. Gutierrez  F. Carceller    J.M.Roda   M. Alonso de Leciñana                               
SPAIN

Cerebrovascular Research Unit. Hospital Universitario La Paz. Universidad Autónoma. Madrid.

BACKGROUND & AIMS: Reperfussion may lessen ischemic cerebral damage, but inhibition of ischemic cascade is necessary. Whether neuroprotection alone is enough, should be achieved prior to thrombolysis or once it occcurs is discussed. We investigate this topic in a rat model. MATERIAL/METHOD: 37 male Long-Evans rats: 4 sham operated and 33 subjected to clot embolization in right ICA distributed in 8 groups: control; rt-PA 5mg/kg 45 min post-ischemia; citicoline 250 or 1000 mg/kg x 3 doses (10 min, 24h and 48h post-ischemia); association of citicoline same dose before rt-PA; 5) association of citicoline, first dose 10 min after rt-PA. Arterial occlusion/recanalization is confirmed by angiography. Plasma determination of TNF-a and IL-6 (ELISA) is made prior to sacrifice at 72h. Ischemic lesion is evaluated by H&E and TUNEL. Results are compared (Fisher). RESULTS: rt-PA produce reperfussion in all treated rats. rt-PA or citicoline at low dose alone produce equal result. The greater reduction of lesion size (p=0.0002) and TUNEL (p= 0.0006) is achieved with the combination of citicoline after rt-PA independently of dose. Citicoline alone or before rt-PA produce similar effect at high dose (1g/Kg) but not at low dose (250mg/Kg). rt-PA, any combination of citicoline-rt-PA and high dose of citicoline alone reduce significatively TNF-a (p=0.0002). IL-6 is reduced only with citicoline any dose after rt-PA or any treatment of citicoline at high dose (p=0.001). CONCLUSION: Low dose of citicoline or rt-PA alone are not sufficient to reduce ischemic damage, unless combining citicoline after rt-PA. High dose of citicoline seems to be the optimal treatment with a tendency to be best when given after rt-PA. High dose of citicoline alone might be sufficient in cerebral ischemia.

Presentation:Oral  13.05.2004  11:50 - 12:00  Room: Stamitzsaal

Neurochemical monitoring in human stroke patients

C. Berger    K. Kiening  S. Schwab                                            
GERMANY

University of Heidelberg

Neurochemical monitoring of brain tissue with microdialysis allows continuous analysis of extracellular substances such as glutamate, glycerol, lactate and pyruvate over several days during the acute stage of human stroke. We investigated whether cerebral microdialysis is able to demonstrate a neuroprotective effect of hypothermia and hemicraniectomy and whether its results are predictive for the outcome. Open, prospective observational study in 24 patients undergoing either moderate hypothermia (33 °C.) or hemicraniectomy as rescue therapy for large, potentially space-occupying MCA infarction. Microdialysis probes were placed concomitantly with intracraniaI pressure (ICP) measuring devices into the frontal lobe of the infarcted and/or non-infarcted hemispheres within 24 hours after stroke onset. Glutamate, glycerol, pyruvate and lactate were analyzed at bed-side every 60 min using the CMA 600 Microdialysis autoanalyser. Average glutamate concentrations in patients treated with craniectomy (5.3 +/- 0.5 mmol/l, p<0.0001; n=6) and hypothermia (14.5 +/- 3.6 mmol/l, p<0.0001; n=14) were significantly lower than in conservatively treated patients (68.3 +/- 5.2 mmol/l; n=4). Glycerol concentration was significantly reduced by hypothermia and craniectomy to 111 +/- 17 mmol/l (p<0.0001) and 138 +/-8 mmol/l (p<0.0001) respectively as compared to conservatively treated patients with 612 +/- 27 mmol/l. The lactate-pyruvate ratio was significantly lower only in the hypothermia and craniectomy group (16.2 +/- 3.3 and 31.3 +/-1.5 vs. 56 +/- 2.9). Microdialysis allows bed-side monitoring of neuroprotective effects of stroke rescue therapies such as hypothermia and craniectomy. High glutamate values may be associated with a higher mortality rate in conservatively treated patients.

http://www.esc-archive.eu/mannheim04/ma_graphics/mg_1031.htm
 

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

Favorable outcome of ischemic stroke in patients pre-treated with statins

J. Martí-Fàbregas    M. Gomis  A. Arboix    A. Aleu   J. Pagonabarraga    R. Belvís  D. Cocho    J. Roquer    A. Rodríguez  J.-L.Martí-Vilalta
SPAIN

Hospital de la Santa Creu i Sant Pau

Background: Statins may be beneficial for patients with acute ischemic stroke. We tested the hypothesis that patients pre-treated with statins at the onset of stroke have less severe neurological effects and a better outcome. Methods: We prospectively included consecutive patients with ischemic stroke of less than 24-hour duration. We recorded demographic data, vascular risk factors, the clinical classification of the Oxforshire Comunity Stroke Project, NIHSS score, admission blood glucose and body temperature, etiology (according to the criteria of the TOAST study), neurological progression at day 3, prior statin treatment and functional outcome at 3 months. We analyzed the data using univariate methods and a logistic regression analysis with the dependent variable of good outcome (Barthel Index -BI- 95-100). Results: We included 167 patients (mean age 70.7 +/- 12 years, 94 men). Thirty patients (18%) were taking statins when admitted. In the statin group, the median NIHSS score was not significantly lower and the risk of progression was not significantly reduced. Favorable outcomes at 3 months were more frequent in the statin group (76.7% versus 51.8%, p=0.015). Predictors of favorable outcome were: NIHSS score at day 3 (OR 0.68, CI 0.59-0.78, p<0.0001), age (OR 0.96, CI 0.92-0.99, p=0.045) and statin group (OR 3.81, CI 0.97-15.15, p=0.056). The model significantly worsened (p=0.03) when the statin variable was removed. Discussion: Statins may provide benefits for the long-term functional outcome when given in the hyper-acute stage of cerebral ischemia. However, randomized controlled trials will be required to evaluate the validity of our results.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

Baseline Markers of Coagulation/Fibrinolysis and Functional Outcome in Patients with Ischemic Stroke Treated with Intravenous rt-PA

J. Martí-Fàbregas    M. Borrell  R. Belvís    D. Cocho   J. Montaner    A. Dávalos  A. Aleu    J Pagonabarraga    J. Fontcuberta  J.-L.Martí-Vilalta
SPAIN

Hospital de la Santa Creu i Sant Pau

Background:The benefits of using rt-PA in acute ischemic stroke are attributable to early recanalization and reperfusion. The probability of recanalization may depend on the balance between procoagulant and profibrinolytic proteins interacting with the clot. We analyzed whether baseline markers of coagulation and fibrinolysis were related to the neurological outcome. Methods/Patients: We prospectively included consecutive patients treated with intravenous rt-PA within 3 hours of the onset of symptoms. A blood sample was obtained before thrombolysis to measure markers of coagulation [Factor VII (%), Fragment 1+2 (mol/l), Fibrinogen (g/l), Factor XIII (%)] and fibrinolysis [Plasminogen Activator Inhibitor-1 -PAI-1 (IU/ml)-, Alfa2-Antiplasmin (%) and Thrombin Activatable Fibrinolysis Inhibitor (functional and antigenic -fTAFI (%) and agTAFI (%)-]. Baseline stroke severity was measured using the NIHSS. Good outcome at 3 months was defined as a modified Rankin Scale (mRS) <2. Statistics: t test. Results: Our study included 114 patients (mean age 68.4+/-12.8 yr, 59% men), with a median NIHSS of 14 points. The mean time from symptom onset to treatment was 154+/-35 minutes. Good outcome was recorded in 44 patients (40%). Plasma levels of markers at baseline were comparable in patients with good and poor functional outcome: Factor VII (80.7+/-21.5 vs 80.6+/-7.6, p=0.99); F1+2 (1.2+/-0.8 vs 1.5+/-1.5, p=0.22); Fibrinogen (3.8 +/-1.1 vs 3.6+/-1, p=0.28); XIII (125.9+/-4.0 vs 138.8+/-41.4, p=0.1); PAI-1 (9.9+/-13.4 vs 8.4+/-12.1, p=0.52); fTAFI (97.0+/-25 vs 95.3+/-25.6, p=0.72); agTAFI (86.8+/-15.2 vs 85.4+/-15.9, p=0.62); Alfa2-Antiplasmin (90.9+/-12.4 vs 93.3+/-17.3, p=0.4). Discussion: In patients treated with rt-PA, baseline markers of coagulation and fibrinolysis are not related to functional outcome.

Presentation:Poster  14 May, 2004  14:00 - 16:00  Room:  

Serum-leptin 3 months after acute stroke reflects risk factors in females but not in males

H. Christensen    G. Boysen                                                 
DENMARK

Bispebjerg Hospital, University of Copenhagen

Background: Leptin is important for body weight regulation but may have adverse effects including impairment of blood pressure regulation and may play a crucial role in the metabolic syndrome. We aimed at describing gender differences, relations to associated risk factors of stroke and relations to outcome of death or recurrent stroke 1 year after the index stroke. Patients and methods: Leptin was analysed by radioimmunoassay in serum from 123 patients (66 men and 57 women), 3 months after acute stroke at morning visits in all cases. Body weight, blood pressure, total cholesterol, triglycerids were also assessed. Mortality and stroke recurrence were assessed by the Hospital Information System 1 year after stroke. Results: Serum-leptin was significantly higher in women compared to men, 15.1ng/mL (95 % CI 11.9 – 18.3) vs. 7.3 ng/mL (95 % CI 6.2 – 8.4), p < 0.001. In women, but not in men, Leptin correlated with systolic and diastolic blood pressure (r = 0.31, p= 0.021; r = 0.34, p=0.006) as well as with body weight (r = 0.61, p <0.001). Leptin did not correlate to total cholesterol or triglycerid levels in this population. Between 3 months after stroke and 1 year after stroke, recurrence occurred in 14 patients, and 12 patients died. In multivariate logistic regression analysis also including stroke severity, coronary heart disease, hypertension, diabetes, total homocystein, and age as independent variables; leptin did not predict recurrent stroke or 1 year mortality. Conclusions: Serum-leptin is highly dependent on gender. Gender differences may be of importance in the study of risk factors of stroke. The study may have been underpowered for this purpose, as epidemiological studies have reported that high leptin increases risk of first stroke.

Presentation:Poster  May 13, 2004  14:00 - 16:00  Room:  

Preexisting dementia in stroke patients with atrial fibrillation: baseline frequency, associated factors and short-term outcome

C. Lefebvre    D. Deplanque  E. Touze    H. Henon   L. Parnetti    F. Pasquier  V. Gallai    D. Leys            
FRANCE

University ofLille

Background: preexisting dementia is frequent in stroke patients and non-valvular atrial fibrillation (NVAF) is independently associated with lower cognitive performances. Objective: to determine the frequency of preexisting dementia in stroke patients with NVAF, their determinants and relationship with short-term outcome. Method: this is an ancillary study of SAFE II, an observational study conducted in patients with previously known NVAF, consecutively admitted for an acute stroke in 40 European centers. Preexisting dementia was evaluated by the IQCODE in Italian and French speakers with a reliable informant. To analyse determinants of pre-existing dementia, we added the 30 patients (classified as non-demented) who did not undergo an QCODE but whose post stroke mini mental state evaluation score was > 28 (> 26 when schooling < 8 years). Results: of 370 patients, 205 had an IQCODE: 39 of them (19.0%; 95% CI: 13.7%-24.4%) met criteria for preexisting dementia. Factors independently associated with preexisting dementia were increasing age and previous ischemic stroke or transient ischemic attack. NVAF patients with preexisting dementia were more likely to die or to be dependent at discharge (OR: 5.0; 95% Cl: 2.2-11.4) Conclusion: the frequency of preexisting dementia in NVAF stroke patients is slightly higher than in non-selected stroke cohorts (19% vs.12-16%). The main determinant beside age, is a previous cerebrovascular event, suggesting a prominent vascular, rather than degenerative, origin. Pre-existing dementia is associated with a worse outcome in patients with NVAF.

Presentation:Poster  May 13, 2004  14:00 - 16:00  Room:  

Extra and intrahospital delay in stroke management with special attention to emergency ward activity as a determinant factor

N. Lopez-Hernandez    A. Garcia-Escriva  F. Gracia-Fleta    J. Carneado-Ruiz   A. Pampliega-Pérez    M. Alvarez-Sauco  P. Llorens    J. Sánchez    J.-M.Molto-Jorda     
SPAIN

Hospital General Universitari d'Alacant

Introduction: The actual tendency in acute stroke management, specially thrombolitic treatment, requires an accurate knowledge of the factors that influence the delay in the arrival of these patients to hospital and the delay in in-hospital management and attention by stroke unit physicians. Our aim has been to analyze these factors in our population paying special attention to a possible role of emergency ward overload as a determinant factor for in-hospital delay. Material and Methods: From a computerized hospital-based registry of our stroke unit we collected data about epidemiologic characterisitics, type of stroke, temporal profile of stroke, time to arrival to the emergency ward, delay in neuroimaging and total number of patients attended on the emergency ward every day as an estimate of emergency ward activity. Results: On the whole we analyzed data from 462 patients. 38% arrived in hospital in less than 3 hours from stroke onset and 52% in less than 6 hours. Patients wiht past history of stroke, those who used an ambulance to come to hospital and non-lacunar and hemorrhagic strokes arrived earlier. About a half of neuroimaging studies were performed in less than two hours after arrival to the emergency ward. Factors influencing time to neuroimaging were attention during on-call time (3.00 pm to 8.00 am) and a lower activity in the emergency ward, although this aspect did not reach statistical signifcance. Conclussions: Our data show, as other series have already shown, that there are many relevant aspects to improve in acute stroke management. One of them seems to be an improvement in emergency ward resources, specially the implementation of fast clinical pathways for stroke patients which might reduce in-hospital delays.

Presentation:Poster  May 13, 2004  14:00 - 16:00  Room:  

Survival and quality of life in the oldest-old stroke patients

J. Stam    F. Stijntjes                                                 
THE NETHERLANDS

Academic Medical Centre, Amsterdam

Background: In Western Europe a stroke occurs in 1,6 - 3,0 % of people>/= 85 years annually and about one third of these patients die within one month after the stroke. Because little is known about quality of life (QOL) after a stroke in the elderly, decisions about treatment restrictions in the acute phase of a stroke are often based upon subjective impressions of family, nurses and physicians. Methods: 64 patients>/= 80 years admitted in 2001-2002 were included in a retrospective study. The National Institutes of Health Stroke Scale (NIHSS) and Barthel Index were extracted from the medical records. In patients who survived we assessed handicap, impairment, QOL, depression and cognitive impairment during home-visits. Prediction models for stroke mortality and handicap were made, and we analysed variables associated with poor QOL. Results: Mean age was 87 years. 44 (69%) patients died, 27 (42%) within 30 days. Age and severity of the stroke were independent prognostic factors of mortality. All patients with NIHSS > 9 and age > 85 died (N=15; predictive value for mortality 100%, 95 % confidence interval 78-100 %). QOL was significantly associated with depression (Spearmans r 0.60; P 0.005), but not with neurological disability. Discussion: Stroke-related mortality in the elderly is high and could be predicted for a subgroup of patients using age and stroke severity as independent variables. If these data are confirmed in large prospective studies, early treatment restrictions could become based on evidence instead of intuition for a subgroup of elderly stroke patients. A small group of patients has an excellent neurological outcome. QOL in surviving patients was related to depression and not to disability.

Presentation:Poster  13 May, 2004  14:00 - 16:00  Room:  

Hyperkinesia ipisilateral (IH) to acute stroke

J. Ghika    P. Vuadens  P. Michel    M. Reichhardt   F. Herrmann    P. Arnold  J. Bogousslavsky                   
SWITZERLAND

CHUV

We prospectively studied 100 consecutive patients in their acute phase of stroke for IH. IH showed significant associations with cortical stroke (p=0.022), either precentral (p=0.009) or postcentral (p=0.005), as well as with lesions of the corona radiata (p=0.008), internal capsule (p=0.046), but surprisingly not in the basal ganglia or brainstem. Logistic regression analysis showed no significant topographic prediction of IH. Niether the ischemic or hemorrhagic nature of lesion, age, changes in tone or reflexes nor ataxia were associated with the presence of IH, whereas being a woman (P00.034), the presences of contralateral sensory deficits (P=0.0001) or conralateral autonomic dysfunction (p=0.004) were significantly associated with IH. IH is associated with cortical strokes, contralateral sensory deficits and dysautonomia, but not with strokes in basal ganglia. It probably shares similar sensory mechanisms with hyperkinesia due to loss of proprioception such as seen in pseudoathetosis, sensory alien hand or hyperconcern rather than hyperkinesis due to basal ganglia lesions.

Presentation:Oral  14.05.2004  16:50 - 17:00  Room: Bruno-Schmitz-Saal

PERSONALITY CHANGE FOLLOWING STROKE: A CARER’S PERSPECTIVE

K.K.Haga    M.S.Dennis  J.M.Wardlaw    M. Sharpe                                     
UNITED KINGDOM

University of Edinburgh, Western General Hospital, Clinical Neurosciences

Background: Mood change following stroke is a well-documented phenomenon, but little is known about personality change in stroke patients. This study evaluated personality change following stroke as experienced and reported by the patient’s “carer” (i.e. spouse or family member). Methods: 50 subjects diagnosed with first-ever stroke (27 male, 23 females; mean age = 72.6 + 9.8 years) and their carers were recruited from inpatient and outpatient clinics at 4-12 weeks post stroke (mean = 7.8 + 3.4 weeks). The subject interview consisted of a structured clinical interview for the DSM-IV (SCID), Barthel, Rankin, Mini-mental state examination (MMSE) and the Hospital Anxiety and Depression Scale (HAD). The carers interview included the “Brain Injury Personality Scale” (BIPS, carer version). The BIPS scale is composed of 23 individual questions to obtain composite scores for 5 main categories of personality change. Results: At approximately one month post-stroke, 32% of stroke patients exhibited significant personality change as observed by the carer (16/50). In 94% of these cases, the carer stated that the patient’s personality change was more distressing than any physical disability. Overall, carers most often complained about changes in frustration levels (18%), depression (16%), dissatisfaction (12%), listlessness (14%) and emotional liability (12%). Of the patients with significant personality change, 44% (7/16) were also diagnosed with a depressive disorder (major or minor depression) based on the SCID interview. Discussion: Significant personality change affects a third of patients in the first 3 months following stroke. These changes in personality were viewed as more distressing to the carer than the physical consequences of the stroke.

Presentation:Oral  14.05.2004  16:40 - 16:50  Room: Bruno-Schmitz-Saal

Mood After Stroke': a Case-Control study investigating the role of biological factors associated with late post stroke depression

K. Chatterjee    D. Barer  S. Fall                                            
UNITED KINGDOM

Stroke Research Unit, Gateshead, University of Newcastle

Background: Though vascular factors may be important in the aetiology of late-life depression, it is not clear whether similar risk factors have a major effect on the risk of late-phase post-stroke depression. We have investigated this in a case-control study. Methods: Stroke survivors over 9 months post-onset were screened for mood disorder by postal questionnaire, then interviewed by KC without prior knowledge of their responses. Depression was diagnosed by DSM-IV criteria. Controls, without depressive symptoms, MADRS score <7 and not recently treated for depression, were matched as closely as possible with the cases for age and ADL score. Results: 40 stroke cases with, and 87 matched controls without depression, were identified. Those with depression were more likely to be current or ex-smokers (80% v 61%), to have previous hypertension (75% v 54%) or peripheral arterial disease (23% v 6%, all p<0.05) or to have had 2 or more strokes (p<0.01). Their systolic, diastolic and mean arterial pressures were 9, 5 and 7 mmHg higher than controls (p<0.02). They had significantly more cognitive impairment (mean MMSE 24 v 27/30, p<0.001), higher serum homocysteine and lower serum folate levels(both p<0.05). There was no significant difference in prevalence of heart disease, atrial fibrillation or serum cholesterol between the groups. In logistic regression, previous hypertension, peripheral vascular disease, number of strokes, MMSE and current blood pressure were independent risk factors for depression. Discussion: These results suggest that patients with hypertension and other risk factors associated with small vessel disease, may be more susceptible to post-stroke depression. Whether controlling such risk factors will reduce the incidence of depression remains to be seen.

Presentation:Poster  May 13, 2004  14:00 - 16:00  Room:  

Stroke Patient's Etiopathogenic Beliefs

A. Croquelois    G. Assal  J.-M.Annoni    F. Staub   A. Gronchi    L. Bruggimann  S. Dieguez    J. Bogousslavsky            
SWITZERLAND

Centre Hospitalier Universitaire Vaudois, Neurology Department

To prospectively investigate etiopathogenic beliefs in a cohort of consecutive neurological inpatients, we developed a short questionnaire regarding their beliefs about the etiology of their disease and the possible influence of the following items : psychological factors, stress, fatigue, excessive work or other activities, poor lifestyle, conflict with another person, a tragic event, chance, and destiny. The answers were compared in the stroke group between subgroups of different age, sex, level of education, and stroke location, and between the stroke group and other diagnostics groups patients. In the stroke group, younger patients evoked psychological factors, excessive work or other activities and a poor lifestyle more frequently than the older ones. A bad lifestyle was more frequently evoked by patients with vertebro-basilar strokes than patients with carotid strokes. Destiny was blamed more frequently by women, patients with a lower educational level, and patients with left hemispheric stroke. Comparing the different diagnostic groups, patients with stroke blamed psychological factors significantly less frequently than patients with chronic central diseases, as did patients with peripheral disease compared to patients with central disease. More affirmative answers were obtained regarding fatigue by patients with chronic central diseases than by stroke patients. Destiny was blamed significantly more frequently by stroke patients than patients with peripheral diseases. We conclude that the patients' etiopathogenic beliefs only partially overlap with medical opinion and this could influence their compliance with treatment. Future work should explore if assessing the patients' beliefs and better explaining the etiology of their disease could improve compliance.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

A quantitative analysis of carotid plaque echogenicity in symptomatic and asymptomatic patients with three dimensional ultrasonography (3D)

D. Artemis    I. Heliopoulos  K. Vadikolias    H. Piperidou   N. Artemis                               
GREECE

Democretian University of Thrace

Background: The literature on studies examining the association between carotid plaque composition and cerebrovascular symptoms is inconsistent. Several studies showed that heterogeneous plaques were more "unstable" and associated with neurologic events while others failed to confirm this observation. We investigated the carotid plaque composition in order to determine whether there is a difference in composition of the plaques in symptomatic and asymptomatic patients with different degree of carotid stenosis. Methods: We studied 35 symptomatic and 43 asymptomatic atherosclerotic plaques causing 30-99% stenosis of the internal carotid artery. The age of the patients was 46-92 (69.12+/- 8.13). We measured the mean gray value (MGV) through the histogram facility of the 3D image analysis software. Results: 1.There was no significant difference in MGV between symptomatic (26.83+/-1073) and asymptomatic (28.26+/-8.41) plaques causing >50% stenosis (p=0.654). 2.Significant differences in MGV were observed in plaques causing <50% stenosis 3.MGV was lower in symptomatic (26.03+/-10.73) and asymptomatic (33.43+/-9.14)patients (p<0.014). Discussion: There was no difference in plaque composition as was estimated in symptomatic and asymptomatic patients with >50% carotid stenosis. This is in accordance with previous results from pathological studies of endartectomy specimens. In contrast the MGV was lower in symptomatic patients with <50% stenosis. Although the number of patients concluded in our study is small, our preliminary results may suggest that the carotid plaque composition as was estimated with the 3D MGV might be useful to distinguish patients with less than 50% carotid stenosis but higher risk for stroke events.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

Oskar Kokoschka and August Forel: life imitating art or a stroke of genius?

D. O'Neill    V. Huf                                                 
IRELAND

Stroke Service, Department of Medical Gerontology, Trinity College Dublin

In the Kunsthalle in Mannheim hangs a powerful and stark painting of the eminent Swiss psychiatrist, neuroanatomist, temperance champion and myrmecologist, August Forel. This was painted in the spring of 1910 by Oskar Kokoschka. The painting is a remarkable psychological portrait but also appears to predict the strokes and right hemiparesis that affected Forel more than a year later. While it is possible that Kokoschka shared a gift of psychic prediction with his mother and grandmother, a more likely explanation can be ascribed to a combination of the artist’s acute perception and the presence of sub-clinical signs of stroke disease. In his autobiography, Forel notes the onset of the stigmata of atherosclerosis from his early fifties: it is also clear that he suffered from at least three strokes rather than the single stroke that is usually attributed to him.

Presentation:Poster  May 13, 2004  14:00 - 16:00  Room:  

Carotid Intima-Media Thickness in Stroke Subtypes

A.T.Walsh    R. O'Riordan  D. Clinch    M. Watts   D. Lyons                               
IRELAND

Stroke Unit, St. Camillus, Hospital, Shelbourne Road, Limerick

Introduction: Carotid Intima-Media Thickness (CIMT) is a powerful predictor of future vascular risk. It may reflect blood pressure load exposure over time. The aim of this study was to determine if an association exists between CIMT and individual stroke subtypes. Methods: A cross-sectional study of 61 successive Stroke Unit patients was performed. Stroke subtypes were determined using the Oxford Community Stroke Project Classification. Haemorrhagic and Unclear Strokes were excluded (n =12). CIMT was measured using B-mode ultrasound (Siemens Sonoline-Omnia) by a single-blinded observer. Blood pressure was measured using a Space-Lab Ambulatory Blood Pressure Monitor. Results: Thirty male and nineteen female patients were studied. The mean age was 75.14 years (range 56-91). The mean (SD) CIMT (mm) for each infarct subtype was partial anterior circulatory infarct 0.9028 (0.27293), total anterior circulatory infarct 0.9115 (0.18275), lacunar infarct 0.9954 (0.21808) and posterior circulatory infarct 0.8320 (0.17065). ANOVA revealed no differences in CIMT between the stroke subtypes (p = 0.544). The differences in means of systolic blood pressure (SBP), diastolic blood pressure (DBP), pulse pressure (PP) and mean blood pressure (MBP) between the stroke subgroups were not significant. There was a trend, however, towards higher mean CIMT, SBP, PP and MBP in the lacunar group.Conclusion: While no significant differences were found, trends towards higher CIMT, SBP, PP, and MBP were observed in lacunar group. This may point to a role for altered large vessel compliance in lacunar stroke pathogenesis. The current data should be expanded to conclusively address this possibility.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

Non-Stroke Admission to a Stroke Unit

J.G.Heckmann    M. Stadter  M. Dütsch    C. Rauch   S. Lanz    S. Seidler  R. Handschu    B. Neundörfer            
GERMANY

Stroke Unit, department of Neurology, University of Erlangen-Nuremberg, Germany

Background: Stroke care has substantially improved during the last decade. A cornerstone of modern stroke care is the institution "stroke unit" which allows rapid diagnosis and treatment. In Germany 80% of all stroke patients are cared by internal specialists. The question, which specialist should be responsible for a stroke unit is still under debate. In this discussion, the aspect of admission of non-stroke patients to a stroke unit is poorly evaluated. Objective: To evaluate the number of patients who are admitted to a national stroke unit but do not suffer finally from stroke and to relate the proportion of non-stroke referrals to the different referral route. Methods: Observational study recording all suspected stroke referrals with regard to final diagnosis during a 12-month period (1.8.2003-31.7.2003). Results: Four hundred sixty-two patients were admitted by 4 routes: 74 by paramedics or by self-presentation, 138 by emergency physicians, 144 by primary care doctors, and 106 were transferred from other hospitals. Eighty-eight patients (19%) had no acute stroke. There was no significant difference among the proportion of non-stroke patients referred by ambulance paramedics and self-presentation (15%), emergency physicians (21%), primary care doctors (15%) and interhospital transfer (24%) [p=0.22, Chi-Square according Pearson]. The most common non-stroke diagnoses were seizure (21%), dissociative disorders (14%), cranial nerve disorders (11%), hypoglycaemia (8%) and transient global amnesia (7%). Conclusion: Misdiagnosis of stroke is common due to the fact that a number of clinical conditions mimic acute stroke. We advocate that all stroke patients are seen early in the course of disease by a neurologist. One solution could be that in stroke units of internal medicine hospitals patients are seen by a consulting neurologist. Alternatively, telemedicine might be useful with the neurologist on duty of a national neurological stoke unit being consulted.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

Cough Provocation is Important in Detecting Venous-to-Arterial Circulation Shunts Using Trans Cranial Doppler

R. Khiani    S. Sastry  C. McCollum                                            
UNITED KINGDOM

South Manchester University Hospital

Background: The accuracy of transcranial doppler (TCD) in detecting venous-to-arterial circulation shunts (vaCs) can be improved by using a valsalva manoeuvre. We studied whether, cough provocation improved the detection of vaCs. Methods: Between 1993 and 1998, young adults (16-39 years) who survived a myocardial infarct (n=77) or ischaemic stroke (n=64) were recruited. Patients underwent TCD with 5 or 6 injections of agitated saline contrast from a brachial vein. Two injection were performed at rest, two during cough provocation sustained for 5 seconds and one-two during a standardised valsalva manoeuvre with a pressure of 40mmHg maintained for 5 seconds. If the patient had a major shunt (>50 micro-embolic signals (MES)) after the first valsalva, no further injections were given. Results: 72 (51.1%) of subjects were positive (>1 MES), for a vaCs. But only 67 (47.5%) were positive, when cough provocation was removed from the dataset. In 7 (5%) subjects, cough provocation upgraded the size of shunt. Five (3.5%) were negative after contrast injection at rest and valsalva, but were reclassified as minor shunts (1-10 MES) after cough provocation. Two subjects were upgraded from minor to significant shunts (11-50 MES) after cough provocation. Discussion: Cough provocation is important in determining the presence and size of vaCs using TCD. Cough provocation should be an integral part of the TCD protocol.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

Femoral and Brachial Vein Injection of Ultrasound Contrast is Necessary to Detect Venous-to-Arterial Circulation Shunts UsingTranscaranial Doppler

R. Khiani    S. Sastry  S. Ray    C. McCollum                                     
UNITED KINGDOM

South Manchester University Hospital

Background:Ultrasound contrast is usually injected from the brachial vein(BV) when using transcranial doppler (TCD) to detect venous-to-arterial circulation shunts (vaCs). We investigated whether femoral vein (FV) injection improved the detection of vaCs. Methods: Between July and September 2003, 20 adults (mean age 46.4 years, 36.3-72.6) with cryptogenic ischaemic stroke and 1 diver with decompression sickness were investigated with TCD (Neurogard, EME, Scimed). Ultrasound contrast consisted of 8mls of normal saline, 1mls of air and 0.5mls of the patient's blood agitated 12 times between two, 10mls syringes and a 3-way tap. Six injections were performed in each subject, 3 from the BV and 3 from the FV. Injections were performed at rest, during a cough and during a standardised valsalva. Results: 13 (65%) subjects had concordant results between femoral and brachial vein injection. One (5%) patient was negative after BV injection but positive after FV injection. The size of right to left shunt was upgraded in 2 (10%) subjects after FV injection and 4 (20%) subjects were upgraded after BV injection. Discussion: Both FV and BV injections of ultrasound contrast are necessary to accurately assess the presence and size of vaCs using TCD. Femoral vein injetion should be an integral part of the TCD protocol, as identification of major shunts is associated with ischaemic stroke and may require percutaneous closure.

Presentation:Poster  May 13, 2004  14:00 - 16:00  Room:  

GLUTAMATE, TNF-alpha AND IL-6 PLASMA LEVELS CHANGES IN FOCAL CEREBRAL ISCHEMIA. PATHOGENIC ROLE OR LESION MARKERS? AN EXPERIMENTAL STUDY.

M. Alonso de Leciñana    M. Gutierrez  F. Carceller    J.M.Roda   E. Díez Tejedor                               
SPAIN

Cerebrovascular Research Unit. Hospital Universitario La Paz. Universidad Autónoma, Madrid

BACKGROUND: TNF-alpha and IL-6 have been implicated in the pathophysiology of cerebral ischemia as inflammatory cytokines, and glutamate in excitotoxicity, but as they might be produced in different physiological and pathological conditions and also as a consequence of any experimental procedure, it is proposed that are markers rather than promoters of cell damage. MATERIAL & METHOD: Focal ischemia is produced in 5 male Long-Evans rats (subjects). 4 sham animals (controls)undergo the same procedure, except for embolization. Other rats are subjected to stress by limb muscle compression. Blood samples are obtained at 3h and 72h after the procedure. TNF-alpha and IL-6 are determined in plasma by ELISA and glutamate by HPLC. Ischemic lesion is measured in H&E stained brain sections and DNA fragmentation evaluated by TUNEL. Results are compared between groups (Fisher). Correlation between biochemical and histological findings is studied (Pearson). RESULTS: Only subjects show cerebral damage (volume of lesion 49,83 +/- 20,36 %; TUNEL positive cells 41,8 +/- 22,06 per field 400x). TNF-alpha is expressed in controls and subjects at 3h and increase at 72h, subjects showing higher levels without significant difference. IL-6 increase only in subjects at 3h (p=0.002) but at 72h it is elevated also in controls. Cytokines increase with time in stress group. Glutamate levels are similar in controls and subjects. Cytokines or glutamate do not correlate well with histological damage in this model. CONCLUSION: Plasma TNF-alpha, IL-6 and glutamate increase not only in animals subjected to focal cerebral ischemia but also in controls and tissue stress group. This suggest that they are probably not specific and that might be reflecting the magnitud of damage rather than a pathogenic role.

Presentation:Oral  14.05.2004  12:00 - 12:10  Room: Hörsaal

Prevalence and correlates of aspirin resistance in a population-based study of TIA, stroke and acute coronary syndromes

L.E.Silver    P. Harrison  H. Segal    P.M.Rothwell Rothwell                                     
UNITED KINGDOM

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

Background: Platelet function tests identify some patients as "aspirin resistant", but the prevalence and risk factors for resistance are uncertain and there are no published data from population-based studies. Methods: We studied consecutive patients with TIA (n=70), ischaemic stroke (n=131), and acute coronary syndrome (n=113) in a population-based incidence study. Citrated (3.2%) blood was tested with the PFA-100, a high sheer test of platelet activity. "Aspirin resistance" was defined as the absence of a prolonged closure time (CT) within a Collagen/Epinephrine cartridge in a patient taking regular aspirin (75-300 mg). Collagen/ADP (CADP) cartridges were also tested Results: 68 (21.7%) of 314 patients (165 male, mean age=74) were "aspirin resistant". Resistance increased with age (p=0.03) but was unrelated to aspirin dose or duration of treatment, type of presenting event, or prior aspirin treatment (i.e. "aspirin failure"). In stroke patients, resistance was strongly associated with higher NIH score (p<0.001) and with total anterior circulation stroke (75% vs 19%, p=0.001). Resistant patients also had shortened median CADP CT (69 versus 83 secs, p<0.001) and increased levels of VWF antigen (215iu/dl vs 181iu/dl p<0.001) and fibrinogen (456 FEU vs 390, p=0.002), each of which remained significant in multivariate analyses. There were no differences in platelet count, haematocrit, mean platelet volume or P-selectin. Conclusion: Approximately 20% of patients with acute vascular events are "aspirin resistant" with the PFA-100. Resistance is strongly associated with increased VWF and fibrinogen levels, and with severity of stroke, suggesting that it may be related to the acute phase response.

Presentation:Oral  14. 05. 2004  16:20 - 16:30  Room: Stamitzsaal

Population-based study of the early risk of stroke after a TIA or minor stroke

A. Coull    J. Lovett  P.M.Rothwell                                            
UNITED KINGDOM

Stroke Prevention Research Unit, University of Oxford

Background: The risk of stroke in the days and weeks after TIA has recently been shown to be higher than was previously thought - based on data from hospital-based studies and from one population-based study performed over 20 years ago. There are no population-based data on the current early risk of stroke after TIA or on the early risk of recurrent stroke in patients presenting with minor ischaemic stroke. Methods: We studied 174 consecutive patients with TIA or minor ischaemic stroke (NIH score </=3) in an ongoing population based incidence study. All patients were followed up for 3 months. We estimated the risk of recurrent stroke at 7 days, 1 month and 3 months after a TIA or minor stroke. Results: Thirty one (18.6%) patients had a recurrent stroke (figure). The risks of stroke at seven days, one month and three months were 8.0% (95%CI=2.3-13.7), 11.5% (4.8-18.2) and 17.3% (9.3-25.3) respectively after a TIA, and 11.5% (95%CI=4.8-11.2), 15.0% (7.5-22.5) and 18.5% (10.3-26.7) respectively after a minor stroke. If the analysis was confined to the 23 patients who had presented to medical attention prior to the recurrent event, the risks of stroke were 7.6% (3.5 - 11.7), 10.1% (5.4 - 14.8), and 14.6% (9.1 - 20.1) respectively. Conclusions: The early risks of stroke after a TIA or minor stroke are much higher than commonly quoted. More research is required to determine whether these risks can be reduced by more rapid instigation of prevention treatment.

http://www.esc-archive.eu/mannheim04/ma_graphics/mg_1051.htm
 

Presentation:Poster  14 May, 2004  14:00 - 16:00  Room:  

Prevalence and severity of aphasia due to first ischemic stroke: A prospective population based study

S. Engelter    M. Gostynski  S. Papa    M. Frei   C. Born    V. Ajdacic-Gross  P. Lyrer                   
SWITZERLAND

Neurological Clinical, University Hospital Basel

Objective: To estimate the prevalence and severity of aphasia due to first ischemic stroke in the canton Basle-City. Methods: In a one-year prospective population based study among the permanent residents of Basle-City (188 015 inhabitants, census 2002) all cases of acute ischemic stroke were recorded. Multiple overlapping sources of information were used. The diagnosis of acute ischemic stroke was based on clinical assessment and corresponding neuroimaging findings. In all in-hospital patients the diagnosis of aphasia was made by a neurologist or a speech therapist. Results: We identified 262 patients with acute first ischemic stroke. The overall incidence rate of first ischemic stroke amounted to 1.39 (95% confidence interval (CI) 1.22 –1.56) per 1000 inhabitants. Incidence rate increased with advancing age from 0.17 (95%-CI 0.02-0.3) for individuals <45 years of age to 10.0 (95%-CI 7.5-12.6) among those aged 85 years or older. Post-stroke aphasia was diagnosed in 78 cases, yielding a 30% prevalence of aphasia. The risk of suffering from post-stroke aphasia increased 4% (2-7%) with each year of age of stroke patients (p<0.01 for age trend). Women had a higher risk of having aphasia after first ischemic stroke than men (odds ratio 1.82; 95%-CI 1.04-3.18). However, after adjustment for age, the gender difference was no longer statistically significant (odds ratio 1.53; 95%-CI 0.86-2.72). Aphasia was mild in 35 (45%), moderate in 22 (28%), and severe in 21 (27%) patients, respectively. Discussion: 1. Aphasia in first ischemic stroke is common. 2. These epidemiological data are important for resource allocation and planning rehabilitation processes.

Presentation:Oral  14.05.2004  11:20 - 11:30  Room: Beethovensaal I

Diffusion weighted imaging and stroke etiology: Lesion features to distinguish cardioembolic stroke versus stroke due to large artery atherosclerosis

L. Bonati    S. Engelter  S. Wetzel    P. Lyrer                                     
SWITZERLAND

University Hospital of Basel

Background: Diffusion weighted imaging (DWI) studies have indicated a link between DWI findings and the underlying pathogenetic mechanism of stroke. However, a comparison of stroke due to large artery atherosclerosis (LAA) and cardioembolism (CE) taking into account lesion characteristics on both DWI and ADC maps has not been made so far. Patients and Methods: From our prospectively ascertained stroke database, 40 patients with LAA and 43 patients with CE were compared with regard to number and topography of (A) all hyperintense DWI lesions and (B) only those hyperintense DWI lesions with hypointense appearance on ADC maps, blinded to the clinical data. Results: (A) All hyperintense DWI lesions: LAA patients had significantly more lesions (4.65, SD 4.87) than CE patients (3.09, SD 4.74) (p=0.01). Multiple lesions occurred in 28 LAA patients (70%) and in 21 CE patients (49%) (p<0.05). Involvement of either anterior and posterior circulations or the anterior circulations bilaterally was present in 5 patients (13%) with LAA and 4 patients (9%) with CE (p>0.05). (B) Hyperintense DWI lesions with hypointense appearance on ADC maps: Multiple lesions occurred in 23 (58%) patients with LAA and 15 (35%) patients with CE (p=0.036). Lesions in either anterior plus posterior circulation or in the anterior circulation bilaterally were rare and only occurred in 3 CE patients (7%) but in none of the LAA patients. Discussion: (1) Patients with LAA had more often multiple hyperintense DWI lesions and a higher number of lesions than patients with CE. (2) A lesions pattern with involvement of either posterior plus anterior circulations or the anterior circulations bilaterally suggested CE only if DWI lesions where restricted to those with hypointense signal on ADC maps.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

How does the conclusion of the PROGRESS trial translate into practice?

C. Lucas    A.-C.Lepoutre  M.-A.Mackowiak-Cordoliani    D. Deplanque   H. Hénon    D. Leys                        
FRANCE

Lille University Hospital

Background: secondary prevention of stroke and TIA has been dramatically improved by PROGRESS trial results. All patients should have perindopril +/- indapamide after a stroke or a TIA, even if the patient have no hypertension. Aim of the study: We evaluated our clinical practices concerning PROGRESS trial results in our stroke unit and after discharge. Patients and methods: We evaluated retrospectively during 2 months the applications of PROGRESS trial results in all stroke patients hospitalized in our stroke unit but also after discharge, during the follow-up by their GPs. Results: One hundred and eighteen stroke patients were hospitalized during these 2 months. Among them, 81 (68.6%) were eligible for secondary prevention by combined therapy based on perindopril +/- indapamide. The reasons of non-prescription in the remaining 37 patients were essentially due to treatment contraindications. This secondary prevention was applied only in 45/81 patients (55%). Concerning the 36 patients who did not receive this treatment in absence of contraindications or intolerance, 18 of them had an ischemic stroke of cardioembolic origin. After discharge, we have up to now only data on 28 patients by 45 concerning the long term follow-up with this secondary prevention. By them, 19 (67.9%) received the combined therapy, 3 (10.7%) only a monotherapy and 5 did not receive any more perindopril neither indapamide, and among them 3 after their cardiologist decision. Conclusions: The secondary prevention by perindopril and indapamide is applicable in two thirds of stroke patients in our stroke unit. However, only one third of patients received it.

Presentation:Poster  14 May, 2004  14:00 - 16:00  Room:  

Under-referral of elderly patients with TIA and ischaemic stroke for carotid imaging: a population based study

J. Fairhead    P. Rothwell                                                 
UNITED KINGDOM

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

Background: Trials have shown that benefit from carotid endarterectomy for symptomatic internal carotid stenosis is increased in the elderly due to their high risk of stroke on medical treatment alone. The prevalence of significant carotid stenosis in patients with TIA or ischaemic stroke also increases with age. However, it is uncertain whether elderly patients are routinely referred for carotid imaging. Methods: We compared referral rates in our ongoing population-based TIA and stroke incidence study (Oxford Vascular Study - OXVASC - population=90,873) with those in the rest of Oxfordshire (population = 589,899) by clinical indication. Data were collected on all referrals for carotid ultrasound, MRA, CTA or angiography for one year in OXVASC and in the rest of Oxfordshire using computerised and written attendance records from all imaging centres in Oxford and surrounding regions. Results: The two populations were similar in age, sex and deprivation score. 202 patients were scanned in OXVASC and 948 patients with TIA or ischaemic stroke from the rest of Oxfordshire. Compared with OXVASC referral rates, the observed rate in patients with TIA or stroke in the rest of Oxfordshire was reduced (RR=0.72, 95%CI=0.62-0.84, p=0.00003), especially in patients aged ≥80 years (0.53, 0.40-0.71, p=0.00001). Conclusion: Our data suggest that many elderly patients with TIA or ischaemic stroke are not referred for carotid imaging despite the high prevalence of carotid stenosis in this age group and the proven benefit of CEA.

Presentation:Oral  14.05.2004  16:30 -16:40  Room: Beethovensaal II

Differential relationship between brain activation and outcome in early and late stroke patients

N. Ward    A.J.Thompson  M.M.Brown    R.S.Frackowiak                                     
UNITED KINGDOM

Wellcome Department of Imaging Neuroscience, Institute of Neurology Others Department of Headache, Brain Injury, and Rehabilitation, Institute of Neurology

Background: After stroke, the pattern of brain activation during performance of a motor task is related to the degree of recovery. Here, we compare this relationship in the early (10-14 days after stroke) and late (at least three months after stroke) post-stroke phases after first ever stroke. Methods: We recruited patients in the early (n=8) and late (n=20) post-stroke phase. None had infarcts involving the hand region of the primary motor cortex. Subjects were studied using functional magnetic resonance imaging whilst performing isometric dynamic hand grip, a task that may be performed by patients with even minimal motor recovery. The actual force exerted and the target force were visually displayed for each subject. Target force was determined as a proportion of each subjects maximum grip strength (with the affected hand) on the day of scanning, in order to control for effort across subjects. The degree of functional recovery of each patient was assessed using a battery of outcome measures. We examined for linear correlations between size of brain activation and outcome scores (on a voxel by voxel basis) in each group. Results: A negative linear relationship between task-related brain activation and outcome was seen in a number of identical primary and non-primary motor regions that was independent of time since stroke. In other words, patients with poorer recovery recruited more widely within a number of motor regions whether in the early or late post-stroke phase. However, in contralesional intraparietal sulcus, contralesional cerebellum, and ipsilesional rostral premotor cortex, this relationship is only seen in the early post-stroke phase, such that patients with poorer recovery recruit these areas in the early but not the late post-stroke phase. Discussion: These results suggest that there are differences in the cerebral implementation of action at different times after injury in patients with poor recovery, but not in those with good recovery. Thus in those patients with most to gain from rehabilitation, different approaches may be required at different stages after stroke.

Presentation:Poster  13 May, 2004  14:00 - 16:00  Room:  

Intracerebral Hemorrhage after Stereotactic Surgery for Parkinson's Disease

J. Martí-Fàbregas    J. Pagonabarraga  A. Gironell    J. Kulisevsky   R. Belvís    D. Cocho  J.-L.Martí-Vilalta                   
SPAIN

Hospital de la Santa Creu i Sant Pau

Background: The characteristics of Intracerebral Hemorrhage (ICH) complicating stereotactic surgery (STS) for patients with Parkinson's disease are not well defined. We report the frequency and topography of ICH and its functional outcome. Methods: We reviewed all patients who underwent STS in our centre from May 1997 to March 2003. The frequency and location of ICH was assessed with cerebral CT. Functional outcome was evaluated with the modified Rankin scale (mRS) at 3 months. Results: Our study included 53 consecutive patients and 99 hemispheres. Their mean age was 61 +/- 8 years, and 60% were men. ICH was diagnosed in 6 patients (11%) and in 7 hemispheres (7%). ICH topography was classified as: Intraventricular (n=3), basal ganglia (n=2) and lobar (n=2). One patient with a lobar ICH scored 4 in the mRS; two patients (one with a basal ganglia ICH and one with a lobar ICH) scored 1 and 2, respectively, in the mRS, with improvement in activities of daily living compared with the presurgical state due to improvement in the disability attributable to Parkinson's disease; finally, four patients scored 0 in the mRS (one basal ganglia ICH, three intraventricular ICH). Discussion: In 11% of patients operated for Parkinson's disease, a symptomatic ICH was a complication. ICH appeared in regions close to the electrode: intraventricular, basal ganglia and lobar. In only one patient (2%) the ICH caused a significant degree of additional functional impairment.

Presentation:Poster  May 13, 2004  14:00 - 16:00  Room:  

The complications and short term outcome of Percutaneous Endoscopic Gastrostomy feeding in Acute stroke

R. Kumar    J. Monaghan  N. Stern    G. Tack   D. McDowell    A. Sharma                        
UNITED KINGDOM

University Hospital Aintree

Background: It has been suggested that Percutaneous Endoscopic Gastrostomy (PEG) insertion and feeding following acute stroke may cause a high number of deaths and complications. However, previous studies have not taken into account the fact that PEG fed patients were likely to have suffered more severe strokes compared to non-PEG stroke patients. The aim of the present study was to investigate post-PEG complicationsand to assess the short term outcome in terms of death and discharge destination following an acute stroke. Methods: The present study included 28 patients on the acute stroke unit, in whom PEG feeding was instituted due to dysphagia, at the University Hospital Aintree and these were matched to 28 non-PEG stroke patients based on stroke type, severity and age. Results: A high proportion of PEG patients had severe strokes (TACS (13) and PACS (11); mean Barthel day 7 = 3.7) and were elderly (mean age 77 years) and the control group were selected to match on these variables.The complication rates were low. 23 PEG patients were discharged alive of which 14 (61%) went to a nursing home. 18 patients were still alive at 6 months. Fewer patients were discharged alive in the control group (19) of which 8 (50%) went to a nursing home. 15 patients were still alive at 6 months. Kaplan Meier analysis showed a nearly significant difference in survival between the two groups at discharge p=0.05; but was non-significant at 6 months. Discussion: The present study demonstrates that PEG feeding following acute stroke has relatively low level of complications and does not cause higher mortality once stroke type, severity and age are taken into account. In addition it shows that PEG feeding may even improve short term survival in severe stroke.

Presentation:Oral  13.05.2004  11:10 - 11:20  Room: Musensaal

Risk Factors for Intracranial Hemorrhage during Natural Course Follow-up in Patients with Untreated Brain Arteriovenous Malformation (AVM)

C. Stapf    H. Mast  R.R.Sciacca    A.V.Khaw   E.S.Connolly    J. Pile-Spellman  JP Mohr                   
FRANCE

Stroke Center / The Neurological Insitute, Columbia University

Background: Several morphologic risk factors for hemorrhagic AVM presentation have been established, but their relevance for subsequent AVM hemorrhage remains less well defined. Methods: We analyzed follow-up data on 622 consecutive patients from the prospective Columbia AVM database, limited to the period between initial AVM diagnosis and the start of treatment (i.e., endovascular, surgical, and/or radiation therapy). Univariate, and multivariate Cox proportional hazard models were applied to analyze the effect of patient age, gender, AVM size, anatomic location, venous drainage pattern, and presence of associated arterial aneurysms on the risk of intracranial hemorrhage during follow-up. Results: The mean pre-treatment follow-up was 829 days (SE+/-88). Overall, 282 (45%) AVM patients initially presented with intracranial hemorrhage and 39 (6%) suffered AVM hemorrhage during the pre-treatment period. Age (HR: 1.05, 95% CI 1.03-1.08), hemorrhagic AVM presentation (HR 5.38, 95% CI 2.64-10.96), deep brain location (HR 3.25, 95% CI 1.30-8.16), and exclusive deep venous drainage (HR 3.25, 95% CI 1.01-5.67) were independent predictors of subsequent hemorrhage. Model estimates of annual hemorrhage rates were 4.5% for those with hemorrhagic AVM presentation, 3.1% for deeply located AVMs, 2.4% for those with exclusive deep venous drainage, and 34.4% in cases harboring all three risk For patients without risk factors the annual hemorrhage rate was 0.9%. Conclusion: Hemorrhagic AVM presentation, age, deep brain location, and exclusive deep venous drainage appear to be independent predictors for intracranial hemorrhage during natural course follow-up. The hemorrhage risk may be low in untreated AVMs without these risk factors.

http://www.esc-archive.eu/mannheim04/ma_graphics/mg_1058.htm
 

Presentation:Poster  May 13, 2004  14:00 - 16:00  Room:  

White matter and other chronic changes on CT brainscans in acute stroke: inter-rater reliability and relationship to late post-stroke depression

K. Chatterjee    D. Barer  S.C.Athey    M.C.Muller   P. Mudd                               
UNITED KINGDOM

Stroke Research Unit, Queen Elizabeth Hospital, University of Newcastle

Background: Diffuse white matter changes, thought to be associated with small vessel disease, are frequently seen on computed tomography (CT) brainscans, especially in older patients. We investigated inter-rater agreement in reporting these and other "chronic" changes on scans of patients with acute stroke, and whether they differed between those with and without depression several months later. Methods: CT brainscans of 40 patients with acute stroke were reported blind by 2 radiologists and 3 stroke physicians, using a structured proforma. The rating scale for white matter changes (WMC) was based on that devised by the European Task Force. Later, scans from 33 patients with post-stroke depression (DSM-IV criteria) and 70 non-depressed stroke survivors, matched for age and disability, were reported separately by 2 investigators, using the same proforma, and consensus ratings were then agreed. Results: Agreement among all raters on chronic changes was moderate: ICC and Kappa for the number, size and location of lesions, degree of cortical atrophy and extent of WMCs varied between 0.4 and 0.6. Agreement on number of lacunar infarcts was only fair (ICC 0.33), while it was good for degree of central atrophy (ICC 0.83). Despite the matching, discrete lesions were seen in 79% of depressed patients vs. 53% of non-depressed controls (p<0.05). Their overall WMC and basal ganglia lesion scores were significantly higher than controls (p<0.05). Adjusting for other predictors in logistic regression, only basal ganglia changes were found to be independent predictors of post-stroke depression. Discussion: Moderate inter-rater agreement can be achieved in interpreting chronic changes on CT scans. Their relationship to late post-stroke depression requires further study.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

Infarction in the centre of the cerebellar arbor vitae is associated with loss of spatial orientation

E. Grips    O. Sedlaczek  H. Baezner    A. Claus   J. Woehrle    M.G.Hennerici                        
GERMANY

Dept. of Neurology Uniklinikum Mannheim University of Heidelberg

Background: Vertigo is an unspecific symptom but characteristic features can indicate on the responsible lesion. In the absence of clinical signs the diagnosis may be missed. Case report: A 45 year old patient suffered from acute severe pain in the right shoulder after lifting a heavy suitcase. Immediately after the onset of pain he experienced 15 seconds of mild unspecific vertigo. After an interval of 4 hours he reported a transient loss of spatial orientation and a feeling being shaked in an airplane during severe turbulances. Because of persisting pain he first came for orthopaedic consultation and when referred to us 5 hours after onset of symptoms, he had completely recovered and was normal on neurological examination. Extracranial Doppler sonography and MRA confirmed a dissection of the right vertebral artery as expected but DW-MRI and FLAIR revealed an unexpected unique small acute lesion of 2 mm in diameter in the centre of the cerebellar worm. Discussion: A history of severe vertigo with loss of spatial orientation -though very short and transient -can be indicative of cerebellar stroke. Although the symptomatology and lesion site are highly unusual, the syndrome might be underestimated due to often inadequate history taking and insufficient imaging. Spatial orientation seams to be integrated in the centre of the arbor vitae.

Presentation:Oral  13.05.2004  11:10 - 11:20  Room: Bruno-Schmitz-Saal

MR findings in patients suffering from Migraine with Aura

O. Sedlaczek    E. Grips  K. Szabo    R. Kern   J. Woehrle    A. Gass  M.G.Hennerici                   
GERMANY

Dept. of Neurology Uniklinikum Mannheim University of Heidelberg

Background Migraine with aura is a disabling, but with regard to outcome benign ailment. Alterations in blood-flow are known to occur in the affected hemisphere, yet MR-findings are only rarely reported. We report MRI and clinical findings in 5 patients who presented with acute onset of aphasic syndromes identified as migraine. Methods All patients presented to our emergency facility with suspected cerebral ischemia. Multiparametric MRI was immediately performed on admission (1.5-6 hours after onset), 24 hours later, and 7 days later and consisted of T2-, T1-, diffusion- (DWI) and perfusion-weighted (PWI) contrasts and magnetic resonance angiography (TOF-MRA). Results Clinical syndromes leading to presentation were classical stroke syndromes: Aphasia, high-grade hemiparesis and hemianopia. Headache associated with the symptoms was missing in 2 patients. Alterations of MRA and PWI were detectable in all patients and vascular territories affected were not restricted to classical territories. Hyperacutely MRA and PWI indicated reduced blood flow and perfusion, after 24 hours there were signs of hyperperfusion on MRA and PWI, which had normalised in all patients after 7d. No DWI/T2 lesions occurred in areas of altered perfusion. Conclusion MRI findings in this group of migraine patients demonstrated 3 different, clearly separated phases of blood flow and perfusion in the absence of DWI lesions. In the aura phase areas of hypoperfusion seen on PWI did not respect the distribution of vascular territories, making focal arterial ischemia, e.g. due to carotid artery dissection, unlikely. This is therapeutically relevant as the exclusion of an infarct prevents unnecessary thrombolysis.

Presentation:Oral  13.05.2004  11:00 - 11:10  Room: Beethovensaal I

The Swedish Malignant Media Infarction Study Long-term results from a prospective study of hemicraniectomy

A. Lindgren    T. Bergenheim  P. Enblad    H.-G.Hårdemark   L.-O.D.Koskinen    S. Naredi  C.-H.Nordström    B. Norrving    J. Malm     
SWEDEN

University Hospital Lund Department of Clinical Neuroscience

Background: The prognosis for patients with malignant middle cerebral artery (MMCA) infarct is serious. Hemicraniectomy may be life saving in the acute phase, but the long-term prognosis is less well known. Methods: We prospectively included patients with left or right MMCA infarct treated with hemicraniectomy at three Swedish university hospitals (Umeå, Lund, and Uppsala) between 1998 and 2002. The main criterion for surgical intervention was if the patients deteriorated from being conscious to being responding to pain only. All patients were followed for at least one year. Modified Rankin Scale (MRS) was assessed at the last follow-up of each patient. A MRS of 2 or less was considered a favourable outcome. Results: Thirty patients, 14 women and 16 men, participated in the study. Median age at stroke onset was 51 (range 17-67) years. Fourteen patients had MMCA infarct on the left side and 16 patients on the right side. Fourteen patients had pupil dilatation before surgery. Hemicraniectomy was performed at a median of 52 (range 13-235) hours after stroke onset. Nine patients died within 1 month after surgery because of cerebral herniation (n=6), myocardial infarct (n=1) or intensive care complications (n=2). No further deaths occurred during follow-up, which was at median 1253 (range 504-2062) days (3.4 years) after surgery. Status for the 21 survivors at the last follow up was: MRS 2 or less (n=6) and MRS 3-5 (n=15). The oldest patient with MRS 2 or less was 53 years at stroke onset. Discussion: The long-term survival after MMCA infarct treated with hemicraniectomy seems to be favourable if the patient survives the acute phase. The outcome assessed with MRS differs substantially between survivors, with a possibility of better outcome among younger patients.

Presentation:Poster  May 13, 2004  14:00 - 16:00  Room:  

Prospective follow-up of patients with moderate carotid stenosis

V. Vukovic    I. Zavoreo  S. Morovic    M.J.Kesic   A. Lovrencic-Huzjan    V. Demarin                        
CROATIA

Department of Neurology University hospital "Sestre milosrdnice" Zagreb, Croatia

Background: Patients with moderate carotid stenosis are not considered to be in the high risk stroke group and their usual treatment is conservative. The aim of this study was to follow up patients with moderate carotid stenosis during 5 years period. Patients and methods: Among 1284 stroke patients hospitalized in 1999; 78 (6 %) patients (48 men, mean age 68, 30 women, mean age 74) had moderate carotid artery stenosis (50-70 %) of at least 1 artery, and 20 % had bilateral moderate stenosis or occlusion of the other artery. A total of 58 patients completed the study; 10 patients were lost during follow-up and 10 patients died early during hospitalization. Results: In 1999 year, 62 (79 %) patients had stroke – 39 (50 %) men, 22 (29 %) women, TIA had 15 (19 %) patients - 8 (10%) men and 7 (9 %) women, 2 (3%) of patients had subarachnoid hemorrhage. Mortality in 1999 was 13 %. First ever stroke had 39 (50 %) patients of whom 41% had stroke ipsilateral to moderate carotid stenosis and 22 (28 %) patients had recurrent stroke. The most common risk factor was hypertension (91 %), while other risk factors were present in the range of 35–40 %. Atrial fibrillation was present in 17 % of patients. Symptomatic stenosis was present in 59 %, asymptomatic in 11%, and ipsilateral amaurosis fugax was present in 31 % of patients. At the end of follow up period mortality was 38 %. Recurrent stroke ipsilateral to carotid stenosis occurred in 39 % of patients and TIA in 18 %, stroke in 2 % and TIA in 2% of others. Carotid endarterectomy during follow up was performed in 50 % of patients, of whom 12 % had stroke. Conclusions: Moderate carotid stenosis in older age groups, especially in men may represent a higher risk factor for stroke than previously believed.

Presentation:Poster  May 13, 2004  14:00 - 16:00  Room:  

CITICOLINE INHIBITS THE EXTRACELLULAR GLUTAMATE ACCUMULATION AFTER EXPERIMENTAL ISCHEMIA BY DIFFERENTIALLY TARGETTING GLUTAMATE TRANSPORT IN NEURONES AND ASTROCYTES.

I. Lizasoain    O. Hurtado  A. Cárdenas    A. Dávalos   R. Lozano    J.J.Secades  J.C.Leza    P. Lorenzo    M.A.Moro  J. Castillo
SPAIN

Departamento de Farmacología, Facultad de Medicina, Universidad Complutense de Madrid.

BACKGROUND AND PURPOSE: Cytidine-5-diphosphocholine (citicoline or CDP-choline), an intermediate in the biosynthesis of phosphatidylcholine, has shown beneficial effects in a number of CNS injury models including cerebral ischemia. Citicoline is the only neuroprotectant that has proved efficacy in patients with moderate to severe stroke. However, the precise mechanism of action in cerebral ischemia is not fully understood. The present study was designed to test the mechanisms of citicoline neuroprotective properties using rat cultured cortical neurones and astrocytes. METHODS: Rat cortical neurones or astrocytes were prepared as described (Romera et al., 2004). Rat neuronal cortical cultures were exposed to oxygen-glucose deprivation (OGD) as described (De Cristóbal et al., 2002) either in the absence or in the presence of citicoline (10-100 microM). Viability was studied by measuring LDH release in the extracellular medium 24 h after OGD. Glutamate release was determined by measuring glutamate in the extracellular medium by RP-HPLC. Astrocytes were incubated either in the absence or in the presence of citicoline (10-100 microM) and [3H] glutamate uptake was determined (De Cristóbal et al., 2002). RESULTS: Incubation with citicoline (10 and 100 microM) prevented OGD-induced LDH (80 and 78% reduction; p<0.05 vs OGD) and glutamate release (60 and 70% reduction; p<0.05 vs OGD) from cultured rat cortical neurones. In addition, citicoline (100 microM) caused an increase in [3H] glutamate uptake in cultured rat astrocytes (138+/-5%; p<0.05 vs control). CONCLUSIONS: Our results show a novel mechanism for the neuroprotective effects of citicoline by decreasing brain glutamate release after ischemia. Romera et al. J. Neuroscience 24 (in press), 2004. De Cristóbal et al. Stroke 33 :261-267, 2002.

Presentation:Poster  May 13, 2004  14:00 - 16:00  Room:  

The role of two MMP1 and MMP2 gene variants in Carotid Atherosclerosis

S. Abilleira    S. Bevan  H.S.Markus    S. von Kegler   M. Sitzer                               
UNITED KINGDOM

Department of Clinical Neuroscience, St. George’s Hospital Medical School, London

Introduction Matrix metalloproteinases (MMPs) are a group of proteolytic enzymes that degrade components of the extracellular matrix during tissue remodelling and have been shown to slow the development and progression of atherosclerosis. Functional polymorphisms in the MMPs have been described which show increased transcriptional activity of the MMP genes, although environmental factors such as smoking may modify these. We have investigated whether two of these variants are associated with an increased risk of early carotid atherosclerosis, as measured by carotid artery intima media thickness (IMT) and established internal carotid plaque, and whether these effects are modified by smoking status. Methods MMP1 A-519G and MMP2 C-735T were studied in a population of 1000 individuals in whom carotid artery IMT was known, and 200 individuals with established carotid plaque (defined as IMT >1.8mm) matched 2:1 with controls. Genotyping was undertaken by PCR and enzyme digestion. Results In a community population of 1000 individuals neither MMP1 A-519G nor MMP2 C-735T showed any association with levels of carotid artery IMT. In a case control study of 200 individuals with established carotid plaque matched 2:1 with controls MMP1 A-519G showed no overall association with carotid plaque (p=0.480), and no association with smoking status. MMP2 C-735T showed no overall association with carotid plaque (p=0.339) but did show a minor protective effect in individuals who had never smoked (p=0.081). This protective effect was lost when examining ex or current smokers (p=0.703). Conclusions Presence of one or more copies of MMP2 C-735T may contribute some protection against development of carotid atherosclerotic plaque. In our sample this protective effect is negated by the effects of smoking, and the borderline significance of the finding may warrant replication in a larger population to fully determine the effects of MMP2 C-735T on development of carotid plaque in non-smokers.

Presentation:Poster  May 13, 2004  14:00 - 16:00  Room:  

Thrombin induced neuroprotection

C. Granziera    J.  Thevenet  J.  Badaut    J.  Bogousslavsky   L.  Hirt                               
SWITZERLAND

Neurology Laboratory, CHUV Lausanne Switzerland

Abstract-Background: Thrombin is a multifunctional serine protease that has been shown to be neurotoxic at high concentrations and neuroprotective at low doses. Objective: To study thrombin neuroprotective effect using models that will allow further characterisation of the mechanisms involved. Methods: Organotypic slices of rat hippocampus were prepared from brains of 10-12 day-old neonatal rats. Ischemia was obtained through oxygen glucose deprivation (OGD). 24h before OGD 0.01U/ml thrombin was added to cultures. Cell death was determined using the fluorescent viability indicator propidium iodide (PI) and expressed as final fluorescence minus background 48h after the onset of injury. Male ICR-CD1 mice were subjected to transient (30 min) occlusion of the middle cerebral artery. Regional cerebral blood flow was monitored in all animals. One day before surgery animals were treated with an intra-cerebroventricular injection of either 0.01 U thrombin or vehicle. Infarct volumes were all measured 72h after ischemia. Data are presented as mean ± SD. Parametric data were compared with Student’s T-test. Results: Thrombin (0.01U/ml) 24 h before OGD significantly reduced cell death on hippocampal slice cultures from 42 +/-15 % (n=5) to 11 +/- 7 % (n=6), (p<0.01). Similarly in vivo, with 0.01 U thrombin administration there was a reduction in infarct volume from 83 +/- 46 mm3 (n=7) to 25 +/- 7 mm3 (n=6), (p<0.01). Conclusion: These data show that low doses of thrombin mediate a strong neuroprotection in two models of transient cerebral ischemia. We are currently investigating the pathways involved in cell survival with the aim to develop new pharmacological tools in stroke therapy and prevention.

Presentation:Poster  13 May, 2004  14:00 - 16:00  Room:  

Lacunar infarct: correlation between clinical presentation and lesion localization.

H. Dib    N. Afsar  K. Agan    S. Aktan                                     
TURKEY

Marmara University School of Medicine

Background: Lacunar infarcts generally present as classical lacunar syndromes and may as well have atypical clinical presentations. Aim: To investigate the correlation between clinical presentation and infarct localization of small ischemic lesions. Methods: Consecutive patients applying to a Community-based University Hospital Neurology Clinic between January 1998 and December 2003 with a new lacunar infarct (lesion smaller than 1.5 cm without cortical involvement) on their diffusion-weighted MRI were included in this study. Clinical syndromes, lesions localization and risk factors were determined. Results: Among a total of 112 patients there were 77 men (mean age 67.0 +/- 10.7) and 35 women (mean age 67.8 +/- 7.9). Ataxic hemiparesis (27.7 %) and pure motor stroke (26.8 %) were the most frequent lacunar syndromes. However, 24 % of patients presented with atypical clinical findings such as internuclear ophthalmoplegia; sensorimotor stroke + ataxia; sensorimotor stroke + dysarthria; pure motor stroke + dysarthria; ataxic hemiparesis + internuclear ophthalmoplegia; ataxic hemiparesis + sensory loss; sensory stroke + ataxia; and dysarthria. The most common risk factors were hypertension (74.1 %), hyperlipidemia (51.8 %), smoking (33.0 %), and diabetes mellitus (28.6 %). Infarcts were mostly localized in the brainstem (47.3 %), internal capsule (28.6 %), thalamus (10.7 %), and subcortical white matter (10.7 %). Patients with classical lacunar syndromes most frequently had internal capsule infarcts whereas patients with atypical presentation had brainstem lesions (p: 0.0063). Discussion: In this study, atypical clinical presentation was found to be most frequently associated with lacunar infarcts located in the brainstem. However, the main etiology was small artery disease in both the classical and atypical presentations.

Presentation:Poster  14 May, 2004  14:00 - 16:00  Room:  

CD40/CD40L genetic variants and cerebral ischemia of the young

S. Debette    C. Lichy  J. Genius    T. Dong-Si   F. Stoll    I. Werner  A.J.Grau    D. Leys    W. Hacke  C. Grond-Ginsbach
GERMANY

University Hospital of Heidelberg

Background: The CD40/CD40L complex plays a key role in inflammation and in particular in the initiation and progression of atherosclerosis. Recently it has been shown to be upregulated in patients with acute cerebral ischemia. Objective: We searched for an association between CD40 and CD40L genetic variants and the occurrence of cerebral ischemia (CI) of the young. Method: A case-control association analysis was conducted on 176 consecutive Caucasian patients aged < 50 years admitted to our centre for CI and 201 Caucasian aged-matched controls. The –1C/T single nucleotide polymorphism (SNP) in the CD40 gene on chromosome 20 and the –732A/T SNP in the CD40L gene on chromosome X (promoter region) were analysed. Results: The frequency of the T-allele in the CD40 –1C/T SNP was not significantly higher in cases than in controls (32.4% vs. 29.4%, p=0.52). In a multivariate analysis CI was not significantly associated with the TT-genotype (OR=1.75, p=0.16). CI due to atherosclerosis and CI with patent foramen ovale (PFO) were both associated significantly with the TT-genotype (respectively: OR=5.69, p=0.027 and OR=4.97, p=0.0017). The frequency of the A-allele in the CD40L –732A/T SNP was not significantly higher in cases than in controls (8.5% versus 5.8%, p=0.24). In a multivariate analysis CI was not significantly associated with the presence of at least one A-allele (OR=1.47, p=0.33). CI with PFO was associated significantly with the presence of at least one A-allele (OR=3.37, p=0.045). Conclusion: In our population of patients < 50 years of age we show no overall significant association between CI and 2 genetic variants in the CD40 and CD40L genes. Nevertheless a significant positive association exists (i) between CI associated with PFO and both the CD40 and CD40L mutant (suggesting the role of an inflammatory trigger in these patients) and (ii) between CI due to atherosclerosis and the CD40 mutant. These results need to be confirmed by another independent study.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

PROGNOSIS OF PATIENTS AFTER HEMICRANIECTOMY VERSUS MEDICAL THERAPY IN MALIGNANT MIDDLE CEREBRAL ARTERY INFARCTION

H. Sirin    A. Sagduyu Kocaman  T. Turhan    B. Dıramalı   A. Fillik    N. Ozdamar                        
TURKEY

Ege University Medical School Hospital

Objective: To review early outcome of the medical therapy and decompressive craniectomy in the large space-occupying middle cerebral artery infarction. Design: We retrospectively reviewed the patients who fulfilled the clinical and imaging criteria for large middle serebral artery infarction underwent hemicraniectomy because of impending herniation despite best medical therapy with the group whom treated only medically in the Neurointensive Care Unit in Ege University Medical School Hospital from 1997 through 2003. The National Institude of Health Stroke Scale (NIHSS) assessed neurological status on admission and at the one week after surgery or medical treatment. At 3 month follow up Glasgow Outcome Scale (GOS) were used to asses the functional outcome. Results: There were 33 males and 32 females with a mean age of 66.8 years (range 42-88). Twenty eight patients ( 43 %) had dominant hemisphere stroke. The mean NIHSS on admission was 19.2 in decompressive group and 20.7 in the medical group. The mean interval between stroke onset and surgery was 80 hours (range 40-182 hours). Six patients (24 %) in the decompressive group and 18 patients (45 %) in the medical group died. At follow up, GOS revealed severe handicap in 12 patients (48 %) at the decompressive group and also 16 patient (40 %) in the medical group. Conclusion: The principle cause of death in patient with malignant middle cerebral artery infarction is edema and cerebral herniation. Early hemicraniectomy may be a useful procedure in patients with large middle cerebral artery territory infarction. A randomised controlled trial is required to substantiate these findings.

Presentation:Poster  14 May, 2004  14:00 - 16:00  Room:  

Incidence and prognosis of subarachnoid hemorrhage in a population based study

C. Marini    R.  Totaro  L.  Olivieri    F.  De Santis   S.  Mearelli    A.  Carolei                        
ITALY

Department of Neurology, University of L’Aquila, L’Aquila, Italy

Background Subarachnoid hemorrhage (SAH) is the less common stroke type, with wide variability in incidence and case-fatality. Nevertheless, epidemiological data from adequate population-based studies are scanty. Methods All cases of first-ever SAH occurring in the L’Aquila district, central Italy, from January 1994 to December 1998 were traced in a prospective population-based registry by active monitoring of multiple sources, including general practitioners and death certificates, and coded according to ICD-9. The ICD-10NA was used when neuroimaging studies were available. Functional outcome was evaluated by means of the modified Rankin scale (mRS). Results We identified 118 incident cases of SAH, 55 in men and 63 in women. Mean±SD age at onset was 60.7±15.9 years and was higher in women than in men (64.7 vs 56.2; P=0.003). Crude annual incidence rate was 7.9 per 100,000 (95% CI 6.4-9.6), 7.6 in men and 8.2 in women. Among the 117 patients (98.3%) with neuroimaging studies, a single ruptured aneurysm was found in 53 subjects (45%), multiple intracranial aneurysms in 3 (2.6%), and an arteriovenous malformation in 6 (5.1%). Site of bleeding remained unspecified in 50 patients (42.7%) while aneurysms were not found in 5 (4.3%). 30-day case-fatality rate was 33.9% (95% CI 25.3-42.4). Long-term survival was higher in patients under 65 than in those 65 years old or older (72.31% vs 33.29%, P=0.0001 Log-rank test). At the 1-year follow-up 53 patients (44.9%) showed mild or no disability (mRS 0-2), 13 (11.0%) were severely disabled (mRS 3-5), and 52 (44.1%) had died. Discussion Our incidence rate of SAH was within the range of previous studies. Incidence of SAH increased with age and was slightly higher in women than in men depending on higher incidence in older women. 30-day case-fatality rate was low and increased with age, with a reduced long-term survival in patients 65 years old or older.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

DIABETIC KETOACIDOSIS PRESENTING AS A CEREBRAL VENOUS SINUS THROMBOSIS

K. De Keyzer    K.  Paemeleire  M. De Clerck    D.  Peeters   J. De Reuck                               
BELGIUM

Department of Neurology, Ghent University Hospital, Ghent, Belgium; Department of Neurology, AZ Groeninge, Kortrijk, Belgium

Background: Cerebral venous sinus thrombosis (CVST) is an uncommon condition with a variable clinical presentation. Predisposing factors can be identified in 65-80% of cases and include pregnancy and puerperium, oral contraceptive use, head injury, dehydration, blood dyscrasias, coagulopathies and systemic diseases. Case report: A 19-year-old woman was admitted with a severe headache associated with nausea, vomiting, photophobia, dizziness and malaise since 2 days. History taking revealed a head trauma 4 days earlier and a cerebral concussion several years before. Clinical examination was unremarkable. A cerebral computerized tomography scan revealed no abnormalities. Following admission she gradually developed psychotic symptoms, dysphasia, cranial nerve palsies and a spastic tetraparesis. A magnetic resonance imaging (MRI) scan of the brain with MR venography revealed a thrombosis of the superior sagittal sinus. Laboratory studies showed dehydration, a raised d-dimer level, a very high serum glucose and a compensated metabolic acidosis. Urinalysis showed severe glucosuria and ketonuria. Screening for coagulopathies was normal. Further history taking revealed polydipsia, polyuria and weight loss. The diagnosis of type 1 diabetes mellitus was confirmed with additional laboratory investigations. Discussion: In our patient a combination of risk factors was found: recent head trauma, dehydration, use of an oral contraceptive and smoking. Since the head injury had been mild without signs of a cerebral concussion and the patient only smoked sporadically, these factors were not thought to be significant. The CVST was most likely triggered by the severe dehydration caused by diabetic ketoacidosis while the intake of an oral contraceptive may have been an additional risk factor. Severe dehydration is a well-known cause of CVST. However, a CVST in associaton with diabetic ketoacidosis has only been reported in children. To our knowledge this is the first case of an adult in whom a CVST was the presenting syndrome leading to the diagnosis of new-onset type 1 diabetes mellitus.

Presentation:Oral  14.05.2004  11:20 - 11:30  Room: Stamitzsaal

Intraarterial thrombolysis in acute vertebrobasilar occlusion: A multicentric retrospective analysis of 180 cases

G. Schulte-Altedorneburg    G.F.Hamann  M. Mull    D. Kühne   M. Liebetrau    H. Brückmann  T.E.Mayer                   
GERMANY

Departments of Neuroradiology and Neurology, Klinikum Grosshadern,University of Munich

Background and Purpose: In case of successful recanalisation local intraarterial fibrinolysis (LIF) has shown to reduce mortality and improve neurologic outcome in acute vertebrobasilar occlusion (VBO). Our purpose was to evaluate parameters predicting a favourable neurologic outcome in a large multicentric cohort. Methods: The data of 180 patients (56 women;mean age,57.9 years) with acute VBO from 5 neuroradiologic centers were retrospectively evaluated. LIF was performed with recombinant tissue-type plasminogen activator or urokinase. Modified Rankin scale (MRS) was used to evaluate the neurologic status before treatment and at the time of discharge or transfer. Patient’s age, etiology of VBO (embolic vs. atherosclerotic), recanalisation success, symptom duration before LIF and pretreatment MRS were correlated with posttreatment MRS. Multiple regression analysis was performed to identify independent variables. Results: The overall mortality was 43%. Complete recanalisation was achieved in 99 (55%) patients and a partial recanalisation in 35 (19%) patients, respectively. The success of recanalisation depended on the volume of the thrombus (p<0.001). Recanalisation of the VBO correlated significantly with a favourable clinical outcome (p<0.001). The clinical outcome correlated strongly with the pretreatment MRS. Early treatment especially short lasting coma led to a positive trend towards a better neurologic outcome (p<0.10). Age and the etiology of VBO did not significantly influence the clinical outcome. Discussion: The neurologic outcome in VBO depends from the success of recanalisation and severity of the pretreatment score. This emphasizes the need of new recanalisation techniques in large thrombus volumina.

Presentation:Oral  13.05.2004  11:20 - 11:30  Room: Stamitzsaal

Using a modified bedside screen to assess swallowing in acute stroke patients

D.J.C.Ramsey    D.G.Smithard  L. Kalra                                            
UNITED KINGDOM

Department of Stroke Medicine, GKT School Of Medicine, London

BACKGROUND: Dysphagia in stroke is often seen as a precursor for the development of pneumonia. This study used a modified bedside screening test to assess swallowing, comparing the results with Speech and Language Therapy (SLT) assessments and clinical outcomes. METHODS: 89 acute stroke patients (maximum 5 days post stroke) were tested swallowing a radio-opaque contrast agent, followed by chest radiography to look for aspirated thoracic contrast. SLT assessments were used as the clinical gold standard to compare with the screen. Outcomes recorded prospectively included frequency of chest infections within the first month and need for later additional dietary changes. RESULTS: 64.0% patients had a safe swallow both clinically and radiologically; 29.2% were thought unsafe clinically but showed no radiological evidence of aspiration; 2.2% were safe clinically but thoracic contrast was visible radiologically (silent aspirators); and 4.5% were unsafe clinically and radiologically. Failing the screen on either clinical or radiological grounds correlated highly with need for dietary changes on SLT assessment (p<0.001), and also correlated with the need for later dietary changes during the first month (p=0.011). However, neither failing the screen nor having SLT-determined dysphagia correlated with the development of early chest infections. DISCUSSION: The significant correlation between the results from the modified swallow screen and the SLT assessments provides validation for use of the screen in acute stroke patients. The correlation with need for later dietary modification is unsurprising, but the lack of association with the development of chest infections suggests that aspiration is not the only prerequisite factor for the development of pneumonia in dysphagic patients.

Presentation:Poster  14 May, 2004  14:00 - 16:00  Room:  

Stroke risk factors in Tbilisi, Georgia: Results of the first population-based study

A. Tsiskaridze    M. Djibuti  G. van Melle    G. Lomidze   S. Apridonidze    R. Shakarishvili  J. Bogousslavsky                   
GEORGIA

Institute of Neurology, Tbilisi, Georgia and Department of Neurology, CHUV, Lausanne, Switzerland

Background: Although stroke is one of the major public health problems worldwide, no population-based study of stroke risk factors has been performed in Georgia. Methods: In the framework of the joint Swiss-Georgian project on stroke epidemiology, we evaluated the importance of the different risk factors contributing to ischemic stroke in Nadzaladevi District of Tbilisi, using a population-based case-control design. One hundred thirty-seven patients with first-ever ischemic stroke (50 men and 87 women; mean age 69.1+/-8.4 years) and 137 age- and sex-matched controls (mean age 68.4+/-9.9 years) were studied. The patients were consecutively identified from the local stroke registry, which is centralized at the Institute of Neurology in Tbilisi. Results: In a multivariate logistic regression analysis of demographic, anamnestic and clinico-laboratory factors, stroke was significantly associated with low formal education (odds ratio (OR) 2.5, 95% confidence interval (CI) 1.4-4.6), heavy alcohol consumption (OR 2.7, 95%CI 1.2-6.0), family history of stroke (OR 2.5, 95%CI 1.2-5.3), arterial hypertension (OR 2.7, 95%CI 1.3-5.4), atrial fibrillation (OR 7.3; 95%CI 3.5-15.2), diabetes mellitus (OR 3.2, 95%CI 1.6-6.5), and history of transient ischemic attack (OR 16.3; 95%CI 4.4-61.5). Discussion: The present study outlines the significance of risk factors for stroke in this Georgian population. We failed to demonstrate an association of ischemic stroke with other traditional risk factors, such as smoking, high body mass index and hypercholesterolemia, which may be explained in part by a different risk profile in the Georgian population, in relation to geographical and lifestyle variations. These findings may have an important implication for stroke prevention in the country.

Presentation:Poster  May 13, 2004  14:00 - 16:00  Room:  

Etiology of sudden disturbances of consciousness in patients with a history of stroke

D. Ryglewicz    W. Lojkowska  K. Niedzielska    A. Wierzbicka   A. Bochynska                               
POLAND

Institute of Psychiatry and Neurology

Disorders of consciousness represent one of the most common neurological symptom in elderly. Their etiology may be connected with cerebral circulation insufficiency, metabolic disorders or epileptic seizures. Differential diagnosis is especially difficult among patients with a history of stroke. The aim of this study was to estimate clinical state and the results of laboratory examinations in postroke patients who suddenly developed disorders of consciousness. Due to the unexpected disorders of consciousness 74 poststroke patients (36 men and 38 women, mean age 69.8) were admitted to the Institute of Psychiatry and Neurology in 2003. On the basis of clinical, biochemical, neurophysiological and neuroimaging examinations in 28 patients (37.8%) poststroke epilepsy, in 29 (39.1%) recurrent stroke and in 17 (22.9%) metabolic disorders were diagnosed. No differences regarding age or sex have been found in those 3 groups of patients. EEG examinations and long term monitoring of clinical symptoms such as fluctuations of consciousness or subtle motor signes appeared to be of the greatest diagnostic importance. On this basis in the group of 28 patients with poststroke epilepsy in 12 nonconvulsive status epilepticus was diagnosed. In remaining 16 patients EEG revealed epileptiform discharges only in 2, while in the majority of cases focal episodic changes were observed. Our study has shown that in sudden disturbances of consciuosnes in patients with a history of stroke the suspicion of poststroke epilepsy should be always taken under consideration. Constant, accurate monitoring of neurological state and EEG may help to differentiate between recurrent stroke or episode of epilepsy. Complex biochemical examination for excluding metabolic cause of disorders always should be performed.

Presentation:Oral  14.05.2004  11:10 - 11:20  Room: Beethovensaal II

Cerebral metabolite and perfusion abnormalities in the diffusion lesion in acute ischaemic stroke – a region-of-interest analysis

V. Cvoro    K. Wartolowska  A.J.Farrall    P.A.Armitage   I. Marshall    M.E.Bastin  M.S.Dennis    J.M.Wardlaw            
UNITED KINGDOM

The University of Edinburgh Department of Clinical Neurosciences

Background: Normal cerebral metabolites (eg N-Acetyl aspartate, NAA) are reduced and abnormal metabolites (eg lactate) increased in acute ischaemic stroke on MR spectroscopic imaging (SI), but the relationship of metabolites to diffusion (DWI) and perfusion (PWI) abnormalities is unclear. Methods: Patients with acute cortical ischaemic stroke were imaged soon after stroke, with DWI (tensor), contrast bolus PWI and single slice MR chemical shift imaging (CSI). The CSI slice was placed on the diffusion slice showing the maximum infarct extent. DWI, PWI and CSI slices were coregistered and processed blind, by: outlining the DWI lesion (region of interest -ROI); superimposing the ROI on the PWI and CSI images; identifying a mirror-image ROI in normal brain; extracting metabolite (NAA, Choline, Creatine, Lactate), PWI and DWI values from lesion and normal ROIs; and comparing the CSI, PWI and DWI ratios. Results: In 14 patients to date, 8 partial anterior circulation strokes, 6 total anterior circulation strokes, aged 37-94 (mean 76) yrs, imaged mean 10 hours after stroke, ROI NAA is significantly reduced vs contralateral side (90 vs 116, p<0.004). Lactate is present in ROI on the ipsilateral side. Increased lactate was associated with raised MTT ratio (r=0.551, p<0.074), but not with CBF or ADC ratio (r= 0.13, r = - 0.12). There was no definite correlation between relative ADC (rADC), rMTT, rCBF and rNAA. Discussion: In early ischemic stroke, in the visible DWI abnormality, lactate is present and increases with increase in MTT. Although NAA is abnormal, the lack of correlation suggests that more detailed subregion analysis is required to determine patterns of abnormality.

Presentation:Oral  13.05.2004  16:00 - 16:10  Room: Beethovensaal II

The Metabolic Syndrome and Early Carotid Atherosclerosis in Middle-aged Men and Women

B. Iglseder    B. Paulweber  M. Hedegger    L. Malaimare   O. Cip    G. Ladurner                        
AUSTRIA

Department of Neurology, Christian Doppler Clinic and Paracelsus Private Medical School Salzburg

Background: The metabolic syndrome, a concurrence of disturbed glucose and insulin metabolism, overweight and abdominal fat distribution, mild dyslipidemia, and hypertension, is associated with subsequent development of type 2 diabetes mellitus, cardiovascular disease and stroke. Type 2 diabetes increases the risk of coronary heart disease (CHD) in women to a greater extent than in men, but there are no data clearly demonstrating sex differences in the development of early atherosclerosis in subjects with the metabolic syndrome. Methods: 1588 middle-aged subjects (1001 males, 587 females) were included in the present study. Metabolic syndrome was defined by the criteria of the National Cholesterol Education Program Adult Treatment Panel III. Early atherosclerosis was assessed by measurement of the intima-media-thickness (IMT) of the carotid arteries. Results: IMT parameters were found significant higher (p<0,0005) in subjects with the metabolic syndrome. After adjustment for several confounders, the difference in the IMT-parameters remained significant, but the effect size Eta² on the IMT-variability of the metabolic syndrome is less marked in men (0,6% vs 2,9%). Computed IMT-values using general linear model equations with age, body mass index, LDL-cholesterol and the metabolic syndrome show the highest values for men with the metabolic syndrome (811,8+/-9,5µm), with similar results for women with (797,6+/-15µm) and men without (788,8+/-5µm) the metabolic syndrome, but significant lower values for women without the metabolic syndrome (735,6+/-7µm). Significant differences in the subcomponents of the metabolic syndrome are found in men for blood pressure and HDL-cholesterol, in women for triglycerides, blood glucose and blood pressure. Conclusions: The effect of the metabolic syndrome on early atherosclerosis is more prominent in women than in men. The study also revealed gender differences for the subcomponents of the metabolic syndrome.

Presentation:Oral  14.05.2004  16:50 -17:00  Room: Konferenzraum OG

Natural history of symptomatic atherothrombotic intracranial stenoses: the GESICA prospective study.

M. Mazighi    R. Tanasescu  X. Ducrocq    S. Bracard   E. Houdart    F. Woimant                        
FRANCE

Hopital Lariboisière

Background: Knowledge on the natural history of intracranial stenoses is limited due to the lack of large prospective studies, and until now there is still no consensus regarding the best medical therapy of these patients. Methods: We conducted a prospective, multicenter observational study in patients with symptomatic intracranial atherothrombotic stenoses. Inclusion criteria were: a transient ischemic attack (TIA) or a minor stroke within 6 months, in the territory of the stenotic intracranial artery. Patients were prescribed anticoagulation and/or antiplatelet agents according to local physician preference and were followed during 3 years. Refractory patients to medical treatment were qualified for more aggressive treatment such as angioplasty. Results: A total of 102 patients with a mean age of 63.3+/-10.4 years were enrolled in 26 centres. The stenoses involved the following intracranial arteries: vertebral artery (22 patients), basilar artery (27 patients), middle cerebral artery (27 patients), and internal carotid artery (26 patients). During the follow-up 43.1% of the patients experienced a TIA or a stroke in the territory of the stenotic artery. The cerebrovascular events were: a TIA (25.5%) and a stroke (17.6%) within a mean follow-up of 23.9 months. Non cerebrovascular events were respectively, coronary artery disease (13.7%) and lower limb arteritis (2.9%), and the vascular mortality rate was 8.8%. A total of 28 angioplasties were performed with a peri-procedural morbi-mortality rate of 14.2%. Discussion: Symptomatic atherothrombotic intracranial stenoses are associated with a high risk of recurrent cerebrovascular events despite antithrombotic agents. Angioplasty has to be considered as a therapeutic opportunity for patients at high risk of stroke recurrence.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

Improved Functional Recovery Associated With Remission of Poststroke Depression

C. TEJERO    J.A.MAURI  O. FABRE    M. GARCES   C. PEREZ    S. SANTOS  E. MOSTACERO                   
SPAIN

Hospital CU Lozano Blesa Zaragoza

Background and Purpose: Poststroke depression is associated with impaired functional recovery compared with similar nondepressed patients. We examined the differences on functional recovery after and before antidepressive treatment. Methods: On the basis of a semistructured psychiatric examination and DSM-IV diagnostic criteria, a consecutive series of patients with poststroke major or minor depression (n=42) were selected. They were examined for change in depressive mood, measured by the Hamilton Rating Scale for Depression (HAM-D), and change in functional status, assessed by the Barthel index (BI), was compared between patients whose depression did and did not respond to treatment with sertraline.Results Patients whose mood improved at follow-up (n=32) had significantly greater recovery in ADL functions at follow-up than patients whose mood did not improve (n=10). There were no differences in demographic variables, lesion characteristics, and neurological symptoms between the two groups. Conclusion:Our findings suggest that remission of poststroke depression over the first few months after stroke is associated with greater functional recovery than continued depression. Early effective treatment of depression may have a positive effect on the rehabilitation outcome of stroke patients.

Presentation:Oral  14.05.2004  11:50 - 12:00  Room: Hörsaal

Increasing Stroke Incidence with Increasing Levels of Socioeconomic Disadvantage.

A. Thrift    H. Dewey  J. Sturm    S. Paul   A. Gilligan    V. Srikanth  R. Macdonell    J. McNeil    M. Macleod  G. Donnan
AUSTRALIA

National Stroke Research Institute, Level 1 Neurosciences Building, Repatriation Hospital - Austin

Background: Although there have been reports that stroke mortality in Australia is higher among low socioeconomic groups, little is known about the association between stroke incidence and socioeconomic status. Our aim was to determine whether stroke incidence in Melbourne, Australia, differed according to socioeconomic disadvantage (SED). Methods: All suspected strokes occurring in a population of 306,631 residents in suburbs north and east of Melbourne, Australia during a 2-year period from May 1997 to April 1999 were found and assessed. Multiple overlapping sources were used to ascertain cases, and standard definitions and criteria were used for stroke and case-fatality. Incidence rates of stroke were age- and sex-adjusted to the European population by the direct method. Patients were categorized into relative levels of SED according to the post code in which they lived at the time of their stroke, using methods adopted by the Australian Bureau of Statistics. Results: A total of 1,422 strokes occurred among 1,331 people during the study period, 1,037 (73%) of which were first-ever-in-a-lifetime strokes. The age- and sex-adjusted incidence rates for stroke increased from 103 to 162 per 100,000 population per year with increasing levels of socioeconomic disadvantage (103, 95% CI 83–123; 119, 95% CI 97–140; 153, 129–177; 162, 95% CI 137–187;  test for rank, p < 0.0001). Interestingly, 28-day case-fatality declined with increasing levels of SED from 29% in the least disadvantaged group to 17% in the most disadvantaged group. Conclusions: The overall incidence of stroke was highest among people with greater SED, and declined as SED decreased. Although people with greater SED had higher stroke incidence a smaller proportion of their strokes were fatal.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

First results of the creation of a stroke unit in Tours Hospital (France)

I. Bonnaud    B.  Giraudeau  D.  Saudeau    B. De Toffol   D. Perrotin    A. Autret                        
FRANCE

Hôpital Bretonneau Tours, France

Background: Our university hospital serves a 300000 inhabitants population. A stroke unit (SU) containing 2 beds in the Intensive Care Unit (ICU) and 4 beds in the department of Neurology, was created in June 2003. Objective To study the changes of stroke patients care occuring since the creation of the SU. Methods: During six months in 2002, when patients were admitted in the emergency department (ED), and during six months in 2003, since the creation of the SU, data were prospectively collected for each patient with suspected stroke: demographic data, mode of transport, time from the onset of symptoms (OS) to arrival, time to brain CT scanner, diagnosis, length of stay (LOS). Results: The 111 patients admitted in the SU were younger than the 324 patients admitted in the ED (76 y.o. vs 68 y.o., p<0.001). Median delay from OS to arrival was lower for the SU patients (180 min vs 310 min, p< 0.001). Emergency transport services were used in 40% of cases for the SU patients vs 17% for the ED patients. Median delay to CT scanner was reduced for the SU patients (100 min vs 160 min, p< 0.001). Since June 2003, nine patients were treated with intravenous thrombolysis (rtPA) in the first 3 hours, five of them had a dramatic recovery at 24 hours. Diagnosis was similar in the two groups, excepted for non-vascular symptoms: 10% of cases in 2002, 18% of cases in 2003. Mean LOS in the SU (ICU and Neurology) was significantly lower : 9 days versus 14 days in 2002 (p<0.001). In hospital fatality rate and proportion of patients discharged at home were similar. Discussion: Creation of a SU was associated with a significant decrease of admission, imaging delays, and LOS. It allowed a better coordination with emergency transport services and a secure use of intravenous thrombolysis.

Presentation:Poster  13 May, 2004  14:00 - 16:00  Room:  

Microalbuminuria in non-diabetic patients with recent stroke

A. Chantzis    A. Staurianou  N. Tzima    M. Belechri   D. Ragou    L. Mantzaris  P. Tsiodra    C. Keramidas            
GREECE

3rd Dept. Internal Medicine, Athens General Hospital, "G Gennimatas"

Background: Microalbuminouria (MA) is considered a marker of widespread vascular damage. The aim of our study was to assess the incidence of MA in non-diabetic patients with recent stroke, its prevalence in the major types of stroke and its relation with severity and outcome of stroke. Methods: We studied patients diagnosed with stroke, confirmed by computed tomography who were admitted to our department. We excluded patients with diabetes mellitus, positive urinalysis, proteinuria, hepatic or renal insufficiency, neoplastic disease or clinical signs of infection. The severity of the neurological deficit was assessed by the Scandinavian Stroke Scale (SSS). The albumin excretion rate was measured in daily urine collection on the second day of hospitalization, using the immunonephelometric method. Among statistical tests applied were Student’s t-test and Chi-Square. Results: Of 129 non-diabetic patients (mean age 79.6 SD>= 7.1 years) with stroke 62 (47.8%) were males and 68 (52.3%) were females. Of those, MA was present 92 patients (70.7%). 115 (88.5%) patients suffer from ischemic stroke and 15 (11.5%) of hemorrhagic type. On the first MA was noticed on 70.4% while on later on 73.3%. Proportion of MA did not differ among gender, patients with history of heart disease and hypertension. However, among patients with history of stroke 74.3% had MA compared with 69.2% on patients who had not history of stroke. Regarding severity patients with MA had lower SSS scores compared with patients with non MA. It seems that MA is related with outcome of patients. Of 16 patients who died 87.5% had MA compared with 56.1% on patients who were stable and 33.3% on patients with amelioration of symptoms (p=0.001). Patients with MA had longer length of stay, although the difference did not reach statistical significance level. Discussion: We found that MA can be detected in approximately 70% of non-diabetic patients with acute stroke. In out data MA was related stroke prognosis as reflected in the length of stay of patients and outcome.

Presentation:Poster  14 May, 2004  14:00 - 16:00  Room:  

INTRACRANIAL STENOSIS IN A GROUP OF ITALIAN PATIENTS WITH ISCHEMIC STROKE

F.  Casoni    A. Colombo  G. Malferrari    P. Nichelli                                     
ITALY

Neurological Clinic

Background: intracranial stenosis is considered to be the leading cause of approxiamtely 8% of all stroke in white patients. The traditional dependence on invasive imaging tecnique to diagnose intracranial stenosis has probably understimate its real prevalence. We investigated by Transcranial Color Doppler ultrasonography (TCCD) the presence of intracranial stenosis in a series of patients with ischemic stroke. Moreover distribution of some vascular risks factors was studied in patients with and without intracranial stenosis. Patients and methods: 134 patients (106 male; 28 female, mean age 63.99+/-9.51) with first ischemic stroke admitted to our Neurological Department between January and December 2002, were studied by extracranial and intracranial ultrasonography. Demographic data (age, sex), diabetes mellitus, hypertension, cigarette smoking, hypercholesterolemia, lipoprotein (a) (Lp(a)), cardiac disease were assessed in each patient. Results: intracranial stenosis were found in 43 (32%) out of 134 patients (33 male, 10 female; mean age 65.53+/-10.7); all intracranial stenosis were confirmed by neuroradiological investigations. In the other 91 patients intracranial atherosclerosis wasn’t found. In the two groups a similar distribution for demographic data, hypercholesterolemia, diabetes mellitus, hypertension, cigarette smoking and cardiac disease was observed.High serum level of Lp(a) was more frequent in the group with intracranial stenosis compared with patients without intracranial atherosclerosis (13.95% versus 3.29%, p=0.03). Conclusion: in our group of patients a high prevalence of intracranial stenosis was found; this datum could be explained by the non invasive tecnique used. A positive correlation between intracranial stenosis and Lp(a) was evidenced. Intracranial atherosclerosis may be considered an important risk factor for ischemic stroke and it should be taken in mind for primary and secondary prevention therapy.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

DIAGNOSTIC EFFICACY OF TRANSESOPHAGEAL ECHOCARDIOGRAPHY IN PATIENTS WITH ISCHEMIC STROKE

R. Dittrich    C. König  M.A.Ritter    A. Allroggen   E.B.Ringelstein    D.G.Nabavi                        
GERMANY

Department of Neurology, University of Muenster, Germany

Background: Since cardioembolism is a frequent cause of ischemic stroke, transesophageal echocardiography (TEE) is widely used to disclose cardiac sources of embolism. However, according to current recommendations, TEE is not declared as compulsory in patients with ischemic stroke. We sought to assess the diagnostic efficacy of TEE and the impact of a simple clinical stratification in patients with ischemic stroke. Methods: We analysed 462 acute stroke patients treated at the local stroke unit who underwent TEE. Since a cardiac right-to-left shunt (RLS) can likewise be detected by transcranial Dopplersonography, we focused on the frequency of non-RLS abnormalities. We stratified patients according to history of any cardiac disease and findings on electrocardiography (ECG) on admission. Results: In 16,0 % of patients a RLS and in 27,1% other embolic sources were found by TEE. In patients without history of cardiac disease and normal ECG, the incidence of non-RLS pathologies declined to 15,8% (OR: 0,5; CI: 0,33 - 0,76). By further selecting patients aged < 50 years from this subgroup, the rate of TEE abnormalities was 10,2 % (OR: 0,31; CI:0,14 - 0,66). In contrast, in patients with positive history of cardiac disease and pathological ECG on admission, 46,3% had significant non-RLS pathologies on TEE (OR: 2,32; CI:1,31 - 4,12). Conclusion: We found non-RLS abnormalities in almost every fourth patient who underwent TEE. Although stratification based on cardiac history and ECG is helpful, it cannot clearly identify those patients in whom TEE is dispensable.

Presentation:Poster  May 13, 2004  14:00 - 16:00  Room:  

MIDDLE CEREBRAL ARTERY STENOSIS MORPHOLOGY AND RECURRENT STROKE RISK IN A GROUP OF ITALIAN PATIENTS WITH ISCHEMIC STROKE: PRELIMINARY DATA.

F.  Casoni    A. Colombo  P. Nichelli    G. Malferrari                                     
ITALY

Neurological Department University of Modena and Reggio Emilia

Background: intracranial symptomatic atherosclerosis is associated with high rate of recurrent cerebrovascular ischemic events, coronary hearth disease and death. We investigated the relationship between the middle cerebral artery stenosis morphology and clinical recurrence by Transcranial Color Doppler ultrasonography (TCCD) and angiopower transcranial ultrasonography. Patients and methods: 43 patients (33 male, 10 female; mean age 65.53+/-10.7) with first ischemic stroke admitted to our Neurological Department between January and December 2002 presented intracranial stenosis. The middle cerebral artery (MCA) stenosis was evidenced in 20 patients. The MCA stenosis were classified into severe (>50%) and mild (< 50%) following the Baumgartner criteria (1999). Moreover we studied MCA stenosis morphology by TCCD and Angiopower transcranial doppler using the contrast agent ( SonoVue, Bracco SA) and we defined 3 types of stenosis: monofocal with and without post-stenotic dilatation and tubular. Clinical and TCCD recordings were performed at 3th, 6 th and 12 th month from the discarge. Results:a new ischemic event during the follow up in the territory supplied by the stenosed MCA occurred in 6 (30%) out of 20 patients. All 6 patients had a severe MCA stenosis 4 with a tubular stenosis and 2 with monofocal stenosis without post-stenostic dilatation. Out of the other 14 patients 8 presented a severe monofocal stenosis with post-stenotic dilatation and the other 6 patients had a mild stenosis with tubular or monofocal morphology. Conclusion: our preliminary data suggest that a severe MCA stenosis with tubular or monofocal without post-stenotic dilation morphology may be considered a predictive factor of ischemic stroke recurrence. Futher studies are needed to confirm our preliminary findings.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

Stroke in young adults related to hypolastic vertebral artery

S. Markoula    S. Giannopoulos  I. Sarmas    M. Argyropoulou   M.  Kosmidou    S. Maragoudaki  AP.Kyritsis                   
GREECE

Department of Neurology, Department of Radiology, University of Ioannina Medical School, GR

Purpose: To present three cases of young adults with lateral medullary stroke related to hypoplastic vertebral artery (VA). All patients, apart from hypoplasia, had two additional atherosclerotic or non atherosclerotic risk factors for stroke. Patients and methods: We report three cases of young adults 37, 38 and 40 years old, one female and two males, who presented with acute onset of homolateral ataxia of limbs, impaired sensation over half of the face and paralysis with lateral hemiatrophy of the tongue, and contralateral impairment of tactile and proprioceptive body sensation. All patients also complained of vertigo, nausea, vomiting, diplopia and dysphagia. Their past medical history included hypertension and dyslipidaemia in one patient, hypertension and migraine in the second patient, and hypertension and autoimmune disease in the third patient. Results: All patients underwent MR angiography and a hypoplastic VA on the side of the infarct was revealed. Although a hypoplastic vertebral artery is not an uncommon finding, mainly asymptomatic, our opinion is that it contributed significantly to the ischaemic lesion in our cases. Conclusions: Hypoplasia of VA is not believed to be a risk factor for stroke since it is a quite common variant up to 40%. However, a stroke may be caused, even in young adults, when hypoplasia coexists with other risk factors for stroke. In our patients, hypoplastic VA coexisted with two other risk factors and this combination provoked stroke in three young adults.

Presentation:Oral  13.05.2004  11:50 - 12:00  Room: Beethovensaal I

PREVIOUS TREATMENT WITH STATINS AND ITS BENEFIT IN ISCHEMIC STROKE OUTCOME: IT IS THE SAME IN ALL SUBTYPES?

R. Merino    E. Díez-Tejedor   J. Gracia    S.  Monteagudo   B.  Fuentes                               
SPAIN

Stroke Unit. Department of Neurology. La Paz University Hospital. UAM. Madrid (Spain)

Background: A recent study suggests that previous treatment with statins could be associated with better outcome in ischaemic stroke. Our goal is to evaluate the possible influence of previous treatment with statins in ischaemic stroke outcome. Methods: Observational and sequential study from Stroke Unit Data Bank (1998-2002). Patients with lacunar (LI) and non lacunar infarction (NLI) (ethiological subtype: Atherothrombotic infarction (AI), cardioembolic infarction (CI) and undetermined origin (UO)) were included. Patients were classified in two groups (with/without previous treatment with statins). Outcome was evaluated by means of modified Rankin Scale (mRS) at discharge (poor outcome: mRS 3-6). Statistic tests: Chi square, ANOVA, multivariate logistic regression analysis. Results: 2231 patients with stroke, 1512 had ischaemic stroke, (985 NLI, 527 LI; age 70,5 +/- 11,8); (38,3%) AI, (38,8%) CI and (22,9%) UO. 5,5%(83) were treated with statins. Previous treatment with statins were associated with a better outcome at discharge in LI (p=0’020) and NLI (p=0’004), mainly in AI (p=0,003), in univariate analyses. Previous treatment with statins was an independent predictor of outcome in NLI p=0,003; OR=2,841 (CI 95%: 1,414-5,707) in a multivariate logistic regression model. Conclusions: Previous treatment with statins is beneficial in ischaemic stroke outcome patients and is an independent prognosis factor in non-lacunar infarction.

Presentation:Poster  14 May, 2004  14:00 - 16:00  Room:  

ACCURACY AND VALIDITY OF DRG14 FOR IDENTIFICATION OF ACUTE STROKE

E. Ballabio    A. Bersano  L Candelise                                            
ITALY

Dipartimento di Scienze Neurologiche IRCCS Ospedale Maggiore Policlinico,Università di Milano

Background/Objectives: Discharge DRGs (Diagnosis Related groups) codes have been used to identify diseases diagnosis for epidemiological, quality of care, and cost studies. The aim of this study was to investigate the validity and the accuracy of DRG 14 for acute stroke diagnosis. Methods: The study evaluated a total of 12696 DRGs14 identified from 447 services of seven Italian regions. The medical records were reviewed by 20 trained medical researchers who recorded information on quality of hospital management, clinical evaluation, diagnostic procedures and in-hospital outcome. The researchers made a new and independent clinical diagnosis on the base of collected information. The doubt cases were reviewed by a senior neurologist. Results: Out of 12696 patients 1622 (12,7%) had an uncorrected DRG14 assignment. 412 (3,2%) errors depended on the administrative problems mostly due to the new reimbursement system and 521 (4,1%) on pour quality of hospital records. The real diagnostic errors were 689 (5,4%). The most frequent conditions misdiagnosed as stroke were: TIA (343), head injury (84), cerebral tumor (22), epileptic seizures (31), metabolic/toxic diseases (63), others (146). Conclusions: According to data from literature we found 5,4% of inaccuracy for stroke diagnosis. The most relevant cause for low validity of DRGs14 recording was the pour quality of clinical records and the administrative problems. These results should be taken into account when the DRGs14 data are used for epidemiological studies.

Presentation:Oral  14.05.2004  11:00 - 11:10  Room: Beethovensaal I

Angiogenesis in symptomatic intracranial large-artery occlusive disease: vascular endothelial growth factor and endostatin level are related to its extent and risk of recurrence

J.F.ARENILLAS    J. MONTANER  C.A.MOLINA    A. ROVIRA   A. ROSELL    M. RIBO  E. SANTAMARINA    A. PENALBA    M. QUINTANA  J. ALVAREZ-SABIN
SPAIN

Neurovascular Research Laboratory, Neurovascular Unit, Vall d'Hebron Hospital, Barcelona

Background: The role of angiogenesis in intracranial large-artery occlusive disease (ILOD) remains unknown. We aimed to investigate the relationship between the level of the proangiogenic vascular endothelial growth factor (VEGF) and the antiangiogenic endostatin, and the extent and risk of recurrence of symptomatic ILOD. Methods: Of a total of 86 consecutive first-ever TIA or ischemic stroke patients with intracranial stenosis, 40 with symptomatic ILOD fulfilled all criteria. ILOD extent was defined as the number of intracranial stenoses on MRA. Plasmatic VEGF and endostatin were determined 3 months after the qualifying event, and patients were followed-up thereafter. Reference values were obtained from 74 controls. Results: A total of 144 intracranial stenoses were confirmed (median number per patient=3). Mean concentrations of VEGF (65.9 +/- 76.3 vs 12.5 +/- 7.5 pg/ml) and endostatin (145.3 +/- 52.3 vs 33.72 +/- 12.9 ng/ml) were higher in patients than in controls (P<.00001 for both). A negative correlation was found between VEGF level and ILOD extent (r=-0.411, P=.008). A VEGF<64 pg/ml (OR 8.2, 1.2-52.8, P=0.02) and an endostatin/VEGF ratio>3 (OR 15.7, CI 2.2-112.3, P=.006) were independently associated with a greater ILOD extent. During a median follow-up of 13 months, 8 patients (20%) experienced a new cerebral ischemic event. These patients had a higher baseline endostatin level (P=.02). A Cox-regression model identified endostatin>185 ng/ml as the only independent predictor of new events (HR 7.83, 1.7-36.9, P=.009), after adjustment for age, sex and risk factors. Patients with a higher endostatin level had a lower % survival free of new events (P=.01, log-rank test, Kaplan Meier curve). Discussion: Lower VEGF level and higher endostatin/VEGF ratio are associated with a greater ILOD extent. High endostatin level predicts further cerebral ischemic events in ILOD patients. Angiogenesis may play a beneficial role in symptomatic ILOD.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

A NEW STROKE UNIT SURVEY IN ITALY

A. Bersano    L. Candelise  R. Sterzi    G. Micieli                                     
ITALY

Dipartimento di Scienze Neurologiche, IRCCS,Ospedale Maggiore Policlinico,Italy

Background/Objectives: It is well known that stroke is associated with high morbidity and mortality. Previous studies and meta-analysis provide evidence favouring care of stroke patients in stroke unit (SU). We published data on SU coverage for seven Italian regions during 2000/01. The aim of this study is to conduct a new survey on acute stroke services for the entire national territory. Methods: Hospital services were identified through the diagnosis-related groups (DRG 14) from national hospital discharges registers. We selected services recording al least 50 acute stroke discharge for year. The characteristics of hospital services were obtained from a structured questionnaire submitted by trained researchers to the doctors in charge of services. SU was defined as a ward that admit acute stroke patients cared in dedicated beds and by dedicated staff. Results: Out of 676 hospital services evaluated during the 2003, 68 were SU. Of these 30 (44%) had a complete monitoring system for all patients. 70% were located in a neurological department. The national coverage for SU services was 10%, ranging from 0 to 50% in different regions. The number of SU increased from 31 (7%) to 43 (12%) in the seven region monitored in our previous survey performed during the 2000/01. Conclusions: Notwithstanding we found an increasing number of SU,at least in the regions previously evaluated, there is still lacking of SU beds and high regional heterogeneity. In 2003 in Italy the stroke patients continue to be treated preferentially in GW.

Presentation:Poster  May 13, 2004  14:00 - 16:00  Room:  

An association between ultrasonographically measured common carotid artery near wall thickness, intima-media thickness and the risk of ischemic stroke.

R. Kazmierski    C. Watala  J. Dorszewska    E. Podsiadly   S. Tylewska-Wierzbanowska    Z. Goncerzewicz  W Kozubski                   
POLAND

Department of Neurology, University of Medical Sciences, Poznan

Background: From the physical aspect, only intima-media thickness (IMT) of the far wall and total near wall thickness (NWT) of the carotid artery could be reliably measured by ultrasound. Measurements of NWT include not only IMT, but also adventitial thickness. Recently, increasing evidence has emerged that adventitial cells are involved in the pathogenesis of atherosclerosis. As there is a known relation between carotid IMT and atherosclerotic risk factors, we decided to explore whether carotid NWT showed similar association with the risk factors and might have an impact on the risk of stroke. Methods: The common carotid artery far wall IMT and NWT were measured by high resolution B-mode ultrasound in 128 persons. The investigated group consisted of 54 patients with a history of atherothrombotic ischemic stroke and 74 sex- and age-matched persons without cerebrovascular diseases. A number of conventional and novel, clinical and laboratory-derived risk factors were assessed. Results: The mean IMT in the common carotid arteries was 0.95 (+/- 0.36) mm and the mean NWT was 1.50 (+/- 0.41) mm. There was a significant correlation between IMT and NWT (r =0.558; p<0.0001). Significant correlations were revealed between IMT or NWT and selected laboratory-derived risk factors, such as: leukocyte count, C-reactive protein and HDL -cholesterol. Classical risk factors, such as: hypertension, current smoking and body mass index showed also significant correlations with both IMT and NWT. Furthermore, there were a significant associations between a history of ischemic stroke and IMT ( r= 0.68; p<0.0001), as well as, NWT (r=0.42; p<0.0001). Discussion: Although both IMT and NWT showed significant correlation with risk factors and stroke occurrence, common carotid far wall IMT showed a closer relation to both risk of stroke and atherosclerotic risk factors than NWT.

Presentation:Oral  13.05.2004  16:20 - 16:30  Room: Stamitzsaal

Course of stroke in chronic and paroxysmal atrial fibrillation.

J. Staszewski    B. Brodacki  K. Tomczykiewicz    J. Kotowicz                                     
POLAND

Department of Neurology, Military MEdical Academy, Warsaw

BACKGROUND: Atrial fibrillation (AF) is a common arrhythmia and an important risk factor for ischemic stroke (IS) with established effective therapy for stroke prevention. Two main forms of AF chronic (cAF) and paroxysmal (pAF) have different influence on systemic blood pressure, cerebral blood flow, platelet aggregation and coagulation. These effects play an important role in acute phase of IS. AIM: to compare the clinical course of IS in patients with cAF and pAF. METHODS: Medical records of 144 consecutive patients with AF and acute IS were reviewed. Patients with newly diagnosed AF were excluded from analysis. Data collected included the use of anticoagulants, stroke risk factors, neurological status on admission and at discharge in Rankin score scale. RESULTS: 100 patients with cAF and 44 patients with pAF were hospitalised due to acute cerebrovascular incidents. There was no significant difference in distribution of hypertension, diabetes, hipercholesterolemia, carotid artery occlusion between cAF and pAF patients. Also the prevalence rate of silence ischemic strokes was equal in both groups (18%).Only one fifth of patients in both groups had received an anticoagulant therapy with only 10% of patients achieving good prophylactic INR (2.0-3.5). Patients with pAF more often had TIAs: 20% vs 9,81% in cAF. Severe strokes (discharge Rankin scale>3) occurred more often in course of cAF (47% vs 18%, p<0.05). Significant correlation between the level of anticoagulation before the incidence and neurological status at discharge in patients with cAF (p=0.000001) and pAF (p=0.020) was found. The level of improvement depended on previous anticoagulation only in cAF group. CONCLUSIONS: Embolic strokes due to cAF are more severe and have worse prognosis than in pAF. Majority of patients with AF do not receive adequate prophylactic treatment, however even inappropriate anticoagulation may improve the outcome of cerebrovascular incident.

Presentation:Poster  May 13, 2004  14:00 - 16:00  Room:  

Lack of Incidental DWI Hyperintensity in Healthy Elderly Individuals

K. Szabo    H. Bäzner  R. Kern    C. Blahak   M.G.Hennerici    A. Gass                        
GERMANY

Neurologische Klinik der Universitätsklinik Mannheim

BACKGROUND: In elderly controls, periventricular and subcortical chronic T2-hyperintense lesions are a common finding. Diffusion-weighted MRI (DWI) detects even very small acute ischemic lesions and differentiates acute from chronic pathology (Fig 1).We investigated 72 individuals aged >65 years with no history of neurological dysfunction and normal neurological examination searching for incidental hyperintense lesions on DWI. METHODS: In addition to a standard MRI protocol at 1.5T, DWI and maps of the apparent diffusion coefficient (ADC) were obtained. T2-hyperintense white matter lesions (WML) were graded according to Fazekas: punctate (1), early confluent (2), confluent (3). Trace DWI (b=1000 sec/mm2) and single direction DWI were evaluated for the presence of hyperintense lesions indicating focal acute ischemia. RESULTS: The WML load was graded 1 in 29/72, 2 in 27/72, and grade 3 in 16/72. No patient showed hyperintense DWI lesions on trace or on single diffusion direction images (Fig 2). However, slight signal variation on DWI images was noted on single DWI in areas of high anisotropy (e.g. splenium of the corpus callosum) or in areas of the T2 shine-through from subcortical chronic lesions. CONCLUSIONS: In this cohort of elderly normal controls with WML grades 1-3, no hyperintense signal abnormality was identified on DWI suggestive of acute focal ischemia. Knowledge of anisotropy effects and T2 shine through phenomena is important and trace DWI may be necessary to confirm findings from intrinsically heterogeneuos signal on images with a single diffusion direction. The lack of DWI hyperintense lesions at the frontal and posterior horns may be viewed as another indication that these lesions are not the result of focal ischemia leading to confluent lesions.

http://www.esc-archive.eu/mannheim04/ma_graphics/mg_1140.htm
 

Presentation:Oral  13.05.2004  11:20 - 11:30  Room: Bruno-Schmitz-Saal

Value of Transcranial Ultrasound Perfusion Imaging in Symptomatic Internal Carotid Artery Occlusive Disease

R. Kern    F. Perren  K. Szabo    A. Gass   M. Hennerici    S. Meairs                        
GERMANY

Dept. of Neurology, University of Heidelberg, Universitätsklinikum Mannheim, Germany

BACKGROUND: Recent studies have shown that ultrasound perfusion imaging (UPI) is capable of detecting perfusion deficits in acute middle cerebral artery (MCA) territory stroke. Whether UPI can distinguish between infarcted tissue and compensated hypoperfusion is unclear. Therefore, we investigated patients with symptomatic ICA occlusive disease using UPI and multimodal stroke MRI including diffusion-weighted (DWI) and perfusion-weighted MRI (PWI) and evaluated tissue perfusion in different regions of the MCA territory. METHODS: 11 patients with unilateral high-grade stenosis or occlusion of the ICA and PWI>DWI lesion size were investigated with UPI after onset of symptoms related to cerebral ischemia. UPI was performed using transcranial pulse-inversion harmonic imaging; time to peak intensity (tpi) and microbubble destruction kinetics were calculated from selected regions of interest (ROI) after injection of the echo-contrast agent Sonovue (2.5 mL bolus followed by constant infusion with 2.5 mL/min). ROIs were placed in tissue considered to be early infarction(DWI and PWI lesion), hypoperfused tissue (PWI lesion only) and in the contralateral hemisphere. RESULTS: Microbubble destruction kinetics generally showed diminished bubble destruction in infarcted tissue, but with high intra-individual variance. Bubble destruction was either diminished or normal in compensated hypoperfusion. Mean tpi measured with UPI was significantly prolonged in infarcted tissue (tpi=33.2+/-4.2s) and in compensated hypoperfusion (tpi=28.6+/-5.2s) compared to the contralateral hemisphere (tpi=21.5+/-3.6s; p<0.05). CONCLUSIONS: UPI can assist in the assessment of perfusion deficits in patients with symptomatic ICA occlusive disease. Whereas this method steadily detects early ischemia compared to normal cerebral tissue, the differentiation between different states of hemodynamic impairment remains difficult.

Presentation:Oral  13.05.2004  16:30 - 16:40  Room: Beethovensaal II

The common carotid artery intima-media complex: Is echointensity more suitable for cerebrovascular risk estimation than intima-media thickness ?

S.C.Tromp    J.M.Voorend  J. Lodder    W.H.Mess                                     
THE NETHERLANDS

Depts. of Neurology and Clinical Neurophysiology; University Hospital Maastricht

Background: Cerebrovascular disease is associated with common carotid artery (CCA) intima-media thickness (IMT). The goal of our study was to compare the relationship of first, the IMT and second, the echointensity of the intima-media complex (IMC) with internal carotid artery plaque formation. Methods: In 86 patients suffering from stroke or TIA, the IMT was measured and the echointensity of the IMC was estimated applying two different methods. First, specialized software was applied (Acoustic Densitometry[AD]), which allows for measuring the integrated backscatter signal before any post-processing. Despite identical ultrasound settings in each patient, the echointensity of the IMC was positively correlated with the echointensity of the adventitia. Therefore, an echointensity index (EI) was computed by dividing the echointensity of the IMC by that of the adventitia. Second, a screen copy was exported and the gray scale median (GSM) value was measured (Photoshop) in a subgroup of 46 patients. Results: IMT and EI were not correlated. IMT was highly correlated with age (p<.001, coefficient 0.4), while EI was not. Patients with a plaque in the internal carotid artery were older (67 versus 59 years, p<.001), had a greater IMT (0.85 versus 0.73 mm, p<.001), and had a higher EI (0.105 versus 0.084, p<.05). EI values as measured with AD and GSM were highly correlated (p<.001, coefficient 0.93). Discussion: IMT and EI are both related to plaque formation in the internal carotid artery. For IMT, this can be largely explained by age effects. EI, however, is an age-independent parameter, which can be computed applying AD, but also the more available GSM technique. Possibly, in future studies the EI will be more suitable for cerebrovascular risk estimation than the IMT.

Presentation:Poster  14 May, 2004  14:00 - 16:00  Room:  

VASCULAR RISK FACTORS AND SEVERITY OF LEUKOARAIOSIS. THE LADIS (LEUKOARAIOSIS AND DISABILITY) STUDY.

A.M.Basile    L. Pantoni  M. Simoni    G. Pracucci   D.  Inzitari                               
ITALY

Department of Neurological and Psychiatric Sciences, University of Florence

Background: Cerebral age-related white matter changes (ARWMC) are radiological findings of supposed vascular origin, mainly linked with aging and hypertension. The impact of vascular risk factors on the severity of ARWMC is however unclear. Methods: The LADIS (Leukoaraiosis And DISability) is a collaborative study involving 11 European centers that aims at evaluating ARWMC as independent determinant of the transition to disability in the elderly. Six-hundred-thirty-nine non-disabled subjects (mean age 74.1 +/- 5.0, M/F: 288/351) with ARWMC of different severity on MRI (mild, moderate, or severe as rated by the Fazekas scale) were assessed at baseline for demographics, vascular risk factors, comorbidities, cognitive, motor, and mood functions. Patients are being followed-up for 3 years with repeated clinical and MRI studies. Results: Mean age (73.3 +/- 5.0, 74.5 +/- 5.2, 75.1 +/- 4.8 years; P=0.001), frequency of hypertension (63.0%, 74.0%, 77.1%; P=0.001), previous stroke (17.2%, 31.3%, 46.8%: P<0.001), and alcohol consumption (49.1%, 60.7%, 60.1%; P=0.013) linearly increased across the 3 ARWMC severity groups. Using entry data in a multiple linear regression analysis model, age (unstandardized coefficient 0.023, P<0.001), hypertension (unstandardized coefficient 0.163, P=0.021), and previous stroke (unstandardized coefficient 0.420, P<0.001) turned out to be the best predictors of ARWMC severity, independently of baseline characteristics and the other vascular risk factors. Discussion: Data from the LADIS study show that age, hypertension, and history of stroke are independent risk factors for ARWMC severity. (supported by the European Union as a Concerted Action, contract no. QLRT-2000-00446).

Presentation:Poster  May 13, 2004  14:00 - 16:00  Room:  

Does Percutaneous Left Atrial Appendage Transcatheter Occlusion (PLAATO™) Prevent Stroke in Patients With Atrial Fibrillation?

Y. Bayard    S. Ostermayer  F. Büscheck    T. Trepels   K. Billinger    H. Sievert                        
GERMANY

CardioVascular Center Frankfurt, Sankt Katharinen

Background: In order to prevent stroke in patients with AF and additional risk factors who are suboptimal candidates for warfarine therapy, 103 persons have been enrolled in the PLAATO™ Multicenter Trial so far (average age=71 yrs, 43-90 yrs; M/ F= 63/ 40). Transcatheter occlusion prooved to be a safe procedure, nonetheless its benefit is still to be discussed. Methods: The risk of stroke for every patient enrolled in the PLAATO™ Multicenter Trial was calculated according to the CHAD2 Risk Classification Scheme. Besides AF, this scheme considers other stroke risk factors such as congestive heart failure, hypertension (systolic >160 mm Hg), age greater than 75 years, diabetes and prior cerebral ischemia. Results: Follow up tests have been performed in 101 patients that were enrolled in the study (68 patient years). Most of the patients having several additional risk factors besides AF, these were added to their personal CHAD2 Score, correlating with the annual risk of stroke. The expected annual stroke rate without treatment was calculated to be 5,3 % on the average (1,9%-18,2%). Two patients whose LAA was occluded sustained a stroke six month after implantation of the device. The annual stroke rate of PLAATO™ patients was therefore calculated to be 2,0 % on the average. Three patients died for reasons that were not related to the device or its implantation at 27, 190 and 328 days after the procedure. Two patients had a TIA at one and 343 days after the procedure. In one patient, a growing echo-dense layer on the device surface was found at the 1 month and the 6 month follow up. It was resolved at the 9 month follow up echo. Conclusions: As far as interim follow up results show, transcatheter occlusion of the LAA with the PLAATO™ device is a safe method and seems to reduce the risk of stroke in patients with AF, who are suboptimal candidates to anticoagulation therapy.

Presentation:Poster  May 13, 2004  14:00 - 16:00  Room:  

Recurrent cerebral ischemia and encephalopathy as presentation of large B cell lymphoma

J. Guimarães    M.J.Rosas  C. Pereira    A. Costa   C. Neves    E. Fonseca                        
PORTUGAL

Hospital de São João. Porto

INTRODUCTION: Intravascular Lymphomatosis (angiotrophic lymphoma) is a rare subtype of extranodal large B cell, non hodking lymphoma (<1%), that spare bone barrow, peripheral blood and cerebral spinal fluid. The nervous system (progressive encephalopathy, and focal neurological deficits) and skin involvement are the first symptoms but shows rapid progression to other organs. The poor prognosis and short survival reflects the difficulty of this diagnosis. We present a case of a patient with a B-cell Lymphoma of the nervous system presented as a rare case of transitory episodes of neurological deficit, indistinguishable from TIAs. CASE REPORT: A 54-year-old man, with no relevant past history, was admitted with transient episodes of left sensory-motor deficit. Initially a vascular study was made: laboratory tests (routine, serologies, protrombotic and immunologic studies), cardiac exams (electrocardiogram, transesophagic echocardiography and 24h-ECG) and cervical and transcranial duplex ultrasound were normal. MRI showed two unspecific lesions, one in the frontal lobe and other in the periventricular region. One month later, he developed a symmetrically weakness of lower extremities and progressive deterioration of cognitive function. E.E.G. revealed an encephalopathy and lactate dehydrogenase, protein C reaction and CSF protein are abnormal. Differential diagnosis with vasculitis, multinfarte dementia, occult neoplasic, fulminant infection, autoimmune disease was excluded. He developed hyperbilirubinemia and the abdominal TC showed hepatosplenomegaly. Hepatic biopsies revealed angiotrophic B-cell Lymphoma (IVL). The patient died one month after admission. CONCLUSION: This case showed how difficult the diagnosis of IVL is. Heterogeneous clinical picture and MRI unspecific lesions can mimic cerebrovascular disease. Although when we have repeated cerebral ischemia of unclear aetiology we should take the IVL diagnosis into account.

Presentation:Oral  13.05.2004  16:00 - 16:10  Room: Hörsaal

Childhood Moyamoya Angiopathy (Disease and Syndrome): "The Zürich Experience"

N. Khan    B.  Schuknecht  E. Boltshauser    P. Roth   H.G.Imhof    Y.  Yonekawa                        
SWITZERLAND

Department of Neurosurgery, University Hospital Zürich, Switzerland

Background and Purpose: Over the last few years a constant increase in the number of diagnosed and henceforth treated cases of Childhood Moyamoya Angiopathy across Europe is evident. We present our series of patients treated with surgical revascularisation procedures from 1997-2003. Methods: Twenty-eight children, (14 Females: 14 males) were angiographically diagnosed with Moyamoya angiopathy (mean ge 8 yrs). These children were referred from local and other centres across Europe. Multiple Cerebral revascularisation procedures were performed after thorough preoperative workup including clinical, CT/MRI, Doppler, angiography and HMPAO SPECT or H215O PET studies. Results: Moyamoya disease was diagnosed in 16 and Moyamoya syndrome was present in 12 children. A combination of multiple direct bypasses (STA-MCA, STA-ACA) along with multiple indirect revascularisation using dura- or arteriosynangiosis were performed. Direct STA-MCA bypass (superficial temporal artery- branch of middle cerebral artery) was performed bilaterally in 25 patients and unilaterally in 3 patients. Additional direct STA-ACA (STA- branch of anterior cerebral artery) bypass was performed in 12 patients. Additional Indirect revascularisation was performed in 26 patients. Only one patient developed immediate postoperative ischemia that recovered completely at 3 months. A Good clinical outcome was seen in all patients at an average of 6 months. Discussion: Presence of childhood Moyamoya Angiopathy (Disease and Syndrome) in Europe is reiterated. Multiple direct bypass combined with multiple indirect revascularisation procedures prove to be the treatment of choice for prevention of further ischemia.

Presentation:Poster  14 May, 2004  14:00 - 16:00  Room:  

Dural sinus thrombosis due to short course oral contraceptive ingestion to delay mensturation in Ramadan

B. Zamani    F. Benaissa  M. Moghaddassi    M. Harirchian   k. Shirkool                               
IRAN

Iran university of medical sciences

Background: In ramadan all moslems should be fast in the day and eat only during night . Women during mensturation period can not have fasting in these days . But they shoud be fast same days after ramadan . Many women prefer to ingest ocp to delay their mensturation period . Dural sinus thrombosis in these years is a frequent diagnosis because of newer imaging techniques and also awareness of neurologists. Always in our hospitals we have some dural sinus thrombosis cases during all the year but in ramadan we have apparenly more cases. Method: In this study we introduce 10 women with dural sinus thrombosis between 25 and 50 yr old all of them hospitalised in this Ramadan all of them had ingested OCP for a short period of time only to delay mensturation . There was no other susceptibility in thiese patiesnts.one of them died because of depp coma and cerebral deep vein thrombosis . 2 had prominant complications and 7 improved . Conclusion : We think short course ocp ingestion and fasting in Ramadan is a strong risk factor for dural sinus thrombosis. Discussion: It is very important to inhibit short course ocp ingestion in Ramadan. another improtant point ,Ramadan in future years will be in summer!!

Presentation:Poster  14 May, 2004  14:00 - 16:00  Room:  

Clinocoradiologic Correlations of Anterior Choroidal Artery Territory Infarction

D. Chang    S Lee  S Yoon    T Ahn   K Chung                               
SOUTH KOREA

Department of Neurology, College of Medicine, Kyunghee University

Background: Although anterior choroidal artery territory infarction is a relatively common type of cerebrovascular disease, the clinical profile in sufficient numbers of patients has not yet been known well in view of lesion distribution. Methods: The study population consisted of 73 consecutive patients with acute infarcts that mainly involved the inferior portion of the posterior limb of internal capsule(PL) and the posterior paraventricular corona radiate region(PV) on magnetic resonance imaging(MRI). Clinical features of those patients were correlated with the MRI results. Results: The lesion distributions were PL(100% of cases), PV(85%), the medial pallidum(11%), the thalamus(5%), the medial temporal lobe(5%), and the crus cerebri(3%). Motor hemiparesis(MH)(100%) and sensory deficits(44%) were frequent presenting symptoms. Only 7 patients(9%) had hemianopsia(HA). The clinical syndromes included pure MH in 32(44%), sensorimotor hemiparesis(SMH) in 27(37%), SMH and HA in 2 patients(3%), and so on. The syndromes in 6 patients with the lesion confined to PL on MRI were pure MH in 4, SMH in 1, MH and hemiballism in 1 patient. All 7 patients with the lesion confined to PV showed pure MH. In 42 patients with PL plus PV lesions, the spectrums included pure MH in 18, SMH in 14, MH and HA in 1, SMH and HA in 1, SMH, HA, and aphasia in 1, MH, HA, and hemineglect in 1, MH, HA, and confusion in 1, SMH and gaze palsy in 2, SMH and myoclonic jerk in 1, MH and depression in 1, MH and memory deficit in 1 patient. Fifty four patients(74%) had an initial neurological improvement within a week, and Fifty nine patients(81%) had a good stroke outcome at 3 months by modified Rankin scale. One year mortality was zero, and 4 patients(5%) had a stroke recurrence within one year. Discussion: Our findings indicate that anterior choroidal artery infarction is a clinical entity separate from other stroke subtypes in view of the lesion distribution, syndromes, and prognosis.

Presentation:Poster  13 May, 2004  14:00 - 16:00  Room:  

Clinicoradiologic Correlations of Anterior Choroidal Artery Territory Infarction

D. Chang    S.M.Lee  S.S.Yoon     T.B.Ahn   K.C.Chung                               
SOUTH KOREA

Department of Neurology, College of Medicine, Kyunghee University

Background: Although anterior choroidal artery territory infarction is a relatively common type of cerebrovascular disease, the clinical profile in sufficient numbers of patients has not yet been known well in view of lesion distribution. Methods: The study population consisted of 73 consecutive patients with acute infarcts that mainly involved the inferior portion of the posterior limb of internal capsule(PL) and the posterior paraventricular corona radiate region(PV) on magnetic resonance imaging(MRI). Clinical features of those patients were correlated with the MRI results. Results: The lesion distributions were PL(100% of cases), PV(85%), the medial pallidum(11%), the thalamus(5%), the medial temporal lobe(5%), and the crus cerebri(3%). Motor hemiparesis(MH)(100%) and sensory deficits(44%) were frequent presenting symptoms. Only 7 patients(9%) had hemianopsia(HA). The clinical syndromes included pure MH in 32(44%), sensorimotor hemiparesis(SMH) in 27(37%), SMH and HA in 2 patients(3%), and so on. The syndromes in 6 patients with the lesion confined to PL on MRI were pure MH in 4, SMH in 1, MH and hemiballism in 1 patient. All 7 patients with the lesion confined to PV showed pure MH. In 42 patients with PL plus PV lesions, the spectrums included pure MH in 18, SMH in 14, MH and HA in 1, SMH and HA in 1, SMH, HA, and aphasia in 1, MH, HA, and hemineglect in 1, MH, HA, and confusion in 1, SMH and gaze palsy in 2, SMH and myoclonic jerk in 1, MH and depression in 1, MH and memory deficit in 1 patient. Fifty four patients(74%) had an initial neurological improvement within a week, and Fifty nine patients(81%) had a good stroke outcome at 3 months by modified Rankin scale. One year mortality was zero, and 4 patients(5%) had a stroke recurrence within one year. Discussion: Our findings indicate that anterior choroidal artery infarction is a clinical entity separate from other stroke subtypes in view of the lesion distribution, syndromes, and prognosis.

Presentation:Poster  May 13, 2004  14:00 - 16:00  Room:  

Evaluation of Serum S100B as a Surrogate Marker for Long-term Outcome and Infarct Volume in Acute Middle Cerebral Artery Infarction

C. Foerch    O.C.Singer  T. Neumann-Haefelin    R. du Mesnil de Rochemont   H. Steinmetz    M. Sitzer                        
GERMANY

Department of Neurology, Johann Wolfgang Goethe - University, Frankfurt am Main

Background: We investigated the usefulness of various serum measures of the astroglial protein S100B to predict long-term outcome and infarct size in acute stroke patients. The purpose was to establish an easily accessible and valid surrogate marker for interventional stroke trials. Methods: We prospectively included n=39 patients (mean age 69.1+/- 11.5yrs) with an acute middle cerebral artery (MCA) infarction presenting <6 hours (h) after symptom onset. S100B was determined at hospital admission, every 8h within the first 3 days and at 12h intervals from day 4 to day 6. Functional outcome was assessed 6 months after stroke using the modified Rankin Scale (mRS). Final lesion size was determined on day 7 by means of standardized volumetry of brain images. Results: Single S100B measures obtained 48-120h after stroke onset as well as peak and AUC values were significantly correlated with mRS scores (Spearman-rho, 0.60 to 0.68; p<0.001), respectively. Using cut points, single S100B values obtained 48-120h after stroke onset revealed ³82% overall accuracy predicting functional outcome. By means of linear regression, the same single S100B values provided R-coefficients ³0.93 with infarct size (p<0.001). Concerning these endpoints, S100B peak or AUC were not superior. Discussion: Single S100B serum measures obtained between 48 and 120h after stroke onset provide high diagnostic accuracy predicting both functional state 6 months after stroke and infarct size on brain imaging in MCA infarction. More complex measures of the S100B kinetic (i.e., AUC or peak) were not superior. We would propose a single S100B measure obtained 48-120h after stroke as an useful surrogate endpoint in acute interventional stroke trials.

Presentation:Oral  13.05.2004  11:10 - 11:20  Room: Stamitzsaal

Factors Influencing the Rate of Change in Clinical Practice. Results of three rounds of clinical audit

P. Irwin    A. Hoffman  D. Lowe    M. Pearson   A. Rudd                               
UNITED KINGDOM

Clinical evaluation and Effectiveness Unit, Royal college of Physicians London

Background: The results of three rounds of National Stroke Audit from england, Wales and Northern Ireland are compared. Methods: Audit of the organization of stroke services and retrospective case-note audit of up to 40 consecutive cases admitted over a 3 month period was conducted in 1998, 1999 and 2001-02. The changes in the organizational, casemix and process results of the hospitals that had participated in all three rounds were analysed. Results: 60% of all eligible trusts from England, Wales and Northern Ireland took part in all three of the audits (1998, 1999 and 2002). Total numbers of cases were 4996, 4841 and 5152 respectively. Casemix results were similar over the three rounds. Mortality rates for 7 and 30 days fell by 3% and 5% respectively. The proportion of hospitals with a stroke unit rose from 48%-73%. The proportion of cases spending most of their stay in a stroke unit rose from 17% in 1998 to 26% in 1999 and 29% in 2002. Improvements achieved in process standards of care between 1998 and 1999 (median change was a gain of 10%) failed to improve further by 2002 (median change was -1%). In all 3 rounds process standards of care were highest in stroke units. Conclusions: The major factor associated with higher standards of care for people with stroke is being managed for most of their stay in a stroke unit. The principle way to improve national standards is to have stroke units of sufficient size and quality to meet local needs.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

Small vessel disease in patients with pseudoxanthoma elasticum - report of three cases

A.M.Pavlovic    J. Zidverc-Trajkovic  M.M.Milovic    Z. Jovanovic   M. Mijajlovic    D.M.Pavlovic  N. Sternic                   
YUGOSLAVIA

Institute of Neurology

Background: Cerebral small vessel disease is rarely described in association with pseudoxanthoma elasticum (PXE), an autosomally inherited connective tissue disorder with skin, eye and vascular manifestations. Although different stroke mechanisms are suggested in PXE patients, arterial hypertension and accelerated atherosclerosis are considered the most important ones. These are first PXE patients with stroke and white matter lesions (WML) reported in Serbia. Cases Description: Case 1: A 49-year-old man presented with recurrent transient ischemic attacks. Evaluation for progressive visual loss and skin changes led to diagnosis of PXE at the age of 42. Multiple lacunar infarctions and confluent periventricular WML were disclosed on brain magnetic resonance imaging (MRI). Case 2: A 71-year-old woman suffered right-sided stroke. Diagnosis of PXE was made at the age of 48 due to severe visual loss and skin changes. Brain MRI revealed multiple lacunar infarctions and subcortical ischemic leukoencephalopathy. Case 3: A 47-year-old woman with prominent skin changes and bilateral amblyopia developed right-sided weakness. Skin biopsy confirmed PXE. Several lacunar infarcts in deep white matter and pons were revealed on MRI. Discussion: All our patients had clinical and histopathological features of PXE and presented with multiple lacunar strokes, two also with extensive confluent WML. PXE should be considered as an etiological possibility in all age groups especially with small vessel disease. Eye and skin examination will disclose PXE distinct clinical signs. Our cases illustrate that PXE is a rare but important risk factor for small vessel disease and stroke in patients of all age groups.

Presentation:Poster  14 May, 2004  14:00 - 16:00  Room:  

Ethnic differences in Ischaemic Stroke Subtypes: The South London Ethnicity and Stroke Study

P. Jerrard-Dunne    J. Birns  R. McGovern    A. Evans   G. Cloud    U. Khan  L. Kalra    A.G.Rudd    C.D.Wolfe  HSMarkus
UNITED KINGDOM

Clinical Neurosciences Dept., St. Georges Hospital Medical School

Background: The incidence of stroke in individuals of African and Afro-Caribbean descent is more than double that of white Caucasians. Stroke is a heterogeneous condition with a number of common aetiological subtypes. The relative contributions of these different aetiologies to stroke in blacks remain undetermined. The aim of this study was to determine whether blacks are more susceptible to particular stroke subtypes compared with whites. Methods: The study consisted of 780 consecutive acute stroke cases presenting to four South London hospitals - 300 black African/Afro-Caribbean and 480 white Caucasian. Using clinical, radiological and ancillary test results, each case was reviewed centrally by a single neurologist using modified TOAST criteria to determine stroke subtype. Results: Small vessel disease (lacunar infarction) was over-represented in black compared with white subjects, multivariate OR 3.15 (1.89 – 5.25), controlling for age, sex, BMI, BP, DM, smoking and cholesterol. In contrast, large vessel carotid artery stenosis and cardioembolic stroke were less common in the black stroke cases, multivariate OR’s 0.49 (0.26-0.94) and 0.47 (0.27-0.81) respectively. The proportion of stroke due to intracerebral haemorrhage was similar in both groups, OR 1.0 (0.6-1.6). Conclusion: These data suggest a high prevalence of small vessel disease, with much lower rates of cardioembolic and large vessel disease stroke in blacks. Defining these stroke subtypes may be key in elucidating the causal pathways underlying the increased stroke risk in individuals of African and Afro-Caribbean descent.

Presentation:Poster  May 13, 2004  14:00 - 16:00  Room:  

Examination of natural coagulation inhibitor proteins in acute phase of ischemic stroke

L. Olah    T. Csepany  Z. Bereczky    A. Kerenyi   M. Misz    J. Kappelmayer  L. Csiba                   
HUNGARY

University of Debrecen, Department of Neurology

Decreased activity of natural anticoagulants (antithrombin-III, protein-C, protein-S) a rare cause of cerebral ischemia, however it can be found frequently in acute phase of ischemic stroke. Our aim was to investigate whether the decreased activity of natural anticoagulants during the acute phase of ischemic stroke is accompanied by worsening of symptoms. Sixty-eight ischemic stroke patients were investigated within 48 hours after stroke. Cerebral hemorrhage was excluded by cerebral computed tomography. Severity of symptoms were assessed and followed by the NIH Stroke Scale. Progressing stroke was defined as worsening of NIH Stroke Scale with at least 3 points during the first 3 days after admission. Antithrombin-III, protein-C, protein-S activities, and concentration of C-reactive protein (CRP) were measured. Progressing stroke was found in 29% of patients. Decreased activity of at least one natural anticoagulant protein was present in 31% of patients. Progression of stroke symptoms occured in 76% of patients with decreased natural anticoagulant activity, while this proportion was only 9% in those with normal natural coagulation inhibitor protein activity (p<0.01). Progressing stroke was also more frequent in patients with elevated CRP value (60%) than in those with normal CRP level (11%; p<0.05). Decreased activity of natural anticoagulants was more frequent in patients with elevated CRP compared with patients with normal CRP. Our results demonstrate the importance of decreased activity of natural anticoagulants in acute phase of ischemic stroke. This abnormality, which was present in 31% of stroke patients, may play an important role in development of progressing stroke, and thus indicates unfavourable outcome.

Presentation:Poster  May 13, 2004  14:00 - 16:00  Room:  

Additive neuroprotective effect of the hypothermic component by cannabinoids in experimental global cerebral ischemia

P.K.Bonfils    J. Reith  L. Thatt    F.F.Johansen                                     
DENMARK

University of Copenhagen, Molecular Neuropathology Group

Cannabinoids have neuroprotective effects, and we have previously demonstrated that hypothermia make up an essential part of the cannabinoid induced neuroprotection in experimental focal ischemia. We have determined the hypothermic component of this neuroprotection in rats treated with Win 55212,2 (WIN), a selective cannabinoid receptor agonist, following global cerebral ischemia. Body temperature was monitored by a radio-pill implant in the peritoneal cavity. Under general anaesthesia all rats had a reversible occlusion of both common carotid arteries combined with systemic hypotension (50mmHg) for 10 minutes. Thirty minutes after ischemia, one group of rats (n=7) received an iv. bolus injection of WIN (3mg/kg) followed by a continuous infusion during 22 hours of a total of 9 mg/kg. Another group of rats (n=6) received the same amount of WIN, but had the temperature clamped between 37,0-38,0C by a heating lamp and a fan. The control group of rats (n=6) received a similar amount of vehicle. All rats were sacrificed 7 days after ischemia. The number of intact and ischemic neurons was counted in a predestinated region of CA1 in all sections with ischemia, and the volume of the ischemic insult in CA1 was measured, see Table 1. The mean body temperatures for the three experimental groups are shown in Fig 1. The neuroprotective effect of WIN can significantly be isolated with respect to the volume of the insult (p<0,001) and the number of ischemic neurons (p<0,001). The volume of the insult significantly demonstrate the hypothermic component of this neuroprotection (p=0,008). In conclusion, WIN induces long term hypothermia and is neuroprotective in experimental global cerebral ischemia. A significant part of this neuroprotection is mediated by induction of hypothermia.

http://www.esc-archive.eu/mannheim04/ma_graphics/mg_1111.htm
http://www.eurostroke.org/Mannheimgraphics/mt_1111.htm

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

Determinants of Microembolism in Patients with Aortic Arch Atheromas: Plaque Burden or Plaque Activity?

Y. Schwammethal    E. Schwammenthal  B. Bruk    A. Tenenbaum   J. Chapman    D. Tanne                        
ISRAEL

Sheba Medical Center, Tel Hashomer Hospital

Background: Dislodgement of a superimposed thrombus is the central pathogenetic mechanism of embolic events in patients with aortic arch atheromas (AAA). The likelihood of such an event may depend on two factors: the size of the emboligenic surface and plaque activity. Because the emboligenic surface area of an AAA is by orders of magnitude larger than that of a carotid plaque, lack of significant microembolism in chronic stroke patients with protruding or complex AAA would support the concept that plaque activity is the decisive element in the pathogenesis of cerebral embolism. Methods: Fifteen patients with large complex AAA detected by transesophageal echocardiography following cerebral embolism were included. All were at-least 1 month after the embolic event, and were examined by 1-hour transcranial doppler (TCD) monitoring of microembolic signals employing a 2-MHz probe fixed on the head using an adjustable frame and recording from the symptomatic MCA. Patients underwent repeated assessment of the aortic arch at that time non-invasively by transthoracic echocardiographic examinations, employing suprasternal second harmonic imaging. Results: There were 13 men and 2 women with a mean age of 72±8 years. The interval between the embolic event and the time of TCD monitoring was 24±22 months. In only 1 of the patients microembolic signals were detected (2 events). Discussion: Despite the large potentially emboligenic surface of AAA microembolic events were absent in all but one patient during a symptom-free random sampling period. This supports the concept that plaque activity is the decisive element in the pathogenesis of cerebral embolism. Because even large plaques are not constantly active, TCD could be of potential value to assess plaque activity.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

Variations in management and outcomes of stroke: differences in three and twelve month survival in four hospitals in Catalonia, Spain

O. Gröne    M. Vergara  M. Aguilar    J. Gendre   J. Llebot    J. Llebot  T. Horacio    E. Duran-Tauleria            
SPAIN

Municipal Institute of Medical Research of Barcelona

Background and purpose: Previous studies reported significant variations in management and survival after stroke. We investigated the degree of variation and its sources in four hospitals of the same level of care located in Catalonia, Spain. Methods: We established hospital-based stroke registers to identify first in a lifetime strokes between 2000 and 2002 and followed up patients at three and twelve months. Data collected include socio-demographic and clinical data, in-hospital resource use, Barthel and Rankin scores, use of health and social services after discharge, and survival. We used Kaplan Meier and Cox proportional hazards regression analysis to compare unadjusted and adjusted three and twelve months survival between hospitals. Results: We registered 637 stroke patients and observed significant differences in pre-stroke risk factors and case-mix variables. Resource use and organization of stroke services differed and can be characterized by a focus on internal medicine, neurology, geriatrics and intensive medicine, respectively. Three and twelve month case-fatality ranged from 18.1 to 31.8% and 24.7 to 36.5%, respectively. After adjustment for case-mix we detected significant differences in survival at three months. Hazard ratios ranged from 0.55 (CI95% 0.2-1.3) to 2.0 (CI95% 1.2-3.6). We did not detect significant differences in survival at twelve months.Discussion: Hospitals followed different approaches towards the management of stroke. We detected significant differences in three months survival, however, differences decrease over time and could not be fully explained despite comprehensive case-mix adjustment. To explain residual variation, we suggest future studies to analyse additional data on rehabilitation, nursing and community services.

Presentation:Oral  14.05.2004  16:10 -16:20  Room: Konferenzraum OG

IS THE CCA- INTIMA MEDIA THICKNESS PREDICTOR OF RECURRENT STROKE?

P. Talelli    G. Terzis  G. Katsoulas    B. Xouliara   A. Chrysanthopoulou    J. Ellul                        
GREECE

University. Hospital of Patras

Background: Common carotid artery intima media thickness (CCA-IMT) has been identified as a risk factor for cerebrovascular disease. We have recently shown that CCA-IMT was not associated with adverse outcome one-year post stroke [1]. In the present study, we set out to investigate the association between CCA-IMT and stroke recurrence one-year after an ischemic stroke. Methods: 284 consecutive patients (mean age 68.7 +/- r12.7, 126 (44%) females) with an acute ischemic stroke were investigated with carotid ultrasound examination, which was carried out by a single operator. Demographic data and conventional stroke risk factors were recorded on admission. Recurrent strokes were recorded within the first year post stroke. Results: Overall, 16 (5.6%) recurrent strokes (all ischemic) occurred within the first year. Patients who experienced recurrent stroke had significantly increased CCA-IMT compared with those who remained free of recurrent stroke (0.881 mm vs 0.789 mm respectively, OR=1.81 (95%CI 1.17-2.80)). After adjusting for age, sex, previous stroke or TIA, vascular risk factors, site/extend of lesion and carotid stenosis in the multiple logistic regression analysis, CCA-IMT was still significantly associated with stroke recurrence (OR=2.09 (95%CI 1.20-3,65)). Discussion: In this study, elevated CCA-IMT was an independent predictor of recurrent stroke within the first year after an ischemic stroke. We are currently studing the role of CCA-IMT as a predictor of stroke and other vascular events three years after an ischemic stroke.

Presentation:Poster  May 13, 2004  14:00 - 16:00  Room:  

PREDICTORS AND THE MORTALITY OF THE RECURRENT STROKE

I. Sarzynska-Dlugosz    A. Czlonkowska                                                 
POLAND

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

Background and purpose: There are differences in determination predictors of recurrent strokes. We aimed to identify predictors for recurrence and to describe prognosis of recurrent stroke in Poland. Methods: We prospectively studied 1283 unselected patients with acute stroke admitted to 2nd Dept. of Neurology Institute Psychiatry and Neurology, Warsaw, Poland. Patients were subjected to investigations regarding risk factors and followed up at 3 and 12 months after the last event. Multivariate regression model were used to analyze predictors of stroke recurrence. Results: Stroke was recurrent in 233 (18,2%). Predictors of recurrence were: hypertension (OR=1,61), cardiac failure (OR=1,45), myocardial infarction (OR=1,60), lack of alcohol consumption (OR=1,45), silent strokes on CT (OR=1,88), ipsilateral 45-69% stenosis of internal carotid artery (ICA) (OR=1,66), contrlateral 70-99% stenosis of ICA (OR=3,21). There were no significant differences of 30-day mortality between patients with recurrent and first-ever stroke (23,2% vs. 18,1%). The 3-month and 1-year mortality after the recurrent stroke were significant higher (43,2% vs. 30,8% and 57,2% vs. 41,3%). Treatment prior to recurrence: 53,2% have been given antiplatelets, 87,4% of patients with hypertension were treated, 13% of patients with atrial fibrillation were receiving anticoagulants. Conclusions: The predictors of recurrent stroke were: hypertension, cardiac failure, myocardial infarction, lack of alcohol consumption, silent strokes, ipsilateral 45-69% and contrlateral 70-99% stenoses of ICA. Patients with recurrent stroke have a markedly higher mortality than patients with a first-ever stroke. Secondary prevention remains an important challenge and should be individualized to achieve optimal results.

Presentation:Poster  13 May, 2004  14:00 - 16:00  Room:  

Is it a TIA or migraine?

N. Vugovic    J. Sahlas  J. Norris                                            
CANADA

University of Toronto

The differentiation of migraine with neurological accompaniments from a transient ischemic attack (TIA) becomes more difficult in older patients where headache is often absent and TIA becomes more likely We prospectively investigated 1482 consecutive patients referred to a Stroke Prevention Clinic over 3 years, and found after investigation that 118 (8%) had migraine attacks, mean age 58+/- 14 yrs with female predominance (p<0.03) 106 were diagnosed by their referring physicians as 'TIAs' and 12 as 'stroke'. Investigations included brain scanning, echocardiography (inc transesophageal) and carotid doppler.A remote history of typical migraine headaches was present in all cases 17-31 yrs previously. In 49% (52/118) symptoms were purely visual, in 35% (37/118) visual plus sensory, and in 16% (17/118) symptoms closely mimicked TIA or minor stroke. The differentiation of migraine from cerebrovascular disease is primarily clinical. Laboratory tests play only a subsidiary role and then in a minority of cases.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

PEROPERATIVE USE OF BISPECTRAL EEG MONITORING TO GUIDE ANESTHETIC MANAGEMENT DURING CAROTID ENDARTERECTOMY RESULTS IN BETTER HEMODYNAMIC CONDITIONS

G. Kox    C. De Deyne  L. Buyse    W. Lansink   G. Lauwers    H. Schroe  R. Heylen                   
BELGIUM

ZOL Campus Sint-Jan Genk

Bispectral EEG monitoring (BIS) measures the hypnotic component of anesthesia. Its use during anesthesia was reported to reduce the amount of hypnotics used by 25 to even 40%. Intravenous hypnotics elicit well-known hemodynamic side-effects (peripheral vasodilation, reduced cardiac output), all possibly resulting in arterial hypotension. This paper reports on the use of BIS to titrate as well hypnotic administration as hemodynamic management in patients undergoing carotid endarterectomy (CEA). With IRB approval, 30 pts undergoing CEA were randomised to blinded or open BIS monitoring. In all pts, anesthesia was induced with propofol, fentanyl and vecuronium. In the open group, propofol was titrated to a BIS of 40-60. In the blinded group, propofol was titrated to good clinical practice. Normal blood pressure (referring to preoperative values) was maintained by the administration of vasopressors (noradrenaline). There were no differences in ASA, age, or preoperative arterial pressure between both groups. In the BIS titrated group we observed a significant reduced use of hypnotics (propofol :mean - 27%). In the BIS titrated group we observed a significant less use of vasopressors (noradrenaline : mean – 42%). Patients in the BIS titrated group revealed significantly less episodes of arterial hypotension (defined as 25% less than normal preoperative arterial pressure) and of arterial hypertension. We observed 32% less episodes of arterial hypotension and 17% less episodes of arterial hypertension in the BIS titrated group. Analysis of BIS values in the blinded group revealed that in a mean of 14% of the total operative time hypnosis was too deep (= BIS below 40). Besides the reduced use of hypnotics, BIS seemed also to result in better peroperative hemodynamic stability. Titrating hypnotics by BIS, reduced its hemodynamic side-effects to a minimum, which resulted in less use of vaso-active medication and in more stable peroperative hemodynamic conditions.

Presentation:Poster  May 13, 2004  14:00 - 16:00  Room:  

Upregulation of androgen-receptors inhibits female preconditioning

R. Huber    M. Timmler  M. W.Riepe                                            
GERMANY

Dept. of Neurology, University of Ulm

Currently, the same strategies are in use for secondary stroke prevention in males and females. However, the most frequently used drug, acetylsalicylic acid (ASA), seems to have a differential benefit in males and females. Correspondingly preconditioning eg, by ASA or 3-nitropropionate (3NP) mediates induction of hypoxic tolerance in the central nervous system in a gender - and moreover in females in an estrus-cycle - dependent manner with major differences during “high level estrogen” stages. For that these differences can only partly be explained by female hormones. Thus we investigated the influence of androgens upon preconditioning. Population spike amplitudes (PSAP) were measured during hypoxic hypoxia and recovery thereof in hippocampal slices from male and female CD1 mice (25 – 35g) with and without pretreatment with a single i.p. injection of 3-nitropropionate (3NP). Posthypoxic recovery of PSAP was 20 +/- 35 % in male control mice and rised to 82+/-32% (p < 0.05 to control) upon application of 3NP (20mg/kg/BW i.p., 1h time interval). In females no effect has been observed during estrus and diestrus (32 vs. 33% and 49 vs 60%). To prove the hypothesis of a potential influence of androgens on this lack of effect, western blots from hippocampal tissue with antibodies against androgen receptors (AR) were performed. AR-expression in males did not change significantly (0,61 and 0,51) upon application of 3NP. During estrus and diestrus lower amounts of AR were detected (0,38 and 0,36 vs. 0,61 A.U., p<0,05 to males), whereby preconditioning resulted in an increase of AR with a loss of this former significance. During estrus a highly significant rise upon preconditioning (0,38+/-0,19 A.U. vs. 0,65+/-0,18, p< 0,01) even resulted in AR-ammounts higher than in native males. In conclusion estrus-cycle dependent upregulation of androgen receptor expression in females might explain inability of preconditioning during some stages of estrus cycle.

Presentation:Poster  14 May, 2004  14:00 - 16:00  Room:  

Alcohol and Risk of Ischemic Stroke in Korean Elderly People : Nested Case-Control Study

Y.-J.Cho    B.-J.Park  S.-H.Choi                                            
SOUTH KOREA

Ilsan Paik Hospital Inje University

Background : The relationship between alcohol consumption and the risk of ischemic stroke remains controversial, and few studies has targeted for Asian elderly people. Method : The eligible cohort(n=14,039) is derived from Korean Elderly Pharmacoepidemiology Cohort(n=46,113) that is population-based dynamic cohort. They are over 65 years of age, living in Busan Metropolitan City between 1993 and 1998, and beneficiaries of Korean Medical Insurance Corporation. The information about alcohol consumption, smoking status, past-medical history, height, weight, and other daily life related variables were obtained by self-administered mailed questionnaire. We confirmed the newly developed ischemic stroke patients(n=177) through hospital-visit review of the medical record. Four controls were allocated randomly to each case(n=708). Adjusted odds ratio(aOR) were calculated from conditional logistic regression analysis with lifelong alcohol abstainers as a reference group. Results : Up to 12 g alcohol per day(1 drinks per day) of average daily alcohol consumption was statistically significant in lower risk of ischemic stroke(aOR, 0.67; 95% CI, 0.46-0.97). Consumption of 12 to 24(aOR, 0.70; 95% CI, 0.30-1.67), 24 to 36(aOR, 0.47; 95% CI, 0.14-1.53), 36 to 48(aOR, 0.88; 95% CI, 0.36-2.16), and >48 g/day of alcohol(aOR, 0.63; 95% CI, 0.30-1.30) were not significantly related to the risk of ischemic stroke. And lower risk of ischemic stroke was observed among subjects who drunk less then 48 g alcohol per each drinking(aOR, 0.56; 95% CI, 0.39-0.81). Conclusions : We conclude that light alcohol consumption was associated with lower risk of ischemic stroke in Korean elderly people.

Presentation:Poster  May 13, 2004  14:00 - 16:00  Room:  

Vascular risk factors before lacunar stroke. How prevalent are they and how do we control them?

N. Lopez-Hernandez    A. Garcia-Escriva  F. Gracia-Fleta    J. Carneado-Ruiz   A. Pampliega-Pérez    M. Alvarez-Sauco  J. Sánchez-Payà    J.M.Molto-Jorda            
SPAIN

Hospital General Universitari d'Alacant

Introduction: Although they are supposed to have a benign outcome, several studies have shown a underdiagnosis of vascular risk factors in lacunar stroke. Our aim has been to describe the prevalence of the main vascular risk factors in a hospital-based stroke registry and the therapeutic strategies used in their control. Material and methods: 156 consecutive patients with lacunar strokes were included. Data about risk factors prevalence was obtained from the patients, their relatives or from previous hospital reports. Results: We found a slight predominance of males (56.2%) and a mean age for the whole group of 71.7±10.9 years. Hypertension was the most prevalent risk factor (67%) followed by Diabetes Mellitus (44.8%), previous stroke/TIA (29.9%) and dyslipemia (28.8%). Patients were already on antiplatelets or anticoagulants in a 28.3%. A significant proportion of dyslipemic patients (24.5%) and hypertensive patients (17.3%) were not receiving any treatment at all at admission. Statins were the most frequently drugs used for lowering blood lipids (68.9%), while combinations of antihypertensive drugs and ACE inhibitors (including ARA II antagonists) alone were the most prevalent agents used for blood pressure control (55.7%). Conclusions: In our opinion our data suggest that patiens with lacunar stroke show a profile of high risk for vascular events and previous control of those factors seems to be insufficient in our population, specially on the basis of recently published trials such as HOPE or LIFE trials, and very specially regarding the use of statins for primary prevention of vascular events.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

Reproducibility, sensitivity and specificity of embolic signal detection by transcranial Doppler

S. Bashford    S. Thom  J. Chataway    D. Ames   A. Hughes                               
UNITED KINGDOM

Department Clinical Pharmacology, National Heart and Lung Institute, Imperial College, London

Background: During transcranial Doppler monitoring it is important that high intensity signals are not incorrectly classified as embolic signals (ES) and that observers detect the same ES. We have determined specific agreement of 2 observers rather than agreement of total number of ES recorded. Method: The middle cerebral artery of 6 patients without prosthetic heart valves at risk of thromboembolism was monitored for 1 hour by observer 1 using a Multidop-T TCD machine with standard recording parameters. The decibel threshold for potential ES (7dB) had been pre-determined by a standard method. Times of potential embolic signals (PES) were noted. Sessions were recorded onto digital audio tape, played back through the TCD machine and reviewed with observer 2 together with raw data. PES were classified as ES if they satisfied consensus criteria (review 1). This was repeated after 5 days (review 2). Rates of ES were compared between reviews 1 and 2 to determine reproducibility using the Kappa Inter-rater agreement test. Results: 36 PES were noted during monitoring. 17 ES were classified at each review. Two ES noted at review and were found at times where no PES had been noted during monitoring. 38 time points had therefore been reviewed twice for ES. The number of observed agreements between reviews was 34 from the possible 38. The Kappa value was 0.787 (95% ci 0.59-0.984); agreement was good. Sensitivity of ES detection during monitoring was 94%. Specificity approached 100%. Discussion: The monitoring by observer 1 showed high sensitivity and specificity for ES detection though reviewing TCD recordings offline with a second observer and raw data can help to further distinguish ES from other signals and showed good reproducibility.

http://www.esc-archive.eu/mannheim04/ma_graphics/mg_1077.htm
 

Presentation:Poster  May 13, 2004  14:00 - 16:00  Room:  

Patients experience deterioration of Health Related Quality of Life between 3 and 12 months after stroke

A.-C.Jönsson    I. Lindgren  B. Hallström    B. Norrving   A. Lindgren                               
SWEDEN

University Hospital Lund

Background: Outcome of stroke patients is often reported by assessment of physical abilities, whereas aspects of mental capacity and social life receive less attention. The patient's own view on life after stroke can be registered by measuring Health Related Quality of Life (HRQL). Methods: We prospectively included 416 first-ever stroke patients in the Lund Stroke Register during a one-year period. Three and 12 months after stroke onset 304 survivors were followed up. Their mean age was 72 (range 18-96) years. HRQL was assessed using the Short Form 36 health survey questionnaire (SF36). Information was collected by personal interview. Personnel and/or spouse/significant others were consulted if patients were unable to communicate. Results from the SF36 assessment are presented as Physical Component Summary Score (PCS) and Mental Component Summary Score (MCS) in the table. Barthel Index (BI) was used to assess disability. Results: Although BI decreased in only 61 cases (20%) between 3 (mean BI 88.6) and 12 months (mean BI 86.4), we found that the patients' self-reports via SF36 showed deterioration of PCS in 164 cases, i.e. no less than 54% of the patients reported that their physical ability had become worse. MCS had deteriorated in 137 cases (45%) at 12 months. Also the patients' SF36 score General Health (GH) was reported to have deteriorated in 144 cases, i.e. 47%. Discussion: Assessment of outcome for stroke patients regarding only physical activity, using e.g. BI, may show results contradictory to the patients' experiences. Our results highlight the need to focus on the patients' own view on quality of life in follow-up programs for stroke patients.

http://www.eurostroke.org/Mannheimgraphics/mg_1078.htm
 

Presentation:Oral  14.05.2004  11:50 - 12:00  Room: Beethovensaal I

Prevalence of stroke and vascular risk factors among first-degree relatives of stroke patients and control subjects. A prospective consecutive study

A. Lindgren    H. Lövkvist  B. Hallström    P. Höglund   A.-C.Jönsson    U. Kristoffersson  H. Luthman    B. Norrving    B. Petersen     
SWEDEN

University Hospital Lund

Background: The prevalence of stroke and vascular risk factors among first-degree relatives of stroke patients may differ compared with relatives of control subjects. This may provide information about a possible genetic or environmental influence on the risk of stroke. Methods: As a part of the Lund Stroke Register study, we invited 930 consecutive patients with first ever stroke and 287 control subjects to complete a questionnaire about all their first-degree relatives. The questionnaires addressed whether any of these relatives had been affected by stroke or TIA, had hypertension, heart disease, diabetes mellitus, or if they were smokers. Results: A total of 607 patients and 261 control subjects returned the questionnaire, providing information on 4978 first-degree relatives. After exclusion of undefined answers, the prevalence of stroke or TIA was 12.3 % and 7.5 % among first-degree relatives of patients and control subjects, respectively (OR 1.73, 95% CI 1.36-2.21). Corresponding results for hypertension was 21.0 % and 16.7 % (OR 1.33, 95% CI 1.09-1.60), heart disease 16.6 % and 15.8 % (N.S.), diabetes mellitus 9.1 % and 8.7 % (N.S.), and smoker or previous smoker 40.2 % and 42.4 % (N.S.). Discussion: The prevalence of stroke or TIA is more frequent among first-degree relatives of stroke patients than among first-degree relatives of control subjects. Recall bias may have influenced our results. However, it is of interest that even though the frequency of hypertension also differed between the two groups of first-degree relatives, the reported prevalences of the other risk factors did not.

Presentation:Poster  May 13, 2004  14:00 - 16:00  Room:  

STROKE IN EVOLUTION: WHAT'S THE MATTER?

V. Karepov    A. Gur  I. Bova    N. Bornstein                                     
ISRAEL

Tel Aviv Medical Centerl

Background: The reasons of clinical deterioration after acute ischemic stroke (IS) still are not sufficiently studied. Objective: To evaluate clinical features, neurological and somatic causes of stroke in evolution. Methods: This prospective study included all consecutive patients with acute first-ever IS admitted to our center over one year. Clinical and laboratory characteristics recorded routinely in the emergency room. CTs of the brain were performed in 97% of the patients. Stroke severity was assessed immidiately after admission, days 1, 2, 3 during hospitalization and before discharge, using Unified Neurological Stroke Scale (UNSS) by neurologists with high level interrater agreement (wK=0.9). We compared clinical and laboratory characteristics between patients who deteriorate (4 or more points decreased from previous UNSS score - stroke in evolution) and those who improved or were in static condition. Multivariate analysis and logistic regression were used. Results: Of a total of 442 patients included in the study, 71 (16.1%) patients had stroke in evolution. More of these patients (95%) had early deterioration (within 72 hours from the stroke onset). Initial mean UNSS score was 24 for improved stroke patients, 23- for patients with static condition, and 10 - for deteriorated stroke. Systemic causes of stroke evolution (acute myocardial infarction, pneumonia, urinary tract infection, deep vein thrombosis, sepsis, gastrointestinal bleeding) were found in 14 (19.7%) of the patients. Most patients with stroke in evolution (80.3%) had neurological causes of deterioration (enlargement of previous cortical lesion, recurrent stroke or hemorrhagic transformation confirmed by CT scans). Conclusion: Early clinical deterioration in patients with acute stroke is not resulted by systemic, but by neurological causes. Initial low UNSS score (10 and less) might predict stroke in evolution.

Presentation:Oral  14.05.2004  11:40 - 11:50  Room: Stamitzsaal

11½ Months Experience: Results of 2024 Telekonsultations The Telemedic Pilot Project of an Integrative Stroke Care in Eastern Bavaria (TEMPiS)

H.J.Audebert    J. Schenkel  C. Kukla    U. Bogdahn   R.L.Haberl    M. Horn                        
GERMANY

Staedtisches Krankenhaus Harlaching

Background: Modern stroke management requires specialized stroke care and advanced stroke expertise. In order to achieve these requirements in non urban areas two specialized stroke centers and 12 general hospitals founded a telemedicine network (TEMPiS) in eastern Bavaria/Germany. Methods: Each network hospital established specialized stroke wards where trained teams manage acute stroke patients. 24 hours each day physicians in the community hospitals are able to contact the stroke centers via a telemedic system including videoconference and transfer of DICOM-data. This service is staffed with an experienced strokologist. Indications for telemedic support were predefined. Results: In 2003 4179 stroke patients have been treated in the network hospitals. Between Feb. 1st 2003 and Jan. 12th 2004 a total of 2024 teleconsultations have been performed with a mean duration of 15 minutes. 79 (~2%) patients received systemic thrombolysis. In 235 patients (11.6%) teleconsultations yielded non-vascular diagnoses. 227 (5.4%) patients were transferred to stroke centers to receive extended diagnostic or therapeutic procedures e.g. for malignant brain infarcts (7%) and basilar artery thrombosis (11%). Transport times are still too long for acute stoke management and have to be improved therefore. User and patient's satisfaction is very good concerning quality of consultation. The technical issues were assessed as good. Audio quality remains to be improved. Conclusions: Telemedicine combined with specialized stroke wards offers advanced stroke care in community hospitals. The telemedic approach provides rapid diagnostic and therapeutic support and is well accepted by all participants. If necessary interhospital transfer to specialized centers can be indicated accurately.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

Voxel-based analysis of the relationship between metabolites, diffusion and perfusion parameters in acute ischemic stroke

V. Cvoro    K. Wartolowska  A.J.Farrall    P.A.Armitage   I. Mrshall    M.E.Bastin  M.S.Dennis    J.M.Wardlaw            
UNITED KINGDOM

The University of Edinburgh Division of Clinical Neurosciences

Background: In acute ischaemic stroke, the relationship between cerebral metabolites on proton MR Spectroscopic imaging (SI) and diffusion (DWI) and perfusion (PWI) abnormalities is unclear. We compared SI, DWI and PWI values in acute ischaemic stroke using voxel-based analysis. Methods: Patients with acute cortical ischaemic stroke had MR DWI (tensor), PWI (contrast bolus), single slice SI soon after stroke. The SI slice was positioned on the DWI slice showing the maximum infarct. Images were processed blind: coregistering the SI, DWI, PWI, placing a 0.5 cm voxel grid on the DWI slice, and coding voxels as “definitely abnormal” (bright, DA), “possibly abnormal” (pale, PA), or normal (N) according to DWI appearance. The voxel metabolites, PWI and DWI values were extracted and compared. Results: Of 16 patients so far, aged 37-94 (mean 75) yrs, 10 had a partial anterior circulation infarct and 6 a total anterior circulation infarct. At mean 9 hrs after stroke, N acetyl aspartate (NAA) was more reduced in definitely abnormal (mean 93.4) than in possibly abnormal (mean 114.5) voxels, and normal brain (mean 141) p<0.0009. Lactate was highest in definitely abnormal voxels (mean 100 DA vs 59 PA vs 16.5 N, p<0.0001), and rose in possibly abnormal voxels as CBF and ADC fell (r=-0.65, p<0.006 and r=-0.62, p< 0.011 respectively). ADC reduction appeared to precede the NAA reduction. Discussion: Voxel-based analysis is possible with combined DWI, PWI and SI data. The degree (brightness) of DWI abnormality corresponds with abnormal metabolite and PWI values. Areas of definite DWI abnormality show greater reduction in NAA and more lactate, indicating more advanced ischaemia, than less abnormal areas.

Presentation:Poster  May 13, 2004  14:00 - 16:00  Room:  

The rat brain investigation with acute hemorrhagic stroke

A.N.Makarenko    I.G.Vasilyeva  N.G.Chopick    N.Yu.Babanina                                     
UKRAINA

Research Institute of Ðharmacology and Toxicology AÌS of Ukraine

Background and Purpose: The most severe form of acute vascular diseases of the brain (AVDB) is represented by hemorrhagic stroke (HS), which leads to death during the first week in 71% of its cases. Effective therapy of HS and its concomitant neurodegenerative processes and secondary vascular dementia are a very difficult problems of neuroscience. The aim of the investigation has been to study reactive morphological changes of the rat brain in the acute period of experimenta1 HS (EHS). Methods: EHS has been evoked in 20 rats Wistar line in accordance to Makarenko et al. (2002) technology; 6 rats formed the control group. The focus of brain destruction and hemorrhagic (about 0.15-0.2 mm3 in size) has been localized in the capsula interna of both hemispheres. PCR-based assay was used for detection herpes simplex virus type 1 (HSV-1) DNA in the brain tissue and blood of rats. Results: Histological examination of the brain has revealed prominent inflammatory changes of the brain in the form of proliferative ependymatitis and foca1 vasculitis in 10 rats from 14 of the experimental group and yet in 1 rat from control group. Inflammatory infiltration has been composed mainly of microglial cells, lymphocytes and strikingly looked similar to morphological changes of brain in some well known viral and chlamydial infections in man. Our data show that in the acute period of EHS activation of dormant infections in the form of encephalitis may occur in the brain rats. Investigation of brain tissue and blood has demonstrated the presence HSV1 in 30% of animals. Discussion: Detection of the viral DNA may reflect the activation of the latent viral infection. In AVDB the possible role in this process may play different tissue factors which depress antiinfectional resistance of the brain and second immunodeficit in promote the activation of the latent cerebral viral infection.

Presentation:Oral  13.05.2004  17:00 - 17:10  Room: Beethovensaal I

Mechanisms of hyperbaric oxygenation (HBO) - induced neuroprotection in transient focal cerebral ischemia in rats.

C.C.Eschenfelder    M. Lou  T. Herdegen    G. Deuschl                                     
GERMANY

Dept. of Neurology, Christian-Albrechts-Universität Kiel

Background: Improving tissue oxygenation in stroke is an important treatment strategy. The underlying mechanisms of HBO-induced neuroprotection remain unclear. Mitochondrial dysfunction and energy failure are crucial in ongoing ischemic cell death. Thus, we investigated markers of mitochondrial function and apoptosis (cytochrome-c, Bcl-2, Bax, activated caspase-9 and –3) under the effect of HBO by means of immunohistochemistry (IR). Material and methods: Male SD rats (180g) were used. Controls: room air (n=6, respectively). Treatment group: single HBO treatment (n=6, respectively). HBO was performed at 100% O2, 3 ATA for 1h at 3h or 6h following MCAO. Transient MCAO was induced for 90 min. Animals were clinically assessed and sacrificed 24h later for IR. Results: Typical granular cytoplasmatic cytochrome-c IR was only seen in HBO treated animals in the penumbra. All other specimens showed a diffuse cytoplasmatic staining, indicating a cytochrome-c release. Bcl-2 was increased in the penumbra by 200% (HBO 3h) and 167% (HBO 6h). No changes were observed in the core. Bax-IR was not changed in HBO groups. Caspase-9 was reduced in penumbra by 57% (HBO 3h) and 38% (HBO 6h). In core, caspase-9 was increased by 167% (HBO 3h) and 163% (HBO 6h). Caspase-3 was increased in the core two-fold at both time points. In penumbra, caspase-3-IR was decreased (78%, HBO 3h; 53%, HBO 6h). Conclusion: Our data suggest a successful inhibition of the intrinsic (mitochondrial) pathway of neuronal cell death by HBO in transient MCAO, probably by rapid restoration of mitochondrial function and energy supply to the cell.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

Abciximab treatment of supratentorial ischemic stroke: An MRI-based open label clinical trial

P.D.Mitsias    M. Lu  B. Silver    D. Morris   C. Lewandowski    S. Daley  H. Ebadian    J.R.Ewing    S. Patel  M. Chopp
USA

Henry Ford Health Sciences Center

Background: Occlusion of an intracranial artery leads to downstream microvascular thrombosis and hypoperfusion. Abciximab may inhibit this phenomenon and lead to successful therapeutic outcomes. We performed an MRI-based open label abciximab clinical stroke trial in order to assess treatment safety, and effect on neurological improvement and ischemic lesion evolution. Methods: We recruited patients with supratentorial ischemic stroke and NIHSS score >=4. All patients had multimodality MRI scans pre-treatment, at 48 hours and 1-3 months after treatment. Abciximab was given IV within 24 hours of stroke onset, 0.25 mg/kg (max 30mg) bolus, followed by 0.125 mcg/kg/min (max 10 mcg/min) infusion for 12 hours. We assesed for intracranial hemorrhage and also compared the early and late treatment response of all patients, as well the DWI lesion evolution of patients with non-lacunar strokes, to untreated stroke controls from our MRI-stroke registry. Results: We treated 29 patients. Baseline NIHSS score was 10 (4-25) (vs 7 for controls). Stroke onset-treatment time was 14.8±5.1 hours. There were no symptomatic intracranial hemorrhages. At 48 hours post-treatment, NIHSS score improvement was 4 [(-3) - (+12)] vs 0 [(-11)-(+6) for controls (n=39), (p=0.0097)]. At 1-3 months NIHSS improvement (n=22) was 5 (vs 4 for control, p=NS). In non-lacunar stroke patients (n=15), DWI lesion size decreased by 25% (vs 39% increase for controls, p=0,0018) at 48 hours. Acute DWI-3 month T2WI lesion size (n=14) increased by 18% (vs 17% for controls). Conclusions: Treatment of acute supratentorial ischemic stroke with intravenous abciximab within 24 hours of onset is safe, results in early neurological improvement and slows the evolution of the ischemic lesion. A larger scale study is needed.

Presentation:Poster  13 May, 2004  14:00 - 16:00  Room:  

Long term hypothermia in patients with subarachnoid hemorrhage

E. Keller    S. Gasser  Y. Yonekawa                                            
SWITZERLAND

Neurointensive care Unit, Dept. of Neurosurgery, University Hospital Zurich

Background: In almost all the studies hypothermia treatment was used for up to a maximum of 72 hours because of potentially hazardous side effects. To date, no larger case series with hypothermia treatment after subarachnoid hemorrhage (SAH) are studied. Purpose: To study the feasibility and efficacy of long term hypothermia in patients with SAH. Methods: Among 169 patients Between 1999 – 2002 among 169 patients after SAH 37 were treated with hypothermia (33°C-34°C) combined with barbiturate coma. Indications for hypothermia/barbiturate coma were severe brain edema with elevated intracranial pressure (ICP) > 20 mmHG, resistant to conventional treatment (osmotherapy, ventricular drainage) and/or cerebral vasospasm (CVS) persistent with hypertensive hypervolemic hemodilution (triple h therapy) and repetitive intraarterial spasmolysis. Cooling was accomplished by using cooling blankets or endovascular cooling catheters. Hypothermia was maintained until ICP remained < 20mmHg for > 24 hours or with vanishing CVS. Results: 22 patients were treated with hypothermia/barbiturate coma because of ICP elevations, 23 patients because of resistant CVS and 8 patients because of both reasons (in total 37 patients). Severity of SAH measured with Hunt and Hess grading in all patients was 5 in 12 (32.5%), 4 in 15 (40.5%), 3 in 5 (13.5%), 2 in 5 (13.5%) and 1 in 0 patients. Good functional outcome (Glasgow outcome score GOS 4 & 5) in all patients was achieved in 14 (38%), moderate disability (GOS 3) in 9 (24.5%), vegetative state (GOS 2) in 1 patient (2.5%) and 13 (35%) of the patients died. Hypothermia combined with barbiturate coma was maintained in mean for 103.7 (+/-93.7) hours up to a maximum of 16 days. Conclusion: In patients with most severe SAH (resistant ICP elevations or refractory CVS) long term hypothermia might be a valuable ultima ratio therapy to reach good functional outcome for at least in more than one third of the patients.

Presentation:Oral  14.05.2004  16:00 -16:10  Room: Beethovensaal II

Hemispheric activation balance and motor recovery after subcortical stroke

C. Calautti    M. Naccarato  S.P.Jones    D.J.Day   A.T.Carpenter    E.T.Bullmore  E.A.Warburton    J.-C.Baron            
UNITED KINGDOM

University of Cambridge and WBIC

After subcortical stroke, both PET and fMRI document a shift of activation balance towards the unaffected side that translates as reduced Laterality Index (LI). We studied the relationship between LI and motor deficit in the different phases of recovery. R-handed adults (age: 45-80 yrs) in the early (n=10, <3 mo from onset) or late (n=12; 3-11 mo) phase after first-ever subcortical stroke were studied with either H215O-PET (n=9) or block-design 3T fMRI (n=13) during affected-hand aurally-cued index-thumb (IT) tapping at 1.25 Hz. All subjects were able to perform the task. Following spatial normalisation to MNI with SPM99, activation maps (p<.001 uncorrected) were generated. Using WFU-PickAtlas, ROIs were automatically generated on each side for M1, S1, SMA and PM cortex, and normalized LIs were calculated for each ROI as modified from Fernandez (NeuroImage, 2001). On scanning day, we obtained the maximum IT taps in 15 secs for each hand, and calculated the unaffected/affected hand ratio (IT-R). Spearman correlations between LIs and IT-Rs were computed. The IT-R was 1.68+/-0.5 and 1.32+/-0.24 for the early and late groups, respectively. Save for a trend for S1 (p= -.6, p=.06), no significant correlation between IT-R and LI was found for the early group, whereas significant negative correlations were found in the late group for M1 and S1 (p= -0.769, p=.01; and -636, p=.03, respectively). Almost identical regression slopes and intercepts were obtained with LIs from PET and fMRI taken separately. We found that in the late phase, the lower the primary sensorimotor LI the worse the outcome, whereas this relationship is absent or very weak in the early phase. This suggests that the relationship between hemispheric activation balance and performance changes as recovery proceeds.

Presentation:Oral  14.05.2004  16:20 - 16:30  Room: Bruno-Schmitz-Saal

Effective detection and secondary intervention for post-stroke depression in a high-risk group; results of a shared care model.

J. Joubert    C. Reid  L. Joubert    D. Barton   D. Ruth                               
AUSTRALIA

Royal Melbourne Hospital

The rate of major depression is increased in patients with stroke. 30-40% of stroke survivors suffer from a significant mood and anxiety disorder and are 3 time more likey to die in the ten years following a stroke than the non-depressed patients. Aim: We shall describe the model and initial results of detection and management of post-stroke depression in the context of a structured shared care protocol for stroke patients at the Royal Melbourne Hospital, Australia. Method : The performance of the shared-care model regarding depression as detected by the telephone-validated PHQ9 tool, will be compared against a "treatment as usual" group discharged to the routine care of general practitioners from an acute stroke service. Patients are randomly assigned to either the shared care or comparison group after consenting to participate in the project. Telephone screenning for depression takes place prior to each GP visit at 3,6,9 and 12 month intervals and the results faxed to the GP. Results: Initial analysis of the data has shown a statistically significant reduction in the treatment group in depression as compared to controls. At one year follow-up, the percentage of patients experiencing some form of depression as assessed by the PHQ9 was significantly less in the shared care group compared to controls (p=0.06). High levels of satisfaction from patients, carers and general practitioners have been expressed. Compliance has been good. Discussion: A structured process of shared care between a stroke service and the general practitioner, employing telephone tracking with prompting and follow-up from the acute stroke unit, facilitates and enhances the detection and management of depression as well as vascular risk factors in accordance with best practice guidelines.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

Morphometric properties of the fibrous cap within carotid artery plaque are not crucial to plaque rupture.

M. Kablau    F. Trostdorf  M. Buchkremer    A. Harmjanz   M. Sitzer    H. Steinmetz                        
GERMANY

University of Heidelberg, Universitatsklinikum Mannheim

Background Which morphologic alterations within a long time asymptomatic internal carotid artery (ICA) plaque are crucial to induce an instable state with high risk of cerebral ischemia is not fully understood. Whether local thinning of the fibrous cap could be a mechanism leading to plaque rupture or ulceration which is more common in symptomatic than in asymptomatic plaques has not been evaluated in human atherosclerosis thus far. Methods Endarterectomy specimens from n=38 consecutive patients undergoing surgery for high-grade ICA stenosis (>/=70%) were transversely sectioned at 2 mm intervals. Each plaque was defined as stable or unstable (n=19/19) by its history of recent ischemic symptoms (<120 days before surgery), additionally each plaque was investigated pathomorphologically if ruptured or not (n=15/24). Detailed morphometric analyses of the fibrous cap based on Elastica van Gieson- and a hematoxylin/eosin-stain were carried out by digital imaging and measurement of each slice. Results Plaque rupture was found more often in symptomatic plaques. Despite this we found no difference between the morphometric properties of the different groups of plaques. The mean area (mm2) of fibrous cap was 2.83+/-0.9 vs. 2.52+/0.9 (P=0.257) for asymptomatic/symptomatic and 2.53+/-1.0 vs. 2.82+/-0.9 (P=0.254) for unruptured/ruptured plaques. The minimal necrotic core-to-lumen distance at the thinnest part of fibrous cap (mm) was 0.10 +/-0.04 vs. 0.08 +/-0.05 (P=0.510) for asymptomatic/symptomatic and 0.09+/-0.05 vs. 0.10 +/-.04 (P=0.705) for unruptured/ruptured plaques. Discussion These data confirm the observation that plaque rupture is more common in symptomatic carotid plaque but gives no evidence that thinning of the fibrous cap is an essential condition for plaque rupture in ICA stenosis.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

Comparison of Intra-arterial Thrombolysis With Conventional Treatment in Patients with Acute Central Retinal Artery Occlusion

M. Arnold    U. Körner  L. Remonda    K. Nedeltchev   H.P.Mattle    G. Schroth  M. Sturzenegger    J. Weber    F. Körner     
SWITZERLAND

Department of Neurology, Ophtalmology and Neuroradiology, University of Bern

Background: Several case series and a recent meta-analysis indicate that intra-arterial thrombolysis (IAT) is effective to treat acute central retinal artery occlusion (CRAO). Methods: Thirty-seven patients with acute monocular blindness because of unilateral thromboembolic CRAO were treated with IAT using urokinase within six hours of symptom onset. Visual outcome was compared with a control group of 19 patients, also seen within 6 hours, but who did not undergo thrombolytic treatment. In both groups some patients were treated by paracentesis and/or acetazolamide. Predictors of visual outcome were evaluated. Results: Visual improvement was more likely with IAT (p=0.01), and the chances to regain a visual acuity of > 0.6 were significantly better (p = 0.04). In the IAT group 8 of 37 patients (22%) regained a visual acuity of > 0.6, in the control group none of the 19 patients. Younger patients were more likely to regain some vision with (p=0.012) or without IAT (p=0.026). Three patients suffered minor treatment related cerebral ischemic events, two TIAs and one minor stroke. However, there were no hemorrhagic complications. Conclusions: This series of patients with CRAO demonstrates that IAT enhances the chances of visual improvement when compared to a group with conventional treatment only. Furthermore, younger patients have better chances to achieve some visual recovery.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

CT Signs of Recent or Remote Infarction During Abciximab Treatment of Acute Ischemic Stroke: An AbESTT Substudy

W. Hacke    H. Adams  A. Davalos    J. Cooper   B. Oemar    J. Leclerc  E. Barnathan                   
GERMANY

University of Heidelberg

Background: The presence of CT signs of remote or recent infarction may increase the risk/benefit ratio in patients receiving reperfusion therapy. We studied outcomes with and without these signs in AbESTT, a double-blind placebo controlled trial of abciximab in acute ischemic stroke. Methods: All CTs were reviewed blindly at the University of Iowa. Analyses were by intent-to-treat, adjusted for baseline NIHSS. Enrollment CT exclusions were: 1) ICH; 2) hypodensity >50% MCA territory; 3) mass effect causing midline shift. mRS responder was defined as mRS=0 if baseline NIHSS 4-7, 1 if 8-14, £2 if 15-22. Results: Symptomatic ICH rates in abciximab and placebo groups were 4% and 1%, respectively. None of the 10 patients with ICH had signs of remote infarct, while 1 in each group had signs of a recent infarct. There were no statistically significant treatment by subgroup interactions.Discussion: CT signs of recent or remote infarction do not increase the risk of symptomatic ICH with abciximab. Point estimates for efficacy outcomes were similar among subgroups. A larger trial, AbESTT-II, is underway to confirm these findings.

 
http://www.esc-archive.eu/mannheim04/ma_graphics/mt_1071.htm

Presentation:Oral  13.05.2004  16:00 - 16:10  Room: Beethovensaal I

TNFR1, THROUGH NF-kappaB ACTIVATION, MEDIATES TOLERANCE AFTER ISCHEMIC PRECONDITIONING.

I. Lizasoain    J.M.Pradillo  C. Romera    O.  Hurtado   A.  Cárdenas    J.C. Leza  M.A.Moro    P. Lorenzo    A. Dávalos  J.  Castillo
SPAIN

Departamento de Farmacología. Facultad de Medicina. Universidad Complutense de Madrid. Spain

Background and Purpose: It has been described that a short ischemic event (ischemic preconditioning: IPC) can result in a subsequent tissue resistance to severe ischemic injury (ischemic tolerance: IT). Although the mechanisms of IPC are poorly understood, TNF-alpha has been implicated and we have demonstrated the up-regulation of its processing enzyme, the TNF-alpha convertase enzyme (TACE/ADAM-17). Therefore, we have now decided to investigate the expression of TNF receptors as well as other signalling mechanisms involved in IT. Methods: Experiments were carried out on male Fischer rats anaesthetised with 2.5% halothane. A period of 10-min temporary middle cerebral artery occlusion (tMCAO) was used for focal IPC, whereas sham surgery was used for control group. To evaluate the ability of IPC to induce IT, permanent MCAO (pMCAO) was performed 48 hours after IPC. 24 hours after pMCAO infarct volume was measured by TTC staining. Results: As we have demonstrated previously, IPC produced a reduction in infarct volume and a reduction on motor deficit measured by a neurological test (SHAM+pMCAO: 244+/-14mm3 and IPC+pMCAO: 98+/-7mm3; n=6-10; p<0.05). Western blot analysis showed that IPC caused up-regulation of TNFR1. The intracerebral administration of TNFR1 antisense oligodeoxynucleotide which caused a reduction in TNFR1 expression, inhibited the IPC-induced protective effect, demonstrating that TNFR1 up-regulation is implicated in IT (IPC+antisense+pMCAO: 165+/-10mm3; n=6; p<0.05 vs IPC+pMCAO). Moreover, treatment with TNFR1 antisense and lactacystin –an specific proteasome inhibitor- blocked IPC-induced NF-kappaB determined as nuclear translocation of p65 by western blot analysis. Lactacystin also inhibited the IPC-induced protective effect (IPC+lactacystin+pMCAO: 130+/-11mm3 n=6;p<0.05 vs IPC+pMCAO). Conclusions: Taken together, these data demonstrate that IPC produces up-regulation of TNFR1 and that the pathway TNFR1/NF-kappaB is involved in IT.

Presentation:Poster  14 May, 2004  14:00 - 16:00  Room:  

How rare are rare strokes? Data from a community-based population stroke incidence study

I. Correia    M.R.Silva  I. Matos    A. Tuna   R. Magalhães    M.C.Silva                        
PORTUGAL

Hospital Geral santo António

Studies on rare causes or clinical presentations of stroke are generally based on hospital case series. Objective: calculate the incidence of rare strokes in the community. Methods: All suspected stroke occurring in a population of 95861 in Northern Portugal during a 24 month period between October 1998 and September 2000 were registered and followed-up at 3 and 12 months by a neurologist. Multiple overlapping sources were used to ascertain cases. Standard definitions and criteria for stroke were applied. Echocardiogram and Echo-Doppler of cervical arteries were included at base-line. Results: During the two year period 501 first-ever stroke were registered; 76% ischemic stroke, 16% primary intracerebral haemorrhage (PIH), 3% subaracnhoid haemorrhage and 5% undetermined type. Investigation was not completed in 102 (26%) ischemic stroke and in 14 (18%) PIH patients. In 12 (2.4%) patients the cause of stroke was considered rare: ischemic - 1 atrial myxoma, 1 vasculitis, 1 MELAS syndrome, 2 HIV infection (one arterial dissection), 1 congenital heart disease, 1 arterial dissection, 1 resulted from a neuroradiological intervention, haemorrhagic stroke – 1 endocarditis, 1 resulted from an neuroradiological intervention, 2 probable amiyoid angiophaty. In 6 patients the clinical presentation was considered rare: 2 ataxic hemiparesis, 3 involuntary movements, 1 acute meningeal syndrome due to a cerebral sinus thrombosis. Considering these rare stroke causes the crude annual incidence rate per 1000 was 0.06 (95% CI: 0.03 to 0.11) and for the rare clinical presentations 0.03 (95% CI: 0.01 to 0.07). Conclusions: In the community, although 23% were not completely investigated, rare causes of stroke or rare clinical presentations are rare when compared to hospital studies.

Presentation:Oral  14.05.2004  12:10 - 12:20  Room: Beethovensaal II

Acute Cerebral CT Evaluation in Stroke Study (ACCESS): CT Interpretation Differs Between Specialties

A.J.Farrall    O. Mielke  R. von Kummer    T. Moulin   A. Ciccone    M. Hill  D. Perry    J.M.Wardlaw            
UNITED KINGDOM

University of Edinburgh

Background: Early ischaemic stroke signs on CT are difficult to identify. Aim: To improve reliability of CT interpretation in hyperacute stroke. Methods: Readers of different nationalities (e.g. European, Canadian), specialties (e.g. General & Neuroradiologists, Neurologists) and experiences (trainee, consultant) test inter- and intra-observer reliability by interpreting 63 CT scans. Readers review CT scans and enter interpretations directly into an internet based, interactive CT viewing site/database (http://www.neuroimage.co.uk). 685 physicians are registered. Results: For each specialty group, average scan evaluation times (minutes +/- 2SD) were: Neuroradiologists 3.7+/-1.1; General Radiologists 3.5+/-1.2; Neurologists 3.1+/-1.1; Stroke Physicians 3.4+/-1.4; Geriatricians 3.2+/-1.4; General Practicioners 2.2+/-1.5; and Emergency Doctors 4.6+/-4.9 (overall time-to-read differences were significant for 13 scans). On each scan, ischaemic changes were identified as “present” or “absent.” Compared to Neuroradiologists, all other specialist groups said ischaemic change was “present” more often on average, as follows: General Radiologists +6.7%, Neurologists +14.7%, Stroke Physicians +9.6%, Geriatricians +22%, General Practicioners +29% and Emergency Doctors +9.2%. Most differences approach statistical significance. A relatively small proportion of scans created much of the disagreement, e.g. in 13, the percentage by which Neuroradiologists’ opinions differed from other specialties was more than 2SD from the mean difference. Discussion: While times taken to assess scans were similar between specialties, positive identification of ischaemic changes resulted in disagreement, verging on significant for Neurologists compared to Neuroradiologists. The specific characteristics of the 13 outlying scans may identify particular sources of disagreement. The ACCESS study closes on 30/04/04. Complete data evaluation will be presented in June.

Presentation:Poster  May 13, 2004  14:00 - 16:00  Room:  

The effects of nimodipine in subcortical vascular dementia: a randomised placebo-controlled trial

D. Inzitari    T. Del Ser  A. Soglian    S. Amigoni   G. Spadari    D. Binelli  L. Pantoni                   
ITALY

Department of neurological and psychiatric Sciences

Background: Subcortical vascular dementia (VaD) is frequent and its treatment is undefined. Objective: To study the efficacy and safety of the calcium-antagonist nimodipine in subcortical VaD. Methods: 242 patients with subcortical VaD (ICD-10 criteria), extensive leukoaraiosis and at least one lacunar infarct on CT were randomized to oral nimodipine 90 mg/day or placebo and followed-up for 52 weeks. 230 patients (121 nimodipine, mean age 75.2 ±6.1 and 109 placebo, 75.4±6.0) were valid for the intention-to-treat analysis. Results: At 52 weeks the primary outcome measure (the SCAG scale) did not differ between nimodipine and placebo groups, but significantly less nimodipine patients showed a deterioration on the MMSE (28.1 vs. placebo 50.5%). Drop-outs and serious adverse events were significantly more frequent in the placebo group (61 vs. 29 and 66 vs. 43, respectively). Both cardio- (21 vs. 10, RR=2.26, 95%CI: 1.11-4.60) and cerebro-vascular (23 vs. 10; RR=2.48, 95%CI: 1.23-4.98) events occurred more commonly among patients treated with placebo, so behavioural disturbances requiring psychiatric intervention (22 vs. 5; RR=3.88; 95%CI: 1.49-10.12). Given the high drop-out rate in the placebo group, a worst rank analysis was performed. Under this analysis also the results of the MMSE and of the Set Test reached the level of significance, both in favour of nimodipine. Conclusions: Nimodipine is of some symptomatic benefit in subcortical VaD. The possible protection, to be confirmed through a further “ad hoc” study, against cardio- and cerebro-vascular events may be of an added value, considering the high risk of such events in patients with severe leukoaraiosis.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

Frequency and factors influencing early rehabilitation in stroke patients across Europe. Results from the European BIOMED II Study of Stroke Care

J. Heidrich    P.U.Heuschmann  P.L.Kolominsky-Rabas    A.G.Rudd   C.D. A.Wolfe                               
GERMANY

Institute of Epidemiology and Social Medicine, University of Münster

Background: Early rehabilitation is a key element of stroke care. Therefore, rehabilitation treatment of specific neurological symptoms should be initiated already during acute hospitalisation. We investigated frequency of physiotherapy, occupational and speech therapy and factors associated with performance of these therapies in stroke patients admitted to acute hospitals across Europe. Methods: Consecutive first-ever stroke patients were sampled prospectively over a one-year-period in 1997–98 through 12 hospital-based stroke registers across 11 European countries. The impact of socio-demographic factors, stroke subtype, comorbidities, neurological symptoms, time to admission, day of admission, and type of hospital on performance of physiotherapy or occupational therapy in patients with paresis and on speech therapy in aphasic patients were assessed using multivariate logistic regression analyses. Results: A total of 1996 patients were included in the study. The mean age was 68.7 years and 53% were female. Overall, 71.6% of patients with paresis received occupational or physiotherapy, ranging from 41.1% to 100% between centres. Older patients (p=0.03) were identified to receive less physiotherapy or occupational therapy, whereas women (p=0.02) and patients admitted to stroke units (p <0.0001) were more likely to get these therapies. Among aphasic patients, 39.3% received speech therapy, ranging from 7.5% to 100% between centres. Older patients (p=0.02) and patients living alone pre stroke (p=0.02) were less likely to receive speech therapy. Discussion: Recently, two thirds of stroke patients with paresis received physiotherapy or occupational therapy, but only one third of aphasic patients was treated with speech therapy in acute hospital settings across Europe.

Presentation:Poster  May 13, 2004  14:00 - 16:00  Room:  

Short and long-term follow-up of patients with stroke due to internal carotid artery occlusion.

M. Paciaroni    G. Mazzotta  V. Caso    M. Venti   P. Milia    G. Silvestrelli  F. Palmerini    M. Acciarresi    L. Parnetti  V. Gallai
ITALY

University of Perugia

Background: The purpose of this study was to assess predictive factors of outcomes in patients with stroke due to an occlusion of the ICA. Methods: Consecutive cases with first-ever ischemic stroke due to ICA occlusion were prospectively examined from the Perugia Stroke Registry. Multiple regression models were used to analyze predictors of mortality, dependency, and ipsilateral stroke recurrence. Results: 177 patients with stroke due to carotid occlusion were included (mean age 71.4+/-14.3 years; 53.1% males). The causes of occlusion were 65.0% atherosclerosis, 22.0% cardioembolism, 9.0% dissection and 4.0% other causes. Fifty-three patients (29.9%) died within 30 days. After a mean follow-up time of 420 days, 45,2% of the patients had died and 74.6% had died or were disabled (mRS>/=3). Additionally, another 10 patients (5,6%) had stroke on the same side as the occluded carotid artery. Age was the only predictor of short-term mortality (77.7+/-9.6 vs. 68.7+/-15.2 years; p<0.0001) and long-term mortality or disability (73.9+/-13.4 vs. 64.1+/-14.6 years; p<0.0001). Age (78.3+/-10.6 vs. 65.7+/-14.5 years; p<0.0001) and contralateral carotid occlusion (OR 25.4: 95% CI 2.5-261.2; p=0.006) were predictors of long-term mortality. Hypertension (OR 0.4: 95% CI 0.2-0.9; p=0.049) was a predictor of a better outcome within 30 days from stroke onset. Hyperlipidemia (OR 0.38: 95% CI 0.2-0.9; p=0.049) and the presence of ipsilateral TIA (OR 0.2: 95% CI 0.07-0.9; p=0.025) were predictors of a better outcome for long-term mortality or disability. No ipsilateral stroke recurrence predictors were found. Conclusions: In patients with stroke due to carotid artery occlusion, the presence of either hypertension, hyperlipidemia or previous ipsilateral TIA increase the likelihood of a better outcome.

Presentation:Oral  13.05.2004  17: 10 - 17:20  Room: Stamitzsaal

GAS6 polymorphisms in patients with ischemic or hemorrhagic stroke

V. Obach    X. Muñoz  M. Revilla    P. Garcia de Frutos   N. Sala    A.M.Planas  A. Chamorro                   
SPAIN

Hospital Clinic IDIBAPS

Background and Purpose: Growth arrest-specific 6 gene product (GAS6) is a recently identified protein with anti-apoptotic and pro-thrombotic effects. Its structure is highly homologous with that of anticoagulant protein S. There is a plymorphism (834 +7 G>A) in intron 8 of the GAS6 gene which has been associated with ischemic cardiopathy and stroke. We investigated whether the prevalence of different single nucleotide polymorphisms in intron 8, Intron 7, intron 3 and exon 11 differed between patients with ischemic or hemorrhagic stroke and controls. Methods: The genotypes for intron 8 (834+7G>A), Intron 7 (713-155T>C), intron 3 (280+170C>G) and exon 11 (1263G>C) of GAS6 gene were evaluated in 500 white patients with ischemic (n=343) or hemorrhagic (n=157) stroke, and in 108 healthy white controls using PCR amplification and enzyme restriction digestion. Results: The prevalence of the AA genotype of GAS6 intron 8 (834+7 G>A) was 12.5%*, 10.2%* and 20.4% in patients with ischemic stroke, hemorrhagic stroke and in controls, respectively (*chi-square, p<0.05 AA vs non-AA compared with controls). After adjustment for age, gender, current smoking, hypertension, diabetes and hypercholesterolemia, the GAS6-intron 8-AA genotype was not independently associated with stroke, OR 0.74, 95% CI 0.39-1.42. The genotype distribution for Intron 7, intron 3 and exon 13 did not differed in patients and controls (data will be presented). Discussion: The GAS6-intron 8-AA genotype is less prevalent in patients with ischemic or hemorrhagic stroke than in healthy controls but differences are mostly explained by the interaction of environmental risk factors. Intron 8, intron 3 and exon 11 polimorphisms are not associated with ischemic or hemorrhagic stroke.

Presentation:Poster  May 13, 2004  14:00 - 16:00  Room:  

Proliferation of myointimal hyperplasia cells of early carotid restenosis inhibited by upregulation of cyclin dependent kinase and HSP 70 expression

Z. Bori    L. Dénes  E. Csonka    Z. Nagy                                     
HUNGARY

Department of Vascular Neurology, Semmelweis University

Background: Myointimal hyperplasia (MIH) causes early restenosis following mechanical intervention. It limits the efficacy of this stroke prevention strategy. The inhibitory mechanisms of the myointimal proliferation have been tested with a new drug candidate Inoxanadine (1,2,4 H oxidiazine-types derivative). It is characterized as a co-inductor of heat shock protein representing with a pronounced cytoprotective effect. Methods: Inoxanadine effect in the concentration of 10-6 -10-8 M has been tested on cells isolated from MIH. For comparison human brain microvessel endothelial cells (HBEC) were used. Wounding migration assay, BrdU incorporation tests were used with or without a p38 MAP kinase inhibitor (SB203580). The cell cycle was analyzed with FACS and cyclin dependent kinase 1A (Cdk1A) was measured by Northern-blot. Results: The candidate drug significantly reduced the cell-proliferation on p38 MAPK-dependent pathway. In MIH, HSP 70 and Cdc1A expression were significantly increased by Inoxanadine treatment by the optimal dose of 10-6 M. but no change was observed in EC proliferation. In the same range of concentration, in dose dependent manner, the test drug increased the migration of HBEC at wounded edge along. Discussion: The p38 MAPK modulated the activity of MIH and the migration of wounded HBEC. Proliferation downstream was connected to the level of HSP70 and Cdk1A. Parallel with increase of phosphorilated-p38 and enhanced HBEC migration was appeared. On the basis of these data, Inoxanadine probable has a therapeutic potential in the prevention of early restenosis following vascular surgery or balloon angioplasty.

Presentation:Poster  May 13, 2004  14:00 - 16:00  Room:  

TRAIL upregulates the proliferation of human brain capillary endothelial cells by activating the ERK pathways

L. Dénes    L. Ernst  I. Petak    Z. Bori   Z. Nagy                               
HUNGARY

Department of Vascular Neurology, Semmelweis Unversity

Background: The myointimal hyperplasy (MIH) is not a rare complication in the early restenosis of the carotid artery following vascular surgery, or stenting. Increased cell proliferation in MIH could be TRAIL protein related as it is in some tumors. The role of TRAIL protein however is not documented in MIH. Methods: The binding of TRAIL/TRAIL-Rs has been investigated in primary human brain capillary endothelial cells (HBECs) and MIH by FACS analysis. The activity of protein kinases ERK 1/2 and phosphorylation of p38 SAPK, JNK were determined by Western-blot analysis. Proliferation capability of primary cells was tested by BrdU incorporation after 10μM TRAIL treatment. Results: Decreased proliferation rate of MIH and enhanced proliferation of HBECs after TRAIL treatment have been observed. Decreased proliferation correlated with expression of death receptors (TRAIL-R1 and -R2). In enhanced proliferation increased TRAIL-R3 and -R4 have been documented. TRAIL activated the protein kinase ppERK 1/2 in HBECs. Moreover, a pharmacological inhibitor of ERK1/2 pathway (PD98059) blocking the TRAIL activity, but not the p38 (SB203580) or the JNK pathways. Contrary, TRAIL treatment decreased the MIH cell proliferation, meanwhile significantly stimulated the pp38, or ppJNK kinases but not the ppERK1/2 Discussion: The ability of TRAIL to promote the survival/proliferation of human brain capillary endothelial cells with inducing ERK1/2 phosphorilation and to induce a downstream on hyperplasia of MIH VSMC by p38/JNK pathway suggesting that the TRAIL/TRAIL-R system could play an important role in retardation of early restenosis. (Supported by OTKA grant 2001 T-037887)

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

Stroke outcomes in atrial fibrillation: is the cost-effectiveness of anticoagulation underestimated?

P.S. J.Miller    F.L.Andersson  L. Kalra                                            
SWEDEN

AstraZeneca R&D Lund

Background: Cost-effectiveness models of anticoagulation in atrial fibrillation (AF) for the prevention of ischemic stroke do not distinguish between type of stroke and are typically based on 3 input parameter estimates: the incremental change in cost and quality-adjusted life years associated with: 1) anticoagulant therapy, a function of drug cost, health care resource use (INR monitoring), and patient factors; 2) adverse (bleeding) events; and 3) ischemic stroke, a function of the differential risk of stroke, stroke mortality, and stroke severity. Results from these models may be sensitive to estimates used for the long-term burden of stroke. Methods: Literature review of studies comparing stroke outcomes in patients with and without AF and studies modelling the cost-effectiveness of anticoagulation. Results: Evidence from 13 studies analysing 10,000 stroke events shows strokes in patients with AF are more fatal, recurrent, and severe compared to patients without AF. The cost of stroke with AF is likely to be higher, as they are associated with longer hospital stays and more impairment, dependency, and institutionalization. Five published economic models were reviewed. None applied AF-specific cost of stroke estimates. Frequency of stroke and severity are obtained from anticoagulation trials. Average nonspecific stroke cost estimates from other sources are attached to each severity category. Discussion: Two issues to consider are whether the severity of the AF strokes that occurred in these trials were typical of those in nonexperimental conditions and whether the unit costs used in these models accurately reflect the resources used by typical AF stroke events. Stroke cannot be considered a homogenous condition in clinical or economic analyses. Existing models are not inaccurate in their approach but they probably underestimate the value of anticoagulation on AF. To make economic models more robust, more data on the longer-term costs of stroke with AF is needed.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

Long lasting ischemic penumbra: case report of a brisk blood pressure reduction on lacunar infarct

A. Rocco    N.  Bonaffini  F.  Puccinelli    M. Toscano   M.  Altieri    V. DiPiero  GL. Lenzi                   
ITALY

Neurological Sciences

Background: Active lowering of blood pressure in the first three days following an acute stroke is associated with the risk of further damage to the brain by reducing perfusion in the ischemic ("penumbra") area. Case Report: A 76- year- old, right handed man with a 20 year long history of hypertension was admitted to the hospital. The patient had been well until the morning when he experience a short-lasting weakness of the left leg. At admission he was found to have a brachial blood pressure of 200/110 mmHg. The neurological examination revealed left leg weakness and a questionable left Babinski reflex (NIHSS = 2). Magnetic resonance imaging of the head with imaging showed one lesion suggestive of acute infarction in the right thalamus. Two days after the hospitalization the blood pressure was noted to be 220/100 mmHg. Ten minutes later after 10 mg of nifedipine sublingually, the patient developed left-side weakness and his blood pressure was 150/80 mmHg. At the neurological examination, left-sided facial and extremity weakness in the left arm and leg was found, and the NIHSS was 8. A new diffusion-weighted magnetic resonance imaging showed a strikingly enlarged lesion of the infarction area in the right thalamus (Figure 1 – 2). In the follow-up, both the patient and the neuroimagines improved. Conclusion: In ischemic stroke, drugs that are rapidly absorbed and can cause precipitous reduction in blood pressure, have to be avoided. Furthermore, clinicians should keep in mind that blood pressure gradually and spontaneously falls during the hospital stay. The reasons for not treating possible transient hypertension is the risk of reducing cerebral blood flow that may further darken the "penumbra".

Presentation:Oral  13.05.2004  17:10 - 17:20  Room: Beethovensaal II

Immunodepression after stroke in humans – a common phenomenon? Role of HLA-DR-Expression on monocytes

K.G.Häusler    W.U. H.Schmidt  T. Helms    F. Föhring   G.J.Jungehülsing     C. Nolte  A. Meisel    U. Dirnagl    H.D.Volk  A. Villringer
GERMANY

Department of Neurology, Charité, Humboldt University Berlin

Background – Infections are a leading cause of morbidity and mortality after stroke. The incidence of infections in stroke patients is significantly higher than hospital-acquired infections in general. We investigated the coherence between immunodepression, infections and severity, size and localisation of acute ischemic stroke. We focus on the monocytic HLA-DR-expression as a marker of immune competence and risk of infection. Methods – Within 24 hours after onset of symptoms an MRI was performed and neurological deficit, immune status (flow cytometry, ELISA, ELISPOT) and ex vivo cytokine production were assessed. MRI and blood measurements were repeated after 3 and 7 days. A follow-up was done after 6 month. Preliminary Results – So far 35 patients were enrolled. The mean NHISS-score was 6 (day 1), 5.4 (day 3) and 4.3 (day 7). Mean size of infarction was 28.3 +/- 6 cm3 (T2, day 3). During 14 days after stroke 6 patients (17%) suffered from pneumonia (n=5) and urinary tract infection (n=2). Within these patients (2 left MCA infarction, 3 right MCA, 1 right ACA) the mean NHISS-score was 11.5 (day 1), 11 (day 3) and 8.1 (day 7). Their mean size of infarction was 68.4 +/- 28 cm3 (T2, day 3). “Immunosuppression” (<15,000 HLA-DR antigens per monocyte) was found in all 6 patients prior to acquired infection as well as in 4 out of 29 patients without infection. One stroke patient with an “immunparalysis” (<5,000 HLA-DR antigens) died due to septicaemia later on. Discussion - The incidence of infections was higher after stroke causing severe impairment or large infarction. A coherence of immunodepression and localisation of stroke will be clarified. Measurement of monocytic HLA-DR expression seems to be a promising tool to identify stroke patients with high-risk of infection.

Presentation:Oral  14.5.05.2004  17:20 - 17:30  Room: Hörsaal

15D-PGJ2 EFFECTS ON BRAIN DAMAGE AFTER ACUTE STROKE ARE INDEPENDENT OF THE BLOOD MARKERS OF INFLAMMATORY RESPONSE

R. Leira    M.A.Moro  M. Castellanos    M. Blanco   J. Serena    J. Vivancos  I. Lizasoain    A.  Dávalos    J. Castillo     
SPAIN

Hospital Clinico Universitario. Santiago

Background and purpose. The 15d-PGJ2 is a natural anti-inflammatory prostaglandin that appears to be the putative endogenous high-affinity ligand for the peroxisome proliferator activated receptor (PPAR) gamma. We previously reported that high plasma levels of 15d-PGJ2 were significantly associated with good outcome and smaller infarct volume in atherothrombotic stroke. This study investigates the relationship between blood levels of 15d-PGJ, interleukine-6 (IL-6), and matrix metalloproteinase-9 (MMP9) in 221 patients with an atherothrombotic hemispheric ischemic stroke of less than 24 hours from onset. Methods. Outcome variables were early neurological deterioration (END) defined as a fall ≥1 point in the Canadian Stroke Scale (CSS) score between admission and 48 hours, infarct volume measured on CT performed on day 4 to 7, and poor neurological outcome (CSS <7) at 3 months. IL-6, MMP9 and 15d-PGJ2 were measured with quantitative ELISA in blood samples obtained on admission. Results. Plasma levels of 15d-PGJ2 correlated negatively with IL-6 (r= -0.34) and MMP9 (r= -41) concentrations (all p<0.001). The adjusted odds ratio of END and poor outcome for 1 pg/mL increase in 15d-PGJ2 were 0.95 [95%CI, 0.94-0.97] and 0.97 [0.96-0.98], respectively. The odds were not modified when IL-6 or MMP9 were included in the logistic model. High IL-6 concentration was selected as a factor independently associated with the early or late poor clinical course. In a generalized linear model, by 1 unit increase in 15d-PGJ2, there was a reduction of 0.47cc [0.32-0.63] in the mean estimated infarct volume. This effect was not modified after adjusting for IL-6 and MMP9 concentrations. Conclusion. The potential neuroprotective effect of 15d-PGJ2 in human atherothrombotic stroke may be partially independent of the acute proinflammatory reaction.

Presentation:Oral  15.05.2004  11:30 - 11:45  Room: Musensaal

The Neurosonology in Acute Stroke Study (NAIS) A multicenter study about the prognostic value of early vascular ultrasound diagnosis in stroke

G.M.von Reutern                                                        
GERMANY

Asklepios Neurologische Klinik Bad Salzhausen

Background: Patients are frequently excluded from i.v. thrombolysis because of improving or minor initial deficit. A considerable proportion of them deteriorate during early follow up. The knowledge of the vascular pathology may help to better understand the underlying hemodynamics. Therefore the Neurosonology Research Group of the WFN sponsored an international prospective multicenter study to test the hypothesis that detection of extracranial or intracranial occlusions by means of ultrasound techniques will provide prognostic information. Methods: Eligible patients where those presenting with a stroke with NIHSS >1, in whom extracranial and transcranial ultrasound could be performed within 6 hours after symptom onset. In pathologic cases of the anterior circulation reexamination was performed 6 and 12 (to 24) hours after stroke onset. The ultrasound examination included the supratrochlear arteries, carotids and intracranial anterior circulation by means of colour coded duplex and transcranial Doppler or duplex sonography. Neurological scaling (NIH, mRS, BI) was performed on day 7 and reevaluated 90 days after stroke by telephone interview (mRS, BI). Results: 452 patients have been enrolled from September 2002 until November by 17 european centers. 44% of patients presented with a middle cerebral artery occlusion or signs of branch occlusions without severe ipsilateral extracranial disease. 28% where found to have extracranial severe stenosis or occlusion on the symptomatic side. From surviving patients 90 days follow up was available in 97,8%. The statistical analysis is still ongoing. Data will presented about ultrasound results as independent factor for the 90 day clinical outcome.

Presentation:Oral  14.5.05.2004  16:00 - 16:10  Room: Hörsaal

MICROALBUMINURIA AND MOLECULAR MARKERS OF ENDOTHELIAL DAMAGE IN HEMORRHAGIC TRANSFORMATION OF ACUTE STROKE

M. Castellanos    R. Leira  J. Serena    M. Blanco   J. Castillo    A. Dávalos                        
SPAIN

Hospital Universitario Doctor Josep Trueta. Girona

Background and Purpose: Microalbuminuria has been recently found as a strong predictor of hemorrhagic transformation (HT) of cerebral infarction. This study analyzes the relationship between microalbuminuria and molecular markers of endothelial damage in 125 patients (50% males, median age 71) with an acute ischemic stroke admitted within 12 hours from symptoms onset. Methods: The volume of ischemic lesion was calculated on diffusion-MRI on admission, and HT was evaluated in a new MRI at 72 hours. Microalbuminuria was measured by nephelometry and considered positive when concentrations were between 20 and 200 microg/min. Molecular markers of inflammation (IL-6 and TNF-alfa) and of endothelial damage (cellular fibronectine [cFn] and matrix metalloproteinase-9 [MMP9]) were determined in blood samples taken at baseline. Results: HT was observed in 35 patients. On admission, patients with subsequent HT showed higher levels of cFn (median [quartiles], 27.2 [21.4-34.9] vs 4.5 [1.3-16.5] microg/mL) and MMP9 (94 [77-130] vs 50 [14,92] ng/mL), and higher frequency of microalbuminuria (74.3% vs 16.7%, p<0.001), in comparison with those without HT (all p<0.001). cFn and MMP9 concentrations were significantly higher in patients with microalbuminuria (p<0.01). Microalbuminuria was associated with a 50 [95%CI, 7-343] fold increase in the risk of HT after adjusting for clinical confounders and DWI lesion volume at baseline. The odds of HT for microalbuminuria (20 [2.5-167]) was partially reduced after adjusting for cFn levels, but not for MMP9 concentrations. Conclusion: The association of microalbuminuria and HT is likely to be independent of the acute endothelial disruption. These findings support the role of prior endothelial damage of microvessels in HT.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

Understanding the metabolic counterpart of the DWI lesion in acute ischaemic stroke: a combined MR/PET study

J. Guadagno    E. Warburton  F. Aigbirhio    P. Smielewski   T. Fryer    D. Day  C. Price    J. Gillard    A. Carpenter  J.-C.Baron
UNITED KINGDOM

University of Cambridge, Wolfson Brain Imaging Centre

There is increasing debate as to what the hyperintense lesion in diffusion-weighted imaging (DWI) of acute ischaemic represents metabolically. To address this question, we imaged acute carotid-territory stroke patients in a prospective study with DWI along with fully quantitative positron emission tomography (PET) - (giving physiological maps of cerebral blood flow (CBF), cerebral metabolic rate of oxygen (CMRO2) and oxygen extraction fraction (OEF)). Method - From 10 patients consented, 5 (3M/2F; 53-84 yrs; NIHSS 6-16) completed the imaging protocol of back-to-back DWI and PET within 21 hours (mean 15.7hrs, range 7-21hrs) of stroke onset. All images were coregistered, with the DWI lesion forming a region of interest (ROI) that was transferred to the PET parametric maps (CBF, CMRO2 and OEF). Patterns of blood flow and metabolism were assessed within the DWI ROI. Results - Within the DWI lesions, CMRO2 was always reduced. In addition the following patterns were observed: low CBF/low OEF, low CBF/high OEF and high CBF/low OEF. These patterns not only could occur in different DWI lesions within the same patient but also within a single discrete DWI lesion. Interestingly, areas of hyperperfusion (with low OEF and low/normal CMRO2 indicating luxury perfusion) and areas of hypoperfusion (with high OEF and normal/slightly reduced CMRO2) were seen on the PET maps outwith the DWI lesions. Conclusion - The DWI lesion consistently represents metabolic failure, but does not have a single flow/metabolism counterpart suggesting temporal dissociations from perfusion. Conversely, oligaemia/ischemia may occur outwith the DWI lesion. Studying more patients at different timepoints along with their outcome structural scans remains an important goal to further characterize the DWI lesion.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

Determinants of Outcome after Staged Endovascular and Surgical Treatment of Brain Arteriovenous Malformations (AVM)

A. Hartmann    C. Stapf  JP Mohr    J. Pile-Spellman   H. Mast                               
GERMANY

Charité Campus Benjamin Franklin

Background: Independently assessed data on neurologic outcome following the often required multi-disciplinary AVM therapy are scarce. Methods: From the prospective Columbia AVM Study Project, the 119 consecutive patients with brain AVM receiving endovascular embolization followed by surgical treatment were analyzed. Neurologic impairment was assessed by a neurologist before and after completed endovascular therapy and before and after surgery. The association of demographic, clinical, and morphologic characteristics with new treatment-related neurologic deficits was investigated using univariate and multivariate statistics. Results: The 119 patients were treated with 240 embolizations (median 2, range 1 to 8) using superselective application of n-butyl cyanoacrylate. Mean follow-up time after surgery was 9.6 13.2 months. Disabling treatment-related complications (Rankin > 2) occurred in 5% (CI 1% to 9%) of the patients (3% from surgery, 2% from embolization). In addition, non-disabling new deficits were observed in another 42% (CI 33% to 51%) of the patients. No patient died. Large AVM size (OR 1.05, CI 1.01 to 1.09), deep venous drainage (OR 3.11, CI 1.25 to 7.71), and AVM location in an eloquent brain region (OR 3.14, CI 1.24 to 7.90) were independently associated with new deficits following staged endovascular and surgical treatment. Patients with hemorrhage as the initial presentation of their AVM were less likely (OR 0.20, CI 0.07 to 0.57) to suffer new deficits from intervention. Conclusions: The 5% rate of disabling complications for staged AVM embolization and surgery therapy confirms prior outcome studies on single-modality treatment. Characteristics previously identified as outcome predictors are also valid for staged AVM therapy.

http://www.esc-archive.eu/mannheim04/ma_graphics/mg_1132.htm
 

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

Prevalence of Hereditary Connective Tissue Disorders, Intracranial Aneurysms and Fibromuscular Dysplasia in Spontaneous Carotid Artery Dissection

D. Benninger    D. Georgiadis  M. Arnold    R.W.Baumgartner                                     
SWITZERLAND

University Hospital of Zurich

Background: Patients with spontaneous dissection of the cervical internal carotid artery (ICAD) have been reported to have an increased prevalence of hereditary connective tissue disorder (CTD), intracranial aneurysms and fibromuscular dysplasia (FMD). This association has been used as argument for the presence of a common underlying arteriopathy of yet unknown origin in ICAD. The aim of this study was to determine the prevalence of CTD, intracranial aneurysm and FMD in patients with spontaneous ICAD. Methods: Consecutive patients with spontaneous ICAD were included who had undergone extensive diagnostic work-up including medical and family history, physical examination, extra- and transcranial color Duplex sonography (CDS), cervical MRI, catheter (CA) and/or MR angiography (MRA), and in addition, cerebral CT and/or MRI in case of ischemia. Results: 276 patients with 300 spontaneous ICAD were included: four (1.4%) patients had a family history of dissection and Marfan syndrome was diagnosed in one (0.4%), but no clinical evidence was found of Ehlers-Danlos syndrome type IV, pseudoxanthoma elasticum, osteogenesis imperfecta or polycystic kidney disease. In 162 (59%) patients with ICAD additional CA and/or MRA were performed at presentation: FMD was diagnosed in 5 of 78 patients (6.4%) examined with CA (with or without MRA), and no patient had an cerebral aneurysm. Discussion: In a minority of patients with spontaneous ICAD evidence is found of a specific arteriopathy, FMD being the most prevalent, while pathogenesis of ICAD remains unsolved in most cases. The comparable prevalence of intracranial aneurysm in ICAD and the general population precludes a common underlying arteriopathy.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

Dynamics of S-100 serum levels during the first few hours after stroke onset as an early predictor for infact volume and outcome.

J.J.Schwarze    A. Liebert  M. Federbusch    R.P.Hofmann   F. Kruggel    L. Beier  J. Klingelhöfer                   
GERMANY

Chemnitz Medical Center

Introduction: Acute Stroke is a medical emergency which requires more or less invasive interventions. Predicting the prognosis at an early stage of the disease is essential for adequate therapy. Peak protein S-100 serum levels on day 3 after the onset have been shown to correlate well with the infarct volume and the clinical outcome after 3 months. It was the aim of this study to investigate the predictive value of protein S-100 serum levels during the first few hours after stroke onset. Methods: Nine patients with a major stroke (majst) and 14 with a minor stroke (minst) with a mean age of 67,3  13,4 years, were included. All patients received a comprehensive neurological evaluation and cranial computer tomography upon admission and on day 7 – 10. In addition we measured the S-100 serum levels during the first 4 days after the stroke. Results: The mean S-100 levels were on admission, 6, 9, 12, 24, 48, 72 and 96 hours after the ischemic event 0.10, 0.11, 0.15, 0.16, 0.53, 1.59, 1.92, 2.14 µg/l in the majst group and 0.11, 0.11, 0.10, 0.11, 0.18, 0.19, 0.21and 0.21 µg/l in the minst group, respectively. There were no differences on admission and 6 hours after the event, small, but statistically not significant differences 9 and 12 hours after the event highly significant (p<0.01) differences 24, 48, 72 and 96 hours after the event. The S-100 serum level correlated well with infarct volume (r = 0.72, p<0.05) and outcome three months after the event (r = 0.68, p<0.05) as early as 24 hours after the ischemia. Discussion: Our study shows that protein S-100 serum levels are very useful as early predictors for outcome and infarctvolume, and may help decision making at an early stage of the disease.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

Paradoxical embolism associated with a laparoscopic procedure – completion of the chain of causation

C. Blahak    Y. Shah  J. Kaden    O. Sedlaczek   H. Baezner    M.G.Hennerici                        
GERMANY

Department of Neurology Universityhospital Mannheim Mannheim, Gemany

Background: Often causative mechanisms of embolic cerebral ischaemia in patients with a patent foramen ovale remain unclear. Although individual patient histories may point to altered intraabdominal or intrathoracic pressure gradients, potential sources of paradoxical embolism like deep vein thrombosis can be detected only in a minor percentage of cases despite extensive diagnostic work-up. We present a patient with an overt mechanism of a paradoxical embolisation into the left middle cerebral artery (MCA) territory originating from a proven deep vein thrombosis, which occurred during a routine laparoscopic cholecystectomy. Case: A 57-year old man underwent a surgically uncomplicated laparoscopic cholecystectomy. Five hours postoperatively during the recovery period, a right sided hemiparesis and global aphasia was noted. Initial cranial computerised tomography (CCT) revealed early signs of an infarction in the territory of the left MCA on the basis of a proximal MCA occlusion through a homogeneous echolucent clot. Cardiac ultrasound confirmed a large patent foramen ovale III° with an atrial septal aneurysm. Along with an elevated titre of d-dimer a clinically asymptomatic thrombosis of the medial gastrocnemius veins as the overt reason for the embolism could be detected. Conclusion: This case is an example with a convincing chain of causation for paradoxical embolisation with subsequent territorial stroke. It exemplifies the often questioned assumption of a temporary reversal of intracardiac or intraabdominal pressure gradients as a mechanism for paradoxical embolisation in patients with a patent foramen ovale.

Presentation:Poster  May 13, 2004  14:00 - 16:00  Room:  

Stroke as a stressor: allostatic load and psychological reactions

A. Sgoifo    M.G.Celani  E. Righetti    S. Ricci                                     
ITALY

Stroke Service USL 2

Background: The role of psychological stress as a stroke risk factor is not very well known. We studied the allostatic load, i.e. the price the body pays for being forced to adapt to adverse daily events, i.e. an overactive or inefficient management of allostatic systems in front of stress. We wished to answer the following questions: can depressive and anxious reactions to stroke be distinguished? Can these reactions be related with disorientation, coping styles and posttraumatic stress disorder incidence after stroke? What is the role of psychosocial factors (social support, functional outcome, long lasting psychological symptoms), as opposed to anatomical and neurochemical ones (lesion side, short lasting psychological symptoms) in poststroke depression etiology? Methods: We studied 48 consecutive non-aphasic stroke patients, hospitalized at the stroke unit of Città della Pieve Hospital; they completed a semi-structural interview repeated in acute and post acute phase after stroke, to assess: 1) retrospective evaluation of allostatic load based on physiological, psychosocial, environmental and personality indexes (cholesterol, well-being, quality of life, stressfull events, DCPR, hostility) 2) actual evaluation (within a week and after 3 month after stroke): side lesion, psychological reactions (anxiety, depression, cognitive disorientation, PTSD). Results: We present here data on phase 2 (the other are being analysed). In the acute phase anxiety incidence assessed with HAS was 43,8% (medium level) and 47.9% (high level). Depression incidence assessed with HDS was 50% (minor), 43.8% (major). There was a significant correlation between the two scales (Spearman test, p= 0,000). Discussion: Anxiety and depression show a large incidence in this small unselected stroke cohort; acute psychological reactions could not be clearly differentiated, due to the high correlation we found.

Presentation:Poster  13 May, 2004  14:00 - 16:00  Room:  

Increased MMP expression after experimental subarachnoid hemorrhage in the rat

S. Nagel    T. Steiner  P. Heinemann    S. Heiland   J.A.Koziol    S. Wagner                        
GERMANY

University of Heidelberg

Background: Some previous reports indicate a coherence of cerebral aneurysms, subarachnoid hemorrhage (SAH) and upregulated metalloproteinase (MMP) expression. We present a preliminary study to examine the intracerebral MMP expression after experimental SAH in the rat. Methods: We used the modified filament model to perforate the circle of Willis with an endovascular suture to induce SAH. A total of 20 animals underwent the surgical procedure. Successful induction of SAH resulting in a visible blood clot on the basal surface of the brain was documented after removal of the brain from the scull. MRI, including diffusion-weighted (DWI), T2-weighted (T2WI), T2*-weighted (T2*WI) and postcontrast T1-weigted (T1WI) imaging was performed 24 hours after the initiation of SAH. MMP 2 and 9 expression was assessed by zymograms of the brain tissue and compared with controls. Results: Sham-operated animals (n=4) did not show any MRI abnormalities and no SAH postmortality. Six animals died prior to 24h because of serious SAH. 10 animals survived 24h with SAH. Among these were five animals with additive parenchymal hemorrhages (PAH), proven by MRI. The MMP 2 and 9 expression was qualitatively upregulated with SAH alone or SAH plus PAH. Sham operated animals showed the same MMP levels as controls (n=4). Conclusions: The method needs refinement to avoid a high percentage of accidental PAH. MMPs are increased in SAH. Blockage of MMPs might lead to better outcome after intracerebral bleeding

Presentation:Oral  14.05.2004  11:20 - 11:30  Room: Hörsaal

LiLAC – Life Long After Cerebral ischemia. Preliminary results on long-term (>10 year) occurrence of a vascular event in patients with cerebral ischemia of arterial origin

I. van Wijk    A. Algra                                                 
THE NETHERLANDS

University Medical Centre Utrecht, department of Neurology

Background: Little is known about the risk of recurrent stroke or other vascular events long after cerebral ischemia. In this study we investigate the long-term risk of a vascular event and prognostic factors. Method: The occurrence of vascular events was evaluated in 2473 of the original 3150 participants of the Dutch TIA Trial (recruitment 1986 - 1989; arterial cause of cerebral ischemia); follow-up is still ongoing. The cumulative event rate was evaluated by Kaplan-Meier analysis. The influence of demographic and clinical characteristics was analysed with Cox univariate and multivariate analysis. The hazard ratios were adjusted for age and sex. Results: Data of 2190 (80.2%) patients could be analysed; mean age at study entry was 65 years. After a mean follow-up of 10.3 years 1166 patients had had at least one vascular event. Three hundred fifty one patients suffered from more than one event. First events were non-fatal stroke in 29%, non-fatal myocardial infarction in 12%, and vascular death in 58%. The cumulative 10-year risk was 42.3% (40.2-44.5) and the average annual hazard 5.4%. The age and sex adjusted hazard ratios (95%CI) were 2.5 (2.2-2.8) for age over 65, 2.0 (1.6-2.5) for history of claudication, 2.0 (1.7-2.5) for diabetes, 1.5 (1.3-1.8) for white matter lesions on the baseline CT scan and 1.6 (1.4-1.9) for Q-waves on the baseline ECG. Conclusions: More than half of the patients with cerebral ischemia suffered from new major vascular events after an average period of 10.3 years. The risk of a vascular event was significantly associated with age over 65, history of diabetes or claudication and with the presence at baseline of white matter lesions on CT or Q-waves on the ECG.

Presentation:Poster  May 13, 2004  14:00 - 16:00  Room:  

NEUROPROTECTIVE ACTIVITIES OF G-CSF ARE MEDIATED BY ACTIVATION OF STAT3 IN NEURONS

W.R.Schäbitz    C. Gümbel  D. Spielvogel    C. Sommer   C. Pitzer    N. Gassler  M. Schwaninger    R. Kollmar    S. Schwab  A. Schneider
GERMANY

Department of Neurology, University of Heidelberg

Granulocyte-colony stimulating factor (G-CSF) decreases infarct size in the rat MCAO (middle cerebral occlusion) model for stroke by roughly 60%, and leads to behavioural improvements in cortical ischemia models. Here we study the neuroprotective effects of G-CSF in vitro. We found that G-CSF has strong neuroprotective properties in the H2O2 model for oxidative stress in differentiated PC12 cells. In primary neurons, G-CSF protects against glutamate-induced cell death. Other cell culture models for different aspects of neurodegeneration are currently being studied. We reasoned that the actions of G-CSF are at least partially mediated by the activation of intracellular protection mechanisms originating at the G-CSF receptor present on neuronal cells. We have studied the potential involvement of the JAK/stat pathway (Signal Transducers and Activators of Transcription). Whereas we found no specific activation of stat5 in primary cortical or hippocampal neuronal cultures, stat3 was very rapidly phosphorylated after the addition of G-CSF, followed by a downregulation of the phosphorylated form at 1 h. This behaviour is similar to stat3 activation patterns known from cells of the hematopoetic lineage. In vivo, nuclear translocation of stat3 was increased in ischemic animals receiving G-CSF. We believe that receptor-mediated stat3 activation triggers initiation of anti-apoptotic pathways in neurons. To systematically assess changes associated with G-CSFs neuroprotective action we are currently conducting a screen for genes regulated by G-CSF in the brain.

Presentation:Poster  May 13, 2004  14:00 - 16:00  Room:  

Risks of death and recurrent vascular events after lacunar and non-lacunar ischaemic stroke (LACI and non-LACI) - a systematic review of follow-up studies

C. Jackson    C. Sudlow                                                 
UNITED KINGDOM

Division of Clinical Neurosciences University of Edinburgh

We compared risks of vascular events after LACI versus non-LACI in a systematic review of follow-up studies. Methods: We used a comprehensive search strategy to identify studies providing stroke subtype-specific information on death, recurrent stroke (RS) and/or myocardial infarction (MI) for one year or more. We extracted information on: patient population studied; ischaemic stroke subtype definitions; follow-up method; outcome definitions; risks of death, RS and MI at one month and from 1-12 months after LACI and non-LACI. Results: We identified 21 studies. Death: We could extract data from 10 studies (3147 patients). After LACI, mortality at one month ranged from 0-2.2%, and from 0.1-1.3% per month thereafter. After non-LACI, one month mortality was 11.0-18.6% and 1.5-2.0% per month thereafter. RS: Where given, definitions of RS varied widely, with minimum time between index stroke and recurrence ranging from 0-21 days. We could extract data from four studies (1012 patients), of which only one defined RS. After LACI, risk at one month was 0-0.7%, and 0.5-0.8% per month thereafter. After non-LACI, risk at one month was 0-4.4%, and 0.2-1.3% per month thereafter. MI: Only three studies reported on fatal and non-fatal MI (513 patients, 14 MIs). Conclusions: Mortality at one month was much lower among LACI than non-LACI, with no clear difference thereafter. Since most studies with data on RS gave no definition, we could not interpret the one month recurrence risks. Recurrence risks beyond one month appeared similar for LACI and non-LACI but data were limited. MI risk after different subtypes of ischaemic stroke has hardly been studied.

Presentation:Oral  14.5.05.2004  16:10 - 16:20  Room: Hörsaal

Predictors of early arterial reocclusion after tPA-induced recanalization

M. Rubiera    C.A.Molina  M. Ribó    J. Montaner   J.F.Arenillas    E. Santamarina  R. Delgado    J. Alvarez-Sabín            
SPAIN

Hospital Vall d´Hebron. Barcelona

We aimed to determine clinical, biological and hemodynamic predictors of early RO in stroke patients treated with iv tPA. We studied 142 consecutive stroke patients with a documented MCA occlusion treated with iv tPA. All patients underwent carotid ultrasound and TCD before tPA bolus. NIHSS scores were performed at baseline and serially <24h. TCD monitoring of MCA RE and RO was performed during the first 2 hours after tPA bolus and repeated when clinical deterioration occurred <24h after documented RE in the absence of ICH. Stepwise logistic regression was used to determine independent predictors of RO. Variables analyzed were age, gender, antiplatelet treatment, NIHSS score, blood pressure, glucose, fibrinogen, D-dimer, platelet and leucocytes count, carotid stenosis/occlusion, location of MCA occlusion, time to treatment, time to RE and degree of RE. Median pre-bolus NIHSS score was 16. After 2-h tPA administration, RE occurred in 84 (61%) patients (33 partial, 51 complete). Of these, 21(14%) patients worsened after an initial improvement and 15 (11%) of them showed RO on TCD. RO was identified at a mean time of 65+/-55 minutes after documented RE. RO was associated (p=0.012) with a lower degree of 24-h NIHSS score improvement than sustained RE. On univariate analysis, age >75 years (p=0.009), history of hypertension (p= 0.05), antiplatelet treatment (p= 0.02), NIHSS score >16 (p=0.003), leucocytes count (p=0.043), beginning of RE <60 min of bolus (p=0.021), and ipsilateral severe carotid stenosis/occlusion (p= 0.001) were significantly associated with RO. In a logistic regression model, NIHSS score >16 (OR 12.3; IC 1.34-45, p= 0.003) and severe ipsilateral carotid disease (OR 21.7; IC 2.13-54.2, p= 0.001) remains as independent predictors of RO. Stroke severity and ipsilateral severe carotid artery disease independently predict RO after tPA-induced MCA RE. Emergent carotid ultrasound may be useful for identifying patients at risk of RO after tPA-induced RE.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

Residual visual processing within the blindfield of cortically blind patients

C. Trevethan    M.J.Macleod  A Sahraie                                            
UNITED KINGDOM

University of Aberdeen

Background: Lesions of the occipital cortex, caused by stroke, trauma or elective surgery lead to visual field defects. Residual processing of visual information within the field defect of such patients has previously been reported in a small number of cases. We aimed to investigate the characteristics of residual vision within the field defect of cortically blind patients. Method: The detection of visual stimuli presented within the field defect of 16 patients was assessed using a temporal two-alternative forced-choice paradigm. One of the two-time intervals contained a suprathreshold grating. The remaining interval contained a uniform screen with luminance similar to the space-averaged luminance of the grating. Magnetic Resonance Imaging was used to determine the extent of brain damage in all cases. Results: 12 out of 16 patients tested were able to detect gratings of low spatial frequencies (< 4 cycles/deg). There was no evidence for visual processing in the locations tested for 4 remaining patients. Conclusions: Residual visual processing in cortically blind patients may not be a rare phenomenon. Our studies also indicate that the spatial channels giving rise to such performance are tuned to low spatial frequencies. The implication of the findings in relation to rehabilitation strategies will be discussed.

Presentation:Poster  May 13, 2004  14:00 - 16:00  Room:  

Cerebrospinal fluid abnormalities and intrathecally synthesized antinuclear antibodies (ANA) in stroke patients with pathological ANA serology and with connective tissue diseases

C. Jacobi    H. Rossmann  B. Storch-Hagenlocher    B.  Wildemann                                     
GERMANY

Department of Neurology, University of Heidelberg

Stroke may be a rare manifestation of connective tissue diseases (CTD). Cerebral ischemia may result from primary CNS involvement of CTD or as an independent event. Diagnosis of CNS involvement is based on technical methods such as cerebral angiography or MRI. Cerebrospinal fluid (CSF) abnormalities are usually non-specific. CTD are associated with detectable ANA titers in serum and ANA are included in the established diagnostic criteria. Here, we examined the presence of intrathecal ANA synthesis in stroke patients with CTD and in a group of stroke patients with pathological ANA serology to assess whether local synthesis of ANA coincides with nervous system involvement by CTD and CSF abnormalities occur in stroke patients with pathological ANA serology. CSF analysis included cell count, cytology, albumin, IgG, IgA, IgM and oligoclonal bands. We used serum and CSF ANA titers, determined by immunfluorescence assay (IFA), and total IgG concentrations to calculate the ANA antibody index (AI). An AI>4 indicates local production of specific antibodies. We included 6 patients with CTD (4 SLE, 2 scleroderma). and positive ANA titers in serum (1:80 up to 1:40000) as well as 8 stroke patients without CTD who had pathological ANA serology (1:160 up to 1:2560). In the study population 3 of 6 CTD patients and 4 of 8 stroke patients without CTD had positive CSF ANA titers (1:10 up to 1:640 versus 1:2 up to 1:10). The AI was <4 in all except one case (range 0,5 to 11,4). In this patient with CTD and stroke the high AI of 11,4 clearly suggested CNS involvement by scleroderma. CSF abnormalities were seen in both groups (e.g. oligoclonal bands, pleocytosis). IFA seems to be a useful method for detection of intrathecally synthesized ANA. Its sensitivity as a diagnostic marker should be tested in a larger group of patients. CSF may be abnormal in stroke patients with pathological ANA serology and CSF examination is warranted in these cases.

Presentation:Oral  14.05.2004  11:10 - 11:20  Room: Stamitzsaal

Sonothrombolysis - speed and pattern of recanalization in acute occlusion of middle cerebral artery main stem occlusion

J. Eggers    B. Koch  I. Koenig    G. Seidel                                     
GERMANY

Neurology, University Hospital of Schleswig-Holstein

Background and purpose: Ultrasound (US) can accelerate thrombolysis in patients with acute ischemic stroke. No clinical data about the needed time of sonification are available so far. Methods: Patients with acute main stem occlusion of the middle cerebral artery (MCA-M1) undergoing intravenous thrombolysis with recombined tissue plasminogen activator (rt-PA) therapy were randomized for a concomitant 1 hour sonification with transcranial 2 Mega Hertz (MHz) US or for a control group. The grade of recanalization measured as thrombolysis in brain ischemia (TIBI) Doppler score was monitored continuously in the US group and every 20 minutes in the control group by transcranial color-coded sonography (TCCS). After 12 and 24 hours after symptom onset a control TCCS examination was performed. Results: Seventeen patients were randomized to the US group, 17 to the control group. After 20 minutes a significant faster recanalization had occurred in the US group (P= 0.008). This effect sustained after 40 minutes (p=0.009) until the end of the sonification after 1 hour (P=0.011). At the end of rt-PA infusion, recanalization occurred in 58.7% (partial 41.2%, complete 17.7%) in the US group, but only in 17.7 % (partial 5.9%, complete 11.8%) of the control group. After 12 and 24 hours after symptom onset no significant difference was detectable any more. In the US group the pattern of recanalization during the first hour showed an early start with stepwise improvement. No sudden complete recanalization occurred. This contrasted to the control group, where the recanalization was rare and occurred abruptly. Discussion: The effect of transcranial TCCS guided 2 MHz Doppler US on the recanalization starts early and leads to a stepwise recanalization. This result could be relevant for further clinical studies.

Presentation:Poster  13 May, 2004  14:00 - 16:00  Room:  

Doubling effort in clinical trials

P. Milia    F.B.Young  K.R.Lees                                            
ITALY

University Department of Medicine and Therapeutics, Western Infirmary, Glasgow

Background and Items: The precision of NIHSS assessment may be improved by using either duplicate or joint assessment using two raters. We assessed if a combination of these approaches could improve prediction of outcome from NIHSS at admission to modified Rankin Scale (mRS) after three months. Methods: We recorded NIHSS and using two raters, both trained on mRS and NIHSS. Admission NIHSS was performed first by a physician and then immediately reassessed by a research nurse, in blinded fashion. Subsequently, the two raters discussed their examination, so to produce a third joint assessment. Outcome examination at three months was done using both NIHSS and mRS, again performed by the two raters separately and then jointly. The inter-observer agreement comparing raters was described using the kappa statistic. Prediction outcome validity comparing the NIHSS at admission with mRS at three months was assessed by Spearman rank correlation. Results: Thirty-three patients were consecutively studied, mean age 72.8 (95% CI:68.7-76.9), 42% male. Two patients died before 3 months; the remaining 31 were reviewed. NIHSS at admission showed excellent agreement between the two raters: kappa for total score 0.91(95% CI: 0.82-0.95). The correlation between either single rater’s total score with the joint examination was strong (0.97 and 0.94 respectively). The mRS at three months showed excellent agreement between the two raters: Spearman 0.97. Baseline NIHSS assessment made by the physician correlated closely with the final mRS: Spearman >0.75 (p<0.0001). Although the NIHSS undertaken by the nurse and the joint rating each had a lower correlation with the mRS at three months the Spearman coefficient remained good: Spearman 0.70 to 0.73 (p<0.0001). Conclusions: Thorough training of investigators allows raters to achieve excellent agreement in NIHSS and mRS assessments, perhaps rendering duplicate assessments redundant.

Presentation:Poster  May 13, 2004  14:00 - 16:00  Room:  

Aspirin resistance measured by the PFA-100 test in patients with ischemic stroke

G.B.Boncoraglio    M.R.Carriero  S. Pogliani    E.A.Parati                                     
ITALY

National Institute of Neurology "Carlo Besta"

BACKGROUND. Aspirin is effective antiplatelet agent and reduces risk of nonfatal MI, nonfatal stroke and vascular death by 20% after ischemic stroke and acute coronary syndromes. However, aspirin fails to prevent 80% of recurrent serious vascular events. One possible explanation is that some patients are resistant to the antiplatelet effects of aspirin as measured with laboratory tests (“aspirin resistance”). Platelet function analyzer (PFA-100) is a valuable tool to quantify congenital and acquired platelet dysfunctions. METHODS. We prospectively included 84 consecutive patients (mean age 54.1 +/-16.6 years, 45 males) referred to our Institute for a first episode of ischemic stroke (n=67) or TIA (n=17). All patients were treated with aspirin 75-325 mg/d. Age, sex, hypertension, hypercholesterolemia, diabetes, smoke, stroke/TIA subtype and etiology were archived in a prospectively-maintained computerized database. PFA-100 assay was performed using standard CEPI and CADP cartridges. RESULTS. 11 patients were excluded due to platelet dysfunction detected with the CADP cartridge. Of the remaining 73 patients, 19 (26%) did not showed the expected aspirin-induced defect with the CEPI cartridge. No significant difference was found among the two groups about vascular risk factors, clinical presentation and presumed etiology. DISCUSSION. One in four stroke/TIA patients may be resistant to aspirin. Aspirin resistance seems to be independent from other known risk factors for vascular events. All patients will be followed up to determine whether aspirin resistance detected with PFA-100 is a predictor of increased risk of stroke recurrence.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

Increase of neurological deterioration after admission due to TIA or stroke with mild symptoms

J. Ferrari    W. Lalouschek  S. Greissenegger    I. Lobentanz   W. Lang                               
AUSTRIA

Hospital Barmherzige Brueder; University clinic of Neurology

Background: Research shows that pathology deteriorate within the first seven days for one to 9% of patients with TIA (transient ischaemic attack) and that the initial severity of stroke is a predictor for symptoms progression. Little is known about the underlying mechanisms leading to deterioration. Methods: Out of 2660 patients of the Vienna stroke registry 589 fullfilled the following criteria:TIA or ischaemic stroke with mild symptoms (NIH</= 5); time of incidence known; admission within 12 hours after onset; documentation of examination evaluable for day of admission,day 1 to 2 and day 5 to 7. Deterioration is defined as an increase of the NIH score of two or more scores within the first seven days. Results: 44 of the 589 patients (7%) showed a clinical deterioration within the first seven days. 86% of them showed a neurological deterioration. 52% of these patients were diagnosed with progressive stroke, 16% with reinfarction and for 18% the root cause remained unclear.The deterioration of the remaining 14% was caused by internal complications. In an univariate analysis the following factors showed significant results for deterioration: increased gucose level , higher NIH score on admission and upper age. Discussion: Our data shows a neurological deterioration for the majority of patients. Therefore the question arises wether a more aggressive antiplateled therapy for patients with TIA or stroke with mild symptoms would be indicated in the acute phase analogue to established therapeutic approaches in cardiology (e.g.combination of antiplateled drugs) to prevent deterioration.

Presentation:Oral  14.05.2004  16:00 -16:10  Room: Konferenzraum OG

Prediction of major vascular events after TIA or minor stroke. A comparison of 6 models.

D.W.Dippel    A.D.Wijnhoud  P.J.Koudstaal                                            
THE NETHERLANDS

Dept of Neurology, Erasmus MC, Rotterdam

Background: Prediction models for major vascular events that were intended for the general population are simple and robust, and rely more on general vascular risk factors, whereas models derived from cohorts of patients with TIA or minor stroke comprise more variables and put more emphasis on stroke characteristics. We compared predictions of 3 population models (Framingham [1], SCORE [2] and Pocock [3]) with predictions of 3 stroke-cohort-based models (SPI-II [4], Hankey [5], and Dutch TIA study [6]) by testing them on a cohort of patients with a recent TIA or minor stroke. Methods: The validation cohort consisted of a 585 patients with a TIA or minor stroke, with a mean follow-up of 2 years. The two-year risk of the composite outcome event of non-fatal stroke, MI or vascular death was 12%. The predictions of each model were evaluated by plotting observed against predicted probabilities, by computing the mean squared error rate (MSE) and the area under the ROC curve (AUC). Estimates were made with Cox or Weibull multiple regression models. Results: The three population-based models severely underestimated overall risk. After adjustment for baseline risk and for prevalence of risk factors, calibration was best in Hankey’s and Pocock’s model, MSEs ranged from 9 to 13% and AUCs ranged from 67% to 71%, except in SCORE’s predictions (p=0.045). Conclusions: Population-based models provide valid and discriminating predictions of major vascular events in patients with a recent TIA or minor stroke, provided that adjustments for baseline risk and prevalence of risk factors have been made.1] Circulation 1998;97:1837 2] Eur Heart J 2003;24:987 3] BMJ 2001;323:75. 4]Stroke 2000;31:456 5] JNNP 1992;55:640 6] Stroke 1993;24:527.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

Stroke-like onset of Wilson's disease associated with a novel mutation (T766R)

S.T.Pendlebury    A. Dalton  P.M.Rothwell                                            
UNITED KINGDOM

Stroke Prevention Research Unit, University of Oxford

Background: Wilson’s disease is an autosomal recessive disorder of copper metabolism. Acute onset hepatic and haematological syndromes have been described, but there are no published reports of an acute-onset neurological presentation. We report such a case, which was initially misdiagnosed as a stroke. Case: A 17-year old male awoke with slurred speech, difficulty swallowing solids and problems walking. The patient, his family and his football team mates insisted that there had been no preceding neurological or psychiatric symptoms. Examination revealed severe dysarthria, slow tongue movements, a brisk jaw jerk and ataxic gait. CT brain scan showed low signal in the right putamen and caudate. A diagnosis of ischaemic stroke was made by the admitting physicians. Subsequently, he was transferred to the neurology ward where intermittent dystonic posturing of the arms was noted. MRI brain revealed bilateral signal change in the basal ganglia and midbrain consistent with Wilson’s disease. Kayser-Fleischer rings were seen on slit lamp examination, caeruloplasmin was low (3mg/decilitre) and urinary copper was increased (83.37 mMol/24 hours). DNA sequencing showed that the patient was homozygous for T766R, a novel mutation in ATP7B, the Wilson’s gene. Discussion: This case demonstrates that Wilson’s disease can rarely present with acute onset neurological symptoms suggestive of stroke and changes on CT brain imaging can be misinterpreted. The fact that our patient was homozygous for a novel mutation in the Wilson’s gene might suggest a link between the unusual clinical syndrome and his genotype.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

Hyperhomocysteinemia and other risk factors for venous thrombosis in patients with patent foramen ovale and ischemic stroke

M.R.Carriero    G.B.Boncoraglio  L. Caputi    C. Matarazzo   E. Ciusani    E.A.Parati                        
ITALY

National Institute of Neurology "Carlo Besta"

BACKGROUND: The association between patent foramen ovale (PFO) and increased risk of ischemic stroke is explained by a paradoxical embolism from a venous thrombus that pass through the PFO to the systemic circulation. Only few studies have investigated the association between PFO and genetic and acquired thrombophilia. METHODS: We examined 167 consecutive patients referred to our Institute for a first episode of ischemic stroke. Patients with lacunar syndrome, history of myocardial infarction, AF on ECG and carotid stenosis >70% were excluded. 73 patients (mean age 42.5+/-13.5 years; 35 men) were further investigated with transesophageal echocardiography and blood tests for factor V Leiden; factor II G20210A mutation; MTHFR C677T mutation; antithrombin III, protein C and protein S deficiencies; presence of lupus anticoagulant and anti-cardiolipin antibodies; hyperhomocysteinemia. The healthy control group for thrombophilia consisted of 100 age and sex matched hospital employees. RESULTS: PFO was found in 24/73 patients. Hyperhomocysteinemia was found in 8/24 PFO+ patients (33.3%), in 13/100 controls (OR 3.35, 95% CI 1.19-9.37) and in 15/49 (30.6%) PFO- patients. No statistically significant differences in the presence of other thrombophilic disorders were found. Although, PFO+ patients had a marked higher prevalence of FV Leiden (8.3% versus 2% in PFO- and 0% in controls) and antiphospholipid antibodies (16.7%, 8.2% and 5.2% respectively). PFO+ patients had also an higher prevalence of migraine, compared with PFO- (25% versus 16.3%). DISCUSSION: In spite of the small sample size, our results confirm the association between PFO and thrombophilic disorders, particularly hyperhomocysteinemia.

Presentation:Oral  15.05.2004  11:20 - 11:30  Room: Musensaal

The effect of dual antiplatelet therapy compared with aspirin on asymptomatic embolisation in carotid stenosis : The CARESS trial

H.S.Markus    E.B.Ringelstein                                                 
UNITED KINGDOM

St George's Hospital Medical School

Background: Silent cerebral microemboli (MES), detected by transcranial Doppler ultrasonography (TCD), have been shown to be an independent predictor of subsequent cerebrovascular events in patients with recent symptomatic carotid stenosis. Therefore MES can be considered as a surrogate marker of clinical efficacy for new antiplatelet agents evaluated in this setting. CARESS (Clopidogrel and Aspirin for Reduction of Emboli in Symptomatic carotid Stenosis) is the first multicentre trial to use Doppler embolic signal detection as a surrogate endpoint to evaluate antiplatelet therapy. CARESS is evaluating whether clopidogrel, on top of aspirin, is superior to aspirin alone in reducing the frequency of MES, in patients with recent symptomatic carotid stenosis. Methods: CARESS is a multicenter, multinational, randomized, double-blind, two-parallel group trial. Patients are treated with either clopidogrel (loading dose of 300mg on Day 1 followed by 75mg once daily) or placebo with both groups receiving aspirin 75mg od. Entry criteria include symptomatic carotid stenosis (greater than 50%), with TIA or stroke within the last 3 months, and at least one MES detected by TCD during a 1-hour screening recording. The primary evaluation criterion is the percentage of MES-positive patients, detected by blinded central reading, on Day 7. Secondary evaluation criteria are (a) the percentage of MES-positive patients at 24 hours, (b) the rate of embolization (number of MES per hour) at 24 hours and Day 7, and (c) safety evaluation based on any adverse events, cerebrovascular events, life threatening and major bleedings, all bleedings. Results: Recruitment ended on Dec 24 2003 and 108 patients have been recruited. Initial results will be presented. Conclusions: CARESS will provide important information, both on the efficacy of dual antiplatelet therapy in acute carotid patients, and on the potential feasibility of using MES as a surrogate endpoint to evaluate antiplatelet therapy. In addition it will provide safety data on the use of a 300 mg loading dose of clopidogrel in patients with recent stroke and TIA.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

The prognosis of FLAIR hyperintense vessels in acute stroke

S. Kamran                                                        
QATAR

Hamad General Hospital

Background. Hyperintense vessels (HVS) on FLAIR have been described as sign of early ischemia in acute stroke. HVS on FLAIR has been reported in diffusion normal strokes. There is no data on the prognosis of HVS in acute stroke. Patients and Methods. All acute stroke patients with FLAIR HVS, were prospectively studied. A diff/perf MR available in all patients,vessel occlusion was confirmed by 3-D TOF MRA contrast angiogram. Treatment (TPA n=4, carotid stent/angioplasty n=1, stent, angioplasty and IA urokinase n=1, EC-IC bypass n=1). Post treatment MRI was repeated in within 24 hours. Clinical condition was graded using pre and post treatment NIH stroke scales.Results. In 1998-99 n=29 patients were selected, n=17 excluded due to incomplete MRI. Of the 12 included in the study n=5 were excluded from treatment (anticoagulation 2, onset >3hours n=3). Age range was 49 to 65 years with 4 women and 8 men. There was n=1 left ICA stenosis >80%, left ICA stenosis and distal MCA occlusion n=1, right ICA stenosis and MCA branch occlusion n=1,left MCA occlusion n=4, distal left MCA branch occlusion n=1, right MCA occlusion 4. n=7 patients treated, average time to treatment thrombolysis 2.3 hours, carotid stent /I/A urokinase 6.4 hours, EC-IC bypass 72 hours. In the treated group n=1 with TPA failed to recanalize. N=6 patients showed recanalization (MRA n=4, angiogram n=3).Average pre-treatment NIHSS 12 (range 8 to 22) and post-treatment (1 month) 5 (range 0 to 12).N=5 patients not treated (n=4 infracted, n=1 no infarct MRA showed recanalization).Average time to repeat MRI was 34 hours (range 2 to 80 hours). Admission NIHSS 11 (range 6 to 24), 1 month NIHSS 9 (range 0 to 18). In patients who developed infraction, area of infarct was equal to FLAIR HVS n=1, and smaller in n=6, HVS was visible beyond the area of infarct.Conclusion. HVS on FLAIR is an early sign of acute stroke.Without treatment it could progress to infarction.

Presentation:Oral  14.05.2004  12:00 - 12:10  Room: Beethovensaal I

Prognosis of dissections with an initially isolated Horner's syndrome

J.M.de Bray    R.B.Baumgartner  B. Guillon    R.  Dziewas   E.  Ringelstein    P. Garnier  X. Ducrocq    J.P.Neau    C. Verny  F. Dubas
FRANCE

neurology

Background : initially isolated Horner's syndrome with or without pain is often due to an internal carotid artery (ICA ) dissection .So far no specific study has investigated their prognosis . Our purpose was to analyze their clinical and prognostic aspects . Methods : multicenter study of 90 consecutive cases defined by isolated Horner's syndrome due to ICA dissection either with intramural haematoma assessed by cervical magnetic resonance imaging (n:70 ) or concordantly seen on at least 2 other imaging techniques like intraarterial angiography ( n :28) and /or magnetic resonance angiography ( n :61 ) and /or Duplex scanning ( n:73 ) . Twenty five females and 65 males were recruited .Their mean age was 50 + 10 years . Median follow- up was 2 years ( range : 0.3 months - 17 years ). Results : Horner's syndrome was painless for 8 patients and painful for 82 patients .After onset of Horner's syndrome , cerebral ischemic events occurred in 15 patients ( 17 %) : 4 transient ischemic attacks and 11 middle cerebral artery completed strokes .Thirty six % of the strokes happened within the first 24 hours and 91% within the first 15 days .Five of the patients with cerebral ischemic events were investigated by intraarterial angiography , all of them had fibromuscular dysplasia . Conclusion :1) the risk of an early ischemic stroke is serious in this series ,without initial antithrombotic treatment in most of the cases .2) the stroke severity could be obvious few hours or days from the onset of Horner's syndrome .3) this kind of dissection could have specific characteristics since there is a majority of males , a slighty older age of the patients and a lower risk of strokes than in other cervical artery dissections .

Presentation:Oral  14.05.2004  16:00 - 16:10  Room: Bruno-Schmitz-Saal

ANGER, HOSTILITY AND AGGRESSION IN THE FIRST DAYS OF ACUTE STROKE

C. Santos    L. Caeiro  J.M.Ferro    R. Albuquerque   M.L.Figueira                               
PORTUGAL

Stroke Unit, Serviço de Neurologia e Serviço de Psiquiatria, Hospital de Santa Maria, Lisboa

Background: Anger includes emotional (anger), cognitive (hostility) and behavioural (aggression) components. In stroke, anger can disturb patient management and create a stressful situation for the family, health-care providers and patients. Objective: Describe the presence of anger in the first 4 days after stroke onset and to analyse its association with 1) demographic, neurological and psychiatric variables; 2) lesion related variables. Methodology: We investigated prospectively the presence of anger in consecutive acute stroke patients hospitalised in a Stroke Unit, using 4 items from the Catastrophic Reaction Scale, 2 items from the Young Mania Rating Scale (YMRS) and 2 items from the Comprehensive Psychopathological Rating Scale (CPRS). Results: We studied a sample of 202 patients (mean age of 57 years old; median of 4 years of education), 135 had a cerebral infarct, 41 had an intracerebral haemorrhage and 26 had a subarachnoid haemorrhage. Anger was detected in 68 (34%) patients. Nine of the 68 stroke patients with anger scored in >4 of the 7 selected items. The items more frequently noticed were the item “Irritability” of the YMRS and the item “Hostility” of the CPRS corresponding to the cognitive and to the behavioural components of anger, respectively. Anger was not associated with demographic, neurological and psychiatric variables, nor with type and location of stroke. Discussion: Anger was frequent in acute stroke patients. Anger was probably triggered by the brain lesion that interferes with the emotional control, resulting in the expression of the cognitive and behavioural components of anger. The lack of an association with clinical and imaging variables, suggests that a contribution of psychological and psychosocial dimensions is also likely.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

The Third International Stroke Trial. Baseline characteristics of patients recruited in the expansion phase

I. Kane    P. Sandercock  R. Lindley    S. Lewis                                     
UNITED KINGDOM

Division of Clinical Neurosciences, University of Edinburgh

Background: Recombinant tissue plasminogen activator (rt-PA) is approved in many countries for use in highly selected patients with acute ischaemic stroke who can be treated within 3 hours of symptom onset. The Third International Stroke Trial (IST-3) seeks to determine whether a wider variety of patients may benefit. This analysis describes the characteristics of the patients randomised in the current phase of the study. Methods: IST-3 is an international, multi-centre, randomised, controlled trial of intravenous rt-PA (0.9mg/Kg, maximum 90mg) in patients with acute ischaemic stroke who can be enrolled and treated as quickly as possible, but within a maximum of 6 hours of onset of symptoms. Once brain imaging has excluded haemorrhage and consent has been obtained, patients are recruited by telephoning a computerised central randomisation line. Brain imaging is repeated at 24-48 hours and follow up is at 7 days and then by postal questionnaire at six months. Results: The start-up phase began in May 2000 and by 22nd December 2003, 180 patients had been recruited from 18 centres in Europe. The median time to randomisation was 3.75 hours and median onset to treatment 4.1 hours. At baseline: 71% of patients were aged over 70; 35% were in atrial fibrillation; 58% of those randomised had total anterior circulation, 32% partial anterior, 7% lacunar and 3% posterior circulation stroke syndromes. The Data Monitoring Committee reviewed the unblinded data (latest review in September 2003) on the effects of treatment on major clinical outcomes in strict confidence and has urged the trialists to increase recruitment as rapidly as feasible. Discussion: The trial is recruiting patients that might benefit from thrombolysis, but do not precisely meet the current criteria of the product licence. By continuing to recruit such patients, reliable evidence will emerge on the effects of thrombolysis in a wider variety of patients.

Presentation:Oral  14.05.2004  11:30 - 11:40  Room: Hörsaal

Natural history of asymptomatic extracranial arterial disease - 25 years follow up

G. Sam    O. Lanczik  M. Siebler    H.P.Hartung   M.G.Hennerici    M. Daffertshofer                        
GERMANY

Universitätsklinikum Mannheim Universität Heidelberg

Background: Knowledge about natural history of asymptomatic EAD cover 10 years follow up. Within that intervall only a minority (about 3%) of the patients with extracranial arterial disease (EAD) will develop symptoms. Purpose: The purpose of this study is to delineate factors affecting the spontaneous very long term natural course beyond 10 year folow up of patients with asymptomatic EAD and hence provide new data for the discussion of appropriate treatment. Methods: Within the collaboration of two university hospitals we prospectively followed 441 patients (267 male/177 female, mean age 62 +/-7 ys) with asymptomatic EAD between1978 and 2003. According to a structured observation protocoll serial Doppler/duplex examinations as well as neurological examinations, neuroimaging diagnostics with extracranial Doppler (ECD), intracranial Doppler (TCD), magnetic resonance angiography (MRA), computed tomography (CT). Hypertension, hypercholesterolemia, diabetes mellitus, smoke, adiposities, heart disease were checked. Analysis used Cox-regression and Kaplan NMeier survival curve. Results: during the study 269 pat. died. Giving an annual mortality rate of 8%. Cardiac dioeseases were the most common cause of deathm (43%). Other non stroke causes (cancer, etc.) were the the second most probable cause of death in 49% of the patients. Stroke was the cause of death in 9 of the patients only resulting in an mean annual mortality rate by stroke of 0.7%. The mean annual risk rate of stroke and TIAs, however, were 2.98%, A tiototal of 100 pts.. suffereda stroke or a TIAs, 24 died due to Stroke. 26 pat. were operated, 67 pat. were alive and asymptomatic. Conclusion: Patient with asymptomatic EAD are not at high risk for stroke even beyond the already known 10 year spontaneous course -- but cardiac risk is high. So asymptomatic carotid disease should serve as a risk indicator for cardiac disease rather than consequencing carotid intervention.

Presentation:Poster  May 13, 2004  14:00 - 16:00  Room:  

Post Stroke Depression: searching for clues

S. Pires-Barata    I. Henriques  S. Mateus    R. Silva                                     
PORTUGAL

Espirito Santo Hospital

Background and purpose: Location, lateralization, cognitive impairment, age and sex are important variables in stroke depression. Some studies observed more then 50% of patients developing post stroke depression (PSD). The correlation between stroke location, lateralization, age, sex and anti-depressive medication and PSD although widely studied is still controversial. We studied the relation between these variables and PSD. Materials and Methods: We interviewed 110 first ever ischemic stroke patients (66 men), 2 to 6 months after stroke. Age varied between 19 and 87 years, with median of 63.5. The median scholarship was 4 years. 54.5% (60) had left hemispheric stroke. We used the Hamilton 21-D scale for depression and the MMSE for cognitive impairment. Patients with more than 6 months after stroke, with aphasia and previous history of depression were excluded. We considered the Oxfordshire classification for ischemic stroke location. In this consecutive, descriptive and correlational study was used the statistical programme SPSS 10.0 for Windows and Qui-square and the C-Pearson. Results: In 110 ischemic stroke patients, 66 fulfilled criteria for depression. We found a significant association between age and depression (c = .369; p= .008). From 88 patients with anterior location, depression was observed in 57. Having an anterior lesion was not significantly associated with depression (c= .191). From 55 patients with lacunar infarct, 36 were depressed, no relation was observed. From 23 patients with cognitive impairment, 14 were depressed. From 41 patients that were on antidepressive medication, only 26 fulfilled depression criteria. Discussion: In the studied group, 60% showed depression after stroke, having 80% an anterior lesion. No relation was observed between stroke location and PSD. Looking for correlations between PSD and stroke variables might contribute to better understanding this controversial issue.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

Treatment of IVIg-related stroke with abciximab

P.DMitsias    A Katramados  B Silver    S Daley   N. Sripathi                               
USA

Henry Ford Health Sciences Center

Background: Several case reports and small series have suggested a link between treatment with intravenous immunoglobulin (IVIg) and stroke, and possible of effectiveness of treatment with tPA within 3 hours of onset. We here report a patient with stroke occurring during infusion of IVIg and response to treatment with IV abciximab. Case Report: An 82 year old woman developed right frontal headache during infusion of IVIg, which she was receiving for multifocal motor neuropathy. She fell asleep, woke up 4 hours later, and was observed to have left side weakness. Upon arrival to our facility NIHSS score was 8 and 4 hours later was 16. Family members consented to participation in an ongoing trial of abciximab in acute stroke within 24 hours of stroke onset. MRI diffusion and perfusion weighted imaging (DWI, PWI) prior to enrollment revealed acute right hemispheric ischemic lesion and a large perfusion deficit with PWI-DWI mismatch. Abciximab treatment was started within 12 hours 25 minutes of symptom onset. Diagnostic investigations failed to reveal large vessel occlusive disease or cardioembolic source. At one month after treatment NIHSS score was 6. Conclusions: IVIg may be a direct cause of ischemic stroke. Treatment with abciximab is safe and effective for stroke related to IVIg. Abciximab treatment is effective even if applied within 13 hours of stroke onset, in the presence of PWI-DWI mismatch.

Presentation:Oral  13.05.2004  11:40 - 11:50  Room: Beethoven II

Memory processes in patients with cerebral White Matter Lesions (WML) of Ischemic Origin using the California Verbal Learning Test (CVLT)

M. Munoz Collazos    E Solano  J Arango    D Pineda                                     
COLOMBIA

Marly Clinic

Background: Memory compromise is an early characteristic of Alzheimer disease while is considered a late symptom in Vascular Cognitive Impairment (VCI). The profile of memory compromise in patients with WML, a subtype of VCI, has not been studied in detail. The Registry of Vascular Cognitive Impairment (RVCI) is a systematic evaluation and follow up of people with White Matter Lesions in Colombia. Objective: Describe memory processes, and find a threshold for memory impairment in patients with WML. Methods: From the RCVI we analyze data from 52 patients older than 50 with WML in T2-FLAIR MRI images, measured volumetrically. Neuropsychological evaluation includes CVLT as a test into a large neuropsychological battery described elsewhere. Tissue volume was independent variable and neuropsychological data the dependent one. For comparison between two groups with large or small volume, we dicotomize the variable using volume levels predefined in earlier reports of Executive Control (ECF) and Motor Complex Functions. (MCF) We use Spearman correlation and Mann-Whitney Test. Results: Total volume of compromised tissue was associated with: third and forth trial, short delay free recall, long delay free recall with and without cue, total correct answers and semantic associations of the CVLT. Clinical expression of memory changes begins at 18 ml of WML or more, a higher volume than ECF or MCF. Conclusion: The present study suggests a specific profile for memory impairment in VCI associated with WML, presented at higher volume of tissue involvement. Early frontal-subcortical involvement in VCI - WML related, probably does not result in a primary amnestic-type storage deficit, but reflects inefficient performance, secondary to poor executive control, self-regulatory impairments, and inefficient search mechanisms.

Presentation:Poster  May 13, 2004  14:00 - 16:00  Room:  

Hemispheric Specificities of Brain Metabolic and Hemodynamic Reorganization in Elderly Ischemic Stroke Patients

V. Kuznetsov    Z. Rozhkova                                                 
UKRAINA

Diagnostic Center

Purpose:Analysis of the metabolism, central hemodynamics and their correlation in elderly stroke patients with reference to hemispheric ischemia localisation. Patients and Methods: 105 elderly patients, 60 to 74 years, after ischemic stroke in medial cerebral artery against background of a cerebral atherosclerosis and arterial hypertension during rehabilitation. Control group included 85 subjects aged 60-77 years. Duplex scanning of brain and neck vessels on an ultrasound instrument Sonoline Elegra (Siemens); ¹H MR spectroscopy of the brain on tomograph 1.5 Magnetom Vision Plus (Siemens). Results: With right hemispheric ischemia localization, the metabolic changes, i.e. decrease of NAA (N-acetyl aspartate) and Cho (choline), were found in occipital gray matter area in both, damaged and intact hemispheres. With left hemispheric ischemia localization such changes were registered only in damaged hemisphere. With more than 60 cm 3 damaged area, the occipital and frontal NAA contents were statistically lower compared to 20 cm 3. Major metabolite contents (NAA, creatine and Cho) correlated with volume blood flow rate in medial cerebral artery of both hemispheres. With right-sided localization, these interrelations are more pronounced. In control subjects the gray and white matter metabolite contents correlated with volume blood flow rate in extracranial vessels of carotid basin. Conclusion: the more prominent changes of metabolism and its correlation with the cerebral hemodynamics have been found in the patients with ischemia localization in the right hemisphere.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

Clinical and neuroradiological features of local intra-arterial thrombolysis with urokinase in basilar artery occlusion

R. Gasparotti    M. Pavia  L. Pinelli    S. Florio   R. Liserre    A. Costa  R. Spezi    V. Vergani    E. Venturelli  M. Magoni
ITALY

Department of Radiology University of Brescia

Basilar artery occlusion usually has a very poor outcome and is associated with a high mortality rate. We performed a retrospective analysis to evaluate clinical and neuroradiological features, outcome and mortality in patients with basilar artery occlusion undergoing intra-arterial thrombolytic therapy. We studied a series of 12 patients, with clinical signs of severe brainstem ischemia with angiographically demonstrated basilar artery occlusions, who received local intra-arterial thrombolytic therapy with urokinase (UK). All the patients underwent a CT scan after 3-12 hours from symptoms onset that showed an hyperdensity of the basilar artery without hypodensity of the brainstem or cerebellum. Nine patients underwent thrombolysis procedures from 4 to 12 hours after symptoms onset, 3 from 12 to 15 hours. Interruption of the procedures was done after 1.200.000 U. UK or after recanalization of the artery. Outcome was evaluated with Modified Rankin scale (mRS) at three months. Seven patient survived: 4 with good outcome (mRS 1-2) and 3 with residual neurological deficit (mRS 3). All these patients have a distal occlusion, 6 with embolic occlusion and 6 with good posterior communicating arteries. In all patients the procedures were interrupted after complete recanalization of the basilar artery. Five patients died. Basilar occlusion was proximal in 4 cases and median in one case; all had atheromasic plaques along the arteries and 2 patients had good communicating arteries. Two patients had complete recanalization of the basilar artery and 2 patients developed hemorrhagic lesions. This study confirms the efficacy of intrarterial thrombolysis with UK in patients with thromboembolic occlusion of the basilar artery. Our clinical data are similar to previus reports with 58% of good outcome at 3 months. Distal occlusion and complete recanalization are related to good outcome.

Presentation:Poster  13 May, 2004  14:00 - 16:00  Room:  

Stroke teams do improve outcomes in acute Haemorrhagic Stroke

M.A.Wani    R. Navarattnasingham  L. Dacey    K. Wareham                                     
UNITED KINGDOM

Department Stroke Medicine, Morriston Hospital, Swansea

Background: Haemorrhagic stroke has a much higher mortality (50% in Oxford Community Stroke Project at 30 days). We present our data on 500 stroke patients managed by acute stroke team. Methods: Information about death and discharge destination at 30 days and 90 days was collected retrospectively through review of case notes and telephone enquiries. Results: 54(10.8%) had primary intracerebral haemorrhage (PICH). 30-day mortality was 10/54(18.51%) in PICH and 53/446(11.88%) in ischaemic stroke (IS). At 90 days the figures were 16/54(29.62%) and 75/446(16.81%) respectively. Data on discharge destination was available on 342 patients (38 PICH and 304 IS). At 30 days there were 8(21.05%) deaths, 9(23.68%) discharged home, none in institutional care and 21(55.26%) still in hospital care in the PICH group. 36(11.84%), 99(32.56%), 11(3.61%) and 158(51.97%) respectively in IS group (P =1.2 two tailed Fischers or Yates 0.18). At 90-day figures were 11(28.94%), 16(42.10%), 0 and 11(28.94%) in the PICH group. In the IS group figures were 47(15.46%), 139(45.72%), 23(7.56%) and 90(29.60%) respectively (Yates corrected p value = 0.06 NS). Discussion: OCSP showed much higher mortality in PICH (50%) as compared with cerebral infarction (10%). Lower mortality (21.05%) at 30 days in our study suggests that acute stroke care of PICH improves early mortality. OCSP was a community-based study, which did not involve acute care. At 90 days there is a suggestion that gap in outcomes between primary intracerebral haemorrhage and cerebral infarction is narrowing. Kelly et al (1984) showed greater functional recovery in PICH than those with cerebral infarction patients studied over a 4-year period. Numbers in our study are small and the data on longer-term outcomes is still awaited. Therefore further very large studies of acute care of primary intracerebral haemorrhage or a meta-analysis of pooled existing data is needed.

Presentation:Oral  13.05.2004  17:00 - 17:10  Room: Beethovensaal II

CRP levels are elevated in cerebral ischemia due to cervical arterial dissection

J. Genius    A.J.Grau  C. Lichy                                            
GERMANY

Dept. of Neurology, University of Heidelberg

Background: Initially considered an innocent bystander marker of vascular inflammation, it has been shown that CRP possesses direct pro-inflammatory effects and may be directly implicated in the pathogenesis of cerebro -or cardiovascular disease. We tested the hypothesis that CRP levels play a cardinal role not only in cerebral ischemia due to atherosclerosis but also in spontanous cervical arterial dissection (CAD). Methods: In 62 patients with cerebral ischemia <60 years old and in 54 sex and age matched population controls, serum CRP levels were measured using a high sensitivity ELISA. Studies in patients were done not earlier than 9 months after the clinical event, present infection and chronic inflammatory diseases were exclusion criteria in all participants. Results: CRP levels were elevated above control levels (540 [330-842] ug/l) in 21 patients with makroangiopathy (2590 [560-3990] ug/l) and in 21 patients with CAD (2370 [575-4780] ug/l) likewise to a comparable extend (p=0.00087 and p=0.00125, respectively). 20 patients with cerebral ischemia of “cryptogenic etiology” had CRP levels (740 [140-7860] ug/l) which were not markedly elevated above control values. If adjusting for conventional risk factors, age and gender, the difference between controls and patients with CAD remained significant (p=0.005), while significance was lost for the makroangiopathy subgroup (p=0.39). Conclusion: In this pilot study, we found evidence for a crucial role of the inflammatory marker and mediator CRP in cerebral ischemia due to CAD, whereas this was not the case in cases with cerebral ischemia without underlying vascular pathology.

Presentation:Poster  14 May, 2004  14:00 - 16:00  Room:  

Stroke management in atrial fibrillation

E. Lungut    V. Poalelungi                                                 
ROMANIA

Central Military Hospital- Bucharest

Atrial fibrillation is associated with an increased risk of systemic thromboembolism an stroke. The risk of stroke averages about 5% per year among all individuals in atrial fibrillation , which is about five to six time greater than for people of the same age who are in sinus rhytm. The proportion of strokes that can be attributed to atrial fibrillation is highest in the very elderly because the prevalence of atrial fibrillation increases with age, from about 2% in general population to 5% in people older than 65 years and 10% in people older than 75 years. However , the population attributable risk cannot be greater than 20%. Atrial fibrillation may occur as a single episode , a series of recurrent episodes ("paroxysmal" atrial fibrillation) or continuously("permanent" or "chronic") but the epidemiological and clinical evidence is insufficient to link either the onset or the chronicity of the atrial fibrillation with the development of embolic stroke. The fact that anticoagulation markedly reduces the risk of first or recurrent stroke among atrial fibrillation patients is not sufficient to confirm causality because , although it is unlikely , this treatment may be working in other ways , such as by inhibiting artery-to-artery embolism. However , for most patients with atrial fibrillation and stroke the association is probably causal.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

Simultaneous study of patent foramen ovale with transesophageal echocardiography and transcranial Doppler Transesophageal echocardiography(TEE) and transcranial Doppler(TCD) are both methods of choice to study patent foramen ovale(PFO), but there are sever

R. Belvís    R.G.Leta  J. Martí-Fàbregas    D. Cocho   F. Carreras    G. Pons  M. Martínez-Lage    A. Martínez-Domeño    J. Pagonabarraga  J.-L.Martí-Vilalta
SPAIN

Hospital de la Santa Creu i Sant Pau

Transesophageal echocardiography (TEE) and transcranial Doppler (TCD) are both methods of choice to study patent foramen ovale (PFO), but there are several detection and quantification discrepancies between the two. These two methods are not performed at the same hemodynamic moment, and furthermore, the Valsalva manoeuvre (Vm) in each one is different. We aimed to compare PFO detection simultaneously performing the two studies, and to correlate their PO quantification classifications. We prospectively included consecutive patients with stroke and applied the TCD protocol of the Consensus Conference (Venice 1999). PFO in TEE was diagnosed when at least 3 microbubbles (mb) were detected in the left atrium within 3 heartbeats after opacification of the right atrium. PFO quantification: 1)TCD: minimum (1-10mb), moderate (10-25mb), massive (>25mb); 2)TEE: small (3-9mb), moderate (10-30mb) and large (>30mb). Statistics: contingency tables (Chi-square and Kappa test) and Student's t-test. We studied 51 patients whose mean age was 56.6+/-12.8 yr and 62.7% were men. TCD detected 16 PFO patients (31.4%), and TEE detected 17 PFO patients (33.3%) at first attempt. At second attempt both methods detected the same 17 patients. PFO in TCD was minimum (10), moderate (3) and massive (4). PFO in TEE was small (9), moderate (1) and large (7). In the PFO quantification there was an excellent correlation (Kappa 0.846, p=0.001) with only 4 (23.5%) discrepancies, all of which were due to TCD infra-estimation in moderate and massive echocardiographic PFO. The correlation of simultaneous TCD and TEE in the detection of PFO is almost perfect, but differences are seen in the quantification by TCD infra-estimation in regard to TEE, mainly in moderate and massive echocardiographic PFO.

Presentation:Poster  May 13, 2004  14:00 - 16:00  Room:  

Obstructive sleep apnea syndrome in patients with acute stroke

M. Humpert    B. Hopmann  M. Böntert    P. Young   D.G.Nabavi    E.B.Ringelstein  R. Dziewas                   
GERMANY

University Hospital Münster

Introduction Recently, some studies have shown an increased prevalence of obstructive sleep apnea syndrome (OSAS) in patients with acute stroke. The aim of the present investigation was to define predictors for OSAS in this group of patients. Furthermore, we examined whether the occurrence of apneas was related to the positioning of patients. Patients and methods 102 acute stroke patients underwent cardio-respiratory polygraphy within 72 hours after onset of neurological symptoms. Multivariate regression analysis including the variables "age", "body mass index", "neck circumference", "NIH-stroke scale score", "lesion site", "stroke etiology" and "previous stroke" was used to identify variables being predictive of OSAS. Results The mean apnea-hypopnea index (AHI) of the patient collective was 17.9+/-17.2/h. 59% of patients had an AHI>10/h and 77.5% had an AHI>5/h. Patients had a significant higher AHI when nursed in the supine position (20.5+/-18.1/h) than in any other position (right 6.9+/-13.7/h; left 7.6+/-14.8/h, other 7,1+/-16,0/h). On multivariate regression analysis, the variables "age" and "previous stroke" were related to the AHI. Discussion According to our results, older patients and patients who already had suffered a stroke in their history are at an increased risk to present with a severe OSAS. Since the severity of upper airway obstruction was significantly worse in the supine position, we suggest that patients with acute stroke should be bedded preferentially on their left or right side.

Presentation:Poster  14 May, 2004  14:00 - 16:00  Room:  

Acute phase parameters in ischemic stroke, intracerebral hemorrhage and subarachnoid hemorrhage

P. Kapeller    W. Wurm  F. Fazekas                                            
AUSTRIA

Medizin Universität Graz

Introduction: Acute phase parameters (APP) such as C - reactive peptide (CRP), leucocyte count (LC) and fibrinogen ( FIB) are well investigated in concern to prognosis and pathogenesis in ischemic stroke (IS). However, data on their importance in intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAB) are scarce. This study provides a comparison between IS, ICH and SAB patients concerning the behavior of APP. Methods: APP (CRP, LC, FIB) were sampled at admission day and on day three in the disease course. IS, ICH and SAB were diagnosed according to clinical investigations and imaging findings. Statistical analyses was done by calculating a time dependent parameter for the course of CRP, L and FIB, and by comparing the level of CRP, LC and FIB at admission and on day three using SPSS ANOVA. Results: The number of investigated patients was 22 for SAB, 32 for ICH and 33 for IS. The course of CRP, LC and FIB in the first three days did not differ significantly between the 3 groups although ICH patients showed a trend towards more severe increase in their CRP levels from day 1 to day 3. ICH more frequently showed isolated CRP increase than SAB or IS patients. The initial mean value of CRP was highest for the IS group, initial mean LC did not differ significantly between groups. IS patients however showed significantly higher levels of FIB at the time of admission. On day three CRP levels in IS and ICH patients were significantly higher than in SAB. Conclusion: APP and especially CRP is not only an important factor in IS but also in patients with ICH. Elevated FIB levels in IS patients at time of admission underline its importance in ischemic stroke.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

Triflusal for preventing serious vascular events in people at high risk

J. Costa    J.M.Ferro  J. Matias-Guiu    J. Avarez-Sabin   F. Torres                               
PORTUGAL

Department of Neurology, Hospital Santa Maria,

Background:Aspirin is the “standard” treatment for the secondary prevention of stroke and other vascular events. Triflusal, antiplatelet agent structurally related to aspirin, appears to be associated with lower frequency of hemorrhagic complications compared to aspirin in several clinical trials for secondary prevention of serious vascular events. Because of this suggestion of a safer profile, and the uncertainty of its efficacy when compared to aspirin, we performed a Cochrane systematic review assessing triflusal in this clinical setting. Methods:Search strategy was performed according to the Stroke Cochrane Review Group methodology. Studies were eligible if they randomly evaluated the efficacy of triflusal for the secondary prevention of serious vascular events among people at high risk, compared with placebo or aspirin. Data collection and analysis was performed independently and crosschecked. Primary outcome was a combined end point (incidence of nonfatal ischemic stroke, nonfatal Acute Myocardial Infarction - AMI, or vascular death). We also assessed the incidence of these events separately and that of hemorrhagic events. Results:Triflusal vs aspirin: Meta-analysis (Peto-Odds ratio, Confidence Interval 95%) of 5 trials (5213 patients) showed no differences for primary outcome (1.01: 0.85-1.2), nonfatal ischemic stroke (0.99: 0.77-1.28), nonfatal AMI (0.90: 0.61-1.31) or vascular death (1.11: 0.86-1.45). Significant differences were found for serious (2.22: 1.47-3.36) and non-serious hemorrhagic events (1.6: 1.31-1.95), favouring triflusal.Triflusal vs placebo: Meta-analysis of 2 trials (403 patients) showed significant difference for primary outcome (2.29: 1.01-5.19) favouring triflusal without differences in adverse events. Discussion:Compared to aspirin, triflusal has a similar clinical efficacy in long-term prevention of vascular events in people at high risk, but is associated with a significantly lower incidence of hemorrhagic complications.

Presentation:Poster  14 May, 2004  14:00 - 16:00  Room:  

Relationship between hsCRP and early arteriosclerosis in different arterial territories

C.C.Schulze Horn    U. Scherpinski  H. Bickel    C. Briesenick   B. Conrad    D. Sander                        
GERMANY

Neurology, Technical University of Munich

Background and Purpose: It is known that inflammation is of particular importance for the development of arteriosclerosis. In recent years several studies focussed on the relationship between hsCRP and coronary heart disease (CHD). INVADE (Intervention project on cerebrovascular diseases and dementia in the district of Ebersberg) is a prospective study that analysed the effect of risk factor modification on stroke in a population based sample. In addition to these factors we also measured new risk factors like high-sensitive CRP (hsCRP), Intima-Media-Thickness (IMT) and ankle brachial index (ABI). Methods: We analysed the relationship between hsCRP and the extent of arteriosclerosis measured by IMT (>= 1mm), ABI (<=0.9) and the incidence of CHD, in 3668 participants aged > 55 (mean age: 69,26, 40,9% men) using multivariate logistic regression techniques. In addition general arteriosclerosis was defined as IMT >=1mm or ABI <=0,9 or incidence of CHD and also correlated with hsCRP. Results: We observed a significant relation between hsCRP and CHD (p = 0,0161), hsCRP and IMT (p= 0,0005), as well as hsCRP and ABI (p< 0,0001). After adjustment for age, sex, BMI, arterial hypertension, cholesterol, smoking and diabetes mellitus there remains a significant relation between hsCRP and ABI (Odds ratio 1,99 [1,22-3,34]); p< 0,007. There is also a significant relation between general arteriosclerosis and hsCRP (Odds ratio 1,43 [1,16-1,77]); p< 0,008. Conclusions: hsCRP is associated with pathological ABI values as a predictor for peripheral artery disease. There was no significant relation after adjustment for IMT and CHD in our populations-based study. However we found a significant association between general arteriosclerosis and hsCRP. Therefore we suppose that arteriosclerosis affect an inflammation.

Presentation:Poster  14 May, 2004  14:00 - 16:00  Room:  

Inflammatory Markers and Stroke in Brazil: Erythrocyte Sedimentation Rate Better than C Reactive Protein or Homocysteine for Predicting Outcome

J. Oliveira-Filho    C.C.Trabuco  L. Hughes    S.C.S.Silva   P.A.P.Jesus    A. Bacellar                        
BRAZIL

Hospital Sao Rafael, Monte Tabor Foundation

Background: Chronic inflammatory processes have been linked to atherosclerosis, stroke risk and outcome. We aimed to examine the contribution of three markers of inflammation in a developing world population. Methods: We prospectively studied patients admitted in the first week after stroke onset, measuring homocysteine, erythrocyte sedimentation rate (ESR) and C reactive protein (CRP) levels on admission. All patients underwent emergency neurological evaluation, being classified according to the National Institutes of Health Stroke Scale (NIHSS) and Oxfordshire Stroke Classification Scale (OSCS). Stroke etiology was defined according to TOAST classification. After 3 months, outcome was measured through Rankin and Barthel scales, with “poor outcome” defined as Rankin score > 2 or Barthel score < 70. Results: One-hundred eleven patients fulfilled entry criteria from November, 2001 to September, 2003. Median NIHSS was 8 (range 0 to 31). Large-artery atherosclerosis was associated with increased ESR compared to other etiologies (53 +/- 27 vs. 37 +/- 22mm/1hr, p=0.027), but no association was found between either homocysteine or CRP and stroke etiologies (ANOVA=NS). After 3 months, 48 patients (43%) reached a poor outcome. Predictors of poor outcome in univariable analyses were (p<0.05): total anterior circulation classification on OSCS, etiologies other than small-vessel atheroclerosis, age, NIHSS score, CRP level and ESR. In the multivariate analysis, remained predictors of poor outcome: NIHSS score (OR=1.32 per 1 point increase; 95%CI=1.17-1.49, p<0.001) and ESR (OR=1.31 per 10mm/1hr increase; 95%CI=1.04-1.66, p=0.012). Discussion: Since ESR reflects not only inflammation but also blood viscosity and fibrinogen levels, ESR may be a more robust marker of outcome than either CRP or homocysteine. Our data shows that ESR predicts outcome independently of stroke severity, etiology or arterial territory.

Presentation:Oral  14.05.2004  12:10 - 12:20  Room: Stamitzsaal

Safety and Efficacy of Statins in the Acute Phase of Ischemic Stroke: the MISTICS Trial.

J. Montaner    P. Chacón  J. Krupinski    F. Rubio   M. Millan    D. Escudero  C.A.Molina    M. Quintana    P. Hereu  J. Alvarez-Sabín
SPAIN

Vall d'Hebron Hospital

Background: Although statins are being used for secondary prevention of ischemic stroke, recent experimental data have shown new pleiotropic effects of these drugs other than cholesterol reduction, responsible of their role in neuroprotection. These properties could be beneficial even in the acute phase of an ischemic stroke. Purpose and methods: We have conducted a pilot, double-blinded, randomized, multicentric clinical trial to study the safety and efficacy of Simvastatin in the acute phase of ischemic stroke (MISTICS, Markers of Inflammation after Simvastatin in Ischemic Cortical Stroke). Efficacy on the neurological outcome and evolution of several inflammation markers was evaluated at baseline, day 1, 3, 5, 7 and 90. Simvastatin/Placebo (Sim/Plac) was given at 3-12 hours from symptom onset (40mg until day 7 and 20mg until day 90) to strokes with cortical involvement (NIHSS score from 6 to 20). Results: From the 60 recruited patients (30 Sim/30 Plac), 56 were finally valid for the efficacy analysis (28 Sim/28 Plac). Demographic profile: 51.8% males, age 73, TOAST: 37.5% cardioembolic and 46.4% atherotrombotic, OCSP: 55.4% TACI. Sim patients improved significantly by the third day (46.4% vs 17.9%, p=0.022). The benefit of statins was also observed in the NIHSS score at day 90 (-9 points Sim vs –5 points Plac). In the Sim group a higher proportion of patients presented dramatic improvements (decrease of <10 points or NIHSS= 0) at day 90 (11 vs 4 patients, p=0.035) OR= 4.5 (1.06-19.5). However, statins group had a greater proportion of infections (OR=2.4, 1.06-5.4) parallel to an increase of IL-6 level (i.e 19.4 vs 9.0, p=0.041, first day). At day seven cholesterol reduction was already present (LDL-Ch 74 vs 116 p<0.001). Conclusions: Treatment with statins initiated in the acute phase of ischemic stroke may improve neurological outcome. A trend to increased number of infections and an overexpression of IL-6 deserves further exploration.

Presentation:Oral  14. 05. 2004  17:20 - 17:30  Room: Stamitzsaal

SILENT CEREBRAL INFARCTION IN CARDIOEMBOLIC STROKE: PREVALENCE AND ASSOCIATED FACTORS ON THE SAFE II STUDY POPULATION

F. Corea    D. Depalque  J. De Reuck    J. Ferro   R. Schmidt    JL. Mas  D. Leys    L Parnetti    V. Gallai     
ITALY

dep. neurology perugia university hospital, Italy

Introduction: The presence of SI has been reported to be associated to a variety of concurrent conditions. Different data suggest that SI should be predictors of first ever strokes in normal dwelling older adults. The SAFE project offered an extensive evaluation of a consecutive population of acute strokes plus a previously known NVAF. Objective of this ancillary study was to determine the prevalence of SI, relationship between SI, patients characteristics, time of onset of AF, previous drug treatment on the subjects consecutively studied in the SAFE project over 5 European countries in 60 different hospital centers. Methods: The study population consisted of 370 patients (154 males) with a median age of 78 years (range: 29-101), consecutively admitted for an ischemic or hemorrhagic acute stroke with clinical deficits lasting more than 24 hours, and a previous history of AF. Patients underwent a detailed evaluation in order to focus on AF characteristics and premorbid antithrombotic prevention. Results: Of 370 patients, 124 (33.3%) had SI on admission CT-scan. Location of SI was deep in 88 patients (70.8%), being deep lacunar in 72 in (58.06%), and superficial in 43 (34.6%). Using logistic regression analysis, we found SI more frequently in patients with a paroxystic AF. Conclusion: SI are present in one third of NVAF-stroke patients and involve more often deep territories. The prevalence of cortical infarcts in this subgroup is at least double than among unselected stroke patients. Our study has shown that SI were more frequently associated with the chronic paroxysmal subtype of AF. Previous anti thrombotic treatments and duration of the arrhythmia did not influence SIs presence.

Presentation:Poster  14 May, 2004  14:00 - 16:00  Room:  

Independent stroke outcome predictors in Poland

M. Niewada    M. Mazurkiewicz  A. Kobayashi    D. Ryglewicz   A. Czlonkowska                               
POLAND

Medical University of Warsaw, Department of Experimental and Clinical Pharmacology

Predictors of stroke outcome are well established. The aim of this study is to confirm their impact on early stroke outcome as independent predictors in Polish patients. The database of the Registry of the National Program for Prevention and Treatment of Stroke, based on the WHO STEPS-Stroke system was reviewed. 11 707 valid cases from 45 centers in Poland hospitalized in the years 2001-2002 were analyzed. The distribution of stroke outcome predictors was analyzed and logistic regression on poor outcome defined as modified Rankin scale 3-6 performed. The mean age of patients was 69.94 years, 48.15% were male, 25.37% had previous stroke, 69.25% hypertension, 27.22% atrial fibrillation, 47.97% coronary heart disease, 12.24% had previous myocardial infarction and 21.99% diabetes. 20.27% smoked and 9.42% abused alcohol. 25.45% had high cholesterol. 44.4% of patients were admitted to hospital within 6 hours of onset, 33.6% within 6-24 hours, 18.6% within 1-7 days and 3.4% over 7 days. 71.1% of patients were alert at admission, 18.9% were drowsy, 2.8% in stupor and 7.2% comatose. 58.45% of patients had antihypertensive treatment prior to stroke, 29.19% took antiplatelet drugs, 28.34% aspirin, 4.35% anicoagulants, 4.12% statins and 18,13% antidiabetics. The overall early case fatality was 19.81% and poor outcome observed in 59.31% of patients. A logistic regression analysis showed that old age, previous stroke, atrial fibrillation, delay in admission and decreased level of consciousness at admission were all independent predictors of poor outcome (p<0.01). Administration of statins prior to stroke was an independent predictor of a favorable outcome p<0.01). The results confirm the impact of stroke risk factors on outcome in a large population. Effective treatment of stoke risk factors, especially atrial fibrillation, fast admission to hospital and a widespread use of statins in patients with cardiovascular diseases may result in a more favorable outcome after stroke.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

RELEVANCE OF GOOD HOMEOSTASIS MAINTENANCE IN ACUTE ISCHEMIC STROKE. IMPACT IN INFARCTION SIZE AND OUTCOME

S. Monteagudo    B. Fuentes  J. Gracia    R. Merino   E. Diez-Tejedor                               
SPAIN

Stroke Unit. Dept. of Neurology. La Paz University Hospital. UAM. Madrid

BACKGROUND: Body temperature (BTª), glycemia and blood pressure(BP) prognostic influence in acute ischemic stroke (AIS) have been demostrated one by one in previous studies. However these variables have not been evaluated all together as a whole physiological condition. Our aim is to study the influence of homeostasis maintenance on infarction size and on functional outcome at 3 months. METHODS: Prospective study during 2002. Patients with AIS (<24 hours) were included. Exclusion criteria: TIA, haemorrhagic stroke, previous dependence, unconsciousness at admission or severe concurrent disease. Homeostasis was defined as the maintenance of BTª≤37,5ºC, glycemia £140 mg/dl and systolic blood pressure (SBP)130-180 mm Hg. Analyzed parametres: Tª, glycemia and SBP at admission and every 8 hours during first 48 hours, infarction size (TC 24h-7day) and modified Rankin Scale (mRS) at 3 months. Stadistical analysis: t-student, U-Mann Whitney, chi-square. RESULTS: 118 AIS patients included. Three of defined homeostatic patterns were present in 6 patients, two in 51, one in 53 and none in 8. The maintenance of three or two of these patterns within the first 48 h was significatly associated to lower infarct size (p=0,018) and better functional outcome (p=0,035) at 3 months. CONCLUSIONS: A tight control of homeostasis during the first 48 hours from AIS onset conditions a lower infarction size and a better outcome. Therefore it, we recommend a precise surveillance of these physiological parametres in the AIS managment.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

Acupuncture for acute stroke: a Cochrane systematic review

S.H.Zhang    M. Liu  K. Asplund    L. LI                                     
CHINA

Department of Neurology, West China Hospital, Sichuan University, P.R.China

Background and objectives: Experimental data indicated that acupuncture-like sensory stimulation activates multiple efferent pathways that can lead to altered activity in numerous neural systems.. Objectives of this review was to assess effectiveness and safety of acupuncture in patients with acute stroke. Methods: A Cochrane systematic review of randomized controlled trials of acupuncture for stroke was performed. Trials published before 2003 were searched using Cochrane collaborative review group search strategy. Trials with acupuncture started within 30 days of stroke onset, compared with placebo/sham acupuncture or open control in patients with acute ischaemic and/or acute haemorrhagic stroke were included. Results: Fourteen trials including a total of 1141 patients met our inclusion criteria. Three trials using sham acupuncture as control were of relatively high quality. When acupuncture was compared with sham treatment, at the end of follow-up there was non-significant trends towards fewer patients being dead or dependent in acupuncture group (Odds ratio [OR] 0.71, 95% confidence interval [CI] 0.39 to 1.30), there was significant trends towards fewer patients being dead or needing institutional care in acupuncture group (OR 0.42, 95%CI 0.21 to 0.83). When acupuncture was compared with open control, there were a few changes in the results (OR 0.74, 95% CI 0.39 to 1.42, OR 0.82, 95%CI 0.41 to 1.66, respectively). Severe adverse events of acupuncture (dizziness, intolerable pain and infection of acupoints) appeared to be rare (5/364, 1.37%). Discussion: Acupuncture appeared to be safe but there was no clear evidence of benefit. As most included trials were of poor quality and the number of included patients was small, larger trials with scientifically sound methodology are required to determine wether or not acupuncture is effective in the treatment of acute stroke in future.

Presentation:Poster  May 13, 2004  14:00 - 16:00  Room:  

Combined ultrasound and microbubbles reduces the size of infarction in an animal stroke model

M. Fatar    M. Stroick  M. Griebe    G. Sam   M. Hennerici    M. Daffertshofer                        
GERMANY

Klinikum Mannheim, University of Heidelberg

Background: Recent studies have demonstrated exciting new potentials for the use of ultrasound and microbubbles for performing cerebral perfusion imaging, MCA clot thrombolysis, and gene transfection. To exclude detrimental side effects we evaluated combined ultrasound and microbubbles in a MCA occlusion model in rats. Methods: MCA occlusion was induced in two groups of Wistar rats (n=16). Rats were insonated with ultrasound for 30 min (2 Mhz) during a continous infusion of microbubbles (SonovueTM) and compared to controls. Animals were sacrificed 24 hours after MCA infarction, brains were removed and silver stained for quantification of infarct volume and evaluated for apoptosis (TUNEL). After brain digestion, IL-6 and TNF-alpha concentration were measured and in 3 animals from each group, microdialysis probes were implanted in the brain prior to MCA infarction to measure changes of glutamate, lactate, glycerol and glucose. Results: Infarct volume in the ultrasound/microbubble group was 186.9 +/-137.2 mm3 compared to control 352.8 +/-92.2 (p=0.04). Quantification of apoptosis in the infarcted area by TUNEL staining showed 47.3 % +/- 9.1 vs. controls 34.8 % +/- 1.4 (p=0.02). No apoptosis was observed outside the infarcted area. The IL-6 and TNF-alpha levels were similar in both groups. Discussion: The combined application of ultrasound and microbubbles showed no harmful effects in this ischemic stroke model. Unexpectedly, however, in animals receiving the combination of ultrasound and microbubbles, the infarct volume was significantly reduced and cell death seemed to be shifted to apoptotic cell death. This suggests a novel neuroprotective role of ultrasound and microbubbles in acute ischemic stroke.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

MRI FEATURES OF HEMORRHAGE TRANSFORMATION OF BRAIN INFARCTION

L. Gubskii    N. Shamalov  V. Skvortsova                                            
RUSSIAN FEDERATION

Russian State Medical University, Chair of Fundamental and Clinical

Background and Purpose: The aim of the study was to compare some MRI features of brain infarction (BI) without and with hemorrhage transformation (HT). Methods: There were compared two groups of patients with hemispheric BI: 22 with and 26 without HT. MRI studies were performed in dynamics at the 0.15T MR-scanner. Contrast (С) of BI was calculated in relation to the intact white matter (wm) as: С = (SIbi - SIwm) / SIwm, where SI - signal intensity. Results: At T1-W images C of HT had a tendency to rise on the 3-d day and was higher than one without HT from the 7-th day of insult (Ris. 1). At FLAIR images a tendency for higher C of HT was from the 1-st day of BI and this difference increased to the 10-14-th days of stroke. For revelation factors connected with this changes, the study of normalized histograms of SI was conducted. At the 1-st day of stroke practically there was no difference between two groups of patients, histograms had one near normal peaks and their correlation was equal to 0.91. At the 3-rd day this index was reduced to 0.72 because of shift of the HT histogram to more high SI figures. These changes was more strong at the 7-th and 10-14-th days (correlation 0.55 and 0.45), there was also second peak on HT histogram. At the 21-30-th days second peak was reduced and the correlation increased to 0.76. Discussion: On FLAIR images the difference of histograms of SI in regions of BI was marked at the 3-d day of stroke. These changes perhaps connected with early lysis of erythrocytes and with the advent of methemoglobin in extracellular fluids. Tendency for increasing C on T1-W images at this period in patients with HT adjusted with this supposition. It is perspective to study diagnostic possibilities of this MRI features for HT in BI.

http://www.eurostroke.org/Mannheimgraphics/mg_1086.htm
 

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

LIGHT-INDUCED AMAUROSIS FUGAX: AN UNUSUAL SYMPTOM OF CAROTID ARTERY STENOSIS

S. Calleja    V. de la Vega  M. Pinera    M.C.Fernandez   B. Fernandez-Llana    C.H.Lahoz                        
SPAIN

Hospital Universitario Central de Asturias

BACKGROUND: Light-induced amaurosis fugax has rarely been reported as a symptom of severe carotid artery stenosis. We report a new case in which clinical symptoms, delayed visual evoked potentials and parameters of ipsilateral cerebral hemodynamic failure returned to normality after carotid endarterectomy was performed. CASE REPORT: A 66-year-old male had been experiencing symptoms of loss of vision in his left eye for the previous two months when exposed to bright light. Additionally he had a two-day history of recurrent transient right leg numbness. Except for a left carotid bruit, the general examination was completely normal. Carotid angiogram demonstrated a severe stenosis of the left internal carotid artery, visual evoked potentials had normal amplitude with increased left side latency, brain SPECT showed a diffuse left hemisphere hypoperfusion and transcranial Doppler demonstrated an exhausted ipsilateral cerebrovascular reactivity. After a left carotid endarterectomy he did not experience new spells of visual loss. Visual evoked potentials returned to normality, whereas brain perfusion and cerebrovascular reactivity significantly improved. DISCUSSION: Our findings support the theory that light-induced amaurosis fugax occurs on a hemodynamic rather than an embolic basis. The brain hemisphere ipsilateral to the damaged carotid artery showed basal hypoperfusion and exhausted reserve, both of which recovered after surgery. Moreover, the visual evoked response delay most likely represents change in function of the macular zone because of reduction in local retinal blood flow, causing an inadequate regeneration of retinal pigments. A prompt recognition of this symptom is critical to timely intervention.

Presentation:Poster  May 13, 2004  14:00 - 16:00  Room:  

Increased stiffness of the carotid wall material in patients with spontaneaous cervical artery dissection

D. Calvet    P. Boutouyrie  E. Touzé    B. Laloux   J.-L.Mas    S. Laurent                        
FRANCE

Service de Neurologie, Hôpital Sainte-Anne, Paris

Background : The etiology of spontaneous cervical artery dissection (sCAD) is largely unknown. An underlying connective tissue disorder has often been postulated, but arterial mechanical properties have rarely been studied. Objective : To determine the elastic properties of a cervical artery, the common carotid artery, and a distal muscular artery, the radial artery in sCAD patients. Methods : We studied 32 patients with previous sCAD (median delay : 2.2 years) and 32 control subjects matched for age, sex and blood pressure. Internal diameter, intima-media thickness, distensibility and Young's elastic modulus were determined at the site of the right and left common carotid arteries and the radial artery using non invasive high-resolution echotracking systems. Results : In patients with previous sCAD, cross-sectional distensibility and compliance of the affected carotid artery did not differ from those of the contralateral carotid artery. Young's elastic modulus (i.e. the stiffness of the wall material) was 58% higher (0.44+/-0.32 vs 0.28+/-0.15 kPa.103, P<0.001) and circumferential wall stress was 14% higher (54+/-12 vs 49+/-12 kPa, P<0.001) in sCAD patients than in controls. In logistic regression analysis, the highest tertile of common carotid artery Young's elastic modulus was associated with the highest risk of sCAD (OR, 8.0; 95% CI, 2.0 to 31.8). Aortic stiffness, assessed from the carotid-femoral pulse wave velocity, and radial artery parameters did not differ between sCAD and controls. Conclusion : Carotid arteries, but not aorta and radial artery, displayed abnormal elastic properties in sCAD patients. Higher stiffness of carotid wall material and circumferential wall stress could increase the risk of dissection in these patients.

Presentation:Poster  14 May, 2004  14:00 - 16:00  Room:  

Is homocysteine a sufficient indicator for vascular diseases?

U. Scherpinski    C.C.Schulze Horn  H. Bickel    H. Gnahn   B. Conrad    D. Sander                        
GERMANY

Neurology and psychiatry, Technical University of Munich

Background and Purpose: The aim of INVADE (Intervention project on cerebrovascular diseases and dementia in the district of Ebersberg) is to analyse the effect of risk factor evaluation and modification on the incidence of stroke and dementia in a population based sample. Risk factors were evaluated and if necessary modified by means of a primary care concept. In addition to several conventional risk factors, homocysteine, high-sensitive CRP (hs CRP), Intima-Media-Thickness (IMT) and ankle brachial index (ABI) were also measured. Methods: We analysed the relationship between homocysteine concentration by using quartiles (1. Quartile < 5,0 µmol/l; 2. Quartile < 6,6µmol/l; 3.Quartile < 8,6µmol/l; 4. Quartile => 8,6µmol/l) and the extent of arteriosclerosis measured by IMT (> 1mm) and ABI (< 0.9) as well as the incidence of coronary heart disease (CHD), in 3701 participants of INVADE (mean age: 69,3; 40,9% men) using multivariate logistic regression techniques. Results: After adjustment for age, sex, BMI, arterial hypertension, diabetes mellitus, cholesterol and smoking we observed a significant relation between homocysteine and CHD for the 4. Quartile (Odds ratio 0,278 [0,08-1,00]); p= 0,0451 as well as for ABI (Odds ratio 1,70 [1,07-2,78]); p= 0,028. In contrast, there was no significant relation between elevated homocysteine and increased IMT. Conclusions: Hyperhomocysteinemia is associated with CHD and pathological ABI values as an indicator for peripheral artery disease but not with early carotid arteriosclerosis. These findings demonstrate that the impact of hyperhomocysteinemia on arteriosclerosis development depends on the vascular territory. We found significant results even for homocysteine values > 8,6 µmol/l compared to the current limit values of homocysteine used in practice (> 15µmol/).

Presentation:Poster  May 13, 2004  14:00 - 16:00  Room:  

Is there an association between atrial fibrillation and cognitive decline - Follow-up results of the cognition and atrial fibrillation evaluation (CAFÉ)

H.L.Park    A.J.Hildreth  C.S.Gray    R.G.Thomson   J.E.O'Connell                               
UNITED KINGDOM

University of Newcastle

Background: In our aging population the burden of dementia is increasing, necessitating the urgent identification of treatable risk factors. Small cross-sectional studies demonstrate associations between non-valvular atrial fibrillation(NVAF), silent cerebral infarction and decreased cognitive function. CAFÉ is a prospective longitudinal cohort study of cognitive decline in people with recent-onset NVAF compared to controls. Methods: 362 people over 60, screened in primary care, underwent baseline assessment including a battery of neuropsychological tests, repeated at 12 months (n=304). Cases (n=174) with recent-onset NVAF, were matched for age, sex and GP practice with controls in sinus rhythm. Data were compared using non-parametric analysis. Results: Baseline characteristics were similar for cases and controls. There was wide variation between individuals in change in performance on the neuropsychological tests over 12 months, with some improving and some deteriorating for each sub-test. Cases (NVAF) significantly(p<0.05) deteriorated in four subtests measuring attention/ non-verbal memory, and significantly(p<0.05) improved in two subtests measuring verbal memory. Controls significantly(p<0.05) deteriorated and improved in the same sub-tests as cases, but significantly(p<0.05) deteriorated in another three subtests measuring attention/non-verbal memory, and significantly(p<0.05) improved in another six subtests. Treatment with warfarin or aspirin did not appear to affect change in cognitive status. Conclusions: For the CAFÉ cohort there was no consistent relationship between NVAF and cognitive decline over 12 months, nor any apparent effect of antithrombotic therapy. Explanations include true independence of NVAF and cognitive decline, or too short a follow-up period.

Presentation:Poster  13 May, 2004  14:00 - 16:00  Room:  

THE CLINICAL AND TOPOGRAPHICAL SPECTRUM OF SUPERIOR CEREBELLAR ARTERY TERRITORY INFARCTS

E. Kumral    A. Kýsabay  C. Ataç                                            
TURKEY

Ege University School of Medicine

Background and Purpose: Infarcts in the territory of the superior cerebellar artery (SCA) are uncommon. The clinical, etiological and stroke mechanisms are not well known in different infarct pattern of SCA. Methods: We studied 60 patients with lesion involving SCA territory diagnosed on MRI which have been selected from 3600 patients with first ischemic stroke consecutively admitted to our stroke unit over a period of 6 years, corresponding to 5,7% of patients with posterior circulation ischemic stroke. Results: We found 7 different patterns of SCA infarct; (1)14 patients with an infarct in the territory medial branch of SCA; (2)9 patients with an infarct in the territory of lateral branch of SCA; (3) 9 patients with a lesion involving medial and lateral branches of SCA; (4) 6 patients with cortical infarcts at the boundary zones between medial (m)/lateral branches of the posterior inferior cerebellar artery (PICA and m and l branches of the SCA; (5) 8 patients with a lesion at the deep boundary zones between l and m SCA, and l and m PICA; (6) 4 patients with infarcts involving the medial rostral cerebellum between the right and left SCA; (7)10 patients with infarcts in the SCA territory and in other vertebrobasilar artery territory, including thalamic, posterior cerebral artery or pontine perforating arteries. The main cause of stroke was large artery disease in 33% of patients, cardioembolism in 25% and unknown cause of infarct in 28%. Conclusion - The clinical picture of SCA is heteregenous depending to underlying stroke patterns and etiologies. The outcome is benign in general, except those with multiple cerebellar artery territories involvement.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

SUBINSULAR STROKES: CLINICAL, TOPOGRAPHICAL, AND ETIOLOGICAL PATTERNS

E. Kumral    T. Ozdemirkýran  C. Alper                                            
TURKEY

Ege University School of Medicine

Introduction: Infarcts in the territory of the subinsular area are exceptional. The clinical, etiological and stroke mechanisms are not well known in this stroke type. Material and Methods : Eleven patients with subinsular stroke (subIS) diagnosed on MRI included in our Registry, corresponding to % 0.4 of 2600 patients with ischemic stroke, were studied. Results : Large-artery disease and mixed etiology were present in 5 patients each (45%). SubISs were located in a deep vascular borderzone between lenticulostriate arteries and small insular cortical penetrating branches of the middle cerebral artery. Subinsular involvement was associated with sensory-motor disturbances (11 patients) and neuropsychological disorders, including aphasia (2 patients with left subinsular involvement), and anosognosia or hemineglect (4 patients with right subinsular involvement). Conclusion : Large artery-disease and cardioembolism may give rise to subIS by hemodynamic mechanisms because of the insufficient collateral circulation in subinsular territory. Subinsular strokes were characterized by sensory-motor disturbances and neuropsychological disorders, including aphasia and neglect.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

Quality indicators for acute ischemic stroke in Spanish Hospitals

J.M.Aguilera    M.D.Jiménez  M. Tejedor                                            
SPAIN

on behalf of the investigators of Stroke Project.

Background and purpose: The consensus statement by Helsingborg Conference demands to stablish quality assessment for evaluating stroke care. The purpose of the present study was to devolop quality indicators for acute ischemic stroke in Spanish Hospitals. Method: We identified a initial list of 61 measures and performances in a tipical stroke patient from guidelines, review criteria and expert opinions. Each potencial indicator was measured along four dimensions: sample size to apply indicators, impact on outcomes, evidence for performance measure, and cost measure. To assess the opinions, we used a modified delphi approach combining three face-to-face meetings of the experts of Stroke Project (SP) to read, discuss and improve the clarity and to specify the indicators. Results: 44 vascular neurologist answered the delphi. The most rated on performance measures were: stroke protocol in Emergency Departament; Stroke Unit; Anticoagulation in atrial fibrillation; Stroke Team; TC head done within 60 min; Carotid imaging; Admission time within 30 min; Stroke code; Whole study within 90 min; Antiplatelets therapy within 48 hours. In last meeting, the experts defined four relevants and feasible outcome measures related to previous selected indicators: rankin score after thrombolysis, mortality along hospitalization, adjusted-length of stay and readmission for new stroke in 28 days. Discussion: The spanish neurologists shows high agreement on structure, time related thrombolytic measures and indication of therapies with high grade scientific evidence. The experts recommended systematic outcome measures to evaluate the quality of stroke care because provides continuous quality improvement.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

ISCHEMIC STROKE IN PREGNANCY AND PUERPERIUM

D.R.Jovanovic    Lj. Beslac - Bumbasirevic                                                 
YUGOSLAVIA

Institute of neurology, Clinical Center of Serbia, Belgrade, Serbia and Montenegro

BACKGROUND: The onset of an ischemic stroke during a pregnancy or puerperium is a rare event with numerous possible causes. This study was undertaken to evaluate the clinical characteristics and causes of the ischemic stroke during gestational period. METHODS: We studied the women with an ischemic stroke that ocurred during pregnancy or within 6 weeks of postpartum, who were admitted to our Department of Emergency neurology from January 1989 to August 2002. Etiology of brain ischemia was confirmed by a selective using of available diagnostic procedures. RESULTS: In 41 women ischemic stroke appeared during a pregnancy or puerperium. Their mean age was 28.2+5.8 years with range 18 to 43 years. In 39% of patients an ischemic stroke appeared during a pregnancy and in 61% of them during 6 weeks of puerperium. In only 5 patients a cerebral venous thrombosis was detected. Pregnancy - specific causes were present in 17% of women (4 eclamptic attacks, 2 postpartum benign angiopathy, and one peripartum cardiomyopathy). The cause of ischemic stroke was embolism in 15% of patients and in 29% of them other determined causes. Among the rest 16 patients three of them were incompletely investigated and in even 13 women no obvious cause than pregnancy or puerperium was detected. During a period of hospitalization 5 patients died, 4 of them with a cerebral venous thrombosis. DISCUSSION: Other investigations found out that pregnancy and especially puerperium carries a substantial risk for developing an ischemic stroke. Our study is consistent with this fact as in one-third of our patients no other possible cause was detected than pregnancy or puerperium itself. Nevertheless, most of the causes of ischemic stroke during a pregnancy or puerperium are similar to those of the young stroke patients.

Presentation:Oral  13.05.2004  16:00 - 16:10  Room: Bruno-Schmitz-Saal

The effect of hormone replacement therapy on stroke risk, type and outcome: a systematic review of data from randomised controlled trials

L.J.Gray    P.M.W.Bath                                                 
UNITED KINGDOM

Institute of Neuroscience

Background: The risk of stroke is low in pre-menopausal women and increases rapidly following the menopause, coincident with diminished circulating levels of oestrogen and progesterone. Hence, hormone replacement therapy (HRT) might protect post-menopausal women from stroke. Methods: Randomised controlled trials of HRT were identified from the Cochrane Library, reviews and reference lists of relevant papers. Event rates for stroke (total, non-fatal, ischaemic, haemorrhagic, poor outcome), myocardial infarction and pulmonary embolism (PE) were extracted and analysed using the Cochrane Collaboration’s software, Revman. Sensitivity analyses were performed by type of HRT: oestrogen alone (mono) versus combined oestrogen and progesterone (dual). Results: Eleven trials (t), involving 23,310 subjects, were identified. HRT was associated with increases in stroke, odds ratio (random effects, 95% confidence intervals) 1.30 (1.09-1.54, t=11), fatal stroke 1.56 (0.84-2.87, t=9), non-fatal stroke 1.21 (1.00-1.46, t=8) stroke with poor outcome (death or disability/dependency) 1.56 (1.11-2.20, t=3), ischaemic stroke 1.28 (1.06-1.56, t=4), and PE 2.05 (1.36-3.08, t=4). No heterogeneity was present in these analyses and effect sizes appeared to be comparable for mono and dual HRT. No effect of HRT on haemorrhagic stroke 1.06 (0.64-1.75, t=4), TIA 0.94 (0.66-1.33, t=4), or coronary heart disease 1.10 (0.95-1.27, t=5) was apparent. Conclusions: HRT is associated with an increased risk of stroke, especially of ischaemic type. Subjects having a stroke on HRT appear to have a worse outcome. HRT cannot be recommended in the prevention of stroke.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

Physiotherapy Intensity After Stroke (PIntAS) Collaborative Overview: An overview using individual patient data

I. Wellwood    P. Langhorne  J. Norrie                                            
UNITED KINGDOM

University of Glasgow

Background: Physiotherapy is a central feature of organized stroke care but there is little direct clinical evidence to support its use. In particular we do not know the optimum amount of physiotherapy for individual patients. We conducted an individual patient data meta-analysis of trials testing greater amounts of physiotherapy. Methods: We carried out a literature search (up to the end of 2002) and included all randomized controlled trials of intensity of physiotherapy. A Collaborative group was formed and trialists provided individual patient data for analysis. Using standard methods (Stewart and Clarke 1995) data were cleaned and categorized by patient details, intervention and outcomes. Results: We incorporated 9 trials (930 subjects). We found no significant differences between patients receiving intensive and standard amounts of physiotherapy in terms of overall impairment or disability scores or length of hospital stay. Secondary analyses showed significant improvements in recovery of Motricity Index scores and walking speed. Discussion: Modest increases in the intensity of physiotherapy after stroke did not produce substantial changes in outcome. Targeted additional therapy in selected patients may improve limb impairment and walking speed.

Presentation:Oral  14.5.05.2004  16:50 - 17:00  Room: Hörsaal

Compression stockings and the prevention of symptomatic venous thromboembolism: data from the Tinzaparin in Acute Ischaemic Stroke Trial

N. Sprigg    L.J.Gray  P.M.W.Bath                                            
UNITED KINGDOM

Institute of Neuroscience, University of Nottingham

BACKGROUND: Venous thromboembolism (VTE) is a well-recognised preventable complication of acute stroke. While compression stockings reduce the risk of VTE in surgical patients their benefit in acute stroke remains uncertain. METHODS: Tinzaparin in Acute Ischaemic Stroke Trial (TAIST) was an international randomised controlled trial comparing 10 days of treatment with tinzaparin (175 IU.kg-1, 100 IU.kg-1) with aspirin (300 mg od). The use of stockings and incidence of symptomatic VTE were prospectively recorded. The efficacy of stockings in preventing adjudicated symptomatic VTE (deep vein thrombosis, DVT, and/or pulmonary embolism, PE) during or within 5 days of completing randomised treatment was assessed using logistic regression adjusted for known VTE risk factors and treatment. RESULTS: 28 VTE (1.9%, DVT 18, PE 13) occurred within 15 days of enrolment in 1,479 patients. Those wearing bilateral stockings for 10 days showed a non significant reduction in the odds of VTE compared to those who wore stockings inconsistently or none, odds ratio (OR) 0.65 (95% confidence intervals, CI 0.26-1.65 p=0.37). Mild stroke (OR 0.95, 95% CI 0.92-0.97, per point increase in SNSS p=0.0002) and treatment with tinzaparin (in a dose dependent manner)were associated with a reduced risk of VTE. CONCLUSIONS: Compression stockings could reduce the rate of VTE by about 35% in patients with acute ischaemic stroke. However, the uncertainty in this finding, low frequency of VTE, and costs (financial, nursing time) of stockings highlight the need for a large randomised-controlled trial (such as CLOTS) to examine the use of compression stockings in this patient group.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

What does ‘community support’ for stroke survivors and families provide? Analysis of support worker records

C. McKevitt    C. Coshall  K. Tilling    A. Rudd   C. Wolfe                               
UNITED KINGDOM

King's College London

Background: Across Europe there are few services providing social support specifically to stroke survivors and families in the community. Evaluations of novel support interventions have generally had disappointing results. Although such interventions are heterogeneous, the nature of the support they provide is unclear in the literature. We aimed to identify what support was provided in a recent RCT of a stroke family support worker. Methods: Content analysis of records kept by support workers. Records were designed as diaries, detailing for each patient/family contact: needs identified, objectives and outcomes. Results: 347 families received the intervention over 2 years. Records were available for 2410 individual contacts. Number of telephone and face to face contacts per family ranged from 1–60. Duration of contacts ranged from 5-420 minutes. Contacts were also made with hospital and nursing home staff and GPs. Needs, identified through discussion with staff, patient and family members, included emotional/psychological support, information and advice. Information was provided about stroke, secondary prevention, medication use, social service entitlements. Other activities included ‘providing a listening ear’, and contacting families simply to ask how they were. Discussion: There was little evidence of rigorous needs assessment. Service delivery was not targeted by level of need. Families were universally assumed to require emotional support and allowing them to opportunity to talk was assumed to meet this need. Most services provided were offered by other professionals but unlike others, the support workers emphasised their on-going availability. The effect of this intervention may have been diminished because it duplicated services, was not targeted according to need and made assumptions about needs and how to meet them.

Presentation:Poster  May 13, 2004  14:00 - 16:00  Room:  

Comparison of extracranial carotid stenosis with magnetic resonance angiography versus duplex ultrasonography

J.H.Lee                                                        
SOUTH KOREA

Department of Neurology, National Health Insurance Corporation Ilsan Hospital

Background and purpose: Time-of-flight (TOF) magnetic resonance angiography (MRA) is commonly used to visualize the carotid arteries. To assess accuracy of MRA as compared with three-dimensional (3D) TOF MRA and reference duplex ultrasonography in diagnosis of carotid artery stenosis. Methods: In 2000-2003, among the patients visited our neurology department, 252 patients underwent 3D TOF MRA and carotid duplex ultrasonography were included in this study. Comparison of extracranial carotid stenosis with magnetic resonance angiography versus duplex ultrasonography was done. Results: When the degree of extracranial internal carotid artery (ICA) stenosis is divided to following group: 1. normal and <50% stenosis, 2. 50-75% stenosis, 3. >75% stenosis or subtotal stenosis, 4. total occlusion by duplex ultrasonography and 1. normal and <50% stensis, 2. >50% stenosis without Flow Void, 3. >50% stenosis with Flow Void, 4. total occlusion by 3D TOF MRA, these groups were well correlated (Kappa value: 0.86). The sensitivity and specificity of a Flow Void artifact for the presence of severe stenosis was 73% and 99%. Conclusion: Accuracy of 3D TOF MRA in diagnosis of extracranial carotid stenosis is similar to that of carotid duplex ultrasonography. Flow void artifacts represented severe stenosis in most of the arteries.

Presentation:Poster  13 May, 2004  14:00 - 16:00  Room:  

THALAMIC HEMORRHAGES. A CLINICO-RADIOLOGICAL STUDY OF 34 PATIENTS.

J. Gállego    M.E.Erro  O. Maisterra    M.  Herrera   I. Ajuria    N. Aymerich  C. Echávarri                   
SPAIN

Unidad de Ictus. Servicio de Neurología. Hospital de Navarra. Pamplona. SPAIN

Background: Neuroimaging appearance and clinical findings of thalamic hemorrhages (TH) are diverse and the long-term evolution is not well known. Methods: We studied 34 consecutive patients with TH included in our Stroke Registry. The functional status was evaluated using the Rankin Disability Scale (RDS) on admission and two months later. Results: TH represent the 6% of all parenchimal hemorrhages. The average age was 71,5 years old, sex distribution: 26 males and 8 females. Hypertension was the most common risk factor, followed in similar proportion by alcohol abuse, treatment with aspirin, oral anticoagulation and cognitive decline. The most frequent clinical manifestation was sensorimotor deficit (76%), 28% presented with drowsiness, 24% dysphasia, 16% hemianopsia, 20% vertical oculomotor disturbances and 20% pure sensitive syndrome. Only 20% were pure TH, 32% extended to ventricular system, 44% to the internal capsule and 16% to the midbrain. The 56% had a size between 1 and 5 mm3, 20% between 6 and 15 mm3 and 16% larger than 16 mm3. The 20% died in the acute stage, on discharge from hospital 36% had a RDS between 0 and 2 and 44% had a RDS between 3 and 5. A 40% could be evaluated two months later, from them one third had cognitive decline as sequalae. Conclusions: There is a significantly male predominance. Hypertension was the commonest aetiology. Pure TH were rare, they frequently extended to adjacent structures. Clinical manifestations were diverse depending on topographical extention. Outcome was not good even in small hemorrhages because of frequent ventricular invasion.

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

Soluble adhesion molecules in acute ischemic stroke

V. Basic-Kes    V. Vargek-Solter  AM. Simundic    E. Topic   V. Demarin                               
CROATIA

Department of neurology, University hospital "Sestre milosrdnuice"

Inflammatory adhesion molecules play a key role in the development of ischemic lesions. Elevated levels of soluble adhesion molecules are reported in stroke, but data are still controversial. Our aim was to explore the potential association of plasma levels of sICAM-1, sVCAM-1, sE-selectin and sL-selectin with acute ischemic stroke. We prospectively enrolled 67 subjects with acute ischemic stroke and 76 healthy controls. The concentrations of soluble adhesion molecules were determined using quantitative sandwich enzyme immunoassay. The mean levels of sICAM-1, sVCAM-1, sE-selectin were higher in patients than in controls), whereas sL-selectin was lower in patients . In patients, levels of soluble adhesion molecules were independent of age, with the exception of sL-selectin, which inversely correlated with age. In controls, sICAM-1 and sVCAM-1 increased with . sL-selectin was higher in diabetics . In patients, soluble adhesion molecule levels did not differ with respect to carotid atherosclerotic disease, smoking status, hypertension and hypercholesterolemia. Some soluble adhesion molecules correlated with blood glucose, lipid parameters and the markers of inflammation. In patients, but not in controls, most of the adhesion molecules correlated among each other. Conclusions Acute ischemic stroke is associated with elevated plasma levels of sICAM-1, sVCAM-1 and E-selectin, independently of age, sex and other recognised stroke risk factors. That increase is an indicator of inflammatory process and is most probably transient in nature. Increased triglycerides, cholesterol and glucose correlate with moderately elevated concentrations of adhesion molecules in asymptomatic individuals pointing to chronic inflammatory activation of endothelium.

Presentation:Oral  14.05.2004  16:30 - 16:40  Room: Bruno-Schmitz-Saal

Time Dynamics of Post-Stroke Fatigue

F. Staub    JM. Annoni  S. Gramigna    J. Bogousslavsky                                     
SWITZERLAND

Centre Hospitalier Universitaire Vaudois

Backgroud: Even though fatigue is a frequent post-stroke sequela, it remains underexplored. Methods: We prospectively studied 94 consecutive patients with a first non-disabling stroke (NIHSS<or=to3 at 6 m) in order to examine the evolution of post-stroke fatigue (PSF) over a one year period. At 6 and 12 months follow-up, patients were evaluated with the Fatigue Assessment Instrument (FAI), Hamilton Depression and Anxiety Rating Scales (HDRS/HARS), disability scale (Rankin), NIHSS and a neuropsychological battery. A cognitive score was internally developed, based on the percentage of tests showing abnormal performances. Comparison between the two follow-ups were carried out using Wilcoxon signed-rank tests. Results: At 6 months, 30% of patients (n=28) had a severe fatigue syndrome (FAI>4), the percentage being of 35% (n=33) at 1 year. A significant improvement between the 2 evaluations was found for the NIHSS (z=-2.913; p<0.0036), Rankin (z=-3.16; p<0.0016) and HDRS (z=-2.47; p<0.01). On the other hand, the FAI fatigue severity score showed no significant change (z=0.38; p<0.7) as well as the HARS and the cognitive score (respectively z=-0.82; p<0.4 and z=-1.27; p<0.2). Conclusion: Our data show that PSF is a stable and long lasting symptom after stroke. Compared to the 6 months follow-up, 1 year rated fatigue remains unchanged despite significant improvement in neurological and functional outcome as well as depression. On the other hand, cognitive impairment and level of anxiety remain constant across time, underlining the critical role of these two variables in the genesis of PSF. Other factors, such as the high psychophysiological cost of a delayed resumption of a professional activity (>6months), may also contribute to the lack of fatigue improvement.

Presentation:Poster  May 13, 2004  14:00 - 16:00  Room:  

ROSIGLITAZONE AND 15-dPGJ2 ARE NEUROPROTECTIVE AFTER EXPERIMENTAL STROKE

M.A.Moro    M.P.Pereira  J.R.Caso    B. García-Bueno   J.C.Leza    I. Lizasoain  P.  Lorenzo    A. Dávalos    J. Vivancos  J. Castillo
SPAIN

Departamento de Farmacología, Facultad de Medicina, Universidad Complutense de Madrid, Spain

Background and purpose: Inflammation contributes to the delayed cerebral damage after ischaemic stroke. Therefore, novel anti-inflammmatory strategies may be useful in the therapeutical management of this pathology. The activation of the nuclear receptor PPARgamma has been shown to exert anti-inflammatory actions. The present study was designed to test whether the PPARgamma agonists 15-dPGJ2 and rosiglitazone, a thiazolidinedione known for its anti-diabetic properties, cause neuroprotection after experimental stroke by inhibiting inflammation. Methods: Male Fisher rats (~250 g) were used. Experimental groups were sham, pMCAO, pMCAO plus rosiglitazone 1 and 3 mg/kg (pMCAO+RSG1/3) and pMCAO plus 15-dPGJ2 1 mg/kg (pMCAO+15dPGJ2), n=6 in each group. Animals were administered rosiglitazone, 15-dPGJ2 or vehicle (10% DMSO in saline) by intraperitoneal injection 10 min after the pMCAO. Infarct volume was determined 48 h after pMCAO by TTC staining. Levels of inducible NO synthase (iNOS) protein were determined by Western blotting and the brain concentrations of the NO metabolites NO2-/NO3- (NOx-) were determined by the Griess reaction. Results: Administration of rosiglitazone (1-3 mg/kg) and 15-dPGJ2 (1 mg/kg) caused a significant reduction in pMCAO-induced infarct volume (164.5+/-13.8, 101.1+/-9.8, 98.2+/-9.7 and 113.8+/-12.6 mm3 in pMCAO, pMCAO+RSG1, pMCAO+RSG3 and pMCAO+15dPGJ2, n=6, p<0.05 vs. pMCAO). Rosiglitazone and 15-dPGJ2 also caused an inhibition of pMCAO-induced brain iNOS expression and a decrease in pMCAO-induced elevation in brain NOx- levels (n=6; p<0.05 vs. pMCAO). Conclusions: Inhibition of inflammatory pathways with the PPARgamma agonists rosiglitazone and 15-dPGJ2 may be a useful therapeutic strategy in the management of stroke.

Presentation:Poster  May 13, 2004  14:00 - 16:00  Room:  

A New Surgical Approach for Intraluminal Middle Cerebral Artery Occlusion Avoiding External Carotid Artery Transection in Rats

N. Fehm    B. Vatankhah  M. Dittmar    Y. Tevetoglu   G. Retzl    T. Spruss  G. Ickenstein    G.. Schuierer    M. Horn     
GERMANY

University of Regensburg, Department of Neurology

Background: Middle cerebral artery occlusion (MCAO) by an intraluminal filament is a widely accepted model of focal cerebral ischemia. Transection of the external carotid artery (ECA), which is a prerequisite for thread insertion, has been shown to cause ischemic damage to the ECA supply territory. In this study a new approach for filament insertion avoiding ECA transection is evaluated. Methods: Wistar rats were subjected to filament MCAO or sham surgery. The thread was inserted via an incision in the common carotid artery (CCA) and advanced until it occluded the middle cerebral artery (MCA). After reperfusion was established, the incision was closed by microvascular suture (n=5) or application of fibrin sealant (n=5). In vivo computed tomography angiography (CT angio) and color duplex sonography were performed for quantification of post-surgical CCA stenosis. In vivo magnet resonance imaging (MRI) was performed for detection of ischemic damage to the ECA territory. Results: There was no significant blood loss up to 14 days after surgery. Antegrade blood flow through the CCA was detected by CT angio and sonography for up to 14 days after surgery in all rats. Stenosis was lower in the fibrin sealant group (19%) compared to the suture group (45%). Ischemic tissue damage in the ECA supply territory was detectable in two rats. Discussion: Filament insertion via the CCA is a new method for MCAO in rats, avoiding ECA transection. After MCAO, reperfusion through the CCA and its branches can be established. Our data suggest an advantage for the use of fibrin sealant for the closure of the CCA, resulting in only slight post-surgical stenosis. In our study, ischemic damage to the ECA territory was seen significantly less frequent (20%) than known in MCAO with ECA-transection (47%).

Presentation:Poster  May 14, 2004  14:00 - 16:00  Room:  

Increased platelet degranulation and monocyte-platelet complex formation in the acute and convalescent phases after ischaemic stroke or TIA

D.J.H.McCabe    H. Harrison  I.J.Mackie    P.S.Sidhu   G. Purdy    A.S.Lawrie  H. Watt    S.J.Machin    M.M.Brown     
UNITED KINGDOM

The National Hospital for Neurology & Neurosurgery, Queen Square, London

Background: Flow cytometric studies of a small number of platelet activation markers have shown that platelets are excessively activated in ischaemic stroke or TIA. However, few studies have measured the percentage of circulating leucocyte-platelet complexes in this patient population. Methods: Whole blood flow cytometry was used to quantify the expression of CD62P, CD63, and PAC1 binding, and the percentages of leucocyte-platelet complexes in acute (1 to 27 days, n = 79) and convalescent (79 to 725 days, n = 70) ischaemic cerebrovascular disease (CVD) patients compared with controls without CVD (n = 27). 99% of CVD patients and 15% of controls were receiving antithrombotic therapy at the time of assessment. Results: The median % CD62P expression and the median % monocyte-platelet complexes were higher in both acute and convalescent CVD patients than controls (p >/= 0.02). Otherwise, there was no significant increase in any other marker of platelet activation in CVD patients compared with controls. There was a positive correlation (Spearman’s rho >/= 0.3) between the percentage expression of CD62P and the percentages of both neutrophil-platelet and monocyte-platelet complexes in the acute phase (p >/= 0.005), and the percentages of all leucocyte-platelet complexes in the convalescent phase after ischaemic CVD (p >/= 0.02). Discussion: Patients with ischaemic stroke or TIA have ongoing excessive platelet activation and monocyte-platelet complex formation at least three months after symptom onset despite treatment with antithrombotic therapy. These data add to our understanding of the cellular mechanisms involved in the pathogenesis of ischaemic CVD, but are not in agreement with recent suggestions that CD63 is a more sensitive marker of platelet activation than CD62P in the subacute phase after ischaemic stroke.

Presentation:Oral  13.05.2004  17:20 - 17:30  Room: Beethovensaal I

High dose aspirin is neuroprotective in a rat focal ischemia mode

F. Xia    C. Berger  W.R.Schaebitz    S. Schwab   A. Grau                               
GERMANY

University of Heidelberg

Background: Acetylsalicylic acid (ASA) is widely accepted for secondary prevention of ischemic stroke. ASA is neuroprotective through various pharmacological action sites. The aim of this study in a temporary middle cerebral artery occlusion (tMCAO) model in rats was to test whether a high dose ASA administered repetitively both in the acute and the chronic stage is superior to a low dose and to a single dose application strategy. Methods: Male Wistar rats were subjected to 90 minutes tMCAO. All animals were randomised and blindly allocated to one of four treatment groups (Placebo, high dose (40 mg/kg), Low dose (20 mg/kg) and one bolus group). Treatment times were at 30 minutes, 6 hours, 24 hours, 2 days, 3 days, and 4 days after MCAO. We assessed the rats neurologically before MCAO, at 24 hours and 5 days after MCAO. Body weight was recorded before and 5 days after MCAO. Infarct size was analysed with 2,3,5-triphenyltetrazolium chloride staining. Results: As compared to saline (164 +/- 13 mm3, n=14), only repeated injections of 40 mg/kg ASA (79 +/- 18 mm3, n=14, P=0.0029) but not of 20 mg/kg ASA (129 +/- 19 mm3, n=15) reduced infarct volume significantly. No significant change was noted with 40 mg/kg ASA injected only once at 30 min after MCAO (117 +/- 16 mm3, n=13). The neuroscore was significantly improved in the high dose group as compared to the placebo group. Discussion: Though the mechanisms of how ASA diminishes ischemic injury after MCAO is not solved yet, our results demonstrate that one bolus administration after stroke onset is insufficient for neuroprotection. A multiphasic administration of a relatively high dosage of ASA early after stroke onset and on subsequent days appears reasonably safe and effective as a primary treatment strategy in ischemic stroke.

http://www.esc-archive.eu/mannheim04/ma_graphics/mg_1113.htm
 

Presentation:Oral  14.05.2004  12:10 - 12:20  Room: Hörsaal

Perceptual, social and personality related factors associated with delays in seeking medical care in patients with symptoms of acute stroke

L. Mandelzweig    D. Tanne  V. Boyko    U. Goldbourt                                     
ISRAEL

Stroke Unit, Department of Neurology, Sheba Medical Center, Tel Hashomer

Background: Despite the availability of reperfusion therapy for treating acute ischemic stroke, most patients (pts) remain ineligible mainly due to delay in seeking help following symptom onset. This study's aim was to identify perceptual, social and personality related factors, which can be addressed in interventions for reducing delay. Methods: During a 2-year period (2000-2002), 209 pts presenting with stroke symptoms were interviewed about their symptom experience, interpretation, and reaction, and brief personality assessments were performed in communicative pts. Odds ratios and 95% confidence intervals for risk of delay in seeking help for more than 3 hours (reaction time) were estimated for all pts, and for men and women separately. Results: After adjustment for age, sex, living alone, prior stroke, symptoms, mode of onset, perceived severity and control of symptoms, contextual factors, pts first noting symptoms, symptom attribution, hesitation, advice of others, contact with ambulance, and high general anxiety, we found that beyond the contribution of clinical factors, perception of symptoms as severe (0.42; 0.17-0.95), advice to seek help (0.18; 0.05-0.63), and contacting an ambulance (0.26; 0.10-0.63) were associated with a short reaction time, while delay was associated with perceived control of symptoms (2.45; 1.08-5.71). Among men, hesitation increased risk of delay (2.67; 0.97-7.74), while in women high general anxiety was associated with seeking help early (0.12; 0.01-0.93). Conclusion: Perceptual, social and personality related factors, in additon to clinical variables, contribute to delay in seeking care in pts with acute stroke symptoms. These findings have important implications for designing programs to reduce delay in seeking medical help.

Presentation:Oral  14.05.2004  16:40 -16:50  Room: Konferenzraum OG

Long-Term Risk of Recurrent Stroke and Rupture of Cervical Aneurysms due to Spontaneous Carotid Dissection

D. Benninger    D. Georgiadis  E. Stöckli    M. Arnold   R.W.Baumgartner                               
SWITZERLAND

University Hospital of Zurich

Background Stroke prevention in patients with cervical aneurysm due to spontaneous dissection of the cervical internal carotid artery (ICAD) is controversial. We performed an observational study to assess the long-term risk of recurrent stroke and rupture of cervical aneurysms. Methods Twenty-three patients (9 women, 14 men; mean age, 45 +/- 7 years) with 29 ICADs causing 26 cervical aneurysms were included. Clinical and color duplex sonographic (CDS) follow-ups were done after 3, 6 and 12 months; thereafter, annual follow-ups were done clinically or by a structured telephone. Further follow-ups including clinical examination, additional CDS, cervical MRI, MR or catheter angiographies were done in patients with suspicion of recurrence of cervical artery dissection. Results Two patients underwent an invasive therapy of the aneurysms: (1) balloon occlusion of the ICA followed by extracranial-intracranial bypass surgery and (2) percutaneous transluminal angioplasty with stent implantation. A malignant MCA infarction precluded follow-up in a patient. Follow-up was 6.9 years (median; range, 0.3-13.8 y) for the 20 patients who were conservatively treated, and 6.5-14.1 years for the two patients with invasive therapy. Antithrombotic therapy included aspirin or warfarin in 14 cases, and had been stopped for various reasons in 7 patients resulting in an antithrombotic-free median follow-up of 4 (range, 0.3-11.5) years. No recurrent stroke or rupture of the cervical aneurysm was documented. Discussion Our data indicate that cervical aneurysms treated with aspirin or warfarin or no antithrombotic therapy have a benign long-term outcome with a low risk of recurrent stroke or rupture, which suggests that conservative therapy of such aneurysms is appropriate in most cases.

Presentation:Oral  13.05.2004  11:20 - 11:30  Room: Beethovensaal I

EARLY ADMISSION TO THE STROKE UNIT IMPROVES CLINICAL OUTCOME

A.G.Silvestrelli     L.Parnetti    M.Paciaroni      V.Caso     P.Milia      M.Venti    F.Palmerini     G.Mazzotta      V.Gallai     
ITALY

Stroke Unit - Department of Neuroscience, University of Perugia

Background and objective. Since acute stroke benefits from the earliest treatment, a continuos improvement in patient arrival time to the Stroke Unit is crucial. The objectives of this study were to record timing from clinical onset to admission, to identify the reasons for delay and to determine if and how much early admission reduces patient disability or mortality at discharge and one month later. Patients and methods. Consecutive acute stroke patients admitted to SU between January 1st 2000 and December 31st 2002 were studied. Demographic and stroke characteristics, etiology and time from symptom onset to arrival in SU were recorded. Results. 35.8% of 1,498 consecutive stroke patients (809 male, mean age 75.3 and median age 77 [range 26-99]) arrived within 3 hours; 62.3% within 6 hours; 37.7% arrived later (> 6 hours). Underestimation of symptoms was the cause of delay in 47.5% of patients. More hemorrhagic than ischemic stroke patients arrived within 3 hours (44.8% vs 33.6%). 78.9% of the <6 hours patients presented a Rankin score > 2 in comparison with 60% of the >6 hours patients. Subjects presenting a TACS, with large vessel disease and cardioembolic stroke arrived earlier. Multiple logistic regression analysis identified as independent predictors of early arrival (<3 hours) advanced age, previous TIA and cardioembolism. In-hospital (8.7%) and one-month (7.3%) mortality were higher in <3 hours patients, while functional outcome after one month was better (32.9% vs16.8%). Conclusions. Advanced age, history of TIA, cardioembolic etiology, severity of neurological deficit and hemorrhagic stroke type all led to earlier arrival time. The main reason for delay was the underestimation of symptoms. Admission within 3 hours reduced patient’s disability at one month. The high rate of patients arrived late due to the underestimated of symptoms shows the need to improve educational programs for the population.