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Kind of presentation: oral

Etiology of Stroke  
  
 
Chairs: D.W.J. Dippel, The Netherlands and A. Gass, Switzerland

Date: Friday 29 May 2009
Time: 9:10 - 9:20
Room: A2

5.
Air pollution and acute stroke hospitalization: preliminary results from Lombardia Stroke Unit Network (SUN)
Introduction: Air pollution is known to be associated with cardiovascular disease; the cerebrovascular disease relationship has not been adequately studied. Patients and methods: A preliminary time-series study was conducted to evaluate the association between daily air pollution and acute stroke hospitalization in Lombardia region in northern Italy. We analyzed 651 consecutive patients, enrolled from SUN database, living in the specific area (catchment 10 km) of Mantova in the 2006-2008 period. Data on temperature, humidity, barometric pressure, particulate matter with aerodynamic diameter less than 10 µm (PM10), carbon monoxide (CO), nitrogen dioxide (NO2), sulfur dioxide (SO2), benzene, nitrico oxide (NO) and ozone (O3) were available from the local environment agency (ARPA). Daily mean values were considered for all pollutants. The association was investigated with the case-crossover design. We evaluated the lag structure (0–7 d lags; lag 0 represents the air pollution level at the day of hospitalization, lag 1 is the level at the previous day, and so on) for airborne pollutants. Conditional logistic regression analysis was fitted to the data to calculate risk and 95% CIs. Results: In the study were consecutively included hospitalized TIAs (12.6%), ischemic (75.7%) and hemorrhagic (11.7%) strokes. The median level of pollutants at admission were: SO2 6.9 (0.5-22); NO2 31.7 (8-74) PM10 levels 40.2 (7.2-144.9). A non significant trend towards the increase of PM10 levels from day 7 to day 0 was found. The logistic regression analysis found a significant correlation between the hospitalization and the increase of airborne nitrogen oxides (NO2 and NO), carbon monoxide and benzene in the area where the patients were living. Conclusion: We conclude that gaseous air pollution could be considered a potential risk factor for stroke unit hospitalization. An extensive analysis inside the SUN database is planned on the whole Lombardia region.
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SUN Lombardia Collaborators
F.Corea, Department of Neurology, Institute of Experimental Neurology, IRCCS San Raffaele, Milano, ITALY
G.Silvestrelli   Stroke Unit, Division of Neurology, Carlo Poma Hospital  Mantova  ITALY
N.Murgia  Section of Occupational Medicine. Respiratory Diseases and Toxicology. University of Perugia  Perugia  ITALY
A.Baccarelli  Department of Preventive Medicine, University of Milan and IRCCS Maggiore Hospital, Mangiagalli and Regina Elena Foundation  Milano  ITALY
A.Lanari  Stroke Unit, Division of Neurology, Carlo Poma Hospital  Mantova  ITALY
S.Micheli  Stroke Unit, Division of Cardiovascular Medicine, University of Perugia  Perugia  ITALY
L.Bertolani  Stroke Unit, Division of Neurology, Carlo Poma Hospital  Mantova  ITALY
P.Previdi  Stroke Unit, Division of Neurology, Carlo Poma Hospital  Mantova  ITALY
G.Miceli  Neurology and Stroke Unit, IRCCS Istituto Clinico Humanitas  Milano  ITALY
G.Comi  Department of Neurology, Institute of Experimental Neurology, IRCCS San Raffaele  Mialno  ITALY
           
         
         
         
         

Kind of presentation: poster

Acute stroke: treatment and concepts  
  
Poster Session Red
Chairs:  

Date: Wednesday 27 May 2009
Time: 12:30 - 14:00
Room:  

3.
The role of antiplatelet agents in 5-year survival after a first-ever acute ischemic stroke
Introduction: Antiplatelet agents are the cornerstone agents in secondary prevention of non cardioembolic stroke. The aim of the study was the comparison of aspirin versus clopidogrel concerning survival of patients after a first-ever acute ischemic stroke. Methods: Phase 4 study in patients with ischemic stroke and an indication for antiplatelet therapy (atherothrombotic, lacunar and cryptogenic stroke subtype). We studied 1167 patients (798 men, 369 women) with an acute first-ever stroke that were hospitalized and received aspirin (group A) or clopidogrel (group B). The patients were followed for 5 years. Statistical analysis included the Kaplan Meier survival curve and multifactorial analysis (Cox regression) to determine the factors that predict independently 5-year survival. Results: The two groups did not differ in the severity of neurological deficit, basic demographic characteristics, risk factors (except sex, men 73.1% in group Β versus 66.6% in group Α, p=0.035 and hypercholesterolemia, 45.3% in group Β versus 38.2% in group Α, p=0.029). The 5-year survival in group B (clopidogrel) was 79.3% (95%CI 72.1-86.6) versus 70.0% (95%CI 66.3-73.7) in group A (aspirin), (log rank test 5.449, p=0.002) and the absolute relative reduction was 13% (95%CI: 9-18). In multifactorial analysis, therapy with clopidogrel versus aspirin was (among other factors) an independent prognostic factor for reduced 5-year overall mortality (Hazard ratio=1.51 with 95% CI 1.03-2.22, p=0.037). Conclusion: The study supports that in clinical practice clopidogrel is superior to aspirin in preventing death after acute ischemic non-cardioembolic ischemic stroke.
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G.Tsagalis, Acute Stroke Unit, Department of Clinical Therapeutics, University of Athens, Athens, GREECE
S.Skalidi   Acute Stroke Unit, Department of Clinical Therapeutics, University of Athens  Athens  GREECE
T.Pappa  Acute Stroke Unit, Department of Clinical Therapeutics, University of Athens  Athens  GREECE
I.Zafiriou  Acute Stroke Unit, Department of Clinical Therapeutics, Alexandra Hospital University of Athens   Athens  GREECE
Z.Barbaressou  Acute Stroke Unit, Department of Clinical Therapeutics, Alexandra Hospital University of Athens  Athens  GREECE
K.Spengos  Department of Neurology, University of Athens  Athens  GREECE
K.N.Vemmos  Acute Stroke Unit, Department of Clinical Therapeutics, University of Athens  Athens  GREECE
         
         
         
         
         
         
         
         

Kind of presentation: poster

Vascular imaging  
  
Poster Session Blue
Chairs:  

Date: Thursday 28 May 2009
Time: 12:30 - 14:00
Room:  

9.
CT angiographic evaluation of carotid plaque in symptomatic vs asymptomatic side in hemispheric TIA / stroke
Background Most studies on carotid disease are based on stenosis alone. We studied carotid plaque morphology using CT angiography (CTA) in TIA/stroke to identify additional factors that may predict plaque activity. Methods From June 2004 to August 2007, patients presenting with hemispheric TIA/stroke and who also had a carotid CTA within 24 hrs were studied retrospectively. CTA was performed using a multislice scanner with 1mm axial sections and sagittal reformats. Scans were interpreted by two blinded readers studying plaque length, width, density, shape, surface and calcification as well as intraluminal thrombus (ILT) in addition to stenosis. An ILT was defined as a pedunculated defect projecting into the vessel lumen. Results 673 patients (408 male, ages 18-91; Mean= 65.8) with good scans and who also had a hemispheric event were included. 349 patients had right-hemispheric symptoms and 324 left. The ipsilateral carotids served as cases (n=673) and the contralateral as controls. STATA software was used for analysis. Univariable logistic regression showed that occlusions [p=0.01], severe stenosis (70-99%) [p=0.06] and ILT [p=0.01] were predictive of symptomatic side. Some features were seen more with the control side such as smooth plaque [p=0.01] and extensive calcification [p=0.03]. There was no correlation between plaque hypodensity [p=0.7] or ulceration [p=0.74] in predicting symptomatic side. In a multivariable logistic regression model, accounting for age, gender and stenosis, ILT was still found to be significant [p=0.048] and extensive calcification seen more with the control side [p=0.047]. It also showed a graded increase in odds ratios as stenosis increased towards occlusion. Conclusion In addition to higher stenosis grades, presence of ILT is highly predictive of symptomatic side in carotid disease. Smooth plaque and severe calcification seems to be protective. This may be useful in radiological risk stratification in carotid disease in addition to stenosis.
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M.Eesa, University of Calgary, Calgary, CANADA
A.Al-Khatami   University of Calgary  Calgary  CANADA
P.Sharma  University of Calgary  Calgary  CANADA
MAl-Zawahmah  University of Calgary  Calgary  CANADA
S.Tymchuk  University of Calgary  Calgary  CANADA
M.Hill  University of Calgary  Calgary  CANADA
A.Demchuk  University of Calgary  Calgary  CANADA
M.Goyal  University of Calgary  Calgary  CANADA
         
         
         
         
         
         
         

Kind of presentation: poster

Etiology of Stroke  
  
Poster Session Blue
Chairs:  

Date: Thursday 28 May 2009
Time: 12:30 - 14:00
Room:  

16.
Microembolic signals due to solid microemboli detected with contrast-enhanced Transcranial Doppler may be associated with PFO-related TIA/stroke.
Background: Contrast-enhanced Transcranial Doppler (c-TCD) can reliably detect right-to-left shunt (RLS), which represents the necessary but not sufficient physiopathologic substrate for paradoxical embolism. The test is considered positive when microembolic signals (MES) due to gaseous microbubbles injected intravenously as contrast medium are recorded in the middle cerebral arteries. Multifrequency devices may discriminate gaseous microbubbles from solid microemboli, whose detection during c-TCD exam could be involved in cerebrovascular symptoms occurrence. Methods: We recorded the number of solid and gaseous MES during multifrequency c-TCD exam in 36 patients (21 females and 15 males, mean age 50 years, range 23-61) with RLS. 24/36 (66%) patients had a recent (>36 hours) cryptogenetic TIA/stroke, 12/36 (34%) migraine with aura. All patients performed transoesophageal echocardiography to evaluate the presence of atrial abnormalities such as patent foramen ovale (PFO) and interatrial sept aneurism (ISA). Results: All patients (36/36) had documented PFO and 2/36 (5.6%) ISA. Total number of microembolic signals was 502 and 86 were solid (17.1%). However, the number and the proportion of solid MES was much higher in patients with cryptogenetic TIA/stroke (78/400, 19.5%; mean 9.8, range 1-44) than in patients with migraine with aura (8/102, 7.8%; mean 2.0, range 1-3). Both patients with PFO and ISA were in the first group and had 30/64 (31.3%, mean 15.0) solid MES. Conclusion: The number and the proportion of solid MES detected during cTCD in patients with recent cryptogenetic TIA/stroke may be associated with PFO, especially if ISA is present. Further research is needed to validate and to better define this observation.
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A.Chiti, Department of Neuroscience, University of Pisa, Pisa, ITALY
G.Gialdini   Department of Neuroscience, University of Pisa  Pisa  ITALY
E.Giorli  Department of Neuroscience, University of Pisa  Pisa  ITALY
E.Terni  Department of Neuroscience, University of Pisa  Pisa  ITALY
G.Orlandi  Department of Neuroscience, University of Pisa  Pisa  ITALY
         
         
         
         
         
         
         
         
         
         

Kind of presentation: poster

Management and economics  
  
Poster Session Blue
Chairs:  

Date: Thursday 28 May 2009
Time: 12:30 - 14:00
Room:  

6.
USE AND COST OF PRESCRIPTION MEDICATION BEFORE AND AFTER ISCHEMIC STROKE IN FINLAND
BACKGROUND AND AIMS Stroke is a disease with multiple risk factors, most of which can be medically treated. Medication cost is one major cause of non-adherence to secondary prevention. We aimed to estimate the use of secondary preventive medication and its costs in ischemic stroke patients in Finland. METHODS We retrieved a record of all prescription medication purchases one year prior and one year post stroke by linking the national hospital discharge registry with the national registry of prescription medications. This analysis includes all ischemic stroke patients treated in Finnish hospitals in the year 2005 who were able to return home after their stroke and thus in a position to purchase medication. RESULTS There were 6975 ischemic stroke patients in Finland in the year 2005, 1389 of whom died early or were permanently institutionalized due to their stroke. Of the remaining 5586 patients 33% purchased varfarin, 32% aspirin+dipyridamole, and 10% clopidogrel within a year of their stroke. Some of these patients bought more than one type of antithrombotic medication, but 33% took only aspirin or nothing at all. The use of any antihypertensives was increased from pre-stroke 64% to post-stroke 78%. 53% used betablockers, 42% diuretics, 34% ACE inhibitors, 23% calcium channel blockers, and 22% ATR blockers after their stroke. Statin use increased from 25% to 58% after stroke. The total medication costs in 2008 values were 840 € one year prior and 1107 € one year post stroke. CONCLUSIONS 1/3 of stroke survivors are on suboptimal antithrombotic medication, 1/5 of them do not have any antihypertensive medication, and 2/5 of patients do not use a statin. Annual medication costs increase by 32% after a stroke. Optimal secondary prevention could potentially prevent hundreds of stroke recurrences. Medication use and adherence are useful quality indicators and should be routinely monitored where possible.
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A.Meretoja, Department of Neurology, Helsinki University Central Hospital, Helsinki, FINLAND
R.O.Roine   Department of Neurology, Turku University Central Hospital  Turku  FINLAND
M.Kaste  Department of Neurology, Helsinki University Central Hospital  Helsinki  FINLAND
T.Erilä  Department of Neurology, Tampere University Hospital  Tampere  FINLAND
M.Hillbom  Department of Neurology, Oulu University Hospital  Oulu  FINLAND
M.Juntunen  National Institute for Health and Welfare  Helsinki  FINLAND
M.Linna  National Institute for Health and Welfare  Helsinki  FINLAND
R.Marttila  Department of Neurology, Turku University Central Hospital  Turku  FINLAND
A.Rissanen  Department of Neurology, Central Finland Central Hospital  Jyväskylä  FINLAND
J.Sivenius  Department of Neurology, Kuopio University Hospital  Kuopio  FINLAND
U.Häkkinen  National Institute for Health and Welfare  Helsinki  FINLAND
         
         
         
         

Kind of presentation: oral

Experimental studies  
 A
 
Chairs: M. Endres, Germany and L. Hirt, Switzerland

Date: Wednesday 27 May 2009
Time: 14:10 - 14:20
Room: A4

2.
The NADPH oxidase Nox-1 mediates brain injury in experimental stroke
Cerebral ischemia and reperfusion is associated with the generation of reactive oxygen species (ROS). ROS are considered to contribute to the brain damage process. Mitochondria and the classic leukocyte-type NADPH oxidase are thought to be the significant sources of ROS in this scenario. Although the NADPH oxidase Nox-1 also produces ROS, nothing is known regarding its role for cerebral ROS formation and ischemia/reperfusion-induced brain injury. We studied this aspect in Nox-1 knockout-mice and their wildtype littermates. After isolation of cells from the murine brain, we demonstrated the expression of Nox-1 in astrocytes, neurons as well as endothelial cells using RT-PCR. Vascular architecture was similar between WT and KO animals as were filament-induced changes in cerebral blood flow in this model of transient focal cerebral ischemia. Lesion volume after one hour of ischemia and 23 hours of reperfusion however was significantly smaller in brains of KO as compared to those of WT mice (WT 77mm3 ± 10, KO 43mm3 ± 10 mean±sem, p<0,05). Accordingly, the clinical brain injury score was significantly lower in KO than in WT mice (modified Bederson score, WT: 1,5, KO: 0,9, p<0.05) We examined the integrity of the blood-brain-barrier in vivo with sodium fluorescein (SF) and Evans blue (EB) as permeability markers. Early BBB damage was significantly smaller in brains of KO as compared to those of WT littermates (SF: WT 149ng ± 19, KO 72ng ± 17, p<0,05). Consequently, brain edema formation was attenuated in KO mice (WT: 57mm3 ± 7, KO: 35mm3 ± 5 p<0.05). These data demonstrate that the Nox-1-containing NADPH oxidase is expressed in the murine brain and is a central event in the pathophysiology of stroke. Direct inhibition of NADPH oxidase may serve as a new approach to reduce brain injury after stroke.
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T.Kahles, JW Goethe University, Frankfurt, GERMANY
S.Heumueller   JW Goethe University  Frankfurt  GERMANY
A.Kohnen  JW Goethe University  Frankfurt  GERMANY
A.Rappert  JW Goethe University  Frankfurt  GERMANY
I.Bechmann  JW Goethe University  Frankfurt  GERMANY
S.Liebner  JW Goethe University  Frankfurt  GERMANY
I.M.Wittko  NINDS  Bethesda  USA
K.H.Krause  Centre Medical Universitaire  Geneva  SWITZERLAND
T.Neumann-Haefelin  JW Goethe University  Frankfurt  GERMANY
H.Steinmetz  JW Goethe University  Frankfurt  GERMANY
R.P.Brandes  JW Goethe University  Frankfurt  GERMANY
         
         
         
         

Kind of presentation: poster

Genetic disorders  
  
Poster Session Red
Chairs:  

Date: Wednesady 27 May 2009
Time: 12:30 - 14:00
Room:  

2.
No evidence for a potential role of mutations in the ACTA2 gene in the etiology of cervical artery dissections and thoracic aortic aneurysms
Background A recent study suggested that missense mutations in the actin gene ACTA2 are responsible for 14% of inherited ascending thoracic aortic aneurysms and dissections. In the present study we performed a mutational analysis of the ACTA2 gene in a series of patients with spontaneous cervical artery dissections (sCAD) as well as in patients with thoracic aortic aneurysms (TAA). Methods 71 MRI-confirmed sCAD patients (22 women and 49 men, mean age 43,3 +/- 9,8 years) and 37 TAA patients (treated by surgery; 9 women and 28 men, mean age 60,0 +/- 12,7 years) were studied. From all patients genomic DNA fragments were amplified with intron-based, exon-specific primers of the exons 2 to 9 of the ACTA2. We searched for mutations in the coding region of the ACTA2 gene by single strand conformational polymorphism analysis and nucleotide sequencing analysis. Results Sequencing analysis revealed only one not yet described missense mutation in exon 9 in one sCAD patient (I371T). In 6/71 sCAD patients and 3/37 TAA patients we found a known single-nucleotide polymorphism (SNP) in the non-coding intron sequence of exon 5. In 1TAA patient we detected a heterozygous missense mutation in the intron sequence of exon 6 and in an nother TAA patient a heterozygous mutation in exon 8. We did not find any mutation in exons 2, 3, 4 and 7. Conclusion In our series of sCAD patients and TAA patients we found one missense mutation in ACTA2. Our data suggest that mutations in the ACTA2 gene do not play an important role in the etiology of sCAD and TAA.
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T.Wiest, Department of Neurology, University of Heidelberg, Heidelberg, GERMANY
C.Grond-Ginsbach   Department of Neurology, University of Heidelberg  Heidelberg  GERMANY
I.Werner  Department of Neurology, University of Heidelberg  Heidelberg  GERMANY
D.Kotelis  Department of Vascular and Endovascular Surgery, University of Heidelberg  Heidelberg  GERMANY
P.Geisbuesch  Department of Vascular and Endovascular Surgery, University of Heidelberg  Heidelberg  GERMANY
D.Boeckler  Department of Vascular and Endovascular Surgery, University of Heidelberg  Heidelberg  GERMANY
         
         
         
         
         
         
         
         
         

Kind of presentation: oral

Epidemiology of stroke  
 A
 
Chairs: A. Tsiskaridze, Georgia and T. Truelsen, Denmark

Date: Wednesday 27 May 2009
Time: 15:00 - 15:10
Room: K2

7.
Metabolic syndrome is not associated with middle cerebral artery (MCA) stenosis and ischemic stroke in Chinese type II diabetic patients
Background: We aimed to assess the association of the metabolic syndrome with middle cerebral artery (MCA) stenosis and subsequent ischemic stroke in Chinese type ІІ diabetic patients. Methods:Transcranial Doppler was performed to define MCA stenosis. Anthropometric parameters (waist circumference and body mass index), blood pressure, and plasma biochemical (lipid and glycemic profiles) were compared between the patients with and without MCA stenosis at baseline. The occurrence of ischemic stroke during the follow-up was recorded and its association with metabolic syndrome was analyzed. Results: Totally, 2,197 type ІІ diabetic patients without symptoms of cerebrovascular disease were recruited. The evidence of MCA stenosis was identified in 272 subjects (12.4%), including 146 (53.7%) subjects with single-vessel involvement. The prevalence of hypertension (p=0.007, OR=1.638, 95% confidence intervals: 1.145-2.345), prevalence of retinopathy (p=0.005, OR=1.533, 95% confidence intervals: 1.138-2.066), age (p=0.001, OR=1.023, 95% confidence intervals: 1.009-1.037), and systolic blood pressure (p=0.012, OR=1.010, 95% confidence intervals: 1.002-1.018) were found to be independent predictors of the prevalence of MCA stenosis. Ischemic stroke occurred in one hundred and eighty-four (8.4%, 184/2197) patients, history of ischemic heart disease (p=0.006, OR=2.846, 95% confidence intervals: 1.353-5.985), MCA stenosis (p=0.009, OR=1.808, 95% confidence intervals: 1.157-2.826), the presence of retinopathy (p=0.005, OR=1.709, 95% confidence intervals: 1.180-2.475), lipid total cholesterol (p=0.032, OR=1.196, 95% confidence intervals: 1.016-1.407) and age (p<0.001, OR=1.065, 95% confidence intervals: 1.045-1.085) were independently associated with ischemic stroke. Neither MCA stnenosis nor ischemic stroke during follow-up period was found to be associated with metabolic syndrome. Conclusions: In Chinese type ІІ diabetic patients, metabolic syndrome seems to affect little on the presence of MCA stenosis and the occurrence of ischemic stroke.
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X.Y.CHEN, Chinsese University of Hong Kong, Hong Kong, HONG-KONG
          
         
         
         
         
         
         
         
         
         
         
         
         
         

Kind of presentation: poster

Epidemiology of stroke  
  
Poster Session Red
Chairs:  

Date: Wednesday 27 May 2009
Time: 12:30 - 14:00
Room:  

37.
First three years multi-region study оn stroke epidemiology in ореn population of 25-74 year-old mеn and women in Russia
Stroke incidence rate in Russia is оnе of the highest in the world, and mortality rate from stroke goes third after heart diseases and turmours of all locations. Within 2001 in Russia there were conducted the multi-region stroke epidemi¬ology index studies in districts in different climate and geografic areas with а Register method which showed difference of incidence, attack, mortality and case fatality from stroke (in borders of Health National project). The higher stroke epidemi¬ology index was registered in eastern regions of Russia as compared to the western ones. Standardized according to the European standard, stroke rate of incidence was 2,78 per 1000 population in Moscow and 4,71 per 1000 population in the East regions of Russia, the onset of the stroke was 0,79 too 1,75 per 1000 population as compared to Moscow and Sachalin. First open studies оn stroke epidemiology in ореn population of 25-74 years-old mеn and women in Russia were started in January 2009 and will be conducted during three years in twelve administrative regions of a large country, Russia. The purpose of the work is to study the rate of incidence, attack, mortality and case fatality from stroke in different regions of the country - in order to organize the proper treat¬mеnt and prevention of an acute stroke. The study will be executed with а Register method according to uniform criteria of Methodological Instruction of Russian National Association of Fight against Stroke. Conclusions: Results of first three years multi-region stroke epidemi¬ology index studies in Russia will be given, and they will show main stroke risk fac¬tors in incidence, attack and case fa¬tality of the stroke in a multi-national country.
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O.A.Кlochihina, Russian State Medical University, Moscow, RUSSIAN FEDERATION
L. V. Stachovskaya   Russian State Medical University  Moscow  RUSSIAN FEDERATION
V. I. Skvorsova  Russian State Medical University  Moscow  RUSSIAN FEDERATION
         
         
         
         
         
         
         
         
         
         
         
         

Kind of presentation: poster

Acute stroke: treatment and concepts  
  
Poster Session Red
Chairs:  

Date: Wednesday 27 May 2009
Time: 12:30 - 14:00
Room:  

33.
DO WOMEN HAVE MORE BENEFIT OF SYSTEMIC THROMBOLYSIS IN ACUTE ISCHEMIC STROKE?, Serbian Experience with Thrombolysis in Ischemic Stroke - SETIS study
Background and Purpose - Female sex is associated with increased stroke severity and poorer functional recovery. Evidence for sex disparity in response to thrombolysis for acute stroke treatment is confusing. Some studies demonstrated that women with stroke have more benefit of intravenous thrombolysis than men and others found nullification of gender effect among women treated with recombinant tissue plasminogen activator (rtPA). The purpose of our study was to determine any gender differences in the efficacy and safety of the systemic thrombolysis in patients with acute ischemic stroke in Serbia. Methods - Data were from the Serbian Experience with Intravenous Thrombolysis in Ischemic Stroke (SETIS) study, a prospective, ongoing, multicenter, open, observational study of all patients received rtPA for acute ischemic stroke in Serbia. We analyzed sex differences in baseline characteristics, functional outcome and treatment complications. Results - Among 60 women and 96 men with stroke, treated with intravenous thrombolysis, we found at 90 days no significant sex differences in excellent functional outcome (50.9% of women vs. 57.0% of men, p=0.5), favorable functional outcome (61.4% of women vs. 68.8% of men, p=0.38) or death (8.8% of women vs. 12.9% of men, p=0.60). These results stayed even after adjustments for age, severity of basal neurological deficit and onset to treatment time. Conclusion - There was no sex differences in functional outcome at 90 days after stroke among patients treated with IV rtPA. This confirms that thrombolytic therapy nullifies sex differences in stroke outcome and suggests that women with stroke have more benefit from rtPA treatment.
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for the SETIS Group
D.R.Jovanovic, Institute of Neurology, Clinical Centre of Serbia, Belgrade, SERBIA
Lj.Beslac-Bumbasirevic   Institute of Neurology, Clinical Centre of Serbia  Belgrade  SERBIA
M.Budimkic  Institute of Neurology, Clinical Centre of Serbia  Belgrade  SERBIA
T.Pekmezovic  Institute of Epidemiology, School of Medicine  Belgrade  SERBIA
M.Zivkovic  Department of Neurology, Clinical Centre Nis  Nis  SERBIA
         
         
         
         
         
         
         
         
         
         

Kind of presentation: poster

Intracerebral/subarachnoid haemorrhage and venous diseases  
  
Poster Session Blue
Chairs:  

Date: Thursday 28 May 2009
Time: 12:30 - 14:00
Room:  

20.
Intravenous Interleukin-1 Receptor Antagonist achieves experimentally neuroprotective cerebrospinal fluid concentrations within a therapeutic time window
Background: The cytokine interleukin-1 (IL-1) has been heavily implicated in experimental ischaemic brain injury. Its naturally occurring antagonist (IL-1RA) is highly neuroprotective. In humans, it shows few adverse effects and inhibits aspects of the systemic acute phase response to stroke. A pilot study showed penetration into cerebrospinal fluid (CSF) at experimentally-therapeutic concentrations, but this was achieved rather slowly. The optimal protocol for rapid delivery of IL-1RA in acute cerebrovascular disease remains unknown and is essential prior to testing biological efficacy in patients. Methods: 25 patients with subarachnoid haemorrhage (SAH) and external ventricular drains inserted for clinical reasons received intravenous (IV) IL-1RA as a bolus followed by a 4 hour infusion. Pharmacometric analysis (simulation) of pilot study data identified the administration regime that could potentially achieve experimentally-therapeutic CSF IL-1RA levels within 30 min (fig 1). For safety reasons, patients were sequentially allocated to five administration regimes. Each regime reflected a stepwise increase in peak plasma concentration of IL-1RA. Plasma and CSF sampling was performed at specified intervals as informed by a D-optimal design. Results: Plasma and CSF concentrations of IL-1RA in all five regimes fell within predicted intervals (fig 2). The regime leading to experimentally-therapeutic CSF concentrations of IL-1RA within 30 minutes in SAH patients was confirmed as a 500mg bolus followed by an IV infusion at 10 mg/kg/h. No significant adverse events were noted. Conclusion: It is possible to achieve experimentally neuroprotective CSF concentrations in patients with SAH within a reasonable therapeutic time window (30 minutes). Pharmacokinetic analysis suggests that IL-1RA transport across the blood-CSF barrier in SAH is passive. Identification of this delivery regime allows further studies of efficacy of IL-1RA in acute cerebrovascular disease.
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J.P.Galea, Brain Injury Research Group, University of Manchester, Salford Royal Foundation Trust & Faculty of Life Sciences, University of Manchester,, Manchester, UNITED KINGDOM
S.Hulme   Brain Injury Research Group, University of Manchester, Salford Royal Foundation Trust  Salford  UNITED KINGDOM
K.Ogungbenro  Centre for Applied Pharmacokinetics Research, University of Manchester  Manchester  UNITED KINGDOM
S.Scarth  Brain Injury Research Group, University of Manchester, Salford Royal Foundation Trust  Salford  UNITED KINGDOM
M.Hoadley  Brain Injury Research Group, University of Manchester, Salford Royal Foundation Trust  Salford  UNITED KINGDOM
S.Grainger  Department of Neurosurgery, University of Cambridge, Addenbrooke's Hospital,   Cambridge  UNITED KINGDOM
K.Carpenter  Department of Neurosurgery, University of Cambridge, Addenbrooke's Hospital,   Cambridge  UNITED KINGDOM
P.Hutchinson  Department of Neurosurgery, University of Cambridge, Addenbrooke's Hospital,   Cambridge  UNITED KINGDOM
A.King  Department of Neurosurgery, University of Manchester, Salford Royal Foundation Trust  Salford  UNITED KINGDOM
L.Aarons  Centre for Applied Pharmacokinetics Research, University of Manchester  Manchester  UNITED KINGDOM
S.Hopkins  Brain Injury Research Group, University of Manchester, Salford Royal Foundation Trust  Salford  UNITED KINGDOM
N.J.Rothwell  Faculty of Life Sciences, University of Manchester  Manchester  UNITED KINGDOM
P.J. Tyrrell  Brain Injury Research Group, University of Manchester, Salford Royal Foundation Trust  Salford  UNITED KINGDOM
         
         

Kind of presentation: poster

Epidemiology of stroke  
  
Poster Session Red
Chairs:  

Date: Wednesday 27 May 2009
Time: 12:30 - 14:00
Room:  

26.
The Influence of Gender on Stroke and Outcome Post-Stroke.
Introduction: While stroke incidence rates are lower in women across all age groups, it has been shown that women, who comprise an increasing percentage of our ageing population, have a worse outcome post-stroke than men. The aim of this study was to assess if there was any difference in outcome in women admitted to our hospital with acute stroke, compared with men. Methods: Since August 2003, the clinical details of all stroke patients admitted to the Acute Stroke Unit at St. Mary’s Hospital have been entered into a detailed database.This was interrogated looking at consecutive admissions from August 2003 to June 2008, to assess if there were any significant differences between men and women with regard to vascular risk factors, stroke type and and in particular clinical outcome. Results: Of 1014 patients, 546 were male and 468 were female. The mean age(SD) of men was 68.64 +/-13.71 years and for women 73.92 +/-12.33 years(p<0.001). 75.1% of men had an admission Modified Rankin Score of 0, versus 68.5% of women(p=0.01). With regard to risk factors, men were more likely to have a history of smoking(48.9% versus 23.1%, p < 0.001) and peripheral vascular disease (8.9% versus 5.3%, p =0.04), while women were more likely to have atrial fibrillation(26.8% versus 15.8%, p<0.001). There was no significant difference between men and women with regard to stroke type using the Bamford Classification. Outcome data was available for 91% of patients and showed no significant difference between men and women with regard to inpatient mortality, length of stay or likelihood of being discharged home. Conclusion: The longer life-expectancy of women, and the direct relationship between advanced age and stroke risk suggests that older women will bear the major burden of the disease in the future. Female patients admitted to our hospital with an acute stroke are older and more dependent on admission than male patients. This does not, however, translate into female patients having a worse clinical outcome than men.
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J.Mc Manus, St Mary's Hospital, London, UNITED KINGDOM
T.Adesina   St. Mary's Hospital  London  UNITED KINGDOM
M.Bhargava  St. Mary's Hospital  London  UNITED KINGDOM
B .Affley  St Mary's Hospital  London  UNITED KINGDOM
S.Banerjee  St. Mary's Hospital  London  UNITED KINGDOM
R.Perry  St Mary's Hospital  London  UNITED KINGDOM
D.Ames  St Mary's Hospial  London  UNITED KINGDOM
         
         
         
         
         
         
         
         

Kind of presentation: poster

Vascular surgery and neurosurgery/interventional neuroradiology  
  
Poster Session Red
Chairs:  

Date: Wednesday 27 May 2009
Time: 12:30 - 14:00
Room:  

4.
Predictors of Hemorrhagic transformation after Multimodal Intra-arterial Reperfusion Therapy for Acute Ischemic Stroke
Background: Although many studies have identified factors that may lead to HT after intravenous thrombolysis, factors relate to HT after multimodal IA therapy are still unclear. We investigated predictors of HT in patients treated with multimodal IA therapy. Methods: We retrospectively reviewed patients with acute ischemic stroke who presented within 6 hours of symptom onset and was treated with thrombolytics infusion, mechanical thrombus disruption with a microcatheter, ballooning angioplasty, or/and stent deployment. We collected information about demographics, baseline National Institutes of Health Stroke Scale (NIHSS) scores, and treatment methods of these patients. HT was diagnosed using gradient echo MR imaging or CT at 12-24 hours after IA therapy and classified into hemorrhagic infarction (HI) type 1 and 2, parenchymal hemorrhage (PH) type 1 and 2. Also HT was classified into asymptomatic hemorrhage and symptomatic. Results: We identified 157 patients with median NIHSS score of 14.3 (range, 4-30). Among 157 patients, 47 (29.9%) had HI, 42 (26.8%) had PH, and 20 (12.7%) had symptomatic hemorrhage. PH was significantly more frequent in patients who had low initial NIHSS score, IA urokinase alone, and combination therapy with intravenous rt-PA. Symptomatic hemorrhage was associated with high initial NIHSS score and occlusion of the distal internal carotid artery (dICA). In multiple logistic regression analysis, PH after multimodal IA therapy is significantly associated with initial NIHSS score OR 1.09; 95% CI 1.03-1.17; p<0.01) and glucose (OR 1.01; 95% CI 1.00-1.01; p=0.04) and symptomatic hemorrhage is significantly associated with the occlusion of the dICA (OR 3.44 95%; CI 1.08-3.44; p=0.04). Door to needle time, age, sex, tandem occlusion, recanalization, and platelet count were not related to PH and symptomatic hemorrhage. Conclusion: Multimodal IA therapy in patients with acute ischemic stroke may be increase the incidence of hemorrhage complication. Especially high initial NIHSS score, high glucose and occlusion of the dICA were associated with hemorrhagic transformation after multimodal IA therapy.
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S. I.Sohn, Depart. of Neurolology, Dongsan Medical Center, Keimyung University, Daegu, SOUTH KOREA
K. H.Cho   Depart. of Neurolology, Dongsan Medical Center, Keimyung University  Daegu  SOUTH KOREA
H. W.Chang  Depart. of Radiology, Dongsan Medical Center, Keimyung University  Daegu  SOUTH KOREA
S. W.Park  Depart. of Neurology, Daegu Fatima Hospital  Daegu  SOUTH KOREA
         
         
         
         
         
         
         
         
         
         
         

Kind of presentation: poster

Vascular surgery and neurosurgery/interventional neuroradiology  
  
Poster Session Red
Chairs:  

Date: Wednesday 27 May 2009
Time: 12:30 - 14:00
Room:  

9.
Reduction in time to carotid endarterectomy is achieved by streamlining referrals of symptomatic carotid stenosis to vascular surgery
Background Carotid endarterectomy (CEA) within two weeks of transient ischaemic attack (TIA) or ischaemic stroke significantly improves outcomes compared with later surgery. We audited our practice in 2006 and found major delays to CEA. Changes have since been made: carotid imaging is prioritised; referral of inpatients with surgical grade stenosis is expedited by same-day telephone referral to vascular surgery; and CEA patients are pre-booked on the next available operating list. This study evaluates the impact of these changes. Methods Data was collected retrospectively for new ischaemic stroke clinic and in-patients referred to stroke services at a single urban teaching hospital from 21/1/08 to 23/7/08 (n=360 post-intervention) and compared with a retrospective patient cohort from 4/1/06 to 28/6/06 (n=342 pre-intervention). Surgical grade stenosis was defined as extracranial internal/common carotid artery stenosis of 70%-99% (European carotid surgery trialists criteria). Results In 2008, 268/360 (74%) patients had anterior circulation ischaemia. Carotid imaging was performed on 190 (70.9%) with 19 (10%) having surgical grade stenosis and 11 (5.8%) having CEA. In 2006, 234/342 (68%) patients had anterior circulation ischaemia. Carotid imaging was performed on 188 (80.3%) with 17 (9%) having surgical grade stenosis and 10 (5.3%) having CEA. Time from symptom onset to CEA was reduced from a median of 109 days pre-intervention to 15 days post-intervention (p=0.001, Mann Whitney U test). In 2006, no patient had CEA within 2 weeks and 1/10 (10%) within 3 weeks; in 2008, 5/11 (45.5%) had surgery within 2 weeks and 9/11 (81.8%) within 3 weeks. Conclusions A major reduction in time from ischaemic stroke or TIA to CEA in patients with symptomatic surgical-grade carotid stenosis was achieved by prioritising imaging and effecting simple changes in referral practice including same day telephone referral to vascular surgery and streamlining booking for operating theatre.
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L.A.Anderton, Glasgow Royal Infirmary, Glasgow, UNITED KINGDOM
F.Wright   Glasgow Royal Infirmary  Glasgow  UNITED KINGDOM
D.Stott  Glasgow Royal Infirmary  Glasgow  UNITED KINGDOM
G.Kerr  Glasgow Royal Infirmary  Glasgow  UNITED KINGDOM
P.Teenan  Glasgow Royal Infirmary  Glasgow  UNITED KINGDOM
G.Roditi  Glasgow Royal Infirmary  Glasgow  UNITED KINGDOM
         
         
         
         
         
         
         
         
         

Kind of presentation: poster

Genetic disorders  
  
Poster Session Red
Chairs:  

Date: Wednesady 27 May 2009
Time: 12:30 - 14:00
Room:  

8.
LOMBARDIA GENS: a regional network for the investigation of genetics of stroke
Background: Physicians should be able to recognize stroke caused by mendelian disorders, since some genetic disorders have proven disease-specific treatments or alternatively a proper diagnosis of a genetic disorder prevents patient exposure to unnecessary therapies and diagnostic tests. Lombardia region has a favourable context characterised by an existing neurological network of centres with high level stroke care and diagnosis and by the presence of high technologies laboratories focused on stroke genetics. Lombardia GENS is a regional network of investigators co-operating, within a prospective multicenter cohort study to evaluate the regional incidence of 6 stroke monogenic diseases ( CADASIL, FABRY DISEASE, MELAS, FAMILIAL HEMIPLEGIC MIGRAINE (FHM), HEREDITARY CEREBRAL AMYLOID ANGIOPATHY, MARFAN SYNDROME). Population studied: all stroke/TIA patients fulfilling the criteria for a suspected monogenic disease, identified by the participant stroke centres during 2008/09. Interventions: Patient demographical, clinical and familial history data are being collected within a standardised form. For each suspected case the ‘diagnostic criteria form’ is also filled in and sent together with clinical data form and blood sample to the specific laboratory for genetic analysis. The final results will be the creation of an homogeneous database and a DNA biobank of all suspected cases for the 6 monogenic diseases, identified during the two years of the study. A carefully collected series covering a wide part of Lombardia land will allow regional incidence studies on monogenic diseases and the implementation of therapeutic trials. This population could be joined to other existing national or international series. Outcome measures: Incidence studies of monogenic disease in Lombardia Region. Differences between different phenotypes (TOAST classification, neuroimaging and risk factors) of ischemic stroke patients in relation to different mutations/genotypes.
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on behalf of Lombardia GENS collaborators
A.Bersano, Fondazione IRCCS Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, Milan, ITALY
E.Ballabio   Fondazione IRCCS Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena  Milan  ITALY
P.Baron  Fondazione IRCCS Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena  Milan  ITALY
G.Boncoraglio  Istituto Nazionale C Besta  Milan  ITALY
E.Parati  Istituto Nazionale C Besta  Milan  ITALY
C.Motto  Azienda Ospedaliera Niguarda Ca’ Granda   Milan  ITALY
R.Sterzi  Azienda Ospedaliera Niguarda Ca’ Granda   Milan  ITALY
C.Ferrarese  Azienda Ospedaliera San Gerardo  Monza  ITALY
M.Corato  IRCCS Istituto Clinico Humanitas  Rozzano  ITALY
G.Micieli  IRCCS Istituto Clinico Humanitas  Rozzano  ITALY
M.Sessa  IRCCS Fondazione San Raffaele del Monte Tabor  Milan  ITALY
G.Comi  IRCCS Fondazione San Raffaele del Monte Tabor  Milan  ITALY
A.Pezzini  Spedali Civili di Brescia  Brescia  ITALY
A.Padovani  Spedali Civili di Brescia  Brescia  ITALY
L.Candelise  Fondazione IRCCS Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena  Milan  ITALY

Kind of presentation: poster

Epidemiology of stroke  
  
Poster Session Red
Chairs:  

Date: Wednesday 27 May 2009
Time: 12:30 - 14:00
Room:  

4.
Marked reduction in cardiovascular deaths in stroke patients. A Northern Sweden MONICA Stroke Registry study.
Background Decreased mortality, and stroke severity, in stroke patients has been reported from several countries. The cause of death in stroke patients is less well studied and the aim of this study was to investigate changes in the patterns of mortality and causes of death. The Northern Sweden MONICA Stroke registry records stroke events in the north of Sweden since 1985. It has been shown that the registry captures 95% of the stroke cases in the region. Methods First ever stroke events in the ages 24 to 74, between January 1, 1985 and December 31, 2003, were identified in the stroke registry. WHO stroke criteria was applied. Subarachnoidal hemorrhages were excluded. Four time-periods were compared in the analyses (1985-1989, 1990-1994, 1995-1999, 2000-2003). Death, and cause of death, at 7, 28, 90, 365 and 730 days were analyzed. Results There were 11 594 cases identified. Mean age 64,5 years, 61% men, 39% women, with no significant changes over time. Mortality declined significantly over time at all time points, comparing the first to the fourth time-period, at 2 years (29,3% to 18,0%), at 7 days (10.3% to 7.5%). Death at 2 years in stroke-related and other cardiovascular causes was reduced, 12.3 to 8.4% and 9.2 to 4,6% respectively. No reduction in deaths related to infection, malignancy or other causes was found, nor was any sex-differences observed. Subsequent analyses of the distribution of deaths over the different periods: 0-7,8-28, 29-90, 91-365 and 366-730 days, showed a consistent trend of reduction in later phases but a higher proportion of deaths was occurring early (0-7) in 2000-2003 compared to in 1985-1989, p 0.02. Conclusion Mortality in stroke patients has declined between 1985 and 2003 in the north of Sweden. The reduction is seen both early and late after stroke and can be ascribed to lower cardiovascular death rates. The less pronounced reduction in the acute phase may have implications for the further development of stroke care.
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E.Uneus, Dept of Medicine, Umeå University, Umeå, SWEDEN
M.Eriksson   Dept of Medicine, Umeå University  Umeå  SWEDEN
P.-G.Wiklund  Dept of Medicine, Umeå University  Umeå  SWEDEN
         
         
         
         
         
         
         
         
         
         
         
         

Kind of presentation: oral

Chronic conditions and rehabilitation  
  
 
Chairs: M. Brainin Austria and J. Bernhardt, Australia

Date: Thursday 28 May 2009
Time: 9:40 - 9:50
Room: K21

2.
Intensive motor training combined with early supported discharge after treatment in a comprehensive stroke unit. A randomised controlled trial
Background: Stroke unit (SU) care with focus on early mobilisation improves functional outcome after stroke. An additional beneficial effect is seen when SU care is followed by an early supported discharge service (ESD). The aim of the present study was to evaluate the effect of intensive motor training combined with ESD after initial treatment in an SU. Methods: A single blinded randomized controlled trial. Patients with mild to moderate stroke with reduced motor function were included within 2 weeks after onset of stroke and allocated to a control group (CG) treated in a comprehensive SU with ESD or to an intervention group (IG) receiving intensive motor training with focus on balance and walking ability in addition. The additional motor training comprised home exercises twice a day and three sessions with physiotherapy each week for the first four weeks after discharge. Primary outcome measure was Berg Balance Scale. Secondary measures were Motor Assessment Scale (MAS), Barthel Index, Timed Up and Go and gait speed (GS) assessed 4 weeks after discharge and 26 weeks after stroke. Results: Sixty-two patients (mean age 76.5±8.8, male 47%) were included. ANCOVA adjusting for stroke severity showed a greater improvement on MAS and GS for the IG (n=30) compared to the CG (n=32). Mean MAS score (max 48 points) was; 35.4±10.1 vs. 33.0±11.1, p=0.040 at 4 weeks; 38.5±9.6 vs. 36.3±10.6, p=0.037 at 26 weeks. Mean GS was 0.81±0.29 vs. 0.67±0.27, p=0.067 at 4 weeks; 0.90±0.30 vs. 0.69±0.35, p=0.047 at 26 weeks respectively. There were no statistically significant differences between the groups for any other outcome measures. Conclusion: Intensive motor training combined with ESD did not significantly improve balance or dependency. However, the intervention seems to have a beneficial effect on overall motor function and gait speed. Improved motor function and gait speed is a clinically important finding and this intensive training concept should be tested out in a larger trial.
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T.Askim, Norwegian University of Science and Technology, Department of Neuroscience, Trondheim, NORWAY
S.Mørkved   St. Olavs Hospital, Trondheim University Hospital, Clincal Services  Trondheim  NORWAY
B.Indredavik  Norwegian University of Science and Technology, Department of Neuroscience  Trondheim  NORWAY
         
         
         
         
         
         
         
         
         
         
         
         

Kind of presentation: poster

Epidemiology of stroke  
  
Poster Session Red
Chairs:  

Date: Wednesday 27 May 2009
Time: 12:30 - 14:00
Room:  

14.
Predictors of mortality in patients with first-ever stroke in Tbilisi, Georgia: A prospective population-based study
Background: Stroke is one of the major public health problems worldwide. However, information about epidemiological patterns of the disease in developing countries is scarce. The purpose of the present study was to determine predictors of mortality after stroke using the data from the joint Swiss-Georgian project on stroke epidemiology in Tbilisi, capital of Georgia, a country with transition economy in the South Caucasus region. Methods: We followed-up a cohort of 233 first-ever stroke patients identified prospectively from 2000 to 2003 in Sanzona district of Tbilisi. All cases of mortality in the cohort were registered and analyzed by using overlapping sources of information and standard diagnostic criteria. Results: Since November 2000 to date, 183 (79%) stroke patients have died. One-month case-fatality was 35%. Fifty-one percent of patients died at one year. By using multivariate Cox proportional-hazards analysis, predictors of early (≤ 1 month from index stroke) mortality were hemorrhagic nature of stroke (Hazard Ratio {HR} 3.2; 95% Confidence Interval {CI} 1.3-11.8) and severe initial neurological deficit as defined by NIHSS >7 (HR 2.6; 95%CI 1.2-19.5), while predictors of intermediate (>1 month and ≤1 year) mortality were diabetes mellitus (HR 1.8; 95%CI 1.2-26.0), cardiac comorbidity (HR 1.5; 95%CI 1.1-21.9) and advanced age (>65 years) (HR 1.4; 95%CI 1.1-24.3). Late (>1 year) mortality was associated merely with advanced age (HR 2.1; 95%CI 1.4-18.3) and cardiac comorbidity (HR 2.5; 95%CI 1.3-20.1) Conclusion: Mortality after stroke in Tbilisi, Georgia is substantially high. This may be due to inadequacy of stroke service and shortages in the secondary preventive measures, which requires special attention of public health authorities. Predictors of mortality in Georgian population do not differ markedly from those reported in other population-based registries.
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A.Tsiskaridze, Department of Neurology and Neurosurgery, Tbilisi State University, Tbilisi, GEORGIA
M.Djibuti   School of Public Health, Tbilisi State Medical University  Tbilisi  GEORGIA
T.Vashadze  Department of Neurology and Neurosurgery, Tbilisi State University  Tbilisi  GEORGIA
I.Burduladze  Institute of Neurology  Tbilisi  GEORGIA
I.Gauarashvili  Institute of Neurology  Tbilisi  GEORGIA
S.Apridonidze  Institute of Neurology  Tbilisi  GEORGIA
R.Shakarishvili  Department of Neurology and Neurosurgery, Tbilisi State University  Tbilisi  GEORGIA
P.Michel  Department of Neurology, CHUV  Lausanne  SWITZERLAND
         
         
         
         
         
         
         

Kind of presentation: oral

Acute stroke: clinical patterns and practice  
  
 
Chairs: M. Hommel, France and A.-C.Jönsson, Sweden

Date: Wednesday 27 May 2009
Time: 8:40 - 8:50
Room: A3

2.
Interest of a validated food frequency questionnaire in clinical practice: An unfavorable dietary score is associated with ischemic stroke and carotid atherosclerosis.
Background and Purpose: Ischemic strokes represent more than 80% of total strokes in Western Countries. The influence of dietary factors is debated and data are limited. We assessed the dietary pattern of ischemic stroke patients under 65 using a validated 14-item food frequency questionnaire (FFQ). Methods: We performed a prospective multi-center study in France. Ischemic stroke patients of under 65 (n=124) were consecutively included and compared with 50 controls. Intake scores for saturated (SFA), monounsaturated (MUFA), omega-3 (omega-3PUFA) and omega-6 polyunsaturated (omega-6PUFA) fatty acids, fruit and vegetables (F-V) and an overall dietary score were evaluated with the FFQ. Results: In stroke patients (mean+/-SD; 52+/-10 years old), 81 (65%) were men. TOAST 1, 2, 3, 4, 5 represented 10%, 7%, 5%, 12%, and 65% respectively. Stroke patients, as compared to controls, had a higher SFA score (6.6±3.0 vs. 4.9±2.7, p < 0.001), lower scores for MUFA (0.8±0.9 vs. 1.5±1.2, p < 0.001), omega-3 PUFA (1.7±1.6 vs. 2.2±1.5, p= 0.013), omega-6PUFA (2.6±2.5 vs. 3.9±2.7, p=0.002), F-V (2.9±1.7 vs. 3.8±1.6, p = 0.005), and a lower overall dietary score (-1.2±5.0 vs. 2.5±4.4, p<0.001). Stroke patients with carotid atherosclerosis (n=54) had a worse overall dietary score than those without (n=68): -2.2±4.4 vs. -0.2±5.2, p= 0.024. Conclusion: This study showed that an unfavorable dietary score is associated with ischemic stroke, especially in patients with carotid atherosclerosis. The 14-item food questionnaire would be useful to assess dietary pattern in ischemic patients. Stroke patients should benefit from dietary nutritional advices, especially if atherosclerosis is detected.
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G.MAHE, University Hospital, Angers, FRANCE
T.RONZIERE   University Hospital  Rennes  FRANCE
B.LAVIOLLE  University Hospital  Rennes  FRANCE
V.GOLFIER  General Hospital  Saint Brieuc  FRANCE
T.COCHERY  General Hospital  Vannes  FRANCE
F.PAILLARD  University Hospital  Rennes  FRANCE
         
         
         
         
         
         
         
         
         

Kind of presentation: poster

Interesting cases  
  
Poster Session Red
Chairs:  

Date: Wednesday 27 May 2009
Time: 12:30 - 14:00
Room:  

40.
CAROTID AND VERTEBRAL DISSECTION IN FIBROMUSCULAR DYSPLASIA - ENDOVASCULAR TREATMENT
Background: Fibromuscular dysplasia (FMD) is an idiopathic, segmental, non-inflammatory and non-atherosclerotic disease of the arterial walls’ musculature, most frequently affecting renal and carotid arteries. It most commonly occurs in middle aged women. Neurological symptoms are seldom present. Arterial dissection is one of the possible mechanisms leading to stroke. Antiplatelet drugs, hypocoagulation, percutaneous angioplasty or surgical repair are therapeutical options for these patients. Case report: A 39-year-old female, was admitted to the hospital because of transient motor dysphasia. Cerebral MRI-DWI showed a signal hyperintensity at the left posterior insular area. Cervical duplex imaging was compatible with left internal carotid artery (ICA) dissection. Angiography revealed extensive dissection of the left ICA with severe stenosis, impossible to catheterize. It also showed a dysplasic right ICA with distal dissection and dissection of the left vertebral artery with irregular stenosis of V2 segment. A Precise® stent was placed in distal right ICA. The morphologic aspects suggested FMD. The patient was discharged on antiplatelets and hypocoagulants. The angiographic re-evaluation performed three weeks later showed spontaneous improvement of the left vertebral dissection and persistent stenosis of the proximal right ICA immediately below the stent placed before. A new Precise® stent was placed at the origin of the right ICA. A severe stenosis persisted in the left ICA. A new angiography performed three months later showed complete resolution of the parietal abnormalities of the supraaortic arteries with only mild focal dissection at the origin of left ICA. The patient is under antiplatelet therapy and completely asymptomatic since then (14 months follow-up). Conclusions: Dissection of the cervical arteries with subsequent ischemic cerebral events is one of the possible complications of FMD. The endovascular treatment with angioplasty and stenting may be a safe and efficacious option in selected patients with cervical stenosis/dissections due to FMD.
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A.A.Silva, Serviço de Neurologia - Centro Hospitalar de Lisboa Central, EPE, Lisboa, PORTUGAL
M.Manita   Serviço de Neurologia - Centro Hospitalar de Lisboa Central, EPE  Lisboa  PORTUGAL
J.Alcântara  Serviço de Neurologia - Centro Hospitalar de Lisboa Central, EPE  Lisboa  PORTUGAL
J.M.Candido  Unidade de Angiografia - Centro Hospitalar de Lisboa Central, EPE  Lisboa  PORTUGAL
J.Reis  Unidade de Angiografia - Centro Hospitalar de Lisboa Central, EPE  Lisboa  PORTUGAL
         
         
         
         
         
         
         
         
         
         

Kind of presentation: poster

Regional/national stroke aspects (EU and beyond)  
  
Poster Session Blue
Chairs:  

Date: Thursday 28 May 2009
Time: 12:30 - 14:00
Room:  

13.
Subacute Casemix Classification for Stroke Rehabilitation. Does It Help?
Background: The Australian National Subacute Non Acute Patient (AN-SNAP) casemix classification was developed for sub and non-acute care for both clinical and funding purposes. Aim: The aim of this review was to analyse various models to explain the variance in length of stay (LOS), discharge destination and functional improvement of patients with stroke in an inpatient rehabilitation unit. Method: All patients admitted to our unit for inpatient rehabilitation with a diagnosis of recent stroke; the Oxfordshire classification subgroup, sociodemographic data, and functional data were identified. The data were analysed using principal components analysis for categorical data (CATPCA) to identify the major underlying factors contributing to variance in outcomes. A categorical regression model was utilised to determine the percentage of variance of the individual variables. Results: 1154 patients were included in the study. Three models for explanation for variance for LOS demonstrated 1. Admission motor Functional Independence Measure (FIM) score: 38.9% increasing to 40.2% if age at admission is added. 2. Total FIM 35.2% (36.8% incl. age). 3. AN SNAP v2: 33.4%. Variance for functional improvement as measured by FIM gain: 1. Admission motor FIM 37.4% (40.5% incl. age). 2. Total FIM 35.7% (38.8% incl. age). 3. AN SNAP v2: 32.3% (33.5% incl. age). Variance for discharge destination: 1. Admission motor FIM 16%. 2. Total FIM 15.7%,. 3. AN SNAP v2: 4.2%. Conclusion: Both the admission motor FIM as well as the admission total FIM were better predictors of variance of LOS, discharge destination or functional improvement than AN SNAP v2 in our rehabilitation service.. This needs to be taken into account when using casemix classification for clinical or funding purposes and it would be preferable to have a classification which explains more of the variance than AN-SNAPv2.
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J.J.Estell, St George and Braeside Hospitals, Kogarah, AUSTRALIA
F.Kohler   Braeside and Liverpool Hospitals  Liverpool  AUSTRALIA
R.Renton  Braeside and Liverpool Hospitals  Liverpool  AUSTRALIA
H.Dickson  Liverpool Hospital  Liverpool  AUSTRALIA
C.Connolly  Braeside Hospital  Wetherill Park  AUSTRALIA
         
         
         
         
         
         
         
         
         
         

Kind of presentation: poster

Epidemiology of stroke  
  
Poster Session Red
Chairs:  

Date: Wednesday 27 May 2009
Time: 12:30 - 14:00
Room:  

49.
Marital status influences prevalence and severity of stroke in mid-aged patients
Background and purpose Mid-aged stroke (40’s and 50’s) is an important social issue because the sufferers are in general actively working members of the society and family. Alterations of marital status have been associated with higher incidence and poorer prognosis of coronary heart disease in the mid-aged population. Up to now, however, the impact of marital status influencing the stroke occurrence has not been elucidated in mid-aged patients with ischemic stroke. We intended to examine the relationship between the marital status and characteristics of ischemic stroke patients. Methods Of all acute ischemic stroke patients who were less than 60 years old and consecutively admitted to a referral hospital between January 2006 and July 2008, a total of 249 eligible patients were enrolled excluding those younger than 40. The subjects were divided into stable (married) and unstable marital status (divorce, dissolution and widowed) groups. Effects of the demographics, conventional stroke risk factors (hypertension, diabetes, smoking, previous stroke history or cardiac disease), and stroke mechanisms were separately examined for the age groups of 40s and 50s. Results Of 249 eligible patients (mean age: 50.9+/-5.9, male: 73%), 106 were 40-49 years of age and 143 were 50-59 years of age. There were no significant differences in the baseline demographics, stroke risk factors, or stroke mechanisms. However, in the 40 to 49 age group, current smoking (72% vs. 48%, p=0.037) and cardiac disease (24% vs. 8%, p=0.024) were significantly higher in the unstable compared to the stable marital. Also, initial stroke severity (p=0.016), cardioembolism proportion (p=0.011), and the proportion of 40s male (p=0.003) were significantly higher in the unstable marital status group. Conclusion These findings suggest that unstable marital status might be an important trigger for the acute ischemic stroke occurrence, particularly for males in their 40s. As compared to the stable marital status group, initial stroke severity and cardioembolic mechanism were significantly higher in the unstable group, which was more distinctive in the males in their 40s.
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I.S.Joo, Department of Neurology, Ajou University Hospital School of Medicine, Suwon, SOUTH KOREA
J.M.Hong   Department of Neurology, Ajou University Hospital School of Medicine  Suwon  SOUTH KOREA
J.H.Lee  Department of Neurology, Ajou University Hospital School of Medicine  Suwon  SOUTH KOREA
W.Y.Li  Department of Neurology, Ajou University Hospital School of Medicine  Suwon  SOUTH KOREA
         
         
         
         
         
         
         
         
         
         
         

Kind of presentation: oral

Acute stroke: treatment and concepts  
 C
 
Chairs: A. Alexandrov, USA and V. Di Piero, Italy

Date: Wednesday 27 May 2009
Time: 16:15 - 16:25
Room: A2

22.
Implant for Perfusion Augmentation Clinical Trial -1 (ImPACT-1). A pilot study evaluating the safety and effectiveness of the Ischemic Stroke System (ISS*) for treatment of Acute Ischemic Stroke
Background: The Sphenopalatine Ganglion (SPG) is a source of vasodilating parasympathetic innervation to the anterior cerebral circulation. In rat stroke models, stimulation of the SPG, results in augmented cerebral blood flow, reduced infarct volume and improved neurological outcome. We present safety and effectiveness data of SPG stimulation within 24 hours of stroke onset in acute ischemic stroke (AIS) patients. Design: A multi-national, open-label study, recruited anterior circulation AIS patients, NIHSS 7-20. The ISS was implanted adjacent to the SPG via the greater palatine canal using a minimal invasive approach. Treatment consisted of 3-4hr daily stimulation for 5-7 days. Primary endpoint was safety reflected by incidence of adverse events; secondary endpoint was effectiveness measured by mRS and NIHSS at 90 days. Results: 98 patients enrolled; To date, 75 completed the study, mean age 57yrs, mean treatment time from stroke onset 19hrs, mean baseline NIHSS 12. The observed mortality rate is within the expected range for patients with similar baseline stroke severity: 12.2% (12/98 pts). The observed incidence and nature of serious adverse events is comparable to similar studies. No mortality cases or serious adverse events were deemed related to treatment. 63 patients completed treatment per protocol and were compared to matched patients from the NINDS control arm (baseline NIHSS 7-20): 52.5% of SPG-stimulated patients had favorable mRS outcome at 90 days (mRS 0-2) as compared to 29% of the matched patients (p=0.001). When analyzing the shift in mRS distributions using the CMH test, the SPG-stimulation group has significantly superior outcome than matched controls (p< 0.0001). Conclusion: SPG stimulation initiated within 24hr from stroke onset appears to be safe and efficacious. We are currently initiating a multinational, multicenter, randomized, sham controlled, pivotal trial (ImPACT-24) to further evaluate SPG stimulation safety and effectiveness in AIS. * The ISS is an investigational device limited for investigational use.
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for the ImPACT-1 study group.
N.M.Bornstein, Department of Neurology Tel Aviv Sourasky Medical Center, Tel-Aviv, ISRAEL
          
         
         
         
         
         
         
         
         
         
         
         
         
         

Kind of presentation: poster

Acute stroke: emergency management, stroke units and complications  
  
Poster Session Blue
Chairs:  

Date: Thursday 28 May 2009
Time: 12:30 - 14:00
Room:  

27.
University Hospital and Prehospital Service Cooperation for Thrombolysis in a Developing Country.
Background - In Brazil only a few centers do thrombolytic therapy (TT) for hyperacute ischemic stroke (HIS). The aim of this study is analyze the first six months of an inter-institutional protocol for treatment of HIS. Methods - We prospectively analyzed 50 patients, mean age of 64.36 + 15.84 (27 women), identified by SAMU (Emergency Medical Service) sent to a Public University Hospital as a possible HIS. All patients fulfilled previous criteria to IV thrombolysis. We analyzed clinical diagnosis after neurological evaluation and brain image. From HIS patients, we analyzed NIHSS at the onset and after 24 hours, 3 months mRS comparing those who were thrombolysed versus non-thrombolysed. Statistical significance was determined at p < 0.05. Clinical Hospital ethical committee approved this study. Results - From all 50 patients, 35 (70%) patients had ischemic stroke, ten (20%) had hemorrhagic stroke, three (6%) had TIA, one (2%) had a seizure and the last one had psychogenic symptoms (2%). From 35 ischemic stroke patients, 15 (43%) underwent IV TT, the mean door to needle time was 54.13 +/- 21.36 minutes. HIS patients submitted to TT had a worse onset NIHSS (14.06 +/- 6) compared to other 20 ischemic stroke patients (7.45 +/- 6.55) (p=0.004), but similar outcome in 24-hour NIHSS (9.69 +/- 7.33 vs 6.2 +/- 7.10) (p=0.160) and 3 months mRS (2.86 +/- 2.16 vs 2.4 +/- 1.98) (p=0.520). There were three deaths in thrombolysed patients and two in non-thrombolysed patients. Conclusions - In Curitiba, a high populated brazilian city, cooperation between Emergency Medical Service and University Hospital identify correctly 70% of ischemic stroke patients and permits TT in 43% of these patients. Even thought HIS patients submitted to TT had worse onset NIHSS, they had a similar recovering compared to non-thrombolysed ischemic stroke patients.
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M.C.Lange, Universidade Federal do Paraná, Curitiba, BRAZIL
V.F.Zetola   Universidade Federal do Paraná  Curitiba  BRAZIL
M.K.Parolin  SAMU Curitiba  Curitiba  BRAZIL
G.M.Albuquerque  SAMU Curitiba  Curitiba  BRAZIL
L.F.Parolin  SAMU Curitiba  Curitiba  BRAZIL
C.Ikuta  SAMU Curitiba  Curitiba  BRAZIL
H.G.Rocha  SAMU Curitiba  Curitiba  BRAZIL
A.F.Fernandes  Universidade Federal do Paraná  Curitiba  BRAZIL
L.N.Zamproni  Universidade Federal do Paraná  Curitiba  BRAZIL
E.M.Nóvak  Universidade Federal do Paraná  Curitiba  BRAZIL
L.C.Werneck  Universidade Federal do Paraná  Curitiba  BRAZIL
         
         
         
         

Kind of presentation: poster

Regional/national stroke aspects (EU and beyond)  
  
Poster Session Blue
Chairs:  

Date: Thursday 28 May 2009
Time: 12:30 - 14:00
Room:  

3.
A National Audit of Australian Post Acute Stroke Services
Background: The nature of Australian stroke rehabilitation services has never been evaluated. Australian Clinical Guidelines for Stroke Rehabilitation and Recovery were produced in 2005. The aim of the 2008 National Stroke Audit was to assess adherence to evidence based recommendations in the guidelines and to describe variations in stroke services across the country. Methods: Clinicians at participating sites completed an organisational survey and also conducted a retrospective audit of 40 patient case notes admitted between 1 January 2007 and 31 December 2007. Results: 97 hospitals contributed organisational data and 68 of those also participated in the clinical audit. In total, 2,119 case notes were audited. Amongst the 97 hospitals surveyed, 8 dedicated stroke rehabilitation units were identified. Most of the surveyed rehabilitation teams reported employing recommended strategies for effective stroke management, such as team meetings (100%), patient-centred management (83%) and ongoing specialist education (54%). Workforce establishment was reported to be below recommended levels. Access to community rehabilitation services varied. The clinical audit identified that while treatment had been provided for most of the consequences of stroke, only some of the therapies provided matched those recommended in the guidelines. For example, sensory impairment (38%), hypertonicity (56%), shoulder subluxation (56%), mobilisation (67-94%), executive function impairment (38-42%) and aphasia (58%). Prior to discharge there appeared to be low rates of home assessments (71%), carer training (67%), or provision of information regarding self-management programs (40%), peer support programs (34%), and sexuality (13%). Conclusions: Analysis of the audit data has provided insights into the performance of the Australian health system at providing post acute stroke care. The audit provides a focus for developing action plans to improve clinical practice and patient outcomes over time.
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On behalf of the National Stroke Foundation National Advisory Committee: National Stroke Audit Post Acute Services and the National Stroke Audit Collaborative
E.Lalor, National Stroke Foundation, Melbourne, AUSTRALIA
D.Harris   National Stroke Foundation  Melbourne  AUSTRALIA
           
         
         
         
         
         
         
         
         
         
         
         
         

Kind of presentation: poster

Vascular imaging  
  
Poster Session Blue
Chairs:  

Date: Thursday 28 May 2009
Time: 12:30 - 14:00
Room:  

33.
Increasing Use of CT Angiography in Interventional Study Sites The IMS III Experience
Background: The use of CT angiography to assess acute stroke patients has rapidly increased over the past five years. This change in clinical practice also affects the process of enrollment and selection of subjects in ongoing acute stroke trials. Methods: IMS III is a trial of intravenous/intra-arterial treatment vs. standard IV t-PA treatment begun within 3 hours of onset in subjects with an NIHSS of 10 or more. Only routine CT is required at baseline although CT angiography is allowed if approved by the coordinating center. At initiation of the study in 2006, a small minority of centers used CT angiography routinely at baseline for assessment of acute stroke patients. Because of an impression of a change in practice over the past several years, all approved IMS III investigational sites in the U.S., Canada, and Australia, were surveyed in November of 2008 as to the use of CT angiography. Results: Of the 53 IMS III Treatment Centers that have been approved to this point, CTA is performed routinely for all acute ischemic stroke patients in 24 of the 53 centers, is variably used at baseline evaluation in an additional 22 centers, and is not used as part of the standard stroke evaluation in five. Two centers did not respond. Conclusion: CT angiography use has rapidly expanded at Stroke Centers who participate in interventional acute stroke trials. The impact of increased use of CT angiography upon time-to-treatment with rt-PA, enrollment of subjects into trials, and potential adverse events associated with contrast use, particularly in those subjects who also undergo angiography, warrant further study.
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IMS III Executive Committee for the IMS III Trial Investigators
J.P.Broderick, University of Cincinnati Academic Health Center, Cincinnati, USA
          
         
         
         
         
         
         
         
         
         
         
         
         
         

Kind of presentation: oral

Acute stroke: treatment and concepts  
 B
 
Chairs: O. Busse, Germany and K. Muir, United Kingdom

Date: Wednesday 27 May 2009
Time: 15:40 - 15:50
Room: A2

20.
Superiority of a new perfusion CT evaluation algorithm over ASPECTS and mismatch estimation in interrater reproducibility and prediction of neurologic outcome after intraarterial thrombolysis
Purpose: Perfusion-CT (PCT) parameters may allow for optimized patient selection for intra-arterial thrombolysis (iaT) in acute ischemic stroke. We evaluated a novel, simple, quantitative, parameter-specific algorithm for interrater agreement and correlation with early neurologic improvement (NI) in comparison with ASPECTS and assessment of tissue at risk. Patients and Methods: 25 consecutive patients (17 w, 8 m, mean 66.7yrs+/-12.4) with M1, proximal M2 or distal ICA occlusion underwent iaT within 6 hours after symptom onset (mean 4+/-1.2h), after noncontrast CT, PCT and CT angiography. Three independent raters blinded for clinicoradiologic data created color-coded CTP maps for CBV, CBF and TTP and processed these with a formula accounting both for size and severity of perfusion deficit. The resulting numeric ratios were analyzed for predicting NI (defined as NIHSS>=7 reduction at discharge), and compared with single-rater and consensus evaluation according to ASPECTS and a visual approach estimating CBF-CBV-mismatch as surrogate for ischemic penumbra. Results: Median NIHSS score on admission was 14, at discharge 5 (p<0.001). Visual mismatch estimates and ASPECTS showed low interrater agreement (intraclass correlation coefficient (ICC): 0.44, and CBF: 0.54, CBV: 0.58, TTP: 0.61, resp.); the former was not associated with NI (p>=0.19). While ASPECTS predicted NI reasonably well with receiver-operator curve - area under the curve (ROC-AUC) values of 0.79 for CBF and 0.78 to 0.90 for CBV, resp., numeric ratios showed high interrater agreement (ICC: qCBF: 0.92; qCBV: 0.86, qTTP: 0.74) and AUC-values (qCBF: 0.85 – 0.88; qCBV: 0.82 – 0.85). Conclusion: PCT parameters calculated by a novel quantitative, simple method are superior to ASPECTS-based assessment and visual estimates for tissue-at-risk in interrater reproducibility. Mismatch estimation is clearly inferior to the other applied algorithms in predicting NI in our cohort of ischemic stroke patients treated with iaT.
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A.V.Khaw, Dept. of Neurology, Ernst Moritz Arndt University, Greifswald, GERMANY
A.Angermaier   Dept. of Neurology and Neuroradiology, Ernst Moritz Arndt University  Greifswald  GERMANY
M.Kirsch  Dept. of Neuroradiology, Institute of Radiology, Ernst Moritz Arndt University  Greifswald  GERMANY
N.Hosten  Institute of Radiology, Ernst Moritz Arndt University  Greifswald  GERMANY
C.Kessler  Dept. of Neurology, Ernst Moritz Arndt University  Greifswald  GERMANY
S.Langner  Dept. of Neuroradiology, Institute of Radiology, Ernst Moritz Arndt University  Greifswald  GERMANY
         
         
         
         
         
         
         
         
         

Kind of presentation: poster

Acute stroke: treatment and concepts  
  
Poster Session Red
Chairs:  

Date: Wednesday 27 May 2009
Time: 12:30 - 14:00
Room:  

39.
Increasing perfusion deficit severity in acute anterior circulation ischemic stroke is related to greater neurologic improvement in patients treated with intra-arterial thrombolysis
Purpose: Patient selection for intra-arterial thrombolysis (iaT) involves weighing risks, additional logistics and time delay against treatment benefits. We aimed to evaluate perfusion CT (PCT) for predicting neurologic outcome in patients with acute anterior circulation ischemic stroke treated with iaT. Patients and Methods: 25 consecutive patients (17 women, 8 men, mean age 66.7yrs+/-12.4) with M1, proximal M2, or distal ICA occlusion underwent iaT within 6 hrs (mean 4+/-1.2) after symptom onset, after noncontrast CT, PCT and CT angiography according to a pre-specified protocol including prospective clinicoradiologic follow-ups. Three independent blinded raters created color-coded CTP maps for CBV, CBF and TTP and processed these with a formula accounting both for size and severity of perfusion deficit. One rater did the same for 22 nonthrombolysed patients matched for age and admission NIHSS as a retrospective control group. The resulting (“KALK”) ratios were analyzed for association with neurologic outcome and compared with an ASPECTS-based evaluation. Results: Median NIHSS score on admission was 14, at discharge 5 (p<0,001). In the control group, lower KALK-ratios representing worse perfusion deficit correlated with less improvement of NIHSS score at discharge (r for CBF: 0.514; CBV: 0.529; p<=0.02). ASPECTS showed a nonsignificant positive correlation (r for CBF: 0.347; CBV: 0.314; p>=0.134). Conversely, in the iaT group severe perfusion deficit as indicated by KALK-ratios was associated with greater improvement of NIHSS score at discharge unanimously by all raters (CBF: r=-0,52 to – 0,56; CBV: r=-0.47 to -0.54; p<=0.03), and less consistently with ASPECTS (CBF: r=-0,14 to -0,44; CBV: r=-0.41 to -0.61). Conclusion: Our results suggest that iaT may be the decisive factor for inverting the association between perfusion deficit severity and early neurological outcome. PCT has the potential to help selecting patients more likely to benefit substantially from iaT.
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A.V.Khaw, Dept. of Neurology, Ernst Moritz Arndt University, Greifswald, GERMANY
A.Angermaier   Dept. of Neurology and Neuroradiology, Ernst Moritz Arndt University  Greifswald  GERMANY
M.Kirsch  Dept. of Neuroradiology, Institute of Radiology, Ernst Moritz Arndt University  Greifswald  GERMANY
N.Hosten  Institute of Radiology, Ernst Moritz Arndt University  Greifswald  GERMANY
C.Kessler  Dept. of Neurology, Ernst Moritz Arndt University  Greifswald  GERMANY
S.Langner  Dept. of Neuroradiology, Institute of Radiology, Ernst Moritz Arndt University  Greifswald  GERMANY
         
         
         
         
         
         
         
         
         

Kind of presentation: poster

Acute stroke: treatment and concepts  
  
Poster Session Red
Chairs:  

Date: Wednesday 27 May 2009
Time: 12:30 - 14:00
Room:  

40.
Safety and efficacy of Cerebrolysin as adjuvant therapy in patients suffering from acute ischemic stroke
BACKGROUND Neurotrophic factors are thought to protect neurons against detrimental lesions in the penumbra area after stroke. Cerebrolysin is a peptide preparation which acts like naturally occurring neurotrophic factors. The aim of this trial was to assess safety and efficacy of Cerebrolysin as an adjuvant therapy in patients suffering from acute ischemic stroke. METHODS In this prospective, randomized, placebo-controlled, double-blind trial, 47 patients suffering from a first acute ischemic stroke with clinical symptoms of middle cerebral artery occlusion were enrolled within 12 hours after onset of symptoms. They received 10 IV infusions of 50 ml Cerebrolysin (n=24) or placebo (n=23) over a period of 10 days concomitant to basic stroke treatment. Primary efficacy analysis was percent change of the MRI infarct volume from day 3 to day 30. Secondary efficacy analysis included mRS, NIH SS, CGI and BI. Analysis of efficacy and safety was done from the ITT analysis set. RESULTS Baseline demographics and clinical characteristics were comparable between both treatment groups except for age (Cerebrolysin: 73.0y; placebo: 66.8y; p=0.05). A significant (p<0.05) reduction in the MRI volume was observed in the Cerebrolysin group over time compared to patients treated with placebo. There is descriptive evidence for a superiority of Cerebrolysin over placebo in the clinical outcome measures on day 30, particularly over the first ten days. Clinical data do not indicate any safety concerns, Cerebrolysin was well tolerated. CONCLUSION The present study confirmed previous findings in acute stroke and showed beneficial effects of Cerebrolysin on infarct volume and clinical outcome with a better and faster performance compared to placebo suggesting a faster recovery under Cerebrolysin treatment. However, due to the small sample size, treatment effects of Cerebrolysin were not statistically significant. Cerebrolysin treatment with up to 50 ml per day is rated safe and well tolerated.
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M.Jech, EBEWE Neuro Pharma GmbH, Unterach, AUSTRIA
N.A.Shamalov   Russian State Medical University  Moscow  RUSSIAN FEDERATION
H.Moessler  EBEWE Neuro Pharma  Unterach  AUSTRIA
V.I.Skvortsova  Russian State Medical University  Moscow  RUSSIAN FEDERATION
         
         
         
         
         
         
         
         
         
         
         

Kind of presentation: poster

Brain imaging  
  
Poster Session Blue
Chairs:  

Date: Thursday 28 May 2009
Time: 12:30 - 14:00
Room:  

14.
Digital atlas reveals heterogeneity in infarct patterns following ICA occlusion
Abstract Background and Purpose: Knowledge of infarct patterns has implications for patient management and design of thrombolytic trials. We hypothesized that the extent of infarction after ICA occlusion depends upon the additional occlusion of the MCA. Methods: Sequential patients with ICA and MCA occlusion on MR were recruited. Forty five patients with ICA occlusion were separated into those with MCA occlusion (ICA-1) and those without MCA occlusion (ICA-2). Infarct patterns were compared between groups and with that of patients with MCA occlusion alone (MCA) using the method of statistical parametric mapping at a voxel based level. Results: There were 25 patients (17 males) in the ICA-1 group, with a median age of 64 years (range: 26-84 years), 20 patients (13 males) in the ICA-2 group with a median age of 67 years (range: 42-80 years), and 41 patients (21 males) in the MCA territory group, with a median age of 73 years (range: 25-87 years). The mean and standard deviation of the infarct volumes were as follows: ICA-1 group 112.5 ml ± 113.4 ml, ICA-2 group 21.1 ml ± 24.1 ml, and MCA group, 68.0 ml ± 66.1 ml. Infarct pattern was similar between the ICA-1 group and the MCA group. Compared with either MCA or ICA-1 groups, infarction was less likely to involve the insula (p<0.0001) and superior temporal lobe (p<0.0001) in the ICA-2 group. Conclusion: The pattern of infarction following ICA occlusion depends on whether there is coexistent MCA occlusion. In the absence of MCA occlusion, infarcts resulting from ICA and MCA occlusion have different topography.
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T.G.Phan, Stroke and Aging Research, Monash University, Clayton, AUSTRALIA
G.A.Donnan   NSRI  Heidelberg  AUSTRALIA
V.Srikanth  Stroke and Aging Research, Monash University  Clayton  AUSTRALIA
J.Chen  Stroke and Aging Research, Monash University  Clayton  AUSTRALIA
D.R.Reutens  Monash University  Clayton  AUSTRALIA
         
         
         
         
         
         
         
         
         
         

Kind of presentation: poster

Management and economics  
  
Poster Session Blue
Chairs:  

Date: Thursday 28 May 2009
Time: 12:30 - 14:00
Room:  

17.
THE ROLE OF PRIMARY HEALTH CARE TEAMS IN PREVENTION OF CARDIOVASCULAR DISEASES
Introduction: Since 1980 cardiovascular mortality has declined in a descent way in EU-15 countries, while in the newly joined countries it is only typical after 1990. Our aim is the show the results of a preventive PHC programme launched by .National Health Desk in 2005. Method: The National Basic Health Care Institute compiled a recommendation to help the prevention of cardiovascular diseases and developed an information system (CardioNET) for screening. In this framework PHC providers undertook to screen 25% of their registered patients and to make a report on patients’ risk parameters on the informatics record. The analysis of reports occurred in the central module of the CardioNET according to geographical areas and age groups. The collected data were statistically analysed with SPSS 14. Results: Out of 345 registered family doctor offices 107 practices made use of the services. Practices sending report counted 92614 registered patients, 28,5% of them were screened, so the condition of the competition, 25%, was performed. During examining of relative incidence of major risk factors it appeared that in the age group of 50 and 70, women’s abdominant type of obesity and high cholelesterol value are more frequent than men’s. In the age group of 20 and 40, the frequency of high risk supports the necessity of cardiovascular screening and the nursing suitable for the results. Discussion: The processed details give a good survey of gender and age composition of those who were examined in the 107 family doctor practices, and of modifiable cardiovascular risk factors.
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A.Siket Ujvarine, Faculty of Health Sciences University of Debrecen at Nyiregyhaza, Nyiregyhaza, HUNGARY
R.Papp   Institute of National Basic Health Care  Budapest  HUNGARY
S.Balogh  Institute of National Basic Health Care  Budapest  HUNGARY
A.Becka  Institute of National Basic Health Care  Budapest  HUNGARY
J. Betlehem  Faculty of Health Sciences University of Pecs  Pecs  HUNGARY
         
         
         
         
         
         
         
         
         
         

Kind of presentation: poster

Epidemiology of stroke  
  
Poster Session Red
Chairs:  

Date: Wednesday 27 May 2009
Time: 12:30 - 14:00
Room:  

42.
Stroke- Seasonality and Weekly Variation in Hungary (2005-2007)
The aim of our study was to find out if a weekly or seasonal change can be seen in the incidence of stroke during a three-year study period in Hungary, and if the occurrence of stroke is influenced by age and sex. Methods: We analyzed stroke patients (N=154.855)received at clinics and hospitals in Hungary (2005-2007). Data were collected from the data-base of the National Health Insurance Fund based on ICD 10. A retrospective data analysis was run using SPSS 14. Results: In Hungary the onset of stroke shows a weekly and a seasonal variation. In the seasonal variation, the peek period of stroke was found during the months of Spring, with lowest number of events during the Summer. There was a significant difference between number of events for each season (p<0.01). The weekly peek period of cerebral circulatory disturbance was found on Monday, with a gradually decreasing tendency towards the end of the week. In age groups we have only found a significant difference with consideration to weekly variation: decrease in the number of events during the weekend is significantly greater in the age group below the age of 60 (p<0.01). Differences between the sexes was similarly only found in the weekly variation of number of stroke events, with a marked difference between the first five days of the week and the weekend (p<0.01). Conclusion: the results of our study show that the incidence of a stroke shows characteristic variation with consideration to seasons and the days of the week.
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I.Kriszbacher, Faculty of Health Sciences University of Pecs, Pecs, HUNGARY
J.Betlehem   Faculty of Health Sciences, University of Pecs  Pecs  HUNGARY
I.Csoboth  Faculty of Health Sciences University of Pecs  Pecs  HUNGARY
I.Vranics  Faculty of Health Sciences University of Pecs  Pecs  HUNGARY
K.Gabara  Faculty of Health Sciences University of Pecs  Pecs  HUNGARY
I.Boncz  Faculty of Health Sciences University of Pecs  Pecs  HUNGARY
A.Olah  Faculty of Health Sciences University of Pecs  Pecs  HUNGARY
E.Zsigmond  Faculty of Health Sciences University of Pecs  Zalaegerszeg  HUNGARY
J.Bodis  Faculty of Health Sciences University of Pecs  Pecs  HUNGARY
         
         
         
         
         
         

Kind of presentation: poster

Heart & brain  
  
Poster Session Blue
Chairs:  

Date: Thursday 28 May 2009
Time: 12:30 - 14:00
Room:  

13.
Beta-Blockers in Acute Ischemic Stroke (BIAS) – protocol for a prospective, randomized, double-blind clinical trial
BACKGROUND – Acute stroke patients already taking beta-blockers are known to have a decreased risk of cardiovascular complications. Besides the anti-arrhythmic impact also anti-hypertensive effects may contribute to this. Furthermore, experimental data show neuroprotective properties of propranolol and in the discussed field of post-stroke immunodepression sympathetic tone is crucial to its mediation. We hypothesize that an early treatment of acute stroke patients with propranolol prevents cardiovascular and neurological complications. Early administration of propranolol may be capable of reducing immunodepression and pneumonia after stroke. METHODS/DESIGN – BIAS is a planned prospective, randomized, double-blind multi centre phase II trial which will start in June 2009. Inclusion criteria are an acute ischemic stroke with an NIHSS score >= 6 and start of treatment <12 h after stroke onset. Exclusion criteria are contraindications to propranolol, preliminary therapy with beta-blockers or antiarrhythmics, severe cardiac diseases, uncontrollable blood pressure and recent myocardial infarction. Primary endpoint of this trial is the incidence of cardiovascular and/or neurological complications within the first 30 days after stroke. Exploratory analyses will contain neurological and functional outcome, immunological parameters, incidence of pneumonia, cardiac arrhythmias and infarct growth according to MRI. Monitoring via Holter ECG, MRI, and clinical examinations will be performed and blood samples are drawn to monitor the immune system. BIAS has a power of 80% to detect a 50% reduction of cardiovascular and neurological complications. DISCUSSION – The planned trial will combine clinical, laboratory and imaging data to evaluate the potential benefit of early propranolol administration in acute stroke patients.
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B.Hotter, CSB - Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, GERMANY
G.J.Jungehulsing   CSB - Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin  Berlin  GERMANY
W.U.Schmidt  CSB - Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin  Berlin  GERMANY
A.Meisel  CSB - Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin  Berlin  GERMANY
C.Meisel  Institute of Medical Immunology, Charité - Universitätsmedizin Berlin  Berlin  GERMANY
P.Martus  Institute for Biostatistics and Clinical Epidemiology, Charité - Universitätsmedizin Berlin  Berlin  GERMANY
J.B.Fiebach  CSB - Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin  Berlin  GERMANY
R.Dietz  Department of Cardiology - Campus Virchow Clinic, Charité - Universitätsmedizin Berlin  Berlin  GERMANY
M.Endres  CSB - Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin  Berlin  GERMANY
W.Haverkamp  Department of Cardiology - Campus Virchow Clinic, Charité - Universitätsmedizin Berlin  Berlin  GERMANY
         
         
         
         
         

Kind of presentation: poster

Intracerebral/subarachnoid haemorrhage and venous diseases  
  
Poster Session Blue
Chairs:  

Date: Thursday 28 May 2009
Time: 12:30 - 14:00
Room:  

19.
Outward hypertrophic remodeling and increased arterial stiffness in patients with ruptured intracranial aneurysms
Background: Because an underlying arteriopathy might contribute to the development and rupture of intracranial aneurysms (IA), we assessed the elastic properties of proximal conduit arteries in aneurysm patients. Methods: In 27 patients with antecedent of ruptured IA and 27 control subjects, we determined arterial pressures, internal diameter, intima-media thickness (IMT), circumferential wall stress and elastic modulus (wall stiffness) in the common carotid arteries using applanation tonometry and echotracking. Moreover, carotid augmentation index (AIx, arterial wave reflections) and carotid-to-femoral pulse wave velocity (PWV, aortic stiffness) were assessed. Results: Compared with controls, patients with IA exhibited higher carotid systolic (108±2 vs. 122±3 mmHg), diastolic (73±1 vs. 81±1 mmHg) and pulse pressures (35±1 vs. 41±2 mmHg), an increased IMT (546±12 vs. 642±13 µm, all P<0.01) with no difference in diameter. IMT was correlated with pulse pressure in controls (r=0.539, P<0.001) but not in patients (r=0.152, P=NS) suggesting a pressure-independent process. Moreover, patients display an increased elastic modulus (211±25 vs. 368±35 kPa, P<0.001) despite a similar circumferential wall stress between groups. Furthermore, patients with IA have higher PWV (7.8±0.2 vs. 8.3±0.2 m.s-1, P<0.05) which contributes to the increase in arterial wave reflections (AIx: 15.8±2.1 vs. 21.1±1.6%, P<0.05) and thus in systolic and pulse pressures. Conclusion: This study demonstrates that patients with IA display a particular carotid artery phenotype with an outward hypertrophic remodeling and altered elastic properties which might contribute together with the fatiguing effect of increased pulsatile stress on the arterial wall to the pathogenesis of IA.
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D.Maltete, Service de Neurologie , Rouen, FRANCE
J.Bellien   Département de Pharmacologie   Rouen  FRANCE
M.Iacob  Département de Pharmacologie   Rouen  FRANCE
F.Proust  Neurochirurgie  Rouen  FRANCE
B.Mihout  Service de Neurologie  Rouen  FRANCE
R.Joannides  Département de Pharmacologie   Rouen  FRANCE
E.Massardier  Service de Neurologie  Rouen  FRANCE
         
         
         
         
         
         
         
         

Kind of presentation: oral

Acute cerebrovascular events (ACE): TIA and minor strokes  
  
 
Chairs: G. Hankey, Australia and J.-L. Marti-Vilalta, Spain

Date: Wednesday 27 May 2009
Time: 9:10 - 9:20
Room: K2

5.
Worsening after TIA or minor stroke in patients treated in acute stroke units – results of the Austrian Stroke Unit Registry
Background: Transient ischemic attack (TIA) is associated with a substantial short-term risk of stroke and thus increasingly recognized as an unstable condition requiring full medical attention. Recently, a variety of risk predictors for worsening after TIA have been identified and combined to risk scores. Our study sought to assess the rate of and predictors for early deterioration after TIA or minor stroke in a large nation-wide survey among Austrian Stroke Units. Methods: Of the 29287 patients that were prospectively entered in the Austrian Stroke Registry (2003 - 2008) 8291 presenting with a TIA or ischemic stroke with mild symptoms (NIH Stroke Scale < 4) were included in our evaluation. Deterioration was classified as worsening during stroke unit care by >/= 2 NIHSS points. Results: 374 (4.5%) showed worsening during SU care by >/= 2 NIHSS points. Neurological deterioration occurred in spite of immediate standard therapy. The risk of neurological deterioration was higher among patients with large vessel and cardio-embolic strokes. In a multivariate stepwise regression analysis adjusted for age, gender and stroke center the following variables emerged as independent significant risk predictors for early neurological worsening: hypertension, diabetes, cardiac decompensation, acute severe infection and stroke etiology. Discussion: The frequency of early deterioration may still be underestimated. Our study reveals a rate as high as 4.5% among 8291 patients with TIA or minor stroke. These findings along with a very low bleeding risk calls for more aggressive therapies in these patients to be established in future RCTs. Predictors for neurological deterioration apart from diabetes, hypertension and the ABCD score are stroke etiology, reinforcing the relevance of an immediate diagnostic work-up, and acute severe infection and cardiac decompensation both conditions requiring adequate attention in the emergency setting.
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J.Ferrari, Hospital Barmherzige Brueder, Vienna, AUSTRIA
M.Knoflach   University Clinic of Neurology  Innsbruck  AUSTRIA
S.Kiechl  University Clinic of Neurology  Innsbruck  AUSTRIA
J.Willeit  University Clinic of Neurology  Innsbruck  AUSTRIA
S.Schnabl  Danube University Krems/GOEG  Vienna  AUSTRIA
L.Seyfang  Danube University Krems/GOEG  Vienna  AUSTRIA
W.Lang  Hospital Barmherzige Brueder  Vienna  AUSTRIA
         
         
         
         
         
         
         
         

Kind of presentation: poster

Vascular surgery and neurosurgery/interventional neuroradiology  
  
Poster Session Red
Chairs:  

Date: Wednesday 27 May 2009
Time: 12:30 - 14:00
Room:  

11.
The RACE to protect brains
Background: Rapid Access Carotid Endarterectomy (RACE) is an evidence-based treatment for symptomatic carotid stenosis. Our vascular centre aims to provide this service within 48h of symptoms in appropriate patients. This study audits safety and efficacy of the first year of RACE. Method: A clear trust protocol was publicised for the RACE pathway. A prospective database was established for all carotid endarterectomies (CE) performed. Outcomes were compared between elective (ECE) and rapid access operations. Results: In one year 96 patients received CE; 20 were performed urgently. There were no significant differences in age or gender between ECE and RACE groups. 23 (30%) of ECE were for asymptomatic stenosis; no other significant differences in surgical indication were seen. 43% of symptomatic ECE were for completed stroke vs 55% of RACE. Median delay between diagnosis and surgery was 113 days for elective and 2 days for RACE patients. There was 1 death following ECE (1.3%) and 1 stroke after RACE (5%); 3 cranial nerve injuries after ECE (3.9%) vs 1 (5%) after RACE; 3 haematomas after ECE (3.9%) vs 1 after RACE (5%) (all n.s.). Anaesthetic method did not influence outcome. The main reasons for delaying surgery in RACE patients were optimisation of patient fitness and availability of theatre time. Conclusion: The RACE pathway dramatically reduces delay without compromising patient safety. In the first year of service we have treated 50% of suitable patients within 48h. Further education of patients and colleagues should reduce delay and improve outcomes for symptomatic carotid disease.
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H. S.Baht, East Kent Hospitals University NHS Trust, Canterbury, UNITED KINGDOM
T.Rix      Canterbury  UNITED KINGDOM
I.Singh     Canterbury  UNITED KINGDOM
G.Gunaratnam     Canterbury  UNITED KINGDOM
D.Hargroves     Canterbury  UNITED KINGDOM
R.Insall     Canterbury  UNITED KINGDOM
J.Senaratne     Canterbury  UNITED KINGDOM
         
         
         
         
         
         
         
         

Kind of presentation: poster

Acute stroke: emergency management, stroke units and complications  
  
Poster Session Blue
Chairs:  

Date: Thursday 28 May 2009
Time: 12:30 - 14:00
Room:  

10.
Rapidly evolving massive cerebral edema following recanalization in an acute ischemic stroke patient after intravenous thrombolysis
Background: Intravenous TPA dissolves thrombi, achieves recanalization & remains the only approved therapeutic agent for ischemic stroke within 3-hours of symptom onset. Recanalization rarely causes cerebral reperfusion injury(CRI). CRI is a known complication after various carotid revascularization procedures for chronic occlusive disease. It is thought to result from impaired cerebral autoregulation. Chronically dilated arteries distal to stenosis cannot modify vascular resistance in response to sudden gush of blood flow, causing cerebral edema or hemorrhage. Sudden release of free radicals upon reperfusion is another possible mechanism for CRI. Methods: We report a patient who showed significant clinical recovery during TPA infusion. However, she deteriorated rapidly 15 minutes after completion of TPA infusion. We describe her further clinical course, neuroimaging findings and final outcome. Results: A 42-years old woman without any known vascular risk factors, presented with acute right middle cerebral artery occlusion(NIHSS 17) & received IV-TPA at 120minutes after symptom onset. Continuous transcranial Doppler monitoring revealed complete recanalization at 22minutes after TPA bolus, associated with clinical recovery (NIHSS at completion of TPA 7points). Her blood pressure remained in normal range. 15minutes after completion of TPA, she showed rapid deterioration(NIHSS 22). No bleeding was seen on urgent brain CT however significant oedema was seen over right cerebral hemisphere. She worsened further(NIHSS 40) & had 2 generalized seizures. She was intubation, mechanically hyperventilated and treated with mannitol. Brain CT repeated 5hours later showed further progression of cerebral oedema and we decided decompression hemicraniectomy (done at 9hours after symptom-onset). She didn’t have any post-operative complications, recovered rapidly & could walk independently 6days after acute stroke(NIHSS 4). Conclusion: Cerebral reperfusion injury should be considered as a differential diagnosis for neurological worsening after IV-TPA, especially in absence of intracranial bleeding. An aggressive therapeutic approach often results in good clinical outcomes.
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V.K.Sharma, National University Hospital, Singapore, SINGAPORE
C.Ning   National University Hospital  Singapore  SINGAPORE
L.Y.L.Litt  National University Hospital  Singapore  SINGAPORE
K.W.Ng  National University Hospital  Singapore  SINGAPORE
P.K.Loh  National University Hospital  Singapore  SINGAPORE
H.L.Teoh  National University Hospital  Singapore  SINGAPORE
B.K.C.Ong  National University Hospital  Singapore  SINGAPORE
B.P.L.Chan  National University Hospital  Singapore  SINGAPORE
         
         
         
         
         
         
         

Kind of presentation: poster

Challenging cases  
  
Poster Session Red
Chairs:  

Date: Wednesday 27 May 2009
Time: 12:30 - 14:00
Room:  

9.
Consent and Thrombolysis in Stroke Patients with Intellectual Disability - initial experience.
Introduction: Stroke Thrombolysis improves functional outcome but can cause serious haemorrhage. Informed consent is difficult and a particular challenge in intellectual disability(ID)patients with stroke. Case 1:50 y.o. man with ID and bipolar affective disorder presented at 60min with right-sided facial and upper limb weakness, severe dysarthria/dysphagia. NIHSS score = 8. Premorbid modRankin 1. CT brain no haemorrhage. Risks/ benefits of thrombolysis explained. Capacity not confirmed but assent evident. Consent by ‘proxy’ unavailable. Thrombolysis administered at 100mins. NIHSS score=5 at 24 hours.90 day outcome favourable; modified Rankin 2; independent mobility,minor supervision with self-care,mild dysarthria,dysphagia with improving oral intake. Case 2: 35 y.o. man with Trisomy-21, ID, and pulmonary hypertension due to large ASD. Presented at 90min with severe right sided weakness and aphasia. NIHSS=14. Premorbid modRankin 3-independently mobile with minor assistance in ADL. CT brain no hamorrhage. Risks/benefits explained;lack of capacity confirmed during interview. Informed consent by ‘proxy’ obtained from parents. Thrombolysis administered at 160mins. NIHSS=6 after 24 hours. Day 14 discharge; Modified Rankin 3; walking with frame;minor assistance with ADLs; speech/cognition at baseline. Discussion: Many authorities advocate explicit consent procedure in stroke thrombolysis[1].We provide prompt verbal, written/diagrammatic explanation of risk/benefit and assess capacity in thrombolysis patients.Patient consent/assent or consent by ‘proxy’ is obtained where possible. Full informed consent requires provision of information, capacity to decide and voluntary choice. Capacity can be difficult to establish in acute stroke patients but is more challenging in assessing and upholding ‘voluntary choice’in ID patients.Our experience shows acute stroke treatment can be delivered effectively to ID patients with due ethical consideration of consent. 1. White-Bateman et al. Arch Neurol. 2007;64:785-792
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K.M.Tan, Adelaide & Meath Hospital.Tallaght, Dublin, IRELAND
T.L.Coughlan   Adelaide & Meath Hospital.Tallaght  Dublin  IRELAND
N.Caffrey  Adelaide & Meath Hospital.Tallaght  Dublin  IRELAND
D.O'Neill  Adelaide & Meath Hospital.Tallaght  Dublin  IRELAND
D.R.Collins  Adelaide & Meath Hospital.Tallaght  Dublin  IRELAND
         
         
         
         
         
         
         
         
         
         

Kind of presentation: poster

Brain imaging  
  
Poster Session Blue
Chairs:  

Date: Thursday 28 May 2009
Time: 12:30 - 14:00
Room:  

26.
Visually evoked changes of cerebral blood flow demonstrated by arterial spin labelling MR perfusion imaging
Background: Visual stimulation is known to activate the visual areas of the occipital cortex which is associated with a mild local increase of cerebral blood flow (CBF), as it may be demonstrated e.g. by functional MRI and transcranial Doppler. Arterial spin labeling (ASL) is a new MRI technique that provides non-invasive information on cerebral perfusion. Given the high sensitivity of ASL perfusion imaging to demonstrate even mild hyperperfusion, we sought to analyze whether this method allows assessment of visually evoked CBF changes in healthy volunteers. Methods: A 1.5T scanner (Magnetom Sonata, Siemens, Erlangen, Germany) was used. ASL perfusion maps were obtained using a single-shot 3D-GRASE read-out module by using time series which allow determining the dynamics of blood inflow to the cerebral microcirculation. For time series, multiple inflow times (TI) ranging from 250 ms to 2500 ms were measured in 10 time steps (TR 3000 ms). Following a measurement with closed eyes, visual stimulation during ASL MRI was performed using an on-off block design with a checkerboard as stimulus: 1Hz, 2Hz and 4Hz flashing checkerboard, 20sec ON/OFF intervals. Microvascular perfusion (CBF) and bolus arrival time (BAT) were extracted from time series using nonlinear least-square optimization. Results: ASL perfusion maps were obtained of 8 healthy volunteers during visual stimulation. A significant local CBF increase of>15% located in the visual areas of the occipital cortex could be identified. ASL perfusion maps show a marked signal increase in both occipital lobes under visual stimulation (white arrows, bottom) compared to the control without visual stimulus (top) (see figure). Discussion: Visually evoked transient hyperperfusion in the occipital cortex may be demonstrated using ASL perfusion techniques. This new approach offers the opportunity to analyze the neurovascular response to exogenous stimuli under various physiological and pathophysiological conditions.
Graphic: http://www.esc-archive.eu/stockholm09/graphics_stockholm/g_AID1041.htm
Table:  
 
M.E.Wolf, Department of Neurology, Uniklinik Mannheim, University of Heidelberg, Mannheim, GERMANY
M.Griebe   Department of Neurology, Uniklinik Mannheim, University of Heidelberg  Mannheim  GERMANY
J.Gregori  Department of Neurology, Uniklinik Mannheim, University of Heidelberg  Mannheim  GERMANY
M.Günther  Department of Neurology, Uniklinik Mannheim, University of Heidelberg  Mannheim  GERMANY
K.Szabo  Department of Neurology, Uniklinik Mannheim, University of Heidelberg  Mannheim  GERMANY
A.Förster  Department of Neurology, Uniklinik Mannheim, University of Heidelberg  Mannheim  GERMANY
A.Gass  Department of Neurology, Uniklinik Mannheim, University of Heidelberg  Mannheim  GERMANY
M.G.Hennerici  Department of Neurology, Uniklinik Mannheim, University of Heidelberg  Mannheim  GERMANY
R.Kern  Department of Neurology, Uniklinik Mannheim, University of Heidelberg  Mannheim  GERMANY
         
         
         
         
         
         

Kind of presentation: oral

Brain imaging  
  
 
Chairs: F. Fazekas, Austria and J. Wardlaw, United Kingdom

Date: Thursday 28 May 2009
Time: 9:40 - 9:50
Room: A4

8.
Perfusion changes have a significant impact on BOLD functional MRI: preliminary experience from carotid stent angioplasty
Background: Blood oxygen level dependent (BOLD) fMRI is increasingly used for studying neuronal activity also in clinical research. An effect of perfusion changes such as from stenosis of supplying vessels on this signal has to be assumed, but the magnitude of this effect has not been tested so far. Carotid angioplasty with stenting (CAS) is a common means for revascularisation in stroke prevention. We felt this to be an ideal scenario to investigate the impact of possible perfusion changes on the BOLD signal. Methods: In this ongoing study, 5 patients (2F/3M; age 48-75 years) with a >70% right-sided symptomatic carotid stenosis (TIAs or nondisabling stroke) underwent perfusion weighted imaging (PWI) and fMRI at 3T before and 2-14 days after CAS. The fMRI paradigm consisted of active finger movements of either side at fixed rate. FMRI data were analysed using SPM 5. Region of interest analyses served to assess signal changes in the primary sensorimotor cortices (SMC). Relative cerebral blood flow (rCBF) and mean transit time (rMTT) were evaluated using singular value decomposition in regions of vascular territories supplying the SMC. Results: Prior to CAS, all patients demonstrated reduced perfusion of the hemisphere ipsilateral to the carotid stenosis. This asymmetry almost normalised after CAS (increase of MTT ratio R/L hemisphere from 0.68 to 0.88, and of rCBF ratio from 0.67 to 0.91). Similarly, at baseline, the extent and strength of SMC activation elicited by finger movements was lower in the malperfused hemisphere and significantly increased after CAS (ratio of the normalised ß-weights R/L hemisphere 0.72 and 0.95, respectively), whereas it remained unchanged in the left hemisphere. Conclusion: This study provides first evidence that perfusion changes strongly influence the strength of BOLD activation and need to be considered as an important confounder in clinical fMRI studies, especially in the setting of cerebrovascular disease.
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C.Enzinger, Department of Neurology, Medical University Graz, Graz, AUSTRIA
G.Reishofer    Section of Neuroradiology, Department of Radiology, Medical University Graz  Graz  AUSTRIA
K.Koschutnig  Section of Neuroradiology, Department of Radiology, Medical University Graz  Graz  AUSTRIA
T.Seifert-Held   Department of Neurology, Medical University Graz  Graz  AUSTRIA
G.Schrötter  Department of Neurology, Medical University Graz  Graz  AUSTRIA
N.E.Simmet  Department of Neurology, Medical University Graz  Graz  AUSTRIA
K.Niederkorn   Department of Neurology, Medical University Graz  Graz  AUSTRIA
F.Ebner  Section of Neuroradiology, Department of Radiology, Medical University Graz  Graz  AUSTRIA
G.Klein   Section of Vascular Radiology, Department of Radiology, Medical University Graz  Graz  AUSTRIA
S.Ropele   Department of Neurology, Medical University Graz  Graz  AUSTRIA
F.Fazekas   Department of Neurology, Medical University Graz  Graz  AUSTRIA
         
         
         
         

Kind of presentation: oral

Very old age (>80 years) and stroke  
  
 
Chairs: A. Czlonkowska, Poland and G. Ford, United Kingdom

Date: Thursday 28 May 2009
Time: 14:50 - 15:00
Room: K21

3.
Stroke care pattern in very old patients: the Lombardy Stroke Unit Registry
Background Acute ischemic stroke (AIS) is a predominantly disease of the elderly, its risk increases exponentially with age and elderly patients have a worse prognosis. We aimed to investigate whether elderly patients with AIS are associated with different diagnostic and treatment strategies. Methods The cohort of patients with AIS between January 2007 and December 2007 in the Lombardy Stroke Unit Registry has been studied. The risk factor considered was age over 80 years. The diagnostic and therapeutic end-points were defined according to the SPREAD guidelines. Univariatate and multivariate analyses adjusting for stroke severity and comorbidities were used. Results A total of 4606 patients (age > 80 years: 1435) were included. Very old stroke patients were less likely to have a complete diagnostic pattern (MRI, transthoracic/ transoesophageal echocardiography, carotid and transcranial Doppler examination). and to receive a secondary prevention therapy at discharge. They were more likely to have bladder catheter and urinary tract infections were more frequently detected (p<0.001). No differences were detected when vital parameter monitoring, DVP prophylaxis, early mobilisation and naso-gastric tube positioning were considered. At discharge they were less likely to receive antithrombotic or oral anticoagulation agents, lipid lowering drugs and audit procedures. These results were confirmed at multivariate analysis. Length of stay was similar in the two groups. Conclusion Age over 80 years is associated with a poor diagnostic and treatment stroke pathway with highest risk to not be treated following the current stroke guidelines. In particular less attention is devolved to the care pathways aspect related with avoiding stroke recurrence. This lack of an optimal treatment can partially explain their worse prognosis.
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SUN Lombardia Collaborators
A.Cavallini, UC Malattie Cerebrovascolari/Stroke Unit, IRCCS Istituto Neurologico C. Mondino , Pavia, ITALY
G.Micieli   UC Neurologia I e Stroke Unit, IRCCS Istituto Clinico Humanitas  Rozzano (MI)  ITALY
M.Gattinoni  UC Neurologia I e Stroke Unit, IRCCS Istituto Clinico Humanitas  Rozzano (MI)  ITALY
S. Quaglini  Dip. Informatica e Sistemistica, Facoltà di Ingegneria, Università di Pavia  Pavia  ITALY
         
         
         
         
         
         
         
         
         
         
         

Kind of presentation: poster

Risk factors: manifestation, treatment and prognosis  
  
Poster Session Blue
Chairs:  

Date: Thursday 28 May 2009
Time: 12:30 - 14:00
Room:  

1.
Plasma homocysteine level is inversely associated with regular physical activity in a population-based sample with 3596 subjects
Objectives: Homocysteine level is associated with atherosclerosis and predicts vascular events. Moreover, increasing evidence suggests an association between homocysteine level and regular physical activity. The aim of the present study was to investigate the association of regular physical activity and homocysteine level in a large population-based sample. Methods: This study was based on the data of the participants of the INVADE (Intervention project on cerebrovascular diseases and dementia in the district of Ebersberg) project. Physical activity was defined as “very active” (more than 3 times per week), “moderately active” (3 times per week or less) and “without regular physical activity”. Overnight fasting venous blood samples were obtained at the time of enrolment in the study. Plasma total homocysteine was measured by a high performance liquid chromatography method at a central laboratory. The relationship between regular physical activity and homocysteine level was analyzed using linear regression model including potential confounders: age, sex, body-mass-index, cigarette smoking, alcohol consumption, self-assessment about current physical status, cardiovascular event or intervention, renal insufficiency and medication intake. Results: Complete baseline data were available in 3596 subjects (mean age 68 years, 40% male). 46% (1647) were very active, 39% (1410) were moderately active, and 15% (539) were not physically active. Mean homocysteine levels were significantly higher in no compared to moderate (8.45 vs. 7.59 umol/l, p<0.001) or high (8.45 vs. 7.16 umol/l, p<0.001) physically active participants. Conclusions: Our data indicate that increased regular physical activity is independently associated with a lower homocysteine level and implicate that the beneficial effects of physical activity on cardiovascular events may be in part explained via a decrease of homocysteine.
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S.Sadikovic, Department of Neurology, Klinikum Rechts der Isar, Technische Universitaet Muenchen, Munich, GERMANY
L.Esposito   Department of Neurology, Klinikum Rechts der Isar, Technische Universitaet Muenchen  Munich  GERMANY
D.Sepp  Department of Neurology, Klinikum Rechts der Isar, Technische Universitaet Muenchen  Munich  GERMANY
R.Feurer  Department of Neurology, Klinikum Rechts der Isar, Technische Universitaet Muenchen  Munich  GERMANY
C.Winkler  Department of Neurology, Klinikum Rechts der Isar, Technische Universitaet Muenchen  Munich  GERMANY
C.Schulze-Horn  Department of Psychiatry, Klinikum Rechts der Isar, Technische Universitaet Muenchen  Munich  GERMANY
H.Gnahn  INVADE Study Group  Baldham  GERMANY
D.Sander  Neurologische Klinik Medical Park Loipl  Bischofswiesen  GERMANY
B.Hemmer  Department of Neurology, Klinikum Rechts der Isar, Technische Universitaet Muenchen  Munich  GERMANY
H.Poppert  Department of Neurology, Klinikum Rechts der Isar, Technische Universitaet Muenchen  Munich  GERMANY
         
         
         
         
         

Kind of presentation: oral

Large clinical trials (RCTs)  
  
 
Chairs: R. Sacco, USA and J.M. Orgogozo, France

Date: Wednesday 27 May 2009
Time: 11:42 - 12:06
Room: Victoria Hall

3.
Economic impact of carotid stenting and endarterectomy on health service resources in patients randomised in the International Carotid Stenting Study (ICSS)
BACKGROUND Carotid stenting and endarterectomy for symptomatic carotid stenosis have been the subject of large clinical trials. They have focused on treatment differences in terms of risk of stroke and showed conflicting results. The impact of both treatments on health service resources has not been widely studied within randomised trials and may influence choice of treatment. METHODS ICSS is a randomised clinical trial comparing carotid stenting and endarterectomy in recently symptomatic carotid stenosis. A within trial economic analysis was undertaken based on a cost-consequence analysis which determined the individual components of treatment cost and individual events witnessed within the 30-day trial period. We prospectively collected information on hospital resource use during treatment to measure treatment costs. Unit costs were obtained from a sample of representative centres. RESULTS 1713 patients were randomised between May 2001 and October 2008 to carotid stenting or endarterectomy in equal proportions. We will present the results of the economic evaluation reporting the major resource costs (including device related costs, theatre time and length of stay in hospital), their relation to major outcome events (stroke, myocardial infarction and death within 30 days of treatment) and the cost-consequence analysis as derived from the within trial data. CONCLUSION The costs of stroke caused by treatment are a major component of the total cost of treatment. As additional length of stay in hospital resulting from stroke largely drives these costs this prospectively collected data captures the stroke-related data in addition to direct operative stay. The results of the economic analysis will be important to consider when within trial treatment effects are small and should have a major influence on health service planning of carotid services.
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ICSS investigators
J.Ederle, UCL Institute of Neurology, London, UNITED KINGDOM
A.McGuire   London School of Economics and Political Science  London  UNITED KINGDOM
R.L.Featherstone  UCL Institute of Neurology  London  UNITED KINGDOM
M.M.Brown  UCL Institute of Neurology  London  UNITED KINGDOM
         
         
         
         
         
         
         
         
         
         
         

Kind of presentation: poster

Acute stroke: emergency management, stroke units and complications  
  
Poster Session Blue
Chairs:  

Date: Thursday 28 May 2009
Time: 12:30 - 14:00
Room:  

20.
INSULIN RESISTANCE AND COAGULATION IN ACUTE ISCHEMIC STROKE
Objective: There are accumulating evidences that insulin resistance(IR) is a risk factor for ischemic stroke. It has also effects on coagulation and fibrinolysis which is important in acute phase of infarct. We have examined the relationships between IR, hemostatic markers and stroke severity in acute ischemic stroke patients. Material and methods: We studied coagulation markers (protein C, free protein S, fibrinogen, von Willebrand factor and antithrombin III) within the first 48 hours of ischemic stroke in 60 non-diabetic patients with and without IR. Results: The protein C (87+/- 20.9; 98.9+/-13.7; p=0.019) and protein S (82.9+/-15.1; 95.3+/-15.8; 0.004) levels of insulin resistant patients were significantly lower. Although NIHS scores (10.37+/-5.2; 9.6+/-6.8;p>0.05), fibrinogen (313.6+-105.2; 286.4+-123.5; p>0.05) and von Willebrand factor (159.2+/-61.4; 136.2+/-55.3; p>0.05) levels were higher in patients with IR, these were not statistically significant. However a negative correlation between NIHS scores and protein S levels (r=-0.363, p=0.004) was detected. Conclusions: Our results suggest the effect of IR on protein C and protein S in acute ischemic stroke. The significant associations of IR and hemostatic markers may be relevant to stroke severity by causing procoagulant tendency.
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A.Ozkul, Adnan Menderes University Faculty of Medicine Neurology Department, Aydin, TURKEY
E.T.Turgut   Adnan Menderes University Faculty of Medicine Neurology Department  Aydin  TURKEY
A.Akyol  Adnan Menderes University Faculty of Medicine Neurology Department  Aydin  TURKEY
C.Yenisey  Adnan Menderes University Faculty of Medicine Biochemistry Department  Aydin  TURKEY
G.Kadikoylu  Adnan Menderes University Faculty of Medicine Hematology Department  Aydin  TURKEY
C.Tataroglu  Adnan Menderes University Faculty of Medicine Neurology Department  Aydin  TURKEY
         
         
         
         
         
         
         
         
         

Kind of presentation: poster

Acute stroke: treatment and concepts  
  
Poster Session Red
Chairs:  

Date: Wednesday 27 May 2009
Time: 12:30 - 14:00
Room:  

2.
Comparison between NIHSS and sNIHSS-5 as predictors of outcome in right and left anterior circulation strokes
Background: Stroke severity at baseline is a strong predictive factor for functional outcome. The National Institutes of Health Stroke Scale (NIHSS) is commonly used because it is a valid, reliable and reproducible scale. However, it is time consuming as it consists of 15 items. A shortened version, the sNIHSS-5, has been developed for easy use in the prehospital setting (Stroke 2002; 33: 2801). It scores only 5 items of the NIHSS (motor right and left leg, gaze, visual fields and language). The purpose of this study was to validate the sNIHSS-5 in a well-documented cohort of acute ischemic anterior circulation stroke patients not treated with thrombolysis. Methods: We studied the baseline NIHSS and sNIHSS-5 in all patients with ischemic stroke who participated in the negative LUB-INT-9 trial and in whom the baseline NIHSS and 12 week modified Rankin Scale (mRS) scores were available. 365 patients had right hemispheric strokes and 308 had left hemispheric strokes. A poor outcome was defined as a mRS score of > 2 at 12 weeks post stroke. Spearman’s p was computed between the NIHSS and the sNIHSS-5. Areas under the receiver operator characteristic curve (C statistics) were used to compare predictive performance of the NIHSS and the sNIHSS-5. Results: There was an excellent correlation between the NIHSS and sNIHSS-5 (0.91 for the whole group, 0.90 for right hemispheric strokes and 0.92 for left hemispheric strokes). C statistics were 0.77 for NIHSS (0.79 for right and 0.76 for left hemispheric strokes), and 0.76 for sNIHSS-5 (same for both right and left hemispheric strokes). Conclusion: Our results confirm that the baseline sNIHSS-5 is as good as the NIHSS at discriminating between stroke outcome in both right and left anterior circulation strokes.
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S.De Raedt, Universitair Ziekenhuis Brussel, Brussels, BELGIUM
R.Brouns   Universitair Ziekenhuis Brussel  Brussels  BELGIUM
J.De Keyser  Universitair Ziekenhuis Brussel  Brussels  BELGIUM
         
         
         
         
         
         
         
         
         
         
         
         

Kind of presentation: poster

Stroke and metabolic syndrome  
  
Poster Session Red
Chairs:  

Date: Wednesday 27 May 2009
Time: 12:30 - 14:00
Room:  

9.
Serum levels of Methylmalonic Acid and Vitamin B12 in acute ischemic stroke
Background:Mitochondrial toxins are produced during cerebral ischemia.It has been shown that a gene for methylmalonyl CoA mutase is expressed in ischemic region. Methylmalonyl CoA mutase,which is a vitamin B12 dependent enzyme,converts methylmalonylCoA to succinylCoA and has an important role both in electron transport chain and Krebs cycle.In case of vitaminB12 deficiency or methylmalonylCoA mutation,methylmalonic acid(MMA)derived from methylmalonyl CoA,accumulates and interferes with mitochondrialfunctions. It's not known whether increased serum level of MMA has any affect on stroke severity.We measured serum levels of MMA and vitaminB12,and evaluated the correlation between stroke severity.Methods:Fifty patients with acute ischemic stroke were included.Clinical status was assessed by National Institute of Health and Stroke Scale (NIHSS) and Modified Rankin Scale (mRS).Stroke subtype was classified according to TOAST criteria.Control group was 55 sex and age matched subjects without a history of stroke and other cardiovascular diseases.Serum MMA was measured by High-Performance Liquid Chromatography with fluorescence detection.Briefly,MMA was extracted from an acidified serum with ethyl acetate. The extract was dried and derivatized with monodansylcadaverine and dicyclohexylcarbodiimide prior to injection on the HPLC.Ethylmalonic acid is used as an internal standard.VitaminB12 tests were evaluated by the Immulite2500 Analyzer System.Principle of theprocedure is a competitive immunoassay.Results:The mean value of MMA in stroke cases was 0,40µmol/L,which is higher than the accepted normal range of 0,05-0,37µmol/L.Mean MMA value in control group was 0,37µmol/L.The difference was not found significant according to t-test.Mean value of vitamin B12 levels in cases was lower than control group (374,4pg/ml and 461,4pg/ml respectively)but the difference was not significant,either.T-test revealed no correlation between the stroke severity and serum levels of MMA and vitamin B12. Conclusion:Despite the tendency of serum MMA levels to increase in acute ischemic stroke,the potantial role in ischemic injury needs to be clarified before the routine use of the test.
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N.Yener, Dokuz Eylul University, Faculty of Medicine, Department of Biochemistry, Izmir, TURKEY
E.Yaka   Dokuz Eylul University, Faculty of Medicine, Department of Neurology  Izmir  TURKEY
D.Kutluk  Dokuz Eylul University Vocational School of Health Services  Izmir  TURKEY
V.Öztürk  Dokuz Eylul University, Faculty of Medicine, Department of Neurology  Izmir  TURKEY
G.Güner  Dokuz Eylul University, Faculty of Medicine, Department of Biochemistry  Izmir  TURKEY
K.Kutluk  Dokuz Eylul University, Faculty of Medicine, Department of Neurology  Izmir  TURKEY
         
         
         
         
         
         
         
         
         

Kind of presentation: poster

Challenging cases  
  
Poster Session Red
Chairs:  

Date: Wednesday 27 May 2009
Time: 12:30 - 14:00
Room:  

1.
Endovascular treatments for uncommon carotid lesions: dissections, chronic total occlusion and carotid web.
BACKGROUND: Various carotid pathologies are encountered in the management of stroke patients, and some of them are refractory to medical therapy. We show cases with uncommon carotid lesions which were successfully treated with endovascular treatments. Methods: In 403 cases with acute ischemic strokes admitted to our stroke unit, four patients participated: two with spontaneous dissection, one with chronic total occlusion, and another with carotid web. Written informed consent was taken from the subject before the procedure. RESULTS: Case1: A 45yo male with dissecting pseudoaneurysm in the left extracranial internal carotid artery (ICA) that led to the cortical embolisms. Rapid expansion of the lesion was ceased by stent deployment. Case2: A 51yo female with occlusive dissection in the left ICA. A balloon catheter with guide wire attached to the stump successfully recanalized the artery. Case3: A 78yo male with the right ICA occlusion. The occluded portion was penetrated by the microwire, and the following angioplasty restored the normal flow. He became ambulatory, and the dementia disappeared. Case4: A 58yo female was suffered from transient faintness and weakness in the left. Angiograms revealed a carotid web in the right ICA. The lesion was a part of fibrous cap turned over the ruptured plaque. A self-expandable stent was deployed, and she became free from the episode. CONCLUSION: Although the management of the atherosclerotic stenoses in ICA had been repeatedly studied, the treatment of uncommon lesions such as carotid dissections leaves much to be discussed. We assumed that the surgical intervention is justified only when the conservative treatment failed to control the problems. Intensive estimation of the lesions by means of multimodal imaging techniques is a fundamental process to best individualize the therapy to each case. Most of the actual procedures were the assortment of the routine techniques in IVR, and safely performed.
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K.Yoshikawa, Department of Neurology, Saiseikai Kyoto Hospital, Kyoto, JAPAN
N.Murakami   Department of Neurology, Saiseikai Kyoto Hospital  Kyoto  JAPAN
         
         
         
         
         
         
         
         
         
         
         
         
         

Kind of presentation: poster

Risk factors: manifestation, treatment and prognosis  
  
Poster Session Blue
Chairs:  

Date: Thursday 28 May 2009
Time: 12:30 - 14:00
Room:  

31.
Allantoin – a candidate biomarker for oxidative stress in acute ischaemic stroke?
Background: The prominent role of urate as an antioxidant had been demonstrated in several studies, indicating its possible role as a protectant in conditions associated with elevated oxidative stress, such as ischaemic stroke (IS). However, various epidemiological studies examining the association between urate and IS had produced conflicting results. Levels of allantoin, the oxidation product of urate and free radicals, may be expected to increase during periods of elevated oxidative stress. The role of allantoin in IS has yet to be elucidated. Here, we sought to investigate the role of allantoin as a potential biomarker of oxidative stress in acute IS. Method: Baseline serum allantoin levels were assayed in 493 acute IS patients within 3 days of stroke onset (cases) and in 98 hospital-based recruited non-stroke participants (controls), after informed consent, using the gas chromatography-mass spectrometry method. Data on demography and vascular risk factors were collected at recruitment. Results: Median allantoin level was significantly lower in cases compared to controls (1.62 vs 2.36 microM, p<0.001). Univariate analyses showed significantly higher proportion of male (61.7 vs 50%, p<0.05), hypertension (78.7 vs 54.1%, p<0.001), diabetes (38.9 vs 36.6%, p<0.05), ischaemic heart disease (26.4 vs 16.7%, p=0.01) in cases compared to controls. Logistic regression showed allantoin to be significantly lower in IS patients compared to controls after adjusting for demographical information and vascular risk factors (OR 0.84 [95%CI 0.74-0.91]). Conclusions: Our results showed that IS patients have a lower level of serum allantoin. This may be an indication of suppressed oxidative stress. This mechanism has yet to be elucidated. However these suggest IS patients may have limited antioxidant available. Low urate level would suggest limited amount of antioxidant available thus limiting its protective ability resulting in ischaemia. Validation studies in larger samples would be required.
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K.Kasiman, Centre for Molecular Epidemiology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, SINGAPORE
J.Gruber   Department of Biochemistry, Yong Loo Lin School of Medicine, National University of Singapore  Singapore  SINGAPORE
S.Y.Tang  Department of Biochemistry, Yong Loo Lin School of Medicine, National University of Singapore  Singapore  SINGAPORE
B.Halliwell  Department of Biochemistry, Yong Loo Lin School of Medicine, National University of Singapore  Singapore  SINGAPORE
H.M.Chang  Department of Neurology, National Neuroscience Institute (Singapore General Hospital Campus)  Singapore  SINGAPORE
M.C.Wong  Division of Medical Sciences, National Cancer Centre Singapore  Singapore  SINGAPORE
C.P.L.H.Chen  Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore  Singapore  SINGAPORE
         
         
         
         
         
         
         
         

Kind of presentation: poster

Acute stroke: emergency management, stroke units and complications  
  
Poster Session Blue
Chairs:  

Date: Thursday 28 May 2009
Time: 12:30 - 14:00
Room:  

16.
In-hospital Acute Myocardial Infarction and Acute Heart Failure in consecutive stroke patients
Background and Purpose: the relationship between cardiovascular event and stroke is well established. However few studies described the prevalence of cardiovascular events in unselected stroke patients. The aims of this study were to evaluate: 1) the prevalence of acute myocardial infarction (AMI) and acute heart failure (AHF) in a population of consecutive patients with stroke; 2) the correlation between AMI and/or AHF and mortality at 3 months; 3) the risk factors for AMI and/or AHF. Methods: Consecutive stroke patients admitted to the Stroke Unit of University of Perugia during the period of June 2005 – September 2008 were studied. During the hospitalization vascular events such as AMI and AHF were recorded. All patient were followed-up for at least 3 months. The measure of outcome was mortality. Results: 814 patients with a mean age of 71.7 years were included. Out of these, 685 patients had an ischemic stroke (84.2%). In the study period 53 patients (6.5%) had AMI and/or AHF (13 AMI alone, 28 AHF alone and 12 AMI associated with AHF). At 3 months, 11 patients were lost at follow-up and 151 had died (18.8%). Death was seen in 32 patients with AMI and/or AHF (60.4%) as compared with 119 of the 750 patients without cardiac complications (15.9%). At logistic regression analysis, the presence of AMI and/or AHF was independently associated with an increased risk for death (p=0.008). At logistic regression analysis, the occurrence of AMI and/or AHF was predicted by history of angina (p=0.003), AMI in the previous 3 months before stroke (p=0.0001), high levels of blood glucose (p=0.047) and high NIHS score on admission (p=0.0001). Conclusions: Both AMI and AHF are potentially lethal complications in patients suffering of stroke and they are independent predictors of poor outcome. The diagnosis and prompt treatment of these complications may be difficult because of the low consciousness and lack of collaboration of acute stroke patients.
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S.Micheli, Stroke Unit and Division of Cardiovascular Medicine - University of Perugia, Perugia, ITALY
G.Agnelli   Stroke Unit and Division of Cardiovascular Medicine - University of Perugia  Perugia  ITALY
F.Palmerini  Stroke Unit and Division of Cardiovascular Medicine - University of Perugia  Perugia  ITALY
V.Caso  Stroke Unit and Division of Cardiovascular Medicine - University of Perugia  Perugia  ITALY
M.Venti  Stroke Unit and Division of Cardiovascular Medicine - University of Perugia  Perugia  ITALY
A.Alberti  Stroke Unit and Division of Cardiovascular Medicine - University of Perugia  Perugia  ITALY
S.Biagini  Stroke Unit and Division of Cardiovascular Medicine - University of Perugia  Perugia  ITALY
A.M.Billeci  Stroke Unit and Division of Cardiovascular Medicine - University of Perugia  Perugia  ITALY
M.Paciaroni  Stroke Unit and Division of Cardiovascular Medicine - University of Perugia  Perugia  ITALY
         
         
         
         
         
         

Kind of presentation: poster

Acute stroke: treatment and concepts  
  
Poster Session Red
Chairs:  

Date: Wednesday 27 May 2009
Time: 12:30 - 14:00
Room:  

34.
THROMBOLYSIS IN ACUTE ISCHEMIC STROKE FROM CERVICAL ARTERY DISSSECTION
Background: Patients with acute ischemic stroke (AIS) are screened for intravenous (IVT) or intra-arterial thrombolysis (IAT) beside stroke aetiology. Cervical artery dissection (CAD) is characterised by stretching and tearing of artery that results in bleeding within the arterial wall. Thrombolytic therapy with or without intra-arterial manoeuvres, could theoretically enlarge the haematoma or favour the rupture of the artery, eventually causing neurological worsening or even death. The aim of our study is to obtain preliminary information as to whether the efficacy and safety of thrombolytic treatments (IVT and IAT combined) performed in patients with CAD differ substantially from those performed in patients with other causes of stroke. Methods: we retrospectively selected patients with AIS due to CAD treated with thrombolytic treatments, admitted to Florence University Hospital, from February 2002 to June 2008. Among patients with AIS due to any other cause than CAD we selected a control group matched for treatment type, sex, age, neurological severity. Primary outcome measures were disability within 6 months, discharge modality, death and any hemorrhagic complications. Results:12 patients (males 83%, mean age 41 years, median NIHSS 18) with AIS due to CAD were treated with thrombolysis (4 IVT, 8 IAT).24 patients (males 67%, mean age 53 years, median NIHSS 15) were included in the control group (9 IVT, 15 IAT). Home discharge was more frequent among controls (27.3% vs 72.7%;p0.715). A good functional outcome (modified Rankin scale score less than 3) was achieved in 4 CAD patients and in 16 controls (33.3% vs 66.7%; p0.081). Symptomatic intra-cerebral haemorrhage occurred in 1 CAD patient treated with IAT. 2 controls died within 3 months. No patients developed a rupture of the dissected vessel. Conclusions: in this albeit limited experience,patients with AIS due to CAD, even if treated with acute thrombolytic treatments, have a poor neurological prognosis. The presence of CAD does not seem to carry an additional risk after IVT or IAT. Larger controlled studies of efficacy and safety of acute thrombolytic treatments in patients presenting with CAD are in order.
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G.L.Lucente, Department of Nerurological and Psychiatric sciences, University of Florence, Florence, ITALY
M.N.Nesi   Department of Nerurological and Psychiatric sciences, University of Florence  Florence  ITALY
P.N.Nencini  Department of Nerurological and Psychiatric sciences, University of Florence  Florence  ITALY
D.I.Inzitari  Department of Nerurological and Psychiatric sciences, University of Florence  Florence  ITALY
         
         
         
         
         
         
         
         
         
         
         

Kind of presentation: oral

Large clinical trials (RCTs)  
  
 
Chairs: R. Sacco, USA and J.M. Orgogozo, France

Date: Wednesday 27 May 2009
Time: 11:42 - 12:06
Room: Victoria Hall

4.
Leukoaraiosis and perioperative risk of stroke in patients treated for symptomatic carotid stenosis randomised in the International Carotid Stenting Study (ICSS)
BACKGROUND Leukoaraiosis predicted increased perioperative risk of endarterectomy in the North American Carotid Endarterectomy Trial. This association has not been tested in an independent cohort and the influence of white matter changes on the risk of carotid stenting is unknown. We therefore examined the association between leukoaraiosis and perioperative risk in patients randomised in the International Carotid Stenting Study (ICSS). METHODS ICSS is a multicentre, international trial in which patients with recently symptomatic carotid artery stenosis suitable for either procedure were randomised in equal proportions between carotid stenting and endarterectomy. Copies of brain imaging (MRI or CT) performed prior to randomisation were routinely collected. Two readers analysed the scans blind to treatment allocation using a published rating scale (Wahlund 2001) validated for MRI and CT. MRI was used in patients in whom both CT and MR were available. Disagreements were resolved by consensus. The severity of leukoaraiosis was correlated with the 30 day risks of treatment using intention-to-treat analysis. RESULTS 1713 patients were randomised at 50 international centres between 2001 and 2008. The association between the severity of leukoaraiosis and the risk of stroke within 30 days of treatment overall will be presented. The prognostic value of white matter changes and their influence on the comparison between endarterectomy and stenting will be tested using a logistic regression. Association between baseline medical risk factors and extent of white matter changes will be assessed. CONCLUSION An association between leukoaraiosis and the risk of treatment will have important implications for the selection of patients for carotid interventions.
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ICSS investigators
J.Ederle, UCL Institute of Neurology, London, UNITED KINGDOM
S.Brew   National Hospital for Neurology and Neurosurgery  London  UNITED KINGDOM
J.Dobson  London School of Hygiene and Tropical Medicine  London  UNITED KINGDOM
R.L.Featherstone  UCL Institute of Neurology  London  UNITED KINGDOM
M.M.Brown  UCL Institute of Neurology  London  UNITED KINGDOM
         
         
         
         
         
         
         
         
         
         

Kind of presentation: poster

Acute cerebrovascular events (ACE): TIA and minor strokes  
  
Poster Session Red
Chairs:  

Date: Wednesday 27 May 2009
Time: 12:30 - 14:00
Room:  

13.
Clinical predictors of "TIA" or "mimic" diagnosis
Background: Transient ischemic attack (TIA) diagnosis may be challenging, and main difficulty is distinguishing it from mimics. We aimed to identify the key clinical features improving this distinction. Methods: Analysis of consecutive patients referred to a TIA clinic from March 2004 to November 2008. Prospective standard clinical assessment was performed. Diagnosis was dichotomized as TIA and mimics, following previous specified criteria. Patients not fulfilling criteria for definite or probable TIA were labelled as mimic. Bivariate and multivariate analyses were performed to identify features associated with TIA or mimics. Results: 360 patients were included, 201 males (55.8%), with a median age of 65 years. Median duration of transient neurological attacks (TNA) was 30 minutes. Diagnoses were: TIA-226 patients (62.8%); mimic-134 patients (37.2%). Ten items independently predicted the diagnosis of patients presenting as TNA: age ≥ 65 years, known hypertension, sudden onset, aphasia, dysarthria, and motor symptoms suggested a TIA; associated non-neurological symptoms, memory disorder, loss of consciousness, or movement disturbance were more suggested of a mimic. The area under the ROC curve for this model was 0.94 (95 CI 0.91-0.96). Conclusions: Several clinical variables can be useful in distinguish TIA from mimics. This model should be refined and validated in other cohorts of TNA patients. It can be used to improve clinical skills for evaluation and provide specific care to TIA patients.
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P.Canhão, Hospital Santa Maria, Lisboa, PORTUGAL
A.C.Fonseca   Hospital Santa Maria  Lisboa  PORTUGAL
         
         
         
         
         
         
         
         
         
         
         
         
         

Kind of presentation: poster

Epidemiology of stroke  
  
Poster Session Red
Chairs:  

Date: Wednesday 27 May 2009
Time: 12:30 - 14:00
Room:  

2.
LUNG FUNCTION PREDICTS FATAL STROKE IRRESPECTIVELY OF BODY MASS AND SMOKING HABITS. A 42 year follow-up study in a general population.
BACKGROUND: During the major part of adult life the body mass index (BMI) tends to increase, the lung function declines and the risk of cerebral stroke increases. We wanted to study the assosiation between BMI and lung function on one side and the outcome of letal stroke. METHODS: A random sample of 6811 Norwegians was invited to a longitudinal cohort study in 1964. 5653 individuals (84%) attended. The mean age was 47.5 years; range 22-75 years. BMI (kg/m2) was calculated from standardized measurements of body height and weight and divided in four groups (<22.0, 22.0-24.9, 25.0-27.9, >=28.0). Forced expiratory volume after one second (FEV1) (l) was measured spirometrically and the percentage of the reference value was calculated (FEV1%). Cerebral stroke as cause of death was registered in the ICD 6-10 code system at National Statistics of Norway. The mean follow up time was 28 years. RESULTS: 543 individuals died from cerebral stroke during follow up. In women the lowest risk of fatal stroke was in the group with BMI less than 22 kg/m2 (Cox proportional hazard ratio (HR) 0.60, 95% confidence interval (CI) [0.40-0.91], p = 0.016), compared to the group with BMI 22.0-24.9 kg/m2 (reference), and there was a statistically nonsignificant trend towards increasing risk with increasing BMI. In men no significant BMI-stroke-associations were found. Lung function (FEV1%) was significantly associated to the risk of fatal stroke for both genders. A ten percent decline in FEV1% was associated to an increased risk of fatal stroke for both genders (HR 1.11, 95% CI [1.03-1.20], p=0.005 and 1.11, 95% CI [1.05-1.19], p=1.001, for men and women respectively) after adjustments to smoking habits. BMI did not significantly influence the FEV1-stroke association. CONCLUSION: BMI is a weak predictor of fatal cerebral stroke in women. Lung function is a significant risk factor for cerebral stroke later in life independently of BMI and smoking.
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A.K.Gulsvik, Department of geriatric medicine, Ullevaal University hospital, University of Oslo, Oslo, NORWAY
M.Mowé   Department of geriatric medicine, Aker University hospital, University of Oslo  Oslo  NORWAY
D.S.Thelle  Department of Biostatistics, University of Oslo  Oslo  NORWAY
T.B.Wyller  Department of geriatric medicine, Aker University hospital, University of Oslo  Oslo  NORWAY
         
         
         
         
         
         
         
         
         
         
         

Kind of presentation: poster

Brain imaging  
  
Poster Session Blue
Chairs:  

Date: Thursday 28 May 2009
Time: 12:30 - 14:00
Room:  

9.
The relationship between temperature of "tissue at risk" and ist conversion to infarction in acute ischaemic stroke. Is brain temperature elevation neuroprotective?
Background: Previously, we showed that in acute ischaemic stroke, brain temperature elevation in the ischaemic lesion is not associated with stroke severity or functional outcome in contrast to pyrexia. To evaluate this further, we investigated the relationship between temperature elevation in "tissue at risk" and the likelihood of ist conversion to infarction (lesion expansion). Methods: We superimposed multi-voxel magnetic resonance spectroscopic temperature imaging onto DWI on admission (<24 hours of first symptoms) and compared this hybrid with 3 to 5 day follow-up DWI data in patients with acute ischaemic stroke. We compared tissue temperatures between 1/ "healthy-looking brain" voxels that converted to infarction on the follow-up DWI ("infarct expansion voxels"; n=63) with 2/ "healthy-looking brain" peri-infarct voxels, which did not convert to ischaemic tissue ("non-expansion voxels"; n=63) on the follow-up DWI. Results: In 16 patients, mean temperature in voxels where lesion did not appear on the follow-up DWI was on average over 1° higher than in voxels where the DWI "healthy-looking tissue" on admission converted to infarction (38.14 vs. 37.01°C respectively), but the difference was not statistically significant (p>0.05) due to wide standard deviations. Discussion: The potential association between elevated peri-infarct tissue temperature and absence of ischaemic lesion expansion suggests the human equivalent of the up-regulation of uncoupling protein 2 (UCP-2), a neuroprotective mechanism seen in experimental ischaemic stoke which simultaneously leads to dissipation of cellular energy into heat (we have previously shown that blood flow is not the explanation). Further studies of UCP-2 expression and regional brain temperature changes in acute ischaemic stroke patients are needed.
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B.Karaszewski, Department of Clinical Neurosciences, University of Edinburgh, UK & Department of Neurology, Medical University of Gdansk, Poland , Edinburgh, UNITED KINGDOM
R.Thomas   Department of Clinical Neurosciences, University of Edinburgh, UK  Edinburgh  UNITED KINGDOM
I.Marshall  Medical Physics & Medical Engineering, University of Edinburgh, UK   Edinburgh  UNITED KINGDOM
P.A.Armitage  Department of Clinical Neurosciences, University of Edinburgh, UK  Edinburgh  UNITED KINGDOM
T.Carpenter  Department of Clinical Neurosciences, University of Edinburgh, UK  Edinburgh  UNITED KINGDOM
K.Lymer  Department of Clinical Neurosciences, University of Edinburgh, UK  Edinburgh  UNITED KINGDOM
M.Dennis  Department of Clinical Neurosciences, University of Edinburgh, UK  Edinburgh  UNITED KINGDOM
J.M.Wardlaw  Department of Clinical Neurosciences, University of Edinburgh, UK  Edinburgh  UNITED KINGDOM
         
         
         
         
         
         
         

Kind of presentation: poster

Risk factors: manifestation, treatment and prognosis  
  
Poster Session Blue
Chairs:  

Date: Thursday 28 May 2009
Time: 12:30 - 14:00
Room:  

30.
Prognostic significance of serum allantoin levels in acute ischaemic stroke patients
Background: Several studies have shown elevated urate level as a cardiovascular risk factor and as an independent predictor of stroke. Allantoin, the oxidative product of urate and free radicals from oxidative stress, has been suggested as a potential biomarker for oxidative stress and possibly acute ischaemic stroke (IS). We aim to determine if serum allantoin measured following acute IS predicts for recurrent vascular events and dependency in Singaporean stroke patients. Method: Baseline serum allantoin levels were assayed in 493 acute IS or transient ischaemic attack (TIA) patients within 3 days of stroke onset using the gas chromatography-mass spectrometry method. Data on recurrent vascular events and dependency (measured on a modified Rankin scale [mRS]) were collected upon follow-up at 1 year. Univariate and multivariate logistic regression analyses were used to determine if allantoin is an independent predictor of vascular outcomes post-stroke. Results: Univariate analysis showed age (p<0.001), gender (p<0.01), ischaemic heart disease [IHD] (p<0.05), atrial fibrillation (p<0.01), stroke subtype (p<0.001), triglycerides (p<0.05), creatinine (p<0.01) and urea (p=0.01) to be associated with poor clinical outcome (mRS>2) at 1 year. However, significant associations were also found between allantoin level and gender (p<0.001), IHD (p<0.01), smoking (p<0.05), previous stroke (p<0.05), triglycerides (p<0.001), creatinine (p<0.001) and urea (p<0.001). Multivariable logistic regression analysis using the above variables showed serum allantoin to be a predictor of better clinical outcome (1.64 vs 1.60 microM, OR 0.74 [95%CI 0.58-0.95]). No significant association was found between allantoin and recurrent vascular outcomes at 1 year. Conclusions: Our results suggest that serum allantoin may be an independent prognostic marker of favourable clinical outcome (mRS<=2) but not recurrent vascular outcomes following acute IS. Validation studies are needed to confirm this finding.
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K.Kasiman, Centre for Molecular Epidemiology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, SINGAPORE
J.Gruber   Department of Biochemistry, Yong Loo Lin School of Medicine, National University of Singapore  Singapore  SINGAPORE
S.Y.Tang  Department of Biochemistry, Yong Loo Lin School of Medicine, National University of Singapore  Singapore  SINGAPORE
B.Halliwell  Department of Biochemistry, Yong Loo Lin School of Medicine, National University of Singapore  Singapore  SINGAPORE
H.M.Chang  Department of Neurology, National Neuroscience Institute (Singapore General Hospital Campus)  Singapore  SINGAPORE
M.C.Wong  Division of Medical Sciences, National Cancer Centre Singapore  Singapore  SINGAPORE
C.P.L.H.Chen  Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore  Singapore  SINGAPORE
         
         
         
         
         
         
         
         

Kind of presentation: oral

Vascular biology  
  
 
Chairs: G. del Zoppo, USA and H. Markus, United Kingdom

Date: Thursday 28 May 2009
Time: 14:40 - 14:50
Room: A3

5.
Mobilisation of circulating progenitor cells in patients with acute cerebral infarction
Background: Circulating progenitor cells are derivatives from adult stem cells and can contribute to the repair of ischemic tissue. The mobilisation of progenitor cells and their beneficial effects have already been shown in patients with acute myocardial infarction. Howerever there is little known so far about circulating progenitor cells during acute cerebral infarction. We investigated in this study the extent and the time frame of the mobilisation of progenitor cells in patients with acute cerebral infarction. Methods: 43 patients admitted to our stroke unit with radiologically verified acute cerebral infarction were consecutively enrolled in this study. Exclusion criteria were chronic inflammatory and malignant diseases. The number of circulating progenitor cells was analyzed by flow cytometry using anti-CD45, anti-CD34 and anti-CD133 (Miltenyi Biotec, Becton Dickinson). Blood samples were taken within 24h after symptom onset, on day 5 and on day 7. Results: The number of circulating progenitor cells was significantly increased on day 5 after symptom onset in patients with acute cerebral infarction compared to the initial value (median[range]: 0,12 cells/µl [0-3,89] vs. 0,33 cells/µl [0-1,69], p=0,001). On day 7 the number of circulating progenitor cells was already lower than on day 5 but still higher than initially (median[range]: 0,29 cells/µl [0-1,56], p=0,214[day0-day7], p=0,299[day5-day7]). Conclusion: This study shows a mobilisation of progenitor cells after acute cerebral infarction. The extent and the time frame of mobilisation are similar after acute cerebral infarction and after acute myocardial infarction. These results may indicate that ischemic tissue activates the mobilisation of progenitor cells independently from the affected organ. A potential beneficial effect of circulating progenitor cells in patients with acute cerebral infarction will further be investigated.
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D.Sepp, Department of Neurology, Technical University of Munich, Munich, GERMANY
I.Ott   Department of Cardiology, Technical University of Munich  Munich  GERMANY
D.Franz  Department of Neurology, Technical University of Munich  Munich  GERMANY
R.Feurer  Department of Neurology, Technical University of Munich  Munich  GERMANY
S.Sadikovic  Department of Neurology, Technical University of Munich  Munich  GERMANY
L.Esposito  Department of Neurology, Technical University of Munich  Munich  GERMANY
P.Zepper  Department of Neurology, Technical University of Munich  Munich  GERMANY
B.Hemmer  Department of Neurology, Technical University of Munich  Munich  GERMANY
H.Poppert  Department of Neurology, Technical University of Munich  Munich  GERMANY
         
         
         
         
         
         

Kind of presentation: poster

Interesting cases  
  
Poster Session Red
Chairs:  

Date: Wednesday 27 May 2009
Time: 12:30 - 14:00
Room:  

6.
Posterior reversible encephalopathy syndrome with atypical presentation
Introduction: Posterior reversible encephalopathy syndrome (PRES) is characterized for headache, encephalopathy, visual disturbances and epileptic seizures. Typical brain MRI shows reversible vasogenic edema in posterior regions. Recently, anterior regions involvement and hemorrhage have been reported. Case reports: Patient1- 59 years old healthy female, observed for vomits and acute, pulsatile, frontal headache of increasing severity, followed by visual disturbances. Examination revealed cortical blindness, nuchal rigidity and positive Kernig sign. BP was 219/108mmHg and body temperature 37ºC. Brain MRI showed T2 hypointensity in left frontal region and multiple cortico-subcortical occipital, frontal and cerebellum hyperintensities. During hospital stay she had visual seizures. Hypertension was treated and secondary causes excluded. Neurological recovering was complete. Two months later, MRI showed frontal focus of hemosiderosis. Patient 2- 62 years old female with Parkinson’s disease with sudden onset of right frontoparietal headache, vomits and high blood pressure (BP: 200/110 mmHg), followed by confusion and visual seizures. 48 hours later she presented left hemiparesis. She had initiated midodrine 1 month earlier. Examination disclosed anosognosia, left hemianopsia and hemiparesis. Brain MRI showed bilateral occipital hyperintensities, involving anterior regions and bilateral superficial hyperintensity, suggesting subarachnoid blood. Hypertension was treated. She progressively recovered. Two months follow-up MRI showed right paramedian cortico-subcortical ischemic focus. Hypertension was attributed to midodrine. Conclusions: In both patients, clinical picture, lesions localization, evolution and follow-up made us consider PRES diagnosis, although lesions extension and subarachnoid hemorrhage was atypical. We consider that, in appropriate clinical setting, PRES should be considered even in the presence of subarachnoidal blood and anterior brain involvement.
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E.Coutinho, Neurology Department - Hospital Santo António, Centro Hospitalar do Porto, Porto, PORTUGAL
J.Damásio   Neurology Department - Hospital Santo António, Centro Hospitalar do Porto  Porto  PORTUGAL
J. P. Pereira  Neurorradiology Department - Hospital Santo António, Centro Hospitalar do Porto  Porto  PORTUGAL
M.Correia  Neurology Department - Hospital Santo António, Centro Hospitalar do Porto  Porto  PORTUGAL
A.Tuna  Neurology Department - Hospital Santo António, Centro Hospitalar do Porto  Porto  PORTUGAL
         
         
         
         
         
         
         
         
         
         

Kind of presentation: poster

Acute stroke: emergency management, stroke units and complications  
  
Poster Session Blue
Chairs:  

Date: Thursday 28 May 2009
Time: 12:30 - 14:00
Room:  

3.
The significance of periodic lateralized epileptiform discharges on outcome in status epilepticus caused by acute stroke
Background: Status epilepticus is associated with high morbidity and mortality and the most important cause of this medical emergency in older people is stroke. Periodic lateralized epileptiform discharges (PLEDs) are a rare electroencephalographic finding and are usually associated with structural lesions caused by cortical stroke. Methods: We evaluated prospectively the occurrence of early seizures after acute stroke in 634 patients admitted to our hospital and among them identified those with status epilepticus (SE). We analyzed the clinical outcome in the patients with SE presenting with PLEDs in their EEG with those without periodic discharges. Results: Fifty-eight patients (8, 8%) had epileptic seizures during the first 14 days after stroke onset and among them nine patients (16%) had status epilepticus. In one third of the patients with SE after acute stroke we observed periodic lateralized discharges (In two patients PLEDs were found and in one patient we detected BiPLEDs). There was no significant difference regarding neuroradiological findings between patients with PLEDs as compared to patients with no PLEDs. The patients presenting with periodic lateralized epileptiform discharges early in the course of SE in the acute phase of stroke had the significantly worse outcome (78% in-hospital mortality vs. 33% in those with no PLEDs; p=0.03). Conclusion: We found significant association between SE and the occurrence of periodic lateralized epileptic discharges on overall mortality in the patients with SE in the acute phase of stroke.
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N.Radojkovic-Gligic, Special Hospital for Cerebrovascular Diseases “Sveti Sava”, Belgrade, Serbia, Belgrade, SERBIA
P.M.Nikic   Special Hospital for Cerebrovascular Diseases “Sveti Sava”, Belgrade, Serbia  Belgrade  SERBIA
V.Paunovic  Special Hospital for Cerebrovascular Diseases “Sveti Sava”, Belgrade, Serbia  Belgrade  SERBIA
         
         
         
         
         
         
         
         
         
         
         
         

Kind of presentation: poster

Risk factors: manifestation, treatment and prognosis  
  
Poster Session Blue
Chairs:  

Date: Thursday 28 May 2009
Time: 12:30 - 14:00
Room:  

16.
Prognostic utility of Interleukin-10 in the prediction of recurrent vascular events after ischaemic stroke
Background: Inflammation has been associated with the development of atherosclerosis and there is increasing evidence of its importance in the pathophysiology of ischaemic stroke. Several studies had investigated various inflammatory cytokines, such as interleukin-10 (IL-10), as prognostic markers for short-term clinical outcome following acute ischaemic stroke. Hence we aim to investigate the role of IL-10 in predicting for longer-term outcomes such as recurrent vascular events post-stroke. Method: Fasting blood samples were obtained from consenting ischaemic stroke patients admitted to the Singapore General Hospital 3 months post-stroke. Follow-ups were arranged semi-annually for 5 years where post-stroke outcomes such as the occurrence of recurrent vascular events were determined. 294 baseline IL-10 was assayed using the commercially available Bio-Plex multiplex system. Univariate and multivariate logistic regression analyses were employed in determining predictors of recurrent vascular outcomes. Results: 32 (11%) patients had recurrent vascular events upon follow-up. Univariate analysis showed that previous stroke (31% vs 15%, p<0.05) and low level of IL-10 (0pg/L vs 0.15pg/L, p<0.05) were significantly associated with recurrent vascular events post-stroke. However, IL-10 level is no longer significantly associated with recurrent vascular events post-stroke in logistic regression analysis (OR 0.99 [95% CI 0.95-1.03]). Conclusions: Low IL-10 may be of prognostic value in predicting recurrent vascular events in ischaemic stroke patients. Validation studies with larger sample size are needed to explore this relationship.
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K.Kasiman, Centre for Molecular Epidemiology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, SINGAPORE
Y.L.Leong   Department of Neurology, Singapore General Hospital  Singapore  SINGAPORE
D.A.De Silva  Department of Neurology, National Neuroscience Institute (Singapore General Hospital Campus)  Singapore  SINGAPORE
H.M.Chang  Department of Neurology, National Neuroscience Institute (Singapore General Hospital Campus)  Singapore  SINGAPORE
M.C.Wong  Division of Medical Sciences, National Cancer Centre Singapore  Singapore  SINGAPORE
C.P.L.H.Chen  Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore  Singapore  SINGAPORE
         
         
         
         
         
         
         
         
         

Kind of presentation: poster

Acute cerebrovascular events (ACE): TIA and minor strokes  
  
Poster Session Red
Chairs:  

Date: Wednesday 27 May 2009
Time: 12:30 - 14:00
Room:  

12.
Measurement of carotid intima-media thickness to assess correct diagnosis of transient ischemic attack
BACKGROUND: The common carotid intima-media thickness (CCA-IMT) has been associated with incidence of stroke and other vascular events. We prospectively investigate the usefulness of CCA-IMT determination in the diagnosis of transient ischemic attack patients (TIA). METHODS: We compared risk factors and ultrasonographic characteristics of 125 consecutive TIA patients with 190 patients with refractory hypertension (rHT) and 107 individuals at intermediate cardiovascular-risk (ICVR). CCA-IMT was measured by B-mode ultrasonography according to Mannheim consensus. Neuroimaging data and clinical symptoms were recorded among TIA patients. RESULTS: CCA-IMT was higher in TIA patients (0.94±0.20mm) compared to rHT (0.81±0.15mm) and ICVR (0.79±0.17mm), p<0,001. TIA patients had more frequently carotid plaques (65.6% versus 45.8% and 45.9% respectively, p<0.001). Compared to controls, TIA patients had more frequently calcified plaques (48.6% vs 3.9%, p<0.001). After matching, IMT remained higher in TIA patients (0.93±0.22 vs .0.83±0.16mm) Among TIA patients, CCA-IMT was correlated positively with age (r=0.298, p=0.001), the presence of carotid plaques (0.99±0.19 versus 0.87±0.19mm, p<0.001), accumulation of risk factors (1.02±0.20 vs 0.91±0.19, p=0.020) and positive Diffusion-Weighted Images (0.99±0.20 versus 0.89±0.20, p=0.010). Moreover, CCA-IMT differed among TIA etiology: large-artery atherosclerosis (1.05±0.16); cardioembolism (0.92±0.18), undetermined (0.89±0.20), small-vessel disease (1.02±0.26) and ABCD2>5 (1.05 vs 0.92), p=0.012. In multivariate analysis, only the presence of carotid plaques (OR 3.01, 1.14 to 7.94, p=0.026) was identified as independent predictor of being in the highest CCA_IMT quartile (>1.056 mm). CONCLUSIONS: The determination of CCA-IMT could improve the diagnosis of transient neurological symptoms. The correlation of high CCA-IMT with etiological subtypes and its association with positive DWI would suggest the possible prognostic significance of CCA-IMT in these patients.
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F.Purroy, Stroke Unit. Hospital Universitari Arnau de Vilanova. Universitat de Lleida, Lleida, SPAIN
B.Coll   UDETMA. Nephrology department. Hospital Universitari Arnau de Vilanova  LLeida  SPAIN
G.Piñol-Ripoll  Stroke Unit. Hospital Universitari Arnau de Vilanova. Universitat de Lleida  Lleida  SPAIN
A.Quílez  Stroke Unit. Hospital Universitari Arnau de Vilanova. Universitat de Lleida  Lleida  SPAIN
J.Sanahuja  Stroke Unit. Hospital Universitari Arnau de Vilanova. Universitat de Lleida  Lleida  SPAIN
L.Brieva  Stroke Unit. Hospital Universitari Arnau de Vilanova. Universitat de Lleida  Lleida  SPAIN
E.Setó  Stroke Unit. Hospital Universitari Arnau de Vilanova. Universitat de Lleida  Lleida  SPAIN
E.Fernández  UDETMA. Nephrology department. Hospital Universitari Arnau de Vilanova  Lleida  SPAIN
         
         
         
         
         
         
         

Kind of presentation: oral

Acute stroke: emergency management, stroke units and complications  
 A
 
Chairs: A. M. Demchuk, Canada and M. Kaste, Finland

Date: Thursday 28 May 2009
Time: 10:10 - 10:20
Room: A2

5.
In-hospital Myocardial Infarction Following Acute Ischemic Stroke
Acute myocardial infarction is expected to be an important medical complication following ischemic stroke. We sought to describe the frequency and impact of in-hospital myocardial infarction following acute ischemic stroke. Methods: Consecutive patients with acute ischemic stroke, who were admitted to 11 Ontario hospitals, were identified from the Registry of the Canadian Stroke Network (2003-06). Functional status at discharge was measured with the modified-Rankin Scale, and categorized into strokes with no or mild-moderate dependency (m-Rankin 0-3) and those with severe dependence or death (m-Rankin 4-6). Multivariable logistic regression was used to determine the independent association between myocardial infarction and clinical outcome (death or severe dependence at hospital-discharge and 1-year mortality). Results: In total, 9,180 patients with acute ischemic stroke were included. The mean age was 72 years (SD 13.9) and 48% were female. Overall, 211 (2.3%) patients were reported to have myocardial infarction during hospitalization. At hospital discharge, 64.9% of patients with in-hospital myocardial infarction had died or were severely disabled, compared to 35.8% in the entire cohort. Mortality at 1-year after ischemic stroke was 21.9% in the entire cohort and 56.4% in patients with myocardial infarction. On multivariable analyses, myocardial infarction was also associated with death or severe dependence at discharge (OR 2.51; 95%CI 1.75-3.59) and mortality at 1 year (OR 3.08; 95%CI 2.18-4.35). Stroke severity (OR 1.17; 95%CI 1.10-1.24), diabetes mellitus (1.69; 95%CI 1.15-2.48) and previous myocardial infarction (OR 1.88 95%CI 1.23-2.87) were independent predictors of in-hospital myocardial infarction. Conclusions: Myocardial infarction is an important medical complication after acute ischemic stroke. Stroke severity, diabetes mellitus and previous myocardial infarction are independent risk factors for in-hospital myocardial infarction.
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On Behalf of the Registry of the Canadian Stroke Network
J.Liao, McMaster University, Hamilton, CANADA
M.J.O'Donnell   McMaster University  Hamilton  CANADA
F.Silver  University of Toronto  Toronto  CANADA
D.Thiruchelvam  Institute for Clinical Evaluative Sciences  Toronto  CANADA
G.Saposnik  University of Toronto  Toronto  CANADA
J.Fang  Institute for Clinical Evaluative Sciences  Toronto  CANADA
L.Gould  Hamilton Health Sciences  Hamilton  CANADA
N.Mohamed  McMaster University  Hamilton  CANADA
M.K.Kapral  University of Toronto  Toronto  CANADA
         
         
         
         
         
         

Kind of presentation: oral

Epidemiology of stroke  
 A
 
Chairs: A. Tsiskaridze, Georgia and T. Truelsen, Denmark

Date: Wednesday 27 May 2009
Time: 14:40 - 14:50
Room: K2

5.
Trends in baseline stroke characteristics: Data from Riks-Stroke, the Swedish Stroke Register, from 1994 through 2007
Background: Changes in life style, risk factors and preventive measures may modify both stroke incidence and characteristics, such as age at onset, severity and type. Little is known about time trends regarding baseline characteristics. Methods: Fourteen year cohorts (1994-2007) from Riks-Stroke, the Swedish Stroke Register, were compared (n=271,185) with respect to number of strokes, age at onset, sex, stroke type and severity, as well as mobility, dressing ability and living conditions before the stroke. Results: The number of reported strokes increased from 1994 through 2005. Thereafter a small decrease was seen. The mean age at first-ever stroke remained at 72.3 years in men, but increased from 76.5 to 77.7 years in women. The proportions of first-ever and recurrent stroke were constant at 71.8% and 28.2%. The proportion of males with lowered consciousness decreased from 17% during the first years, to 15.5% in later years, but females remained unchanged at 21.4%. The proportion of cerebral infarction increased at the expense of intracerebral hemorrhage and stroke of unspecified type. The prevalence of atrial fibrillation increased in both men and women, indicating a higher frequency of cardioembolism. There were no temporal changes regarding walking ability or dressing ability before the stroke. However, in the later years somewhat more patients received home help service or lived in nursing homes. This is in agreement with that the proportion of patients who live alone increased (in both sexes) during these years. Conclusions: Even in this relatively short time period many baseline characteristics changed. Women now are somewhat older at time of a first-ever stroke, and stroke seems to have become milder disease in men. While intracerebral hemorrhage decreased, cardioembolism seems to have increased as a pathogenic factor. Changes in the prevalence and treatment of cardiovascular risk factors in the background population may have occurred.
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P.Appelros, Department of Neurology, Örebro University Hospital, Örebro, SWEDEN
K.Asplund   Department of Public Health and Clinical Medicine, Umeå University Hospital  Umeå  SWEDEN
B.Norrving  Department of Neurology, Lund University Hospital  Lund  SWEDEN
B.Stegmayr  Department of Public Health and Clinical Medicine, Umeå University Hospital  Umeå  SWEDEN
A.Terént  Department of Medical Sciences, Uppsala University Hospital  Uppsala  SWEDEN
K.Hulter Åsberg  Drug and Therapeutic Committee, County Council of Uppsala  Uppsala  SWEDEN
         
         
         
         
         
         
         
         
         

Kind of presentation: poster

Brain imaging  
  
Poster Session Blue
Chairs:  

Date: Thursday 28 May 2009
Time: 12:30 - 14:00
Room:  

4.
Baseline Early Ischemic CT Changes and Reperfusion Status: Both May Influence Final Infarct Size
BACKGROUND: In the NINDS tPA Study, increased early ischemic changes on CT scan, as measured by lower baseline Alberta Stroke Program Early CT Score (bASPECTS), were associated with larger 24-hour infarct volumes, but were not influenced by treatment assignment; reperfusion status was not available in this study. We tested whether reperfusion status may independently affect the relationship between bASPECTS and final infarct volume in the pooled Interventional Management of Stroke (IMS) I/II trials. We also explored whether higher bASPECTS are associated with higher revasculariization rates. METHODS: The IMS trials treated severe ischemic strokes (NIHSS>/=10) within 3 hours of onset with combined IV/IA thrombolysis. In IMS II, ultrasound via the EKOS MicroLysus® Catheter was also used. ASPECTS were determined retrospectively by consensus readings of baseline CT scans blind to outcome. This analysis included only ICA-T and M1 occlusions to limit variability. Successful reperfusion was defined as Thrombolysis in Cerebral Infarction (TICI) 2-3. Digital CT infarct volumes were determined using Cheshire 4.4.8 Image analysis software. RESULTS: In this subcohort of ICA-T and M1 cases (n=60), the median 24-hr infarct volume was 82 cc (mean 98; range 6-333) and the reperfusion rate was 63%. No association was seen between reperfusion rates and bASPECTS dichotomized at both > 4 (p=1.0) or >7 (p=0.61). Among reperfusion cases (upper thick line), every one-unit decrease in bASPECTS score was associated with a 14 cc increase in 24-hours infarct volume (p=0.0007). Nonreperfusion cases (lower thick line) were associated with a 36 cc increase in 24-hour infarct volume at a given ASPECTS score (p=0.08). See graph. CONCLUSIONS: Our findings suggest that reperfusion may reduce final infarct volume regardless of bASPECTS score. We also confirm that bASPECTS predicts final infarct volume. These findings require further study in larger cohorts using clinical outcomes.
Graphic: http://www.esc-archive.eu/stockholm09/graphics_stockholm/g_AID1070.htm
Table:  
for the IMS I and II Investigators
P.Khatri, University of Cincinnati, Cincinnati, USA
M.D.Hill   University of Calgary  Calgary  CANADA
R.H.Martin  Medical University of South Carolina  Charleston  USA
T.A.Tomsick  University of Cincinnati  Cincinnati  USA
J.P.Broderick  University of Cincinnati  Cincinnati  USA
J.A.Carrozzella  University of Cincinnati  Cincinnati  USA
G.Ramadas  University of Cincinnati  Cincinnati  USA
A.M.Demchuk  University of Calgary  Calgary  CANADA
         
         
         
         
         
         
         

Kind of presentation: poster

Regional/national stroke aspects (EU and beyond)  
  
Poster Session Blue
Chairs:  

Date: Thursday 28 May 2009
Time: 12:30 - 14:00
Room:  

4.
Stroke presentation and hospital management: comparison of neighbouring healthcare systems with differing health policies
Background: Acute stroke care is shaped by healthcare policies. Differing policies in similar populations allow for assessment of policy impact on health and healthcare outcomes. Our aim was to compare stroke presentation and hospital care in two adjacent healthcare systems with differing healthcare policies. Northern Ireland is a part of the UK National Health system: the Republic of Ireland has a mixed public/private system. Methods: Interviews and chart review of consecutive acute stroke admissions in Northern Ireland (NI) (n=103) and the Republic of Ireland (RoI) (n=100). Results: Marked regional contrasts were evident for key aspects of hospital care. NI performed significantly better on 15 of 16 quality of care (Sentinel Audit) items. Delivery on standards was significantly better in NI for early assessment (NI 72%; RoI 54%, p<0.01), multidisciplinary review (NI 69%; RoI 31%, p<0.001) medications review (NI 54%; RoI 19%, p<0.001) and for discharge-rehabilitation planning (NI 83%; RoI 8%, p<0.001). Pre-admission prescription of advised cardiovascular medications was similar between regions for antihypertensives and anticoagulants but significantly higher in NI for antiplatelets (NI 65%; RoI 38%, p=0.001) and lipid-regulating medication (NI 44%; RoI 26%; p=0.006). Prescribing levels increased in both regions and all medication categories by discharge but with significantly lower levels in NI for antihypertensives (NI 60%; RoI 75%, p=0.025). NI patients were more functionally dependent (mean Barthel Index 10.5 vs 12.7 (RoI), p=0.013) and less aphasic (mean Frenchay Aphasia Screening Test 17.8 vs 16.8 (RoI), p=0.022). Conclusions: In similar neighbouring acute stroke populations, differing healthcare policies were associated with significant differences in processes of patient care. Policy reform is an important tool in ensuring optimal stroke care delivery.
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D.O'Neill, Adelaide and Meath Hospital, Dublin, IRELAND
V.L.S.Crawford   Queen's University  Belfast  UNITED KINGDOM
J.Dinsmore  Queen's University  Belfast  UNITED KINGDOM
R.W.Stout  Queen's University  Belfast  UNITED KINGDOM
C.Donnellan  Trinity College  Dublin  IRELAND
H.McGee  Royal College of Surgeons in Ireland  Dublin  IRELAND
         
         
         
         
         
         
         
         
         

Kind of presentation: poster

Management and economics  
  
Poster Session Blue
Chairs:  

Date: Thursday 28 May 2009
Time: 12:30 - 14:00
Room:  

2.
Antihypertensive drug use after first stroke in routine care: results from the General Practitioner Research Database (GPRD)
Background: Guidelines emphasize the importance of antihypertensive drugs for secondary stroke prevention. Data is lacking on use of antihypertensive drugs according to published guidelines in routine clinical care. Methods: The General Practitioner Research Database (GPRD) is a primary care database containing information from over 400 general practices across the UK. Patients registered in the GPRD with first stroke between 1997 and 2006 were identified. Information on comorbidities, drug prescription, survival and stroke recurrence was available. Recommended first line antihypertensive treatment was defined based on guidelines of the British Hypertension Society in respective years. The impact of antihypertensive drug use on risk of death and survival free of recurrent stroke was estimated using multivariable Cox proportional hazard models. Results: 48239 patients with a diagnosis of first stroke were identified in the GPRD. From hypertensive stroke patients surviving 3 months after stroke 75% received any antihypertensive drugs within this period, increasing from 66% in 1997 to 83% in 2006 (p<0.001). 18% of hypertensive stroke patients surviving at least 3 months had no antihypertensive treatment prior to stroke; of whom 45% received any antihypertensive drug within the first 3 months after stroke and 31% first line treatment as recommended by guidelines (increasing from 24% in 1997 to 37% in 2006; p<0.001). Not recommended and recommended first line treatment was associated with beneficial effect on survival (hazard ratio compared to none treatment (HR) 0.79; 95% CI 0.63-1.00 and HR 0.63; 95% CI 0.53-0.75, respectively); recommended treatment also reduced the risk of recurrent stroke (HR 0.82; 95% CI 0.71-0.96). Conclusions: Prescription of antihypertensive drugs as well as adherence to published guidance improved over time. First line treatment according to established guidelines was beneficial in stroke survivors in routine clinical care.
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A.M.Toschke , King's College London, London, UNITED KINGDOM
M.Gulliford   King's College London  London  UNITED KINGDOM
C.D.A.Wolfe   King's College London  London  UNITED KINGDOM
A.G.Rudd   King's College London  London  UNITED KINGDOM
P.U.Heuschmann  Charite Berlin  Berlin  GERMANY
         
         
         
         
         
         
         
         
         
         

Kind of presentation: poster

Epidemiology of stroke  
  
Poster Session Red
Chairs:  

Date: Wednesday 27 May 2009
Time: 12:30 - 14:00
Room:  

36.
Improving Subtype Classification in TOAST-defined Cryptogenic Stroke in the North Dublin Population Stroke Study
Introduction Stroke recurrence rates and treatment strategies differ according to stroke mechanism and subtype. Refining subtype classification may thus improve the design of stroke clinical trials. Although the TOAST system is widely used, up to 40% of patients are designated as cryptogenic and inter-rater reliability is only moderate (kappa~0.5). We investigated an alternative algorithm, the ?Causative Classification System? (CCS) in a large population-based stroke cohort. Methods In a prospective cohort study in 294,592 North Dublin inhabitants, all first-ever ischaemic stroke (FES) patients were identified over one year and TOAST subtype classified after investigation completed. Using a standardised protocol, clinical and diagnostic data were abstracted from medical records and the web-based CCS algorithm applied. Results 381 FES cases were identified in the first year. Of these 112 (29.4%) were ?Stroke of undetermined aetiology? as per TOAST. This was due to 2 or more possible mechanisms in 31/381 (8.1%) (Group A), incomplete evaluation in 36/381 (9.5%) (Group B) and negative evaluation in 45/381 (11.8%) (Group C). 80.6% (25/31) of group A, 13.9% (5/36) of group B, and 6.7% (3/45) of patients in group C had re-classification of subtype after application of the CSS algorithm (to Cardio-aortic [9/33, 27.3%], Large Artery [8/33, 24.2%], Small Artery [10/33, 30.3%], Other Causes [6/33, 18.1%]). Fewer patients were classified as undetermined aetiology using the CCS compared to TOAST (20.7 vs 29.4%, p<0.001). Inter-rater reliability was good (kappa=0.7). Discussion In this observational study, fewer strokes were classified as ?Undetermined cause? using the CCS, particularly for patients with 2 or more potential aetiologies after investigation. In clinical trials, where mandatory investigations more frequently uncover competing aetiologies, the CCS may have additional utility, improving trial design and facilitating subtype analyses.
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M.Marnane, Neurovascular Clinical Science Unit, Mater University Hospital and University College Dublin, Dublin, IRELAND
O.Sheehan   Neurovascular Clinical Science Unit, Mater University Hospital and University College Dublin  Dublin  IRELAND
C.Duggan  Neurovascular Clinical Science Unit, Mater University Hospital and University College Dublin  Dublin  IRELAND
A.Merwick  Neurovascular Clinical Science Unit, Mater University Hospital and University College Dublin  Dublin  IRELAND
N.Hannon  Neurovascular Clinical Science Unit, Mater University Hospital and University College Dublin  Dublin  IRELAND
E.Callaly  Neurovascular Clinical Science Unit, Mater University Hospital and University College Dublin  Dublin  IRELAND
D.Ni Chroinin  Neurovascular Clinical Science Unit, Mater University Hospital and University College Dublin  Dublin  IRELAND
G.Horgan  Neurovascular Clinical Science Unit, Mater University Hospital and University College Dublin  Dublin  IRELAND
J.Duggan  Department of Medicine for the Older Person, Mater University Hospital  Dublin  IRELAND
L.Kyne  Department of Medicine for the Older Person, Mater University Hospital  Dublin  IRELAND
J.Moroney  Department of Neurology, Beaumont Hospital  Dublin  IRELAND
A.Moore  Department of Medicine for the Older Person, Beaumont Hospital  Dublin  IRELAND
P.M.E.McCormack  Department of Medicine for the Older Person, Connolly Hospital  Dublin  IRELAND
L.Daly  School of Public Health and Population Science, University College Dublin  Dublin  IRELAND
P.J.Kelly  Neurovascular Clinical Science Unit, Mater University Hospital and University College Dublin  Dublin  IRELAND

Kind of presentation: poster

Vascular biology  
  
Poster Session Blue
Chairs:  

Date: Thursday 28 May 2009
Time: 12:30 - 14:00
Room:  

4.
Expression studies of protein S, GAS6 and their TAM receptors in carotid atherosclerotic plaques
Background: Recent studies suggest that pathways initiated by the interaction of the plasma vitamin K-dependent proteins, GAS6 and protein S (PS) with the tyrosine kinase receptors TYRO3, AXL and MERTK (TAM) may have a relevant role in atherogenesis. Furthermore, studies of our group indicated an association between polymorphisms of GAS6, TYRO3 and MERTK and both carotid atherosclerosis and stroke. Goal: The aim of this study was to analyze mRNA and protein expression of PS, GAS6 and their TAM receptors in carotid atherosclerotic plaques. Material and Methods: We analyzed mRNA and protein samples isolated from 20 carotid plaques of endarterectomized (CEA) patients by real-time quantitative RT-PCR and western blot assays. We knew plaque morphology, intra-plaque angiogenesis and type of stroke suffered. As controls, we included 6 normal carotid arteries obtained from organ donors or post-mortem autopsies. Relative mRNA expression studies were performed using TaqMan Low Density Arrays (Applied Biosystems). Results: PROS1, AXL and TYRO3 mRNA was less expressed in carotid plaques than in normal arteries, independently of the plaque characteristics. Expression was reduced further in samples from patients who suffered from stroke than in asymptomatic ones. mRNA expression of MERTK was higher in plaques than in normal carotid arteries but this was not statistically significant. There was no difference in GAS6 expression. Western blot results of GAS6, AXL and MERTK (significantly increased in the plaques) were in concordance with the mRNA results. By contrast, PS expression was higher in the carotid plaques than in normal arteries, thereby suggesting infiltration of this protein from plasma. Conclusion: The increased expression of PS and its receptor MERTK in carotid atheroma plaques reinforces a role of the PS-MERTK interaction in carotid atherogenesis. These results also confirm a role for PS independent of its traditional anticoagulant role.
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B.Hurtado, Translational Research Laboratory, Catalan Institute of Oncology, Barcelona, SPAIN
X.Muñoz   Translational Research Laboratory, Catalan Institute of Oncology  Barcelona  SPAIN
N.Garcia  Translational Research Laboratory, Catalan Institute of Oncology  Barcelona  SPAIN
P.Garcia de Frutos  Department of Cell Death and Proliferation, Institute for Biomedical Research of Barcelona (IIBB-CSIC-IDIBAPS)  Barcelona  SPAIN
J.Krupinski  Hospital Universitari Mutua de Terrassa  Barcelona  SPAIN
N.Sala  Translational Research Laboratory, Catalan Institute of Oncology  Barcelona  SPAIN
         
         
         
         
         
         
         
         
         

Kind of presentation: poster

Interesting cases  
  
Poster Session Red
Chairs:  

Date: Wednesday 27 May 2009
Time: 12:30 - 14:00
Room:  

11.
Spastic paretic facial contracture with atypical clinical presentation following lateral bulbar infarction
Case Presentation: A 62 year old female presented with Wallenberg’s Syndrome accompanied by ipsilateral facial paresis. MRI showed posterolateral bulbar infarction. After an initial severe course complicated with aspiration pneumonia leading to intubation for 3 weeks, she recovered with mild dysarthria, right ptosis, right facial weakness, and mild sensory-motor hemiparesis on the left side of the body. About 2 months after discharge she began experiencing episodes that comprised of right hemifacial contracture and unpleasant tightness sensation on the same hemiface, nasal congestion, tearing, worsening of dysarthria, dysphagia and unsteady gait lasting 5-10 minutes. Six months later, the duration of these episodes increased to hours. Severity of symptoms also increased, leading to significant impairment of quality of life and required hospitalization. EMG of the right facial muscles at rest showed high frequency motor unit potential activity. Blink reflex, facial motor evoked potential studies and brainstem auditory evoked potentials were normal. Discussion: These findings are suggestive of facial contracture associated with intrinsic brainstem lesions. Association of spastic paretic hemifacial contracture in this patient with unpleasant sensory complaints and the long duration of the episodes with worsening of stroke symptoms make this case unique.
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N.Yesilot, Istanbul University, Istanbul School of Medicine, Department of Neurology, Istanbul, TURKEY
Z.Matur   Istanbul University, Istanbul School of Medicine, Department of Neurology  Istanbul  TURKEY
H.N.Ceylan  Istanbul University, Istanbul School of Medicine, Department of Neurology  Istanbul  TURKEY
O.Coban  Istanbul University, Istanbul School of Medicine, Department of Neurology  Istanbul   TURKEY
R.Tuncay  Istanbul University, Istanbul School of Medicine, Department of Neurology  Istanbul  TURKEY
S.Zarko Bahar  Istanbul University, Istanbul School of Medicine, Department of Neurology  Istanbul  TURKEY
A. E.Oge  Istanbul University, Istanbul School of Medicine, Department of Neurology  Istanbul  TURKEY
         
         
         
         
         
         
         
         

Kind of presentation: oral

Experimental studies  
 A
 
Chairs: M. Endres, Germany and L. Hirt, Switzerland

Date: Wednesday 27 May 2009
Time: 15:30 - 15:40
Room: A4

10.
Embryonic stem cell derived neural progenitor cells in rat photothrombotic ischemia: Functional recovery and impact on endogenous dendritogenesis
Backround: Transplantation of various stem cells was found to be improve functional recovery in animal stroke models. The optimal stem cell population for transplantation was, however, not determined so far. The underlying mechanisms of functional recovery also remain unclear. We assessed embryonic stem cell derived neural progenitor cells (NPC) in focal cerebral ischemia regarding functional recovery improvement and investigated some potential underlying mechanisms. Methods: Rats underwent photothrombotic ischemia. 24 hours after the onset of ischemia, animals received either 5 million NPC´s (n=10, x-gal positive labelled) i.v. or vehicle (n=14). To prevent graft rejection cyclosporine (10mg/kg, i.p.) was administered daily. The adhesive tape removal test and the cylinder test were performed weekly for 4 weeks. To determine the fate of the transplanted cells brain sections were immunostained for x-gal and the neuronal marker NeuN. Golgi-Cox stained brain sections were analyzed regarding dendritogenesis of endogenous neurons close to the infarction. Results: NPC treated rats performed significantly (p<0.05) better in the adhesive tape removal test than vehicle treated animals. There was no significant difference between the treatment groups in the cylinder test. Immunohistological analysis revealed that only a small amount of transplanted cells reached the brain. These cells partially differentiated into mature neurons as indicated by double staining for NeuN/x-gal. Analysis of dendritogenesis revealed that NPC transplantation significantly (p<0.05) enhanced the number of dendritic branches as well as the number of total dendritic length of endogenous neurons. Conclusion: We demonstrated that transplantation of NPC´s enhance functional recovery after focal cerebral ischemia. This effect correlated with an induction of endogenous dendritogenesis, whereas cell migration to the brain and neuronal differentiation seems to be less important for functional improvement.
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J.Minnerup, Dept. Of Neurology, University Muenster, Muenster, GERMANY
          
         
         
         
         
         
         
         
         
         
         
         
         
         

Kind of presentation: oral

Acute stroke: treatment and concepts  
 C
 
Chairs: A. Alexandrov, USA and V. Di Piero, Italy

Date: Wednesday 27 May 2009
Time: 17:35 - 17:45
Room: A2

30.
Impact of a Telemedicine System on Acute Stroke Care in a Community Hospital
Background We aim to describe the impact of the implementation of a telemedicine system on the administered care to acute stroke patients admitted to a Community Hospital (ComH) Methods In January 2007 a TelS was established between a ComH lacking a neurologist on call and a Reference Stroke Center (RefSC) located 70 kilometers away. TelS allows urgent remote evaluation by a specialized neurologist (physical exam and neuroimaging), supervised indication of thrombolytic treatment or decision of urgent transfer to the RefSC. During the first year of TelS we studied the impact on different indicators for all acute ischemic stroke patients admitted to the ComH and compared the results with the previous year. Results The number of acute stroke patients admitted to the ComH were: 201 in 2006 and 198 in 2007. TelS was activated 75 times (38%). During 2007 the number of stroke patients evaluated by a specialized neurologist increased (17% Vs 38%;p>0.001) and interhospital transfers were reduced (17% Vs 10%;p=0.04). The number of thrombolytic treatments was doubled: 4.5% (n=9) in 2006 Vs 9.6% (n=19, 12 of them in the ComH) in 2007 (p=0.07). TelS allowed also to reduce the time to tPA treatment from symptom onset (210 Vs 162min; p=0.05) and increase the number of patients treated in the 0-3 hours window (30 Vs 68%; p=0.04) Conclusion Telemedicine improves the quality of medical care administered to acute stroke patients admitted to a ComH and reduces the number of inter-hospital transfers.
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M.Ribo, Hospital Vall d'Hebron. Barcelona, Barcelona, SPAIN
A.Pedragosa   Hospital General de Vic  Barcelona  SPAIN
C.A.Molina  Hospital Vall d'Hebron. Barcelona  Barcelona  SPAIN
M. Rubiera  Hospital Vall d'Hebron. Barcelona  Barcelona  SPAIN
E.Santamarina  Hospital Vall d'Hebron. Barcelona  Barcelona  SPAIN
O.Maisterra  Hospital Vall d'Hebron. Barcelona  Barcelona  SPAIN
J.Alvarez-Sabin  Hospital Vall d'Hebron. Barcelona  Barcelona  SPAIN
         
         
         
         
         
         
         
         

Kind of presentation: oral

Acute stroke: treatment and concepts  
 A
 
Chairs: J.-C. Baron, United Kingdom and K. Lees, United Kingdom

Date: Wednesday 27 May 2009
Time: 9:20 - 9:30
Room: A2

6.
Acute CTA Screening of Severe Ischemic Strokes for Intra-Arterial Reperfusion Therapy: Time Lost May Adversely Affect Clinical Outcome
BACKGROUND: CT angiography (CTA) is increasingly used to screen for a proximal arterial occlusion prior to mobilizing the neurointerventional team and incurring the risk of the digital subtraction angiogram (DSA). However, patients with severe ischemic strokes are likely to have a proximal occlusion, and the time lost could decrease their chances of a good clinical outcome. We sought to determine the maximum time for CTA imaging and interpretation that would make routine CTA screening worthwhile for patients with severe strokes (NIHSS>/=10) already initiated on intravenous (IV) rtPA at <3 hours from symptom onset. METHODS: A decision analysis was developed using data from a comprehensive literature review and the Interventional Management of Stroke (IMS) I/II pilot trials. The reference case included: CTA sensitivity 98%, CTA specificity 98%, CTA time (imaging + interpretation) 11.7 minutes, probability of occlusion (ICAT, M1, M2) on DSA 88%, DSA stroke risk 0.5%, CTA transient nephropathy risk 2%, probability of reperfusion with IA therapy 54%, 0.34% loss of probability of good outcome (modified Rankin 0-2) per minute lost for IA reperfusion, and post-stroke lifespan 2 years. One-way, two-way, and probabilistic sensitivity analyses were performed on all variables. RESULTS: No CTA screening was the preferred choice (expected value, 0.89 vs 0.86) unless imaging and interpretation could be completed in <2 minutes. For every six DSAs eliminated by CTA screening, there would be one additional case with poor outcome (modified Rankin 3-6). The findings were robust in sensitivity analyses. The most influential variables were CTA time and the probability of a proximal occlusion (graph). CONCLUSION: Patients with severe ischemic strokes presenting at <3 hours are best served by foregoing CTA screening and expediting DAS after initiating IV rtPA. This approach would lead to six unnecessary DSAs but one fewer case with death or severe disability.
Graphic: http://www.esc-archive.eu/stockholm09/graphics_stockholm/g_AID1085.htm
Table:  
 
P.Khatri, University of Cincinnati, Cincinnati, USA
E.C.Jauch   Medical University of South Carolina  Charleston  USA
M.L.Flaherty  University of Cincinnati  Cincinnati  USA
J.P.Broderick  University of Cincinnati  Cincinnati  USA
S.D.Yeatts  Medical University of South Carolina  Charleston  USA
M.G.Hunink  Erasmus University  Rotterdam  THE NETHERLANDS
         
         
         
         
         
         
         
         
         

Kind of presentation: oral

Acute stroke: treatment and concepts  
 C
 
Chairs: A. Alexandrov, USA and V. Di Piero, Italy

Date: Wednesday 27 May 2009
Time: 17:15 - 17:25
Room: A2

28.
INTERVENTION PROTOCOL INCREASES FREQUENCY AND AMOUNT OF EARLY MOBILISATION OF ACUTE STROKE PATIENTS: RESULTS FROM A PHASE II RCT (AVERT).
Introduction: Early mobilisation may be an important feature of acute stroke unit care. However little is known about schedule of physical therapy in current acute care. This study describes therapy delivered to all participants in A Very Early Mobilisation Trial (AVERT) and examines whether an intervention protocol led to delivery of earlier and more intensive therapy. Methods: A multicentre, phase II RCT. Patients within 24 hrs of confirmed stroke with physiological parameters within set limits were included. Excluded were patients with severe premorbid disability, comorbidities or requiring palliative care. The very early mobilisation protocol delivered by a nurse/physiotherapy team, began within 24 hrs of stroke and was delivered 5 days a week up to 14 days post stroke. Protocol safety was reported previously. Both groups received standard care. All therapy sessions were recorded on Personal Digital Assistants. Outcome measures were schedule and nature of therapy. Results: 71 patients were recruited from two hospitals, 58% of whom had a moderate or severe stroke. Baseline characteristics were not different between groups. The intervention group was mobilised earlier after stroke (Control median 30.8 hrs (IQR 23.0-40.0); Intervention 18.1 hrs (12.4-21.5); p=<0.001), received more minutes of therapy per day (Control 18.3 mins (10.8-33.7); Intervention 48.5 mins (33.7-80.1); p=<0.001), had more sessions per day (Control 1.0 (0.5-1.6); Intervention 3.8 (2.5-4.8); p=<0.001) and spent higher proportion of therapy time out of bed (Control 41.5% (24.6-64.2); Intervention 76.8%; (58.4-86.8), p=<0.001). Standard care was similar in both groups (Minutes per day p=0.241; Proportion therapy time out of bed p=0.602). Conclusions: This is the first study to detail standard physical therapy delivered in the acute phase after stroke. We found that a trial protocol promoting earlier and more frequent mobilisation on top of standard care was feasible even for those with severe stroke.
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R.M.van Wijk, Maastricht University, Maastricht, THE NETHERLANDS
L.Churilov   National Stroke Research Institute  Melbourne  AUSTRALIA
J.Bernhardt  National Stroke Research Institute AND La Trobe University  Melbourne  AUSTRALIA
         
         
         
         
         
         
         
         
         
         
         
         

Kind of presentation: poster

Interesting cases  
  
Poster Session Red
Chairs:  

Date: Wednesday 27 May 2009
Time: 12:30 - 14:00
Room:  

12.
POSTPARTUM CEREBRAL ANGIOPATHY PRESENTING AS CEREBRAL HEMORRHAGE AND INFARTION.
Background:Stroke in the puerperium is a diagnostic challenge. Postpartum cerebral angiopathy is a rare cause for stroke. It usually develops with headache, seizures and focal neurologic deficits due to reversible vasoespasm in cerebral vessels. It has been associated to the use of simpathomimetic drugs and ergot alkaloids. Its presentation as a cerebral hemorrhage is unusual. Methods: We describe a 41-year-old patient (gravida 5, para 1) with history of a toxic oil syndrome, migraine and viral hepatitis type C. No complications on current pregnancy except for an arterial disruption during delivery. She was treated with norepinephrine for severe hypotension and cabergoline to avoid breastfeeding. On day 12 postpartum she developed headaches and visual abnormalities. Results: Physical examination revealed an homonymous right hemianopsia. Laboratory tests showed haemoglobine 10.3 mg/dL and coagulation parameters were normal. Urine analysis: proteins 439 mg/L. Cranial CT revealed a left occipital intracraneal hemorrhage. CT-angiography ruled out the presence of arterial aneurism or arteriovenous malformation. No venous thrombosis was described on MRI. Few days later she reports bilateral hemianopsia. She also presented several episodes of transient neurological deficits during her hospitalization. Transcranial Doppler testing showed mild-severe vasospasm signs measured by Lindegaard index. A new diffusion-weighted MRI revealed a right occipital cerebral infarction. Angiographic study confirmed multiple arterial narrowings envolving proximal arteries on the circle of Willis. Treatment with steroids and nimodipine was started with no new neurological symptoms. An MRI-angiography conducted one month later showed normalization of the cerebral arteries. Conclusion: Postpartum cerebral angiopathy should be considered in the differential diagnosis in stroke in the postpartum period, even when it developes as a cerebral hemorrhage.
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M.Martínez, Department of Neurology. University Hospital La Paz. UAM, Madrid, SPAIN
B.Fuentes   Stroke Unit. Department of Neurology. University Hospital La Paz. UAM  Madrid  SPAIN
J.Fernandez-Dominguez  Stroke Unit. Department of Neurology. University Hospital La Paz. UAM  Madrid  SPAIN
M.J.Aguilar-Amat  Department of Neurology. University Hospital La Paz. UAM  Madrid  SPAIN
E.Diez-Tejedor  Stroke Unit. Department of Neurology. University Hospital La Paz. UAM  Madrid  SPAIN
         
         
         
         
         
         
         
         
         
         

Kind of presentation: oral

Vascular imaging  
  
 
Chairs: R. Ackerman, USA and G. Seidel, Germany

Date: Thursday 28 May 2009
Time: 16:40 -16:50
Room: A3

5.
MRI plaque imaging identifies high risk patients for therapy of carotid artery stenosis
Background MRI-based plaque imaging allows to classify carotid plaques in different lesiontypes thus revealing high risk plaques that are associated with spontaneous thrombembolic cerebral infarction. We aimed to investigate whether MRI- plaque imaging might also predict the risk for periprocedural cerebral ischemia and neurological outcome in patients who undergo invasive therapy of carotid artery stenosis. Methods Seventy-eight consecutive patients undergoing invasive therapy of carotid artery stenosis were enrolled. Each patient was imaged with a 1.5-T scanner using bilateral phased-array carotid coils. T1-, T2-, time-of-flight (TOF)-, and proton-density (PD)-weighted studies were obtained. Carotid plaques were classified as lesion type I–VIII according to modified AHA criteria. Histology data were available for 28 patients. One day before and one day after intervention diffusion-weighted imaging (DWI) was obtained and neurological examination was performed. Results Sixty-six patients underwent carotid endarterectomy; 12 patients underwent carotid artery stenting. Four patients were excluded because of insufficient MR image quality. Concordance between histology data and MRI-classification was was 92.3 %. In n=22 patients (29.7%) with MRI-defined high-risk lesion types periinterventional DWI lesions were detected, whereas DWI lesions were seen in 3 patients (4.1%) with MRI-defined stable lesion types (P<0.0001). Nine patients (12.2%) with MRI-defined unstable lesion types developed periinterventional neurological symptoms versus 1 patient (1.4%) with stable MRI-defined lesion type (P<0.01). Conclusions Patients with MRI-detected unstable plaques were at a higher risk of developing periprocedural DWI lesions and new neurological symptoms after intervention. MRI-based plaque imaging might be used for prior risk assessment in patients undergoing invasive therapy of carotid artery stenosis.
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H.Poppert, Technische Universität München, München, GERMANY
L.Esposito   Technische Universität München  München  GERMANY
R.Feurer  Technische Universität München  München  GERMANY
D.Sepp  Technische Universität München  München  GERMANY
S.Sadikovic  Technische Universität München  München  GERMANY
C.Winkler  Technische Universität München  München  GERMANY
O.Pauly  Technische Universität München  München  GERMANY
M.Schleef  Technische Universität München  München  GERMANY
A.Bockelbrink  Technische Universität München  München  GERMANY
B.Hemmer  Technische Universität München  München  GERMANY
         
         
         
         
         

Kind of presentation: poster

Acute stroke: emergency management, stroke units and complications  
  
Poster Session Blue
Chairs:  

Date: Thursday 28 May 2009
Time: 12:30 - 14:00
Room:  

15.
CT Angiography and CT Perfusion in acute ischemic stroke: safety, feasibility and clinical relevance
Background - A combination of plain computed tomography (CT), CT angiography (CTA) and CT perfusion (CTP) may provide complementary information about etiology and therapeutic options in acute ischemic stroke. We assessed the frequency of relevant intracranial occlusions, presence of a penumbra and outcome in acute stroke patients, who were potentially eligible for either i.v. or i.a. thrombolytic therapy. Methods - We included patients with acute ischemic stroke who were admitted within 6 hours from stroke onset. All patients underwent CT, CTA and CTP. For feasibility we noted scanning time and safety parameters. CTP maps based on the Wintermark criteria were used to calculate infarcted and penumbral areas. Good outcome was defined as a modified Rankin score of less than 3 at 1 week. Results – A representative sample of 50 acute stroke patients was included in the study. Three were excluded post hoc because of incomplete data. Total median scanning time was 20 minutes (IQR: 13-31). No adverse events occurred and no thrombolytic treatment was missed because of duration of scanning. Intracranial proximal arterial occlusion was present in 11/47patients (23%). All had a penumbra, except for one with a basilar artery occlusion. Size of penumbra and infarct were larger and NIHSS scores were worse in those with an intracranial occlusion. Only 2/11 patients (18%) with an intracranial occlusion had a good outcome, compared to 25/36 (69%) of those without an occlusion. Conclusions – Triple CT is safe and feasible in acute stroke patients. Relevant intracranial occlusions are common, and occur in about a quarter of the patients assessed within 6 hours. All of these have a penumbral area. Triple CT can directly identify patients with a worse prognosis who may potentially benefit form endovascular treatment.
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E.J.van Dijk, Erasmus MC University Medical Centre and University Medical Centre Sint Radboud, Rotterdam and Nijmegen, THE NETHERLANDS
R.A. Kranenburg   Erasmus MC University Medical Centre   Rotterdam  THE NETHERLANDS
A.van der Lugt  Erasmus MC University Medical Centre   Rotterdam  THE NETHERLANDS
M.H.den Hertog  Erasmus MC University Medical Centre   Rotterdam  THE NETHERLANDS
M.Dirks  Erasmus MC University Medical Centre  Rotterdam  THE NETHERLANDS
D.W.J.Dippel  Erasmus MC University Medical Centre   Rotterdam  THE NETHERLANDS
         
         
         
         
         
         
         
         
         

Kind of presentation: poster

Epidemiology of stroke  
  
Poster Session Red
Chairs:  

Date: Wednesday 27 May 2009
Time: 12:30 - 14:00
Room:  

7.
The Ludwigshafen Stroke Study (LuSSt) Case Fatality Rates for first-ever stroke (FES)
Background and Purpose- Improvements in stroke care can be expected to lead to lower mortality after stroke. Population-based stroke registries are required to obtain reliable data on stroke mortality. Here we report results from a population-based stroke registry from Ludwigshafen a.Rh., an industrial city in Southwestern Germany. Methods- The Ludwigshafen Stroke Study (LuSSt) is a population-based stroke registry in the city of Ludwigshafen (about 167.000 residents), Rhineland-Palatine, Germany. Starting January 2006 multiple overlapping methods of case-ascertainment were used. Follow-up was performed at 28 days, 3 and 12 months. Results- In 2006 347 patients suffered a first ever ischemic stroke and 34 a first ever intracerebral hemorrhage (Total: 381). Follow-up could be performed in 362 (95,0%) patients at day 28 and after 3 months, respectively and in 359 (94,2%) patients after 12 months. Overall crude case fatality rates were 11,9% (95%CI: 8,9-15,6) at day 28, 16,3% (95%CI: 12,9-20,5) at 3 months and 23,4% (95%CI: 19,3-20,0) at 12 months. Case fatality rates for ischemic stroke was 10,0% at day 30, 13,9% at 3 months and 21,7% at 12 months. Respective rates for intracerebral hemorrhage were 28,1% at day 28, and 40,6% both at 3 and 12 months. Conclusion- Case fatality rates after ischemic and particularly after hemorrhagic stroke are still high, however, our present rates are lower than those from previous European population based stroke registries. This could reflect recent improvements in stroke care, however, comparisons between different countries and different times have to be viewed with caution and our data are only based on the analysis of one year.
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S.B.Rose, Department of Neurology, Klinikum Ludwigshafen, Ludwigshafen am Rhein, GERMANY
F.Palm   Department of Neurology, Klinikum Ludwigshafen  Ludwigshafen am Rhein  GERMANY
B.Bode  Department of Neurology, Klinikum Ludwigshafen  Ludwigshafen am Rhein  GERMANY
C.Urbanek  Department of Neurology, Klinikum Ludwigshafen  Ludwigshafen am Rhein  GERMANY
F.Buggle  Department of Neurology, Klinikum Ludwigshafen  Ludwigshafen am Rhein  GERMANY
A.J.Grau  Department of Neurology, Klinikum Ludwigshafen  Ludwigshafen am Rhein  GERMANY
         
         
         
         
         
         
         
         
         

Kind of presentation: oral

Experimental studies  
 B
 
Chairs: P. Lindsberg, Finland and P. Sharma, United Kingdom

Date: Wednesday 27 May 2009
Time: 16:15 - 16:25
Room: A4

10.
Kinetics of vasogenic edema formation in the first three hours of ischemic stroke
Background Brain edema formation is a serious complication of ischemic stroke and can lead to mechanical compression of adjacent brain structures, cerebral herniation and death. The space-occupying effect of edema furthermore impairs regional cerebral blood flow, which would be of particularly importance in the penumbra-phase of stroke. The present work evaluates the natural course of edema formation in the hyperacute phase of focal cerebral ischemia. Methods Using the macrosphere embolisation technique, middle cerebral artery occlusion (MCAO) or a sham procedure was performed in rats within the MRI-scanner (in-bore occlusion). Pre- and postischemic images thus could be compared on a pixel-by-pixel base. T2-relaxation time (T2-RT), a marker for brain water content, was measured in regions of interest. Evans blue extravasation was assessed in additional animals 20 and 155 minutes after MCAO. Results A significant increase in T2-RT was detectable as early as 20 to 45 min after MCAO (p<0.05). At this early time-point the midline-shift (MLS) amounted to 0.214cm ±0.092cm in the MCAO- and to 0.061cm ±0.063cm in the sham-group (p<0.01). T2-RT and MLS increased linearly thereafter. Evans blue extravasation was visible in all animals indicating in increased permeability of the blood brain barrier (BBB) at 20 and 155 minutes. Conclusions Vasogenic brain edema occurs much earlier than expected following permanent MCAO and results in MLS and mechanical compression of adjacent brain structures. Since compression effects can impair regional cerebral blood flow, early edema formation might contribute significantly to infarct formation and thus represents a rewarding target for neuroprotection.
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T.Gerriets, Department of Neurology, Justus Liebig-University, Giessen, GERMANY
M.Walberer   Department of Neurology, Justus Liebig-University  Giessen  GERMANY
N.Ritschel  Department of Neurology, Justus Liebig-University  Giessen  GERMANY
M.Tschernatsch  Department of Neurology, Justus Liebig-University  Giessen  GERMANY
C.Mueller  Department of Radiology, Kerckhoff-Clinic  Bad Nauheim  GERMANY
G.Bachmann  Department of Radiology, Kerckhoff-Clinic  Bad Nauheim  GERMANY
M. Schoenburg  Department of Cardiac Surgery, Kerckhoff-Clinic  Bad Nauheim  GERMANY
M.Kaps  Department of Neurology, Justus Liebig-University  Giessen  GERMANY
M.Nedelmann  Department of Neurology, Justus Liebig-University  Giessen  GERMANY
         
         
         
         
         
         

Kind of presentation: poster

Epidemiology of stroke  
  
Poster Session Red
Chairs:  

Date: Wednesday 27 May 2009
Time: 12:30 - 14:00
Room:  

44.
CONTRIBUTION OF DIFFUSION-WEIGHTED MAGNETIC RESONANCE IMAGING TO THE DIAGNOSIS IN PATIENTS WITH TRANSIENT ISCHEMIC ATTACK
OBJECTIVE: Diffusion-weighted magnetic resonance imaging (DWI) is a sensitive diagnostic tool for detecting acute ischemic lesions in patients with transient ischemic attacks (TIAs). The usefulness of the presence or absence of DWI abnormalities in the diagnostic workup of TIA patients still remains controversial. It would be interesting to know how the presence of DWI abnormalities influences the diagnosis of TIA patients METHODS: Two hundred consecutive TIA underwent diffusion-weighted brain imaging (DWI) (3.8±1.7 days after symptoms onset). The presence of acute ischemic lesions (DWI abnormalities) was related to clinical features and etiology. RESULTS: DWI abnormalities were identified in 94 (47%) patients. Logistic regression model identified only motor impairment (OR 1.49, 95% CI 1.11 to 1.99, p=0.007) as independent predictor of acute ischemic lesions. There were no differences among etiologic subtypes. Distribution of DWI lesions was: cortical 27, subcortical 27, scattered lesion in one artery territory 31 and in multiple territories 9. We observed lesion pattern non corresponding to clinical symptoms in 14% of carotid territory symptomatology and in 65% of patients with undetermined territory symptoms (absence of cortical symptoms and proportional motor impairment). CONCLUSION: Our data added evidence of the clinical utility of DWI in TIA patients. DWI changed the suspected vascular TIA localization and the suspected etiology mechanism in two of five cases with acute infarction.
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F.Purroy, Stroke Unit. Hospital Universitari Arnau de Vilanova. Universitat de Lleida, Lleida, SPAIN
M.I.Gil   Institut de diagnòstic per la imatge. Hospital Universitari Arnau de Vilanova  LLeida  SPAIN
R. Begué  Institut de diagnòstic per la imatge. Hospital Universitari Arnau de Vilanova  Lleida  SPAIN
A.Quílez  Stroke Unit. Hospital Universitari Arnau de Vilanova. Universitat de Lleida  Lleida  SPAIN
G.Piñol-Ripoll  Stroke Unit. Hospital Universitari Arnau de Vilanova. Universitat de Lleida  Lleida  SPAIN
J.Díez  Institut de diagnòstic per la imatge. Hospital Universitari Arnau de Vilanova  Lleida  SPAIN
C.Vicandi  Institut de diagnòstic per la imatge. Hospital Universitari Arnau de Vilanova  Lleida  SPAIN
J. J.Sanahuja  Stroke Unit. Hospital Universitari Arnau de Vilanova. Universitat de Lleida  Lleida  SPAIN
L.Brieva  Stroke Unit. Hospital Universitari Arnau de Vilanova. Universitat de Lleida  Lleida  SPAIN
         
         
         
         
         
         

Kind of presentation: oral

Acute stroke: treatment and concepts  
 B
 
Chairs: O. Busse, Germany and K. Muir, United Kingdom

Date: Wednesday 27 May 2009
Time: 14:00 - 14:10
Room: A2

10.
Body temperature at 24 hours rather than initial body temperature is related to functional outcome in acute stroke.
Background Subfebrile temperatures and fever have been recorded in about a third of patients on the first day after stroke onset and are associated with poor outcome. However, the temporal distribution of this association is not well established. Aim To determine the prognostic value of body temperature at two points in time with regard to functional outcome and death. Methods We analyzed data of 1332 patients who had been included in the Paracetamol (Acetaminophen) In Stroke (PAIS) trial within 12 hours of stroke onset. The relation between poor outcome (death, or a modified Rankin Score >2) or death alone on the one hand, and initial body temperature and body temperature 24 hours after enrollment (adjusted for initial body temperature) on the other was expressed as odds ratios per 0.1°C. An adjustment for the impact of age, sex, NIHSS score, stroke type, ischemic stroke subtype was made with multiple logistic regression. Results Body temperature over 37.5°C was observed in 171 patients (12%) at enrollment, and in 366 (26%) 24 hours later. After adjustment for potential confounders, no association was found between initial body temperature and poor outcome (aOR 1.1; 95 % CI 0.8 to 1.3) or death (aOR 1.1; 95% CI 0.6 to 1.7). Increased body temperature at 24 hours was significantly associated with poor outcome (aOR 1.3; 95% CI 1.1 to 1.7) and death (aOR 1.5; 95 % CI 1.1 to 1.9). Conclusion Contrary to most observational studies, we found no relation between initial body temperature and poor outcome at 3 months. However, patients with increased body temperatures at 24 hours had a significantly increased risk of poor outcome. These results suggest that an early rise in body temperature rather than the initial temperature is an important determinant of clinical outcome after stroke. PAIS was sponsored by the Netherlands Heart Foundation, grant number 2002B148.
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and the PAIS investigators
H.M.den Hertog, Erasmus MC University Medical Center Rotterdam, Rotterdam, THE NETHERLANDS
H.B.van der Worp   University Medical Center Utrecht  Utrecht  THE NETHERLANDS
H.M.A.van Gemert  Meander Medical Center  Amersfoort  THE NETHERLANDS
P.J.Koudstaal  Erasmus MC University Medical Center Rotterdam  Rotterdam  THE NETHERLANDS
D.W.J.Dippel  Erasmus MC University Medical Center Rotterdam  Rotterdam  THE NETHERLANDS
         
         
         
         
         
         
         
         
         
         

Kind of presentation: poster

Risk factors: manifestation, treatment and prognosis  
  
Poster Session Blue
Chairs:  

Date: Thursday 28 May 2009
Time: 12:30 - 14:00
Room:  

38.
Secondary Prevention Clinics - safe and effective discharge plan for patients presenting with Stroke/TIA
Background: Following development of a rapid access daily neurovascular service for cerebrovascular disease we encountered a large increase in the volume of patients having to return to general clinics to address issues of secondary prevention which could not be resolved on initial assessment. To address this problem we established a 5 day/week nurse led secondary prevention clinic to help manage this additional volume of work. Methods: We performed an audit of the activity of the clinic in its first 9 months of operation assessing rate of concordance to published standards of care achieved through the clinic. Results: A total of 123 patients were referred to the clinic of whom 5 have required readmission to hospital. 82 (39 male, mean age 66.7yrs; 43 female, mean age 63.7yrs) were fully assessed and discharged following a median of 2 (range 1-11) visits. Risk factors identified at presentation included hypertension (62%) previous stroke or TIA (22%), Atrial Fibrillation (18.3%) and Diabetes (11%). On presentation to the clinic only 40 subjects’ blood pressure (48.7%) was controlled within ESO guideline levels. 69 subjects (85.2%) were controlled on discharge. 9 subjects (11%) had an existing diagnosis of diabetes at clinic presentation. The clinic identified a further 12 (14.6%) diabetic subjects and 18 (22%) with impaired glucose tolerance. 15 (18.3%) had a diagnosis of atrial fibrillation at presentation of which, 8 were receiving anticoagulation therapy. A further 3 patients (3.7%) were diagnosed with Atrial Fibrillation and 14 (77.7%) were stabilised on anticoagulation therapy prior to clinic discharge. Conclusion: Secondary Prevention Clinics provide a detailed and effective assessment of Stoke risk factors and management. They provide a safe and effective early discharge plan for patients presenting with Stroke/TIA and facilitate the effective running of the other acute neurovascular services.
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L.Smyth, St. James's Hospital, Dublin, IRELAND
J.Harbison   St. James's Hospital  Dublin  IRELAND
D. J.Ryan  St. James's Hospital  Dublin  IRELAND
S.Phillips  St. James's Hospital  Dublin  IRELAND
S.Walsh  St. James's Hospital  Dublin  IRELAND
         
         
         
         
         
         
         
         
         
         

Kind of presentation: oral

Small vessel and white matter disease  
  
 
Chairs: H.Bäzner, Germany and N. Futrell, USA

Date: Thursday 28 May 2009
Time: 15:50 - 16:00
Room: A4

12.
BONE MARROW-DERIVED PROGENITOR CELLS IN CADASIL (CEREBRAL AUTOSOMAL DOMINANT ARTERIOPATHY WITH SUBCORTICAL INFARCTS AND LEUKOENCEPHALOPATHY)
Background: CADASIL is an inherited microangiopathy clinically characterized by migraine, stroke, psychiatric and cognitive disturbances progressing to dementia and disability. Pathogenesis is not fully understood. Altered endothelial dependent vasodilatation has been reported suggesting a role of endothelial dysfunction. Endothelial progenitor cells (EPCs) and hematopoietic progenitor cells (HPCs) derived from bone marrow participate in endothelium health maintenance and ischemic areas revascularization. No data are available about the possible role of these cells in CADASIL. Aim: To evaluate the role of EPCs and HPCs in CADASIL. Methods: 29 CADASIL patients (genetic diagnosis) and 29 sex and age-matched healthy controls (mean age 54 yrs) were enrolled in a multicenter prospective study. HPCs and EPCs were measured in peripheral blood using flow cytometry. HPCs were defined as positive for CD34, CD133 and CD34/CD133; EPCs as positive for CD34/KDR, CD133/KDR and CD34/CD133/KDR. Results: While HPCs levels were similar between the two groups, EPCs were significantly reduced in CADASIL patients [CD34/KDR:0.05 vs 0.1 cells/µl, p=0.005; CD133/KDR:0.07 vs 0.1 cells/µl, p=0.006; CD34/CD133/KDR:0.05 vs 0.1 cells/µl, p=0.001]. The difference remained statistically significant in multivariate logistic regression models adjusted for age, gender and statins use. Dividing CADASIL patients according to clinical picture severity, group A (with stroke or dementia, n=16, mean age 60) showed a significant lower HPCs number than group B (without stroke and dementia, n=13, mean age 48). Moreover, lower HPCs levels significantly correlated with worse cognitive and motor performances. Conclusions: We documented an association between EPCs and HPCs and CADASIL suggesting a pathogenic role of endothelial dysfunction and HPCs in modulating the phenotype. If confirmed in larger samples, our results may suggest the evaluation of new therapeutic strategies favoring stem cells mobilization.
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F.Pescini, Department of Neurological and Psychiatric Sciences, University of Florence, Florence, ITALY
F.Cesari   Department of Medical and Surgical Critical Care, University of Florence  Florence  ITALY
B.Giusti  Department of Medical and Surgical Critical Care, University of Florence  Florence  ITALY
C.Sarti  Department of Neurological and Psychiatric Sciences, University of Florence  Florence  ITALY
G.Pracucci  Department of Neurological and Psychiatric Sciences, University of Florence  Florence  ITALY
E.Zicari  Neurometabolic Unit, Institute of Neurological Sciences, University of Siena  Siena  ITALY
S.Bianchi  Neurometabolic Unit, Institute of Neurological Sciences, University of Siena  Siena  ITALY
M.T.Dotti  Neurometabolic Unit, Institute of Neurological Sciences, University of Siena  Siena  ITALY
A.Federico  Neurometabolic Unit, Institute of Neurological Sciences, University of Siena  Siena  ITALY
M.Balestrino  Department of Neurological Sciences, Ophtalmology and Genetics, University of Genoa  Genoa  ITALY
C.Gandolfo  Department of Neurological Sciences, Ophtalmology and Genetics, University of Genoa  Genoa  ITALY
R.Abbate  Department of Medical and Surgical Critical Care, University of Florence  Florence  ITALY
L.Pantoni  Department of Neurological and Psychiatric Sciences, University of Florence  Florence  ITALY
D.Inzitari  Department of Neurological and Psychiatric Sciences, University of Florence  Florence  ITALY
         

Kind of presentation: poster

Interesting cases  
  
Poster Session Red
Chairs:  

Date: Wednesday 27 May 2009
Time: 12:30 - 14:00
Room:  

7.
PSEUDOVASCULAR CENTROPONTINE MYELINOLYSIS
We report the case of a man, 56 years-old, who presented a sudden right hemiparesia with aphasia. In his medical history, he suffered from hypertension and type 2 diabetes with retinopathy and neuropathy. He arrived in stoke unit 1 hour and 50 minutes after hemiparesia and aphasia onset with hyperglycemia at 35 mmol/L and malignant hypertension at 230/120 mmHg. A treatment by intravenous insulin and Urapidil was started. Two hours and 15 minutes after onset, he presented a right motor seizure with secondary generalization before MRI procedure. He received 1 mg of intravenous clonazepam and MRI procedure could only be performed for diffusion and ADC sequences. This first MRI was normal without any stroke image. The patient benefited of a treatment by Urapidil, intravenous insulin and 1 g per day of Levetiracetam. Forteen hours after onset, he presented 38.5°C hyperthermia and drowsiness. A cerebral CT-scan with contrast product revealed normal. An electroencephalogram was performed and showed global low cerebral activity. A lumbar puncture showed moderately elevated cervicospinal fluid proteins (0.55g/L), normal glycorrhachia, no bacteria, no neoplastic cells and a negative PCR for HSV, enterovirus and CMV. The patient completely recovered 4 days later. A second MRI was performed at 5 days after onset and showed an isolated centropontine myelinolysis. No hyponatremia was observed at any time and initial calculated osmolarity was 320 mosm/L. We suspect the diagnosis of post-seizure paresia and aphasia due to hyperglycemia without ketose and centropontine myelinolysis due to hyperosmolarity. This unusual case with a pseudostroke symptomatology underlined the importance of an initial good quality cerebral imaging, as provided by MRI, notably before thrombolysis.
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M.Barbieux, Unité neuro-vasculaire, Pôle Psychiatrie-Neurologie, CHU de Grenoble, GRENOBLE, FRANCE
O.Véran   Unité neuro-vasculaire, Pôle Psychiatrie-Neurologie, CHU de Grenoble  GRENOBLE  FRANCE
L.Vercueil  Laboratoire d'explorations fonctionnelles du système nerveux, Pôle Psychiatrie-Neurologie, CHU de Grenoble  GRENOBLE  FRANCE
G.Besson  Neurologie générale, Pôle Psychiatrie-Neurologie, CHU de Grenoble  GRENOBLE  FRANCE
O.Detante  Unité neuro-vasculaire, Pôle Psychiatrie-Neurologie, CHU de Grenoble  GRENOBLE  FRANCE
         
         
         
         
         
         
         
         
         
         

Kind of presentation: poster

Risk factors: manifestation, treatment and prognosis  
  
Poster Session Blue
Chairs:  

Date: Thursday 28 May 2009
Time: 12:30 - 14:00
Room:  

26.
TAFI activation peptide and CRP show association with 2-year outcome after ischemic stroke
Background: There are few data on biomarkers that may help in the assessment of prognosis after ischemic stroke (IS). Here we report on the relation between 6 hemostatic markers, CRP and outcome 2 years after IS. Methods: The Sahlgrenska Academy Study on Ischemic Stroke (SAHLSIS) includes 600 patients with IS before 70 years of age. Stroke subtype was defined using TOAST criteria. Blood sampling was performed in the acute phase and at 3-month follow-up. Plasma levels of tPA antigen and activity, PAI-1 antigen, intact thrombin activatable fibrinolysis inhibitor (TAFI), released TAFI activation peptide (TAFI AP), fibrinogen, and CRP were determined. Patients were followed-up after 2 years by telephone interviews, review of medical records, and search in national medical registers. Functional outcome was assessed according to the modified Rankin Scale (mRS). Results: Data were obtained from 594 patients. After 2 years 83 patients had suffered the combined outcome death, recurrent stroke/TIA or myocardial infarction. In a multivariate model including acute biomarkers, previous stroke, vascular risk factors, and TOAST subtype, CRP and TOAST subtype predicted recurrence/death with an OR per 1 SD increase in CRP of 1.3; 95% CI 1.1-1.5, p<0.001. In a similar model including follow-up biomarkers, TAFI AP and a previous stroke predicted recurrence/death with an OR per 1 SD increase in TAFI AP of 1.5; 95% CI 1.2-2.0, p<0.01. Acute CRP and acute tPA antigen showed independent associations to unfavorable outcome (mRS 3-6) (OR 1.7; 95% CI 1.1-1.7, p<0.001 and 1.3; 95% CI 1.1-1.6, p<0.01, respectively). Among follow-up biomarkers, TAFI AP showed independent association to deterioration in functional outcome with an OR of 1.3 (95% 1.0-1.5, p<0.05) for an increased score on mRS at 2 years compared to 3 months. Conclusion: Acute phase CRP and 3-month TAFI AP show independent associations to recurrent vascular events or death and functional outcome 2 years after ischemic stroke.
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K.Jood, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at University of Gothenburg, Göteborg, SWEDEN
P.Redfors   Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg  Göteborg  SWEDEN
A.Gils  Laboratory for Pharmaceutical Biology, Faculty of Pharmaceutical Sciences, Katholieke Universiteit Leuven  Leuven  BELGIUM
S.Nilsson  Department of Mathematical Statistics, Chalmers University of Technology  Göteborg  SWEDEN
C.Blomstrand  Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg  Göteborg  SWEDEN
P.J.Declerck  Laboratory for Pharmaceutical Biology, Faculty of Pharmaceutical Sciences, Katholieke Universiteit Leuven  Leuven  BELGIUM
C.Jern  Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg  Göteborg  SWEDEN
         
         
         
         
         
         
         
         

Kind of presentation: poster

Vascular biology  
  
Poster Session Blue
Chairs:  

Date: Thursday 28 May 2009
Time: 12:30 - 14:00
Room:  

3.
Monocyte subtypes predict clinical course and prognosis in human stroke
Backround: The number of circulating monocytes increases after stroke, but monocytes are a heterogeneous population and monocyte subtypes have not been studied before in human stroke. Methods: In 46 consecutive patients and 13 age-matched controls we used flow cytometry in order to measure the proportion and phenotype of monocyte subsets as well as their interaction with platelets at admission and at predetermined time points of follow-up. We studied whether changes in monocyte subsets related to clinical course. Results: The proportion of the most abundant classical CD14highCD16- monocytes did not change, whereas CD14highCD16+ monocytes increased and CD14dimCD16+ monocytes decreased after stroke. Monocyte subtypes showed clear-cut phenotypical differences. In particular, CD14highCD16+ monocytes had the highest expression of TLR2, HLA-DR and the angiogenic marker Tie-2 and CD14dimCD16+ monocytes had the highest expression of the costimullatory CD86 and the adhesion molecule CD49d. Platelet-monocyte interactions were highest in CD14highCD16- and lowest in CD14dimCD16+ monocytes. In adjusted models, poor outcome, increased mortality, and early clinical worsening after stroke were associated to increased proportion of classical CD14highCD16- monocytes at baseline. Contrarily, mortality and infarction size were inversely related to CD14highCD16+ or CD14dimCD16+ monocytes, respectively. Patients with stroke associated infection did not differ at baseline, but later had a greater increase of CD14highCD16+ monocytes. Conclusion: After stroke each monocyte subtype has a different time course and is associated to a distinct clinical pattern. Therefore, monitoring of monocyte subtypes could help to identify the risk of complications early after stroke onset.
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X.Urra, Stroke Unit. Hospital Clinic, Barcelona, SPAIN
S.Amaro   Stroke Unit. Hospital Clinic  Barcelona  SPAIN
M.Gómez-Choco  Stroke Unit. Hospital Clinic  Barcelona  SPAIN
V.Obach  Stroke Unit. Hospital Clinic  Barcelona  SPAIN
A.M.Planas  Institut d’Investigacions Biomèdiques de Barcelona, Consejo Superior de Investigaciones Científicas  Barcelona  SPAIN
A.Chamorro  Stroke Unit. Hospital Clinic  Barcelona  SPAIN
         
         
         
         
         
         
         
         
         

Kind of presentation: poster

Risk factors: manifestation, treatment and prognosis  
  
Poster Session Blue
Chairs:  

Date: Thursday 28 May 2009
Time: 12:30 - 14:00
Room:  

32.
Growth-differentiation factor-15 in ischemic stroke: relation to stroke outcome
BACKGROUND: Growth-differentiation factor-15 (GDF-15) is a stress-responsive member of the TGF-beta cytokine superfamily and emerging biomarker in patients with cardiovascular disease. The role of GDF-15 in patients with acute ischemic stroke has not been investigated. METHODS: Blood samples were obtained from 64 patients with ischemic stroke or TIA 6, 12, and 24 hours, and 3, 7, and 90 days after symptom onset. Clinical outcome (mRS and NIHSS) was assessed at 7 and 90 days. Plasma / serum concentrations of GDF-15, IL-6, MCP-1, TIMP-1, and S100B were measured by immunoassays. RESULTS: GDF-15 levels at 6 hours ranged from 737 to 5563 ng/L; 79% of the patients presented with GDF-15 levels above the previously defined upper limit of normal (1200 ng/L). After 12 hours GDF-15 levels decreased. At day 7 still 64% of the patients presented with GDF-15 levels above the limit of normal (at 90 days: 59%). GDF-15 levels at the early timepoints (6 to 12 hours) were associated with the inflammatory markers IL-6, MCP-1, and TIMP-1 (GDF-15 vs. TIMP-1: r=0.51, p<0.001; GDF-15 vs. IL-6: r=0.55, p<0.001; GDF-15 vs. MCP-1: r=0.45, p<0.001). GDF-15 levels at each time point were related to age. At 24 hours GDF-15 was related to brain damage as reflected by S100B (r=0.53; p<0.001). GDF-15 levels at 12, 24 hours, and 7 days after stroke onset were associated with an adverse clinical outcome at 7 and 90 days. The prognostic information provided by GDF-15 was independent from age, and the cerebrovascular risk factors hypertension, diabetes mellitus, and hyperlipidemia. CONCLUSION: Our data show, for the first time, that the circulating levels of GDF-15 are increased in patients with ischemic stroke in relation to stroke severity. GDF-15 levels appear to provide prognostic information concerning functional outcome at 7 and 90 days.
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H.Worthmann, Hannover Medical School, Hannover, GERMANY
T.Kempf   Hannover Medical School  Hannover  GERMANY
A.B.Tryc  Hannover Medical School  Hannover  GERMANY
A.Goldbecker  Hannover Medical School  Hannover  GERMANY
Y.T.Ma  Hannover Medical School  Hannover  GERMANY
M.Deb  Hannover Medical School  Hannover  GERMANY
A.Tountopoulou  Hannover Medical School  Hannover  GERMANY
R.Dengler  Hannover Medical School  Hannover  GERMANY
R.Lichtinghagen  Hannover Medical School  Hannover  GERMANY
K.C.Wollert  Hannover Medical School  Hannover  GERMANY
K.Weissenborn  Hannover Medical School  Hannover  GERMANY
         
         
         
         

Kind of presentation: poster

Acute stroke: emergency management, stroke units and complications  
  
Poster Session Blue
Chairs:  

Date: Thursday 28 May 2009
Time: 12:30 - 14:00
Room:  

29.
Ambulance nurses´ prediction of acute computed tomography in patients with stroke/TIA-symptoms and/or altered level of consciousness
Background: When treating patients suffering acute ischemic stroke, the outcome of thrombolytic therapy is time dependent. In-hospital delay may account for 16% of total time lost between stroke onset and computed tomography (CT). The aim of the study was to determine whether ambulance nurses and emergency department doctors had agreement regarding: (1) if a patient should be admitted for an acute CT (CT decision), and (2) if a patient is stable enough to go to the radiology department without a prior medical intervention made by a doctor (stability decision). Methods: Eligible for our prospective questionnaire survey were patients with symptoms of stroke and/or a Glasgow Coma Scale score <15 arriving with ambulance to the emergency department during a period of October-December 2008. Patients below the age of 18 and patients suffering trauma or cardiac arrests were excluded. For each patient, the ambulance nurse and the emergency department doctor on call completed a questionnaire about CT decision and stability decision (blinded for each other). Cohen’s kappa was used to determine the agreement. Results: Of 67 patients included; 32 suffered only stroke/TIA-symptoms, 21 only altered level of consciousness and 14 both. The median time (min-max) between rating by ambulance nurses and emergency department doctors was 30 (0-413) minutes. The outcome of the CT decision is presented in table 1 (kappa coefficient 0.32) and the outcome of the stability decision is viewed in table 2 (kappa coefficient 0.19). Conclusion: There is a fair agreement between ambulance nurses and emergency department doctors regarding patients’ need of an acute CT and a slight agreement when it comes to whether patients were considered stable enough to go to the radiology department without a prior medical intervention made by a doctor. Predefined criteria and additional training are required for ambulance nurses to be able to make decisions about acute CT without first consulting a doctor.
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Table: http://www.esc-archive.eu/stockholm09/graphics_stockholm/t_AID1109.htm
 
P.Blomqvist, Medical faculty, Uppsala University, Uppsala, SWEDEN
H.Blomberg   Centre of Emergency Medicine, Ambulance service  Uppsala  SWEDEN
H.Toss  Department of Medical Sciences, Cardiology  Uppsala  SWEDEN
J.Johansson  Centre of Emergency Medicine, Ambulance service  Uppsala  SWEDEN
E.Lundström  Department of Neuroscience, Neurology and Rehabilitation Medicine  Uppsala  SWEDEN
         
         
         
         
         
         
         
         
         
         

Kind of presentation: oral

Experimental studies  
 B
 
Chairs: P. Lindsberg, Finland and P. Sharma, United Kingdom

Date: Wednesday 27 May 2009
Time: 16:45 - 16:55
Room: A4

13.
Dipyridamole confers protection following acute focal cerebral ischemia in the rat.
BACKGROUND: Dipyridamole (DP) is a platelet inhibitor that has been previously shown to have antithrombotic benefit in the prevention of stroke, particularly when combined with low dose of aspirin. Recent experimental studies have reported as well that pre-treatment with DP promotes anti-inflammatory, antioxidative and neuroprotective effects in cerebral ischemia. We aimed to determine whether post-treatment with DP, an experimental paradigm more close to clinical stroke therapy, can also exert neuroprotection. METHODS: Male Sprague-Dawley rats (n=48) were anesthetized with isoflurane and subjected to 120 min (group 1) or 90 min (group 2) of transient middle cerebral artery occlusion (MCAo). Reperfusion was allowed during the 24h or 48h follow-up (group 1 and 2, respectively). Animals were treated at the onset of reperfusion with either i.v. DP (100 mg/Kg) or vehicle. Rats in group 2 also received vehicle or DP dose (60 mg/Kg) orally at 24h and 36h after MCAo. Primary endpoints were infarct volume, evaluated using 2,3,5-triphenyltetrazolium chloride staining, and neurological outcome measured at 60 min, 24h and 48h following MCAo. RESULTS: DP treated animals subjected to 120 min MCAo showed a significantly neurological improvement at 24h when compared with neurological score after 60 min of occlusion (p= 0.0006). A slight non-significant trend in the infarct size was observed compared to the vehicle-treated group (24.5% vs. 29.19%, p=0.6282). However, when a shorter period of ischemia (90 min) and a long-lasting DP treatment were conducted, a significant reduction in the infarct volume was observed (7.9% vs. 24.4%, p= 0.0381). That was accompanied with a significant improvement in the neurological score (p=0.0065). CONCLUSION: DP protects from ischemic injury when given after MCA occlusion, suggesting that development of new acute therapies based on or combined with DP treatment might be beneficial for stroke patients.
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L.García-Bonilla, Neurovascular Research Laboratory, Vall d'Hebron Hospital., Barcelona, SPAIN
V.Sosti   Neurovascular Research Laboratory, Vall d'Hebron Hospital.  Barcelona  SPAIN
M.Hernández-Guillamón   Neurovascular Research Laboratory, Vall d'Hebron Hospital.  Barcelona  SPAIN
A.Rosell  Neurovascular Research Laboratory, Vall d'Hebron Hospital.  Barcelona  SPAIN
J.Montaner  Neurovascular Research Laboratory, Neurology Department, Vall d'Hebron Hospital.  Barcelona  SPAIN
         
         
         
         
         
         
         
         
         
         

Kind of presentation: poster

Vascular surgery and neurosurgery/interventional neuroradiology  
  
Poster Session Red
Chairs:  

Date: Wednesday 27 May 2009
Time: 12:30 - 14:00
Room:  

10.
2 Year Audit of Carotid Endarterectomy in the UK
Background As part of a stroke improvementment programme an audit of carotid endarterectomy (CEA) in the UK was carried out in order to assess the speed of provision of CEA and the outcomes. Methods All surgeons in the UK performing CEA (396)were invited to contribute to the audit. Data entry was via a web-based system. Data was recorded in 2 phases; phase 1 included in-hospital data; phase 2 included follow up data. Cases performed between 1st December 2005 to 31st December 2007 Results 61% (240/396) eligible surgeons contributed 5513 cases. Hospital Episode Statistics recorded 9913 cases for the same time period. Follow up data was available for 4964 cases. The median age of patients undergoing CEA was 71 (male) and 72(female), 84% were symptomatic for carotid disease. The time between symptom and referral was greater than 2 weeks in 62% and between most recent symptom and surgery was greater than 2 weeks in 78%. The median time from referral to surgery was 40 days (IQR 17-84). Stroke physicians and neurologists were more efficent sources of referral than other professional groups. Consultant anaesthetists were present in 97% of cases and consultant surgeons were scrubbed in 97%. Median duration of operation was 1hr 56mins. Shunts were used in 43% and 68% were closed with a patch. The stroke rate by follow up appointment was 2.4% and the stroke and 30-day death rate was 2.5%. The rate of cranial nerve injury was 4.5%. Conclusions This is the largest audit of CEA performed in the UK. It is self reported data and not all surgeons contributed and so it has to interpreted in context. The audit has demonstrated a low complication rate. However there are unacceptable delays between the patients'symptom and surgery and public and professional awareness of what to do in the event of a TIA or stroke needs to be a key objective of primary care organisations and acute Trusts.
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On behalf of the UK carotid endarterectomy audit steering group
A.Halliday, St George's University , London, UNITED KINGDOM
T.Lees   Freeman Hospital  Newcastle upon Tyne  UNITED KINGDOM
D.Kamugasha  Royal College of Physicians  London  UNITED KINGDOM
A.Hoffman  Royal College of Physicians  London  URUGUAY
T.Rudd  St Thomas's Hospital  London  UNITED KINGDOM
         
         
         
         
         
         
         
         
         
         

Kind of presentation: oral

Intracerebral/subarachnoid haemorrhage and venous diseases  
  
 
Chairs: J.S. Kim, South Korea and C. Stapf, France

Date: Thursday 28 May 2009
Time: 8:50 - 9:00
Room: A3

3.
IMPACT OF ACUTE 24-HOUR BLOOD PRESSURE MONITORING VARIABLES ON INTRACEREBRAL HEMORRHAGE OUTCOME
Background: Acute blood pressure (BP) course after acute intracerebral hemorrhage (ICH) is considered an important determinant of outcome and a major therapeutic target. However, little is known about the prognostic value of different characteristics of acute BP profile. We aimed to determine the BP parameters that best predict ICH outcome using noninvasive 24h-BP monitoring. Methods: We prospectively studied 45 patients with acute (<6h) supratentorial ICH. Systolic (SBP), diastolic (DBP) BP and pulse pressure (PP) were recorded every 15-minutes during the first 24h after admission using a Spacelabs 90207 monitor. Maximum and minimum values, 24h-mean levels and standard deviations were calculated to assess BP variability. ICH volume was measured on baseline (<6h) and follow-up (24h) CT scans. GCS and NIHSS scores were recorded on baseline and 24h to evaluate early clinical course. Outcome was assessed at 3 months using mRS. Results: On admission, 39 (86.7%) patients were hypertensive. Ten (22.2%) patients experienced early neurological deterioration (ED) and 15 (33.3%) died at 3 months. Increased 24h- mean SBP (p=0,007) and 24h-mean PP (p=0,015) were the only BP variables significantly associated with ED. Similarly, patients who died had a greater 24h-mean SBP (p=0,003) and 24h-mean PP (p=0,012) during the first day. A 24h-mean SBP>163 mmHg emerged as an independent predictor of mortality (OR 17, 95%CI 1.7-180, p=0.004). BP variables were not correlated with initial stroke severity, baseline ICH volume or ICH growth. Conclusions: Higher mean SBP and PP on 24h-BP monitoring are associated with a worse clinical course and an increased risk of death in patients with acute ICH. We suggest that both components of BP profile should be taken into account when designing future therapeutic strategies.
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R.Delgado-Mederos, Hospital de la Santa Creu i Sant Pau, , Barcelona, SPAIN
R.Ribosa   Hospital Vall d'Hebron  Barcelona  SPAIN
P.Coscojuela  Hospital Vall d'Hebron  Barcelona  SPAIN
O.Maisterra  Hospital Vall d'Hebron  Barcelona  SPAIN
M. Ribó  Hospital Vall d'Hebron  Barcelona  SPAIN
G.Ortega  Hospital Vall d'Hebron  Barcelona  SPAIN
P.Delgado  Hospital Vall d'Hebron  Barcelona  SPAIN
E. Santamarina  Hospital Vall d'Hebron  Barcelona  SPAIN
M.Rubiera  Hospital Vall d'Hebron  Barcelona  SPAIN
F. Romero  Hospital Vall d'Hebron  Barcelona  SPAIN
J.Álvarez-Sabín  Hospital Vall d'Hebron  Barcelona  SPAIN
C.A.Molina  Hospital Vall d'Hebron  Barcelona  SPAIN
         
         
         

Kind of presentation: oral

Small vessel and white matter disease  
  
 
Chairs: H.Bäzner, Germany and N. Futrell, USA

Date: Thursday 28 May 2009
Time: 14:40 - 14:50
Room: A4

5.
CEREBRAL AUTOREGULATION IN THE EARLY STAGES OF CADASIL (CEREBRAL AUTOSOMAL DOMINANT ARTERIOPATHY WITH SUBCORTICAL INFARCTS AND LEUKOENCEPHALOPATHY)
Background: CADASIL is a micro-angiopathy leading to cerebral white and deep grey matter damage caused by Notch3 gene mutations and clinically characterized by strokes, migraine, cognitive and psychiatric disturbances. Among the pathogenetic hypotheses, failure of cerebral hemodynamics has been suggested and reduced cerebrovascular reactivity was reported in CADASIL, while cerebral autoregulation was not found affected. Aim: To assess the adaptation of cerebral circulation to acute blood pressure increase in CADASIL. Methods: 10 CADASIL patients (mean age 41±9 yrs) and 10 gender-matched healthy controls (mean age 34±8 yrs) were studied. All CADASIL patients were in early disease stages: one asymptomatic, 5 suffered from migraine or psychiatric disturbances, 1 psychiatric disturbances and mild cognitive deficits, and only 3 had a history of minor stroke. None was demented. A 30% maximal right isometric hand grip (HG) stimulation was applied for 90 seconds. Transcranial Doppler ultrasound (TCD) (Multidop X 4, DWL) was used to continuously monitor middle cerebral arteries mean velocity (MCAmv). HG index was calculated as following: (MCAmv during HG stimulation - baseline MCAmv)/MCAmv during HG stimulation. Results: Vascular risk factors were absent among controls and present only in few cases: diabetes mellitus (1), hypertension (2), smoking (3). HG index was significantly higher in cases than controls (0.054±0.071 vs -0.047±0.107, p=0.028). Since CADASIL patients were older, we compared HG index between 6 younger (<45yrs) cases (mean age 35±6 yrs) and the 10 controls confirming that higher index value was present also in this CADASIL subgroup (0.051±0.089, p=0.083). Conclusions: With the limitation of the small sample size, our data suggest the presence of cerebral autoregulation impairment in early CADASIL stages. Since autoregulation can be measured non-invasively by TCD, this simple exam can be used to study disease pathogenesis and progression in young patients.
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Table:  
 
F.Pescini, Department of Neurological and Psychiatric Sciences, University of Florence, Florence, ITALY
F.D'Abate   Department of Medical and Surgical Critical Care, University of Florence  Florence  ITALY
C.Sarti  Department of Neurological and Psychiatric Sciences, University of Florence  Florence  ITALY
S.Bianchi  Neurometabolic Unit, Institute of Neurological Sciences, University of Siena  Siena  ITALY
M.T.Dotti  Neurometabolic Unit, Institute of Neurological Sciences, University of Siena  Siena  ITALY
A.Federico  Neurometabolic Unit, Institute of Neurological Sciences, University of Siena  Siena  ITALY
S.Castellani  Department of Medical and Surgical Critical Care, University of Florence  Florence  ITALY
D.Inzitari  Department of Neurological and Psychiatric Sciences, University of Florence  Florence  ITALY
L.Pantoni  Department of Neurological and Psychiatric Sciences, University of Florence  Florence  ITALY
         
         
         
         
         
         

Kind of presentation: poster

Epidemiology of stroke  
  
Poster Session Red
Chairs:  

Date: Wednesday 27 May 2009
Time: 12:30 - 14:00
Room:  

53.
Frequency of intracranial vessel anomalies in cerebrovascular patients
Background. The impact of intracranial cerebral artery anomalies is not enough known. The aim of this study is to describe the frequency of intracranial arterial anomalies. Methods. We analyzed retrospectlively a continuous series of 502 patients admitted to the stroke unit of our teaching hospital for whom a cerebral MRI and MR-Angiography were performed. Results. Overall, 291 (58%) patients were male, with a mean (± S.D.) age of 65aa (± 15). A diagnosis of ischemic stroke was done in 57% of cases, of TIA in 16% of patients, hemorrhagic stroke in 10.8%, subarachnoid hemorrhage in 1.1%, cerebral venous sinus thrombosis in 1% and 14% of patients had other CNS diseases. Intracranial cerebral artery anomalies were found in 86 patients (27.8%). The posterior cerebral artery presented 38 (44 %) anomalies: fetal origin from homolateral carotid cerebral artery in 32 cases (15 on the right side, 12 on the left side, 5 on both side) and hypoplasia in 6 (3 on the right side, 2 on the left side, 1on both side). The anterior cerebral artery presented hypoplasia in 15 cases (17,4%):12 on the right side, 3 on the left side. The posterior communicants artery was hypoplastic in 13 patients (15%): 3 on the right, 2 on the left, 8 on both side. The vertebral artery was hypoplastic in 7 cases (8,1%):1 on right side and 6 on left side. Among 13 (7,4%) remaining anomalies, we found 1 hypoplastic anterior communicants cerebral artery, and 1 case of Moya-Moya like vessel anomalies. Discussion. In our casistic the fetal origin of posterior cerebral artery is the most frequent Circle of Willis variant. Interestingly, when it was present on the right side it is always associated with a hypoplasia of another right artery, on the contrary when it is on the left side it was not associated with any other vessel anomalies. Further studies are necessary to better understand the influence of these vessel anomalies on the site of acute vascular lesion and on outcome of stroke patients.
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A.Correnti, Unità di Trattamento Neurovascolare, Department of Neurological Sciences, University of Rome "La Sapienza", Rome, ITALY
E.Puca   Unità di Trattamento Neurovascolare, Department of Neurological Sciences, University of Rome "La Sapienza"  Rome  ITALY
S.Lorenzano  Unità di Trattamento Neurovascolare, Department of Neurological Sciences, University of Rome "La Sapienza"  Rome  ITALY
A.Mancini  Unità di Trattamento Neurovascolare, Department of Neurological Sciences, University of Rome "La Sapienza"  Rome  ITALY
M.Rojas Beccaglia  Radiology, Policlinico Umberto I, University of Rome "La Sapienza"  Rome  ITALY
G.F.Gualdi  Radiology, Policlinico Umberto I, University of Rome "La Sapienza"  Rome  ITALY
M.Prencipe  Unità di Trattamento Neurovascolare, Department of Neurological Sciences, University of Rome "La Sapienza"  Rome  ITALY
D.Toni  Unità di Trattamento Neurovascolare, Department of Neurological Sciences, University of Rome "La Sapienza"  Rome  ITALY
         
         
         
         
         
         
         

Kind of presentation: poster

Vascular biology  
  
Poster Session Blue
Chairs:  

Date: Thursday 28 May 2009
Time: 12:30 - 14:00
Room:  

14.
TLR4 expression in monocytes is an independent prognostic factor in human stroke
Background: Toll-like receptors are pattern recognition receptors. They are expressed in many immune cells, most notably in antigen presenting cells. TLR4 is involved in the brain damage in experimental ischemia. In humans, monocyte numbers increase after stroke. However, the prognostic significance of various monocyte antigens in stroke patients remains unsettled. Methods: We used flow cytometry in 45 consecutive strokes and 13 age-matched controls to asses the phenotype of monocytes, including their expression of TLR4, TLR2, the antigen presenting HLA-DR, the adhesion molecule VLA-4, and the production of cytokines after stimulation. Cortisol, TNF-a, IFN-g, and IL-10 were measured in serum. The effects of these parameters on the risk of SAI and poor outcome were tested in multivariate analyses adjusted for confounders (NIHSS score and age). Results: Compared to controls, stroke patients had reduced expression of HLA-DR, increased expression of TLR2, and impaired production of TNF-a in monocytes. Distinct immune mechanisms were related with functional outcome and the risk of SAI; In multivariate analyses, poor outcome was associated to high expression of TLR4 (quartiles, OR 9.61, 95% CI 1.27-72.47;p=0.02) whereas a rise of cortisol and IL-10 in serum and reduced production of TNF-a in monocytes were independent predictors of SAI. Conclusions: In human stroke, poor outcome is associated to innate responses mediated by TLR4 in monocytes, whereas the occurrence of SAI reflects the immunosuppressive and anti-inflammatory effects of corticoids, IL-10, and deactivated monocytes. This suggests that agents specifically targeting the innate immune response elicited by TLR4 may be promising for the treatment of stroke in humans.
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X.Urra, Stroke Unit. Hospital Clinic, Barcelona, SPAIN
M.Gómez-Choco   Stroke Unit. Hospital Clinic  Barcelona  SPAIN
S.Amaro  Stroke Unit. Hospital Clinic  Barcelona  SPAIN
V.Obach  Stroke Unit. Hospital Clinic  Barcelona  SPAIN
M.Vargas  Stroke Unit. Hospital Clinic  Barcelona  SPAIN
A.M.Planas  Institut d’Investigacions Biomèdiques de Barcelona, Consejo Superior de Investigaciones Científicas  Barcelona  SPAIN
A.Chamorro  Stroke Unit. Hospital Clínic  Barcelona  SPAIN
         
         
         
         
         
         
         
         

Kind of presentation: poster

Vascular biology  
  
Poster Session Blue
Chairs:  

Date: Thursday 28 May 2009
Time: 12:30 - 14:00
Room:  

12.
Inhibition of p38 MAPK Abolishes the Protective Effect of the Antioxidant PDTC on Brain Endothelial Cells
Background – Blood-brain barrier disruption plays an important role in edema formation and lesion development in cerebral ischemia and reperfusion. The endothelial cells of the brain microvasculature are exposed to metabolic and acute inflammatory challenges in stroke. The mitogen-activated protein kinase p38 (p38 MAPK) is activated in response to many cell stressors and generally promotes cell death and formation of inflammatory mediators. Its pharmacological inhibition has been shown to be protective in the murine model of middle cerebral artery occlusion (MCAO). Methods – Cell death was induced in bEnd.3 cells by exposure to tumour necrosis factor alpha (TNFa, 50 ng/ml) and cycloheximide (CHX, 20 microg/ml), an inhibitor of translation that was not cytotoxic when administered alone at this concentration. We measured LDH release for general cell death assessment and caspase-3 cleavage by Western blotting to determine apoptotic cell death. p38 MAPK activation was induced by the antioxidant pyrrolidine dithiocarbamate (PDTC, 100 microM) and two p38 MAPK inhibitors were used to asses the significance of p38 MAPK for endothelial cell survival. Results – Exposure of the bEnd.3 cells to TNFa + CHX leads to a significant induction of cell death after 6 h (LDH in the supernatant 17 % of LDH after complete cell lysis, p < 0,001). Western blotting for caspase-3 activation shows a strong induction of apoptosis which is attenuated by PDTC. A time dependent phosphorylation and hence activation of p38 MAPK is induced by PDTC and pretreatment with inhibitors of p38 MAPK abolished the protective effect of PDTC. Conclusions – Even though inhibition of p38 MAPK via intracerebroventricular injection in animal studies has been shown to reduce lesion size in experimental stroke, our cell culture data point out that inhibition of p38 MAPK, especially via a systemic route, may cause damage to the blood-brain barrier by promoting cell death of the microvascular endothelium.
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W.Rölz, Klinik für Neurologie, Klinikum der Johann Wolfgang Goethe Universität, Frankfurt am Main, GERMANY
B.Czech   Pharmazentrum Frankfurt, Klinikum der Johann Wolfgang Goethe Universität  Frankfurt am Main  GERMANY
T.Neumann-Haefelin  Klinik für Neurologie, Klinikum der Johann Wolfgang Goethe Universität  Frankfurt am Main  GERMANY
J.Pfeilschifter  Pharmazentrum Frankfurt, Klinikum der Johann Wolfgang Goethe Universität  Frankfurt am Main  GERMANY
         
         
         
         
         
         
         
         
         
         
         

Kind of presentation: oral

Brain imaging  
  
 
Chairs: F. Fazekas, Austria and J. Wardlaw, United Kingdom

Date: Thursday 28 May 2009
Time: 8:40 - 8:50
Room: A4

2.
MR spectroscopy choline and lactate brain concentration measurements for early determination of prognosis and direction of infarct expansion in acute stroke patients.
Background: The ability to predict ischaemic lesion growth very early of the stroke would be very helpful in its clinical management. Perfusion and diffusion imaging techniques have not fulfilled the initial expectations of sensitive and selective determination of "tissue at risk". We investigated the potential of magnetic resonance (MR) spectroscopy (lactate and choline concentrations measurements) combined with diffusion imaging (DWI) for this purpose. Methods: We superimposed multi-voxel MR spectroscopic lactate and choline concentrations imaging onto DWI on admission (<24 hours of first symptoms) and compared this hybrid with 3 to 5 day follow-up DWI data in patients with acute ischaemic stroke. We compared the concentrations between: 1/ "healthy-looking brain" voxels that converted to infarction on the follow-up DWI ("infarct expansion voxels"; n=63) with 2/ "healthy-looking brain" peri-infarct voxels, which did not convert to ischaemic tissue ("non-expansion voxels"; n=63) on the follow-up DWI. Results: In 16 patients, mean choline and lactate concentrations in voxels where healthy tissue on admission converted to infarction were much higher than in voxels where ischaemic lesion did not appear on the follow-up DWI (choline: 6237.75 vs. 2547.9 institutional units, p<0.05; lactate: 1896.23 vs. 862.28 institutional units, p<0.05). Discussion: Lactate and choline concentrations, which can both be measured non-invasively even in severely ill patients with MR techniques, could be used to predict conversion of "healthy-looking tissue" or ?tissue at risk? To infarction in acute stroke but larger studies are needed to confirm this association.
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B.Karaszewski, Department of Clinical Neurosciences, University of Edinburgh, UK & Department of Neurology, Medical University of Gdansk, Poland, Edinburgh, UNITED KINGDOM
R.Thomas   Department of Clinical Neurosciences, University of Edinburgh, UK  Edinburgh  UNITED KINGDOM
I.Marshall  Medical Physics & Medical Engineering, University of Edinburgh, UK  Edinburgh  UNITED KINGDOM
P.A.Armitage  Department of Clinical Neurosciences, University of Edinburgh, UK  Edinburgh  UNITED KINGDOM
T.Carpenter  Department of Clinical Neurosciences, University of Edinburgh, UK  Edinburgh  UNITED KINGDOM
K.Lymer  Department of Clinical Neurosciences, University of Edinburgh, UK  Edinburgh  UNITED KINGDOM
M.Dennis  Department of Clinical Neurosciences, University of Edinburgh, UK  Edinburgh  UNITED KINGDOM
J.M.Wardlaw  Department of Clinical Neurosciences, University of Edinburgh, UK  Edinburgh  UNITED KINGDOM
         
         
         
         
         
         
         

Kind of presentation: poster

Epidemiology of stroke  
  
Poster Session Red
Chairs:  

Date: Wednesday 27 May 2009
Time: 12:30 - 14:00
Room:  

5.
Cognitive Function in Elderly Men is a Predictor of Ischemic Stroke.
Background: Our aim was to study the predictive power of cognitive function for later incidence of fatal or non-fatal stroke or transient ischemic attacks (TIA) and stroke subtypes. To measure the cognitive function we used three different tests. Methods: The study is based on the Uppsala longitudinal Study of Adult Men cohort. The examinations were performed at age 70 years. The cognitive tests used were the Mini Mental State Examination (MMSE) and Trail Making Test (TMT) A and B. Results: In 930 men, free from stroke at baseline, 166 developed stroke or TIA during a follow-up of up to 13 years using registry data obtained from the Swedish Hospital Discharge Record (SHDR) and the Cause-of death Register (CDR). In univariate Cox proportional hazards analyses, a 1-standard deviation increase in result TMT B was associated with a higher risk for brain infarction (HR 1.86, 95% CI 1.14-3.04, n=105) but not for the total group stroke/TIA (HR 1.24, 95% 0.84-1.83) or the subgroup of intra cerebral haemorrhages (HR 1.40, 95 % 0.50-3.91). The predictive value of TMT B was still significant after adjustment for education level and traditional risk factors, such as blood pressure. Conclusion: Cognitive function in elderly men, measured by Trail Making Test B, predicted subsequent brain infarction independently of education and traditional risk factors in a community-based sample of elderly men.
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B.Wiberg, Department of Public Health and Caring Sciences/Geriatrics, Uppsala, SWEDEN
L.Lind   Department of Medical Sciences  Uppsala  SWEDEN
L.Kilander  Department of Public Health and Caring Sciences/Geriatrics  Uppsala  SWEDEN
B.Zethelius  Department of Public Health and Caring Sciences/Geriatrics  Uppsala  SWEDEN
J.Sundström  Department of Medical Sciences  Uppsala  SWEDEN
         
         
         
         
         
         
         
         
         
         

Kind of presentation: oral

Experimental studies  
 B
 
Chairs: P. Lindsberg, Finland and P. Sharma, United Kingdom

Date: Wednesday 27 May 2009
Time: 16:55 - 17:05
Room: A4

14.
Pyrrolidine Dithiocarbamate (PDTC) Reduces Lesion Size After MCAO in Mice – Activation of Hsp70 Does not Seem to be the Protective Mechanism
Background – The antioxidant and inhibitor of nuclear factor kappa B (NF-KB) pyrrolidine dithiocarbamate (PDTC) has been shown to reduce lesion size after transient and permanent cerebral ischemia in the rat and in the gerbil. The mechanism of this protective effect is yet unclear. Heat shock proteins (Hsp) are known to be expressed in response to a multitude of cell stresses and the expression of Hsp70 has been shown to be protective in stroke since Hsp70 -/- mice had greater lesions after MCAO. Methods – C57BL/6 mice were subjected to transient MCAO for 2 h followed by 22 h of reperfusion. PDTC was injected i.p. before the onset of reperfusion. Lesion size was detected by TTC staining of 4 brain slices of 1 mm each adjacent to the bregma. Immunofluorescence staining for Hsp70 was performed. Brain microvascular endothelial cells (bEnd.3) were cultured and exposed to PDTC. Thereafter, Hsp70 expression was assessed by Western blotting. Results – Treatment of PDTC (n=9) at the onset of reperfusion reduced lesion volume by approximately 60 % compared to vehicle treated animals (n=7). Lesion volume was 43 + 5 mm3 in vehicle treated animals and 17 + 7 mm3 in PDTC treated animals (means +/- SEM; p=0,012; unpaired t-test). Hsp70 was expressed in the ischemic hemispheres of vehicle treated animals, the contralateral hemisphere showed no expression. Surprisingly, in PDTC-treated animals there was only a very low induction of Hsp70, although PDTC led to a massive induction of Hsp 70 in cell culture experiments. Conclusions – PDTC reduces infarct size in mice with a therapeutic time window of two hours. Despite the massive induction of Hsp70 by PDTC in vitro and the known property of Hsp70 to be protective in the murine stroke model, upregulation of Hsp70 is not involved as a protective mechanism in our animal model. It rather seems that the induction of Hsp70 is a stress response that occurs in the vehicle treated animals and is prevented by the protective substance PDTC.
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B.Czech, Pharmazentrum Frankfurt, Klinikum der Johann Wolfgang Goethe Universität, Frankfurt am Main, GERMANY
W.Rölz   Klinik für Neurologie, Klinikum der Johann Wolfgang Goethe Universität  Frankfurt am Main  GERMANY
T.Neumann-Haefelin  Klinik für Neurologie, Klinikum der Johann Wolfgang Goethe Universität  Frankfurt am Main  GERMANY
J.Pfeilschifter  Pharmazentrum Frankfurt, Klinikum der Johann Wolfgang Goethe Universität  Frankfurt am Main  GERMANY
         
         
         
         
         
         
         
         
         
         
         

Kind of presentation: poster

Genetic disorders  
  
Poster Session Red
Chairs:  

Date: Wednesady 27 May 2009
Time: 12:30 - 14:00
Room:  

5.
POLYGENIC JUVENILE STROKE
Background: The prevalence of ischemic stroke affecting patients younger than 50 y.o ranges from 3 to 12.3%. Epidemiological and familial studies provided evidences that genetic factors have a role in stroke occurrence particularly among individuals presenting with stroke at young age. Monogenic disorders explain less than 1% of all young strokes. Stroke is a complex disease in which genetic factors have been supposed to act in additive co-effect. However, despite family history studies demonstrated that genetic factors are much more important in young individuals, most of studies conducted so far did not include age stratification analyses. The aim of this paper is to identify, thought an updated literature review, the role of several candidate genes in young adult stroke. Methods: Paper search was undertaken in electronic databases from 1960 to May 2008 for case control studies, prospective cohort studies, reviews and meta-analyses in English-language investigating the role of several candidate genes (F5, F2, FGA, FGB, F7, F12, F13A1, vWF, SERPINE1, ITGB3, ITGA2B, ITGA2, GP1BA, ACE, AGT, NOS3, MTHFR, CBS, MTR, APOE, LPL, PON1, PDE4D, ALOX5AP) in ischemic stroke in patients aged from 0 to 50 years. The results of association studies were reported as odds ratio (OR) and 95% confidence intervals (95% CI) as calculated by the authors. Results: we found that only three polymorphisms (c.1691G>A, c.20210G>A, c.677C>T) of three candidate genes (F5, F2, MTHFR) are possibly associated with increased stroke risk in young subjects. Discussion: Although we did not identify significant associations between juvenile stroke and specific genes, we indicate a list of genes possibly generating a susceptibility to stroke, that could be a starting point for future research. The hope is that understanding the genetic basis of juvenile stroke will lead to better management of these patients and will facilitate the understanding of pathogenetic mechanisms of adult stroke.
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A.Bersano, Fondazione IRCCS Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, Milan, ITALY
E.Ballabio   Fondazione IRCCS Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena  Milan  ITALY
A.Pezzini  Neurologia Vascolare, Spedali Civili di Brescia  Brescia  ITALY
A.Padovani  Neurologia Vascolare, Spedali Civili di Brescia  Brescia  ITALY
N.Bresolin  Fondazione IRCCS Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena  Milan  ITALY
P.Baron  Fondazione IRCCS Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena  Milan  ITALY
L.Candelise  Fondazione IRCCS Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena  Milan  ITALY
         
         
         
         
         
         
         
         

Kind of presentation: poster

Chronic conditions and rehabilitation  
  
Poster Session Blue
Chairs:  

Date: Thursday 28 May 2009
Time: 12:30 - 14:00
Room:  

22.
The relationship between perceived participation and different aspects of functioning, contextual factors and health conditions among a sample of persons with stroke in Iran
Background: Stroke is one of the most common causes of disability and the most common neurological diagnosis among clients treated by occupational therapists. The concept of participation, defined as “involvement in a life situation”, is often described as a goal of rehabilitation when the International Classification of Functioning, Disability and Health (ICF) is used as a conceptual framework in rehabilitation. Participation can be affected due to disabilities after stroke. The consequences resulting from stroke can lead to participation restrictions and dependency in clients, which in turn can directly affect on their life satisfaction. The purpose of this study was to identify different aspects of functioning, contextual factors, and health conditions associated with participation after stroke. Method: A total of 102 persons with first-ever stroke with the age range 27 to 75 years were assessed in different aspects of functioning, contextual factors, and health conditions. Participation was assessed using the Persian version of Impact on participation and Autonomy questionnaire (IPA-P). Results: The findings of this study showed that physical function was found to be the most important variable associated with performance-based participation whereas mood state was the most important variable associated with social-based participation. Conclusions: The results suggest considering physical function, mood state, and access to social support to enhance participation in daily life occupations in rehabilitation process after stroke. Implications for occupational therapy practice: Findings of this study will document how persons with stroke perceive their participation after stroke. This information will be helpful in predicting their needs for OT interventions to help them improve their participation in valued life situations.
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M.Fallahpour, Karolinska Institutet (Sweden), Department of Neurobiology, Care Sciences and Society, Division of Occupational Therapy, Stockholm, SWEDEN
K.Tham   Karolinska Institutet (Sweden), Department of Neurobiology, Care Sciences and Society, Division of Occupational Therapy  Stockholm  SWEDEN
M.T.Joghataei  Iran University of Medical and Health Sciences, Department of Anatomy  Tehran  IRAN
H.Jonsson  Karolinska Institutet (Sweden), Department of Neurobiology, Care Sciences and Society, Division of Occupational Therapy  Stockholm  SWEDEN
         
         
         
         
         
         
         
         
         
         
         

Kind of presentation: poster

Epidemiology of stroke  
  
Poster Session Red
Chairs:  

Date: Wednesday 27 May 2009
Time: 12:30 - 14:00
Room:  

45.
RE-AUDIT TIMING OF SCAN IN STROKE PATIENTS.
This audit was carried out at Ysbyty Gwynedd Hospital Bangor that is situated in North Wales. this hospital is 450 beded and covers a large geogriphical area from Holyhead in the north to Tywyn in the south and from Pwllheli in the west to Llandudno in the east.There is a stroke ward in the hospital called prysor ward which is 15 beded ward. the stroke patients are first admitted in AMU ( tryfan) ward from where they are transferred to prysor ward. according to Royal College of Physician Guidlines 'brain imaging should be under taken as soon as possible in all patients, within 24 hours at most of onset of symptoms'. NICE Guidlines 68-Stroke also reiterates this standard. The first audit was done in 2006 to find out the time of CT Scan in patients with stroke. The results showed that out of 58 patients only 14% had thier CT Scan in 24 hrs while 86% had after 24 hrs which is well below the standard. After this results some changes were introduced in the system to speed up the process of CT Scan i.e 1- Signing the CT Scan form immediately when the patient is admitted in AMU. 2- sending form immediately to radiology departement. 3- Introduction of blue stickers on CT Scan request form so that radiology departement are aware that these patients are to be CT scanned within 24 hrs. To close the loop we did a re-audit in june 2008 to find out whether we have achieved the standards or not. In this audit 55 patients were included out of which 37% of patients had thier CT Scan done within 24 hrs of admission while 63% didnot have CT Scan within 24 hrs of admission. This re-audit showed that there has been significant improvement as in the first audit only 14% of the patients had CT Scan done within 24 hrs of admission while in 2008 37% of patients had CT Scan within 24 hrs of admission. Still there is a long way to go and more measures needs to be taken to achieve the standards which is that 100% of the patients should have thier CT Scan in 24 hrs of admission.
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S.Elghenzai, Ysbyty Gwynedd Hospital, Bangor, UNITED KINGDOM
          
         
         
         
         
         
         
         
         
         
         
         
         
         

Kind of presentation: poster

Regional/national stroke aspects (EU and beyond)  
  
Poster Session Blue
Chairs:  

Date: Thursday 28 May 2009
Time: 12:30 - 14:00
Room:  

10.
Acute ischemic stroke in Poland – the comparison of national hospital-based stroke registries in 2000-2008.
Background: To estimate changes in ischemic stroke clinical presentation, the acute care and outcomes in stroke centers participating in national hospital-based stroke three registries from 2000 to 2008 in Poland. Methods: We compared ischemic stroke patients data in three national hospital registries: the PNSPTR (Polish National Stroke Prevention and Treatment Program) Registry and two editions of POLKARD (National Cardiovascular Disease Prevention and Treatment Program) Registry collecting data for 2000-2001, 2004-2005 and 2007-2008, respectively. WHO Steps Stroke and Swedish Stroke Registry (Riks-Stroke) based questionnaires were used to collect data on ischemic stroke patients admitted to participating centers. To ensure the quality only centers that reported at least 100 patients were analyzed. Results: We analyzed data from 26, 73 and 123 centers and 8736, 20542 and 26361 ischemic stroke patients registered in PNSPTR Registry and first and second edition of POLKARD Registres, respectively. The prevalence of risk factors (i.e. atrial fibrillation, ischemic heart disease, diabetes, smoking and alcohol abuse) decreased from 2000 to 2008. The control of risk factors improved, with the exception for hypotensive agents used in hypertensive patients. More patients were admitted within first hours following stroke onset (in second edition of POLKARD Registries 32,9%, 46,5% and 56,2% patients were hospitalized within 3, 4,5 and 6 hours). More ischemic stroke patients received aspirin and less were reported to be treated with antibiotics and nootropic drugs. The mean hospital stay decreased by one day from 13,4 to 12,2 days. Early outcomes have improved: the in-hospital mortality decreased from 15,2 in PNSPTR Registry to 11,6 and 12,0% in POLKARD Registries. Conclusions: The ischemic stroke care and outcomes improved in the last decade in Poland. These beneficial effects needs further monitoring in Poland.
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M.Niewada, Medical University of Warsaw, Department of Pharmacology, Warsaw, POLAND
I.Sarzyńska-Długosz   Institute of Psychiatry and Neurology, 2nd Neurological Department  Warsaw  POLAND
M.Skowrońska  Institute of Psychiatry and Neurology, 2nd Neurological Department  Warsaaw  POLAND
A.Kobayashi  Institute of Psychiatry and Neurology, 2nd Neurological Department  Warsaw  POLAND
B.Kamiski  Department of Division of Decision Analysis and Support, Institute of Econometrics, Warsaw School of Economics  Warsaw  POLAND
A.Czlonkowska  Institute of Psychiatry and Neurology, 2nd Neurological Department  Warsaw  POLAND
         
         
         
         
         
         
         
         
         

Kind of presentation: poster

Interesting cases  
  
Poster Session Red
Chairs:  

Date: Wednesday 27 May 2009
Time: 12:30 - 14:00
Room:  

8.
Short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms secondary to symptomatic severe carotid stenosis and carotid dissection
Background: Short-lasting unilateral neuralgiform headache attacks with cranial autonomic features (SUNA) have not been described with atherosclerotic carotid stenosis/dissection. Case 1: A 48 y.o. woman presented with recurrent, stabbing left retro-orbital pains, left eye lacrimation and blurring, and right sided numbness/weakness, 3-6 times/day, lasting <10 minutes. Background history included migraine, diabetes, smoking, hypertension and coronary artery disease. Brain MRI showed left MCA infarction. Extracranial MRA revealed left ICA stenosis. TCD revealed multiple left MCA emboli. Her symptoms improved on clopidogrel, but resolved on IV Heparin. She had left carotid endarterectomy, with no further symptoms of SUNA or TIA on follow up. Case 2: A 33 y.o. male smoker had a 2 month history of intermittent right sided throbbing headaches, lasting <5 mins, with right eye pain, blurring, lacrimation and conjunctival injection. He suddenly developed central chest pressure, and sharp, shooting pains radiating from the right interscapular region to the right posterior neck and eye, with subsequent left facial numbness, dysarthria, and left hemiplegia. MRI brain showed right MCA infarction. CT thorax did not reveal aortic dissection. Extracranial MRA and axial T1 fat-suppressed MRI confirmed right ICA dissection. He started aspirin, and headaches settled after 16 days. Ten months after stroke onset, he represented with intermittent, right temporal stabbing pains, lasting 2?3s, with no autonomic features, followed by a right MCA TIA. Repeat MRI showed no acute infarction. Formal angiography revealed right ICA stenosis, but no new dissection. Discussion: The rapid response to anti-thrombotic therapy, despite ongoing embolisation, suggests that the thrombogenic?inflammatory milieu of a ruptured carotid atherosclerotic plaque may contribute to the pathogenesis of SUNA. Carotid dissection may cause ?symptomatic? SUNA, and must be considered in patients with SUNA and TIA or stroke.
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J.A.Kinsella, The Adelaide and Meath Hospital, Dublin, incorporating the National Children’s Hospital, Trinity College Dublin, Ireland, Dublin, IRELAND
W.O.Tobin   The Adelaide and Meath Hospital, Dublin, incorporating the National Children’s Hospital, Trinity College Dublin, Ireland  Dublin  IRELAND
L.Costelloe  The Adelaide and Meath Hospital, Dublin, incorporating the National Children’s Hospital, Trinity College Dublin, Ireland  Dublin  IRELAND
B.Egan  The Adelaide and Meath Hospital, Dublin, incorporating the National Children’s Hospital, Trinity College Dublin, Ireland  Dublin  IRELAND
H.Angus-Leppan  University Department of Clinical Neurosciences, Royal Free and University College Medical School, Royal Free Hospital, London, U.K.  London  UNITED KINGDOM
D.J.H.McCabe  The Adelaide and Meath Hospital, Dublin, incorporating the National Children’s Hospital, Trinity College Dublin, Ireland  Dublin  IRELAND
         
         
         
         
         
         
         
         
         

Kind of presentation: poster

Risk factors: manifestation, treatment and prognosis  
  
Poster Session Blue
Chairs:  

Date: Thursday 28 May 2009
Time: 12:30 - 14:00
Room:  

46.
Prospective 5 years follow-up of a cohort of patients undergoing carotid endarterectomy
Background- Carotid artery disease accounts for 10-20% of ischemic strokes, but atherosclerosis is a chronic systemic disease with a long-term repercussion to all vascular systems. Methods- Our objective was to analyse prospectively patients scheduled for carotid endarterectomy (CEA) in our hospital. We included patients with a minimum follow-up of 5 years. We recorded clinical history, vascular risk factors and treatment. We performed general blood analysis, plaque and serological biomarkers analysis before CEA and on follow-up. We analysed the characteristics of the atherosclerotic plaques by imaging technics and anatomo-pathology. We recorded postoperative complications, mortality and morbidity rates. Further, annual carotid dupplex was performed and ipsilateral restenosis or contralateral carotid progression was scored. Results- We included 100 patients with a follow-up of 5.5 to 8.7 years. There were 86 men and 14 women with a mean age of 69 years (range 46-84). 37 patients were asymptomatic. Most of the patients had multiple risk factors. 16 patients died on follow-up, 2 of postoperative complications and 12 of vascular cause. 9 patients suffered a cerebrovascular event and 8 had cardiac event. 18 patients requiered coronary or carotid revascularisation surgery. 23 patients had progression of the contralateral carotid stenosis and 11 restenosis of the operated carotid. On statistical analysis, patients with progression or restenosis of carotid lesion, active smokers and diabetics suffered more from new vascular events. Lipid profile and metaloproteinases were associated with progression/restenosis of carotid lesion and vascular events. Patients without anitplatelets or renin-aniotensin-system blockers suffered more vascular events and patients without anitplatelets and statins suffered more progression/restenosis of carotid lesions (p<0.05). Conclusion- Patients who suffer from carotid restenosis or have clear progression of the contralateral carotid stenosis are at the highest risk to develop new vascular event after CEA. Lipid profile and serum metaloproteinases seem to be a good biomarkers for the increased risk.
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M.A.Font, Department of Neurology, University Hospital of Bellvitge (HUB), Fundació IDIBELL, Barcelona, SPAIN
A.Carvajal   Department of Neurology, University Hospital of Bellvitge (HUB), Fundació IDIBELL  Barcelona  SPAIN
I.Rico  Hospital Universitari Mutua de Terrassa, Department of Neurology  Barcelona  SPAIN
E.Catena  Department of Neurology, Hospital de Vilafranca del Penedès  Barcelona  SPAIN
H.Quesada  Department of Neurology, University Hospital of Bellvitge (HUB)  Barcelona  SPAIN
J.Krupinski  Hospital Universitari Mutua de Terrassa, Department of Neurology  Barcelona  SPAIN
         
         
         
         
         
         
         
         
         

Kind of presentation: poster

Acute stroke: treatment and concepts  
  
Poster Session Red
Chairs:  

Date: Wednesday 27 May 2009
Time: 12:30 - 14:00
Room:  

48.
Dissociation of early outcome of aphasia versus other deficits after IV-rtPA thrombolysis in acute stroke patients
Background: Informal clinical observation suggested to us that aphasia recovers relatively better than other deficits early after IV-rtPA in stroke patients with minor deficits while the reverse seemed the case in those with severe deficits. We thus retrospectively analyzed the benefit from thrombolytic therapy in evaluating the short term outcome of aphasia as compared to the other deficits. Methods: In 243 acute ischemic stroke patients admitted within 3 hours from symptom onset and treated with IV-rtPA, stroke severity was assessed according to the NIHSS scale at admission and at 24 h after thrombolysis. 73 patients suffered from aphasia. Improvement of aphasia was defined by the gain of >=1 point in the NIHSS aphasia score and global neurological improvement by the gain of >=4 points in the NIHSS. Patients were divided into 3 groups: minor strokes: NIH <=7; moderate strokes: NIH <=8>=15, and major strokes: NIH >=16. Results: Improvement of aphasia occurred in 7/16 minor strokes, in 10/25 moderate strokes, and in 9/32 severe strokes. Improvement of NIH ≥4pts occurred in 3/16 minor strokes, 15/25 moderate strokes and in 17/32 severe strokes. When analyzing all groups (X2 (df=2) 3.817 p=0.074 (1-tailed), there was a statistical trend in favour of our prediction. When analyzing only the groups with minor versus severe deficits, for which we had a clinical suggestion (Fisher Exact : p=0,073) shows a trend, while (X2 (df=1) 3.662; p=0.0277 (1-tailed)) is significant. Discussion: Our retrospective analysis confirms the clinically suspected dissociation between a good early recovery of aphasia in minor strokes relative to their recovery of other NIHSS deficits, and reversely in patients with severe strokes a better recovery from other deficits than from aphasia. The reason for this might be that the size of the neural network supporting language is larger than that of other functions and thus smaller penumbra recovery might lead to greater functional improvement.
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C.Kremer, UMAS, University Hospital of Malmö, University of Lund, Malmö, SWEDEN
J.Kappelin   UMAS, University Hospital of Malmö, University of Lund, Neurology; Stroke Unit  Malmö  SWEDEN
F.Perren  HUG, University Hospital and Medical Faculty of Geneva, Neurology, Stroke Unit   Geneva  SWITZERLAND
         
         
         
         
         
         
         
         
         
         
         
         

Kind of presentation: oral

Acute stroke: emergency management, stroke units and complications  
 C
 
Chairs: A. Davalos, Spain and H. Mattle, Switzerland

Date: Thursday 28 May 2009
Time: 16:40 - 16:50
Room: A2

20.
Complications of Hypothermia Applied for Preventing Cerebral Edema after Large Hemispheric Infarction
Background: Large hemispheric infarction carries a mortality rate of 40–80%. Management of brain swelling includes mild to moderate hypothermia, osmotherapy, and decompressive hemicraniectomy. Methods: We treated 44 patients with large hemispheric infarctions between August 2006 and July 2008 with the combination of insulin infusion (target glucose 4.6-6.1 mmol/L), mild hypothermia (33-35˚C) using a systemic surface cooling or intravascular heat exchange device, and hypertonic saline (3% sodium chloride acetate) at a rate 1ml/kg (goal sodium 150-155 mmol/L) within 72 hours of symptom onset. We predefined and collected all complications and procedures that could potentially occur during the hospital course in the Columbia University Large Hemispheric Infarctions Outcomes Project database, evaluated their frequency and the patient’s neurological outcome at 3 months. Results: Of the 44 patients 19 had right-sided infarctions and median age was 64.5 (range 38-83) years. Baseline NIHSS was 17.8+/-5.6. At 3 months, 24 patients had died; support had been actively withdrawn in 19 cases. The mRS was 1 in 1 patient, 3 in 4 patients, 4 in 3 patients and 5 in 12 patients. The most frequent complications included pulmonary edema (n=34), tracheobronchitis (n=25), hypotension (n=25), thrombocytopenia (n=23), atrial fibrillation with rapid ventricular response (n=14), sepsis and septic shock (n=14), acute renal failure (n=10), anemia requiring transfusion (n=12), aspiration and ventilator-acquired pneumonia (n=10), urinary tract infection (n=8), coagulopathy (n=8), leucopenia (n=6), rhabdomyolysis (n=7), myocardial ischemia (n=3), and paralytic ileus (n=3). Conclusions: Mild hypothermia (33-35 °C) offers a feasible alternative strategy to decrease massive cerebral edema after large hemispheric infarction as part of intensive care treatment protocol. Several complications may counteract the therapeutic effect of hypothermia, therefore detailed attention should be given to their prevention and management.
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K.E.Wartenberg, Carl Gustav Carus University Hospital Dresden, Dresden, GERMANY
C.M.Reichelt   Carl Gustav Carus University Hospital Dresden  Dresden  GERMANY
U.Becker  Carl Gustav Carus University Hospital Dresden  Dresden  GERMANY
H.Hentschel  Carl Gustav Carus University Hospital Dresden  Dresden  GERMANY
A.Kunz  Carl Gustav Carus University Hospital Dresden  Dresden  GERMANY
V.Puetz  Carl Gustav Carus University Hospital Dresden  Dresden  GERMANY
I.Dzialowski  Carl Gustav Carus University Hospital Dresden  Dresden  GERMANY
S.A.Mayer  Columbia University  New York  USA
           
         
         
         
         
         
         

Kind of presentation: oral

Acute stroke: treatment and concepts  
 C
 
Chairs: A. Alexandrov, USA and V. Di Piero, Italy

Date: Wednesday 27 May 2009
Time: 17:05 - 17:15
Room: A2

27.
Results of the FRALYSE randomized study: effect of the duration of rt-PA infusion on the the functional outcome in patients with acute cerebral infarct.
Background Cerebral thrombolysis, according to ECASS and NINDS, involves a duration of infusion of 60 minutes of rt-PA. The Lyon rt-PA protocol was performed with a duration of infusion of 90 minutes (0.8 mg/kg) and yielded a slightly higher good prognosis rate. The FRALYSE study was designed to evaluate the potential superiority of a low dose-long infusion procedure. Methods The FRALYSE-clinical study was a randomized study concerning patients with acute cerebral infarcts involving 2 arms, one (A) with a long rt-PA infusion procedure (infusion of 90 minutes, 0.8 mg /kg, bolus 10%) and the other one (B) with the NINDS method (rt-PA infusion of 60 minutes, dose 0.9mg/kg, bolus 10%), in a window of 7 hours. The evaluation at 90 days was blinded. The primary endpoint was disability at 90 days. Five centers participated in the study: Lyon, Nice, Bourg, Nantes and Auch. Carotid artery territory and vertebro-basilar infarcts were included. Exclusion criteria will be presented in detail. Results Three hundred and sixty patients have been included. Preliminary security results released by the Security Committee indicate that the mortality rate is 7.7% and the symptomatic hematoma rate (according to the NINDS definition) is 5.4%. The statistical calculations are in progress and will be presented at the Congress Discussion Whatever will be the results of the comparison between the 2 arms, intravenous thrombolysis with rt-PA according to the procedures of the study appear as safe in a 7 hour therapeutic window.
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P.TROUILLAS, Cerebrovascular Unit, Universite LYON, LYON, FRANCE
M.H.MAHAGNE   Neurovascular Unit, Hôpital Pasteur  NICE  FRANCE
S.CAKMAK  Cerebrovascular Unit   LYON  FRANCE
L.DEREX  Cerebrovascular Unit   LYON  FRANCE
F.PHILIPPEAU  N eurology Service  BOURG  FRANCE
N.NIGHOGHOSSIAN  Cerebrovascular Unit, Universite LYON 1  LYON  FRANCE
X.H.SUN  Cerebrovascular Unit, Universite LYON 1  LYON  FRANCE
J. Cl.PEYRIEUX  STATMED  LYON  FRANCE
M.MALBEC  Neurology Service  AUCH  FRANCE
Ch.MAGNE  Neurovascular Unit  NANTES  FRANCE
J. CL. FROMENT  Neuroradiology Service, Un iversité LYON 1  LYON  FRANCE
M.HERMIER  Neuroradiology Service, Un iversité LYON 1  LYON  FRANCE
         
         
         

Kind of presentation: poster

Experimental studies  
  
Poster Session Red
Chairs:  

Date: Wednesady 27 May 2009
Time: 12:30 - 14:00
Room:  

44.
‘Stroke in Silico’: a computational approach of acute stro Clues to the difference in efficacy of treatments between acute ischemic stroke in rodents and Humans.
Background Numeric modelling is a multidimentional and multiscales approach of complex phenomena and of their connections. Results can be expressed either in term of quantities or as a global description of a phenomenon. Numeric modelling can be applied in biology at different levels from cell receptors to populations and in different time frames from acute stroke to society outcomes. Moreover it can be useful to test new hypothesis. In therapy, one of its main applications is a faster and cheaper evaluation of therapies as compared to real world experimentations in animals or in human clinical trials. Our goal was to study differences in efficacy of neuroprotective agents between rodents and humans. Methods We used a description at the cellular and ionic levels of all the reported phenomena supposed to explain the difference in efficacy between human and rodents such as severity of ischemia and astrocytes/neurons ratio. Judgement criteria were imaging results (ADC) and energy metabolism (proportion of residual ATP). We used a series of simple differential equations for this approach. We used a ‘global’ approach (phenomenological) to study the effect of brain architecture (gyrocephalia). The end point was the development of spreading depression waves. For that characterisation we used diffusion equations. Computations were obtained using Matlab. Results We found differences in efficacy for various neuroprotective agents according to the difference in the ratio astrocytes/neurones and according to severity of ischemia. Moreover, the spreading depression waves, ‘spontaneously developing’ in ischemic brains were limited in their extension in gyrocephalic brains. Conclusions Our results may contribute to the explanation of a difference in efficacy of neuroprotective agents between rodents and humans, which are linked to differences in cells types’ ratio and brain anatomy.
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M.Hommel, INSERM CIC 003, Grenoble, FRANCE
M.A.Dronne   IM Th UMR CNRS   Lyon  FRANCE
E.Grenier  ENS UMR CNRS  Lyon  FRANCE
G.Chapuisat  ENS UMR CNRS  Lyon  FRANCE
T.Dumont  IM Th UMR CNRS  Lyon  FRANCE
A.Jaillard  IFR1 INSERM  Grenoble  FRANCE
J.P.Boissel  IM Th UMR CNRS   Lyon  FRANCE
         
         
         
         
         
         
         
         

Kind of presentation: oral

Acute stroke: treatment and concepts  
 C
 
Chairs: A. Alexandrov, USA and V. Di Piero, Italy

Date: Wednesday 27 May 2009
Time: 16:55 - 17:05
Room: A2

26.
Ultra-early thrombolysis in acute ischemic stroke linked to better outcome: an observational study from Helsinki centre data in the International Stroke Thrombolysis Registry (SITS-ISTR)
Background Thrombolysis with intravenous administration of alteplase was proven effective in clinical trials of acute ischemic stroke, and pooled analysis of the major placebo-controlled trials indicates benefit from early thrombolysis. We analyzed our Helsinki centre data on stroke thrombolysis obtained from SITS-ISTR registry for a representative single-center assessment of the effect of onset to treatment time (OTT) on outcome. Methods Data on 926 consecutive patients treated at the Helsinki University Central Hospital from 2003 to 2008 were analyzed. In the current analysis, we included all 878 stroke patients who received intravenous alteplase (0.9 mg/kg of body weight) within 4.5 hours from symptom onset,. Using univariate methods and multivariable logistic regression we assessed the association of the time intervals of OTT with a favourable 3-month outcome (modified Rankin scale 0-2). Results Median age was 70.5 years (mean 68, range 16-93), median OTT 115 minutes, and median National Institute of Health Stroke Scale (NIHSS) 9 (mean 10.5, interquartile range 6-15). Of the 878 patients, 257 (28 %) had an OTT of 90 minutes or less. Within this subpopulation, the subjects with severe stroke (uppermost NIHSS quartile) had a better chance of good recovery (OR 5.3, p<.01) and lower mortality (OR 0.63, p=.02). The lowest percentile of OTT (70 minutes or less) had a better overall chance of good recovery (OR 1.9, p=.02). In the multivariable model, better outcome was associated with lower base-line glucose level, younger age, lower NIHSS, and the interaction between NIHSS and OTT. Conclusion Ultra-early thrombolysis is associated with a better outcome after ischemic stroke, especially in patients with severe stroke. Our single center data support the idea that well organized stroke service and strin-gent streamlining of pre- and in-hospital delays to ensure immediate access to thrombolysis in eligible patients improve the stroke outcome.
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L.Soinne, Helsinki University Central Hospital, Helsinki, FINLAND
O.Häppölä   Helsinki University Central Hospital  Helsinki  FINLAND
P.J.Lindsberg  Helsinki University Central Hospital  Helsinki  FINLAND
T.Sairanen  Helsinki University Central Hospital  Helsinki  FINLAND
D.Strbian  Helsinki University Central Hospital  Helsinki  FINLAND
M.Kaste  Helsinki University Central Hospital  Helsinki  FINLAND
         
         
         
         
         
         
         
         
         

Kind of presentation: poster

Epidemiology of stroke  
  
Poster Session Red
Chairs:  

Date: Wednesday 27 May 2009
Time: 12:30 - 14:00
Room:  

32.
The correlation between inflammatory markers and carotid artery stenosis feature obtained by duplex sonography.
Background The main role of internal carotid artery stenosis in the pathogenetic mechanism of ischemic stroke is distal embolisation originating from unstable carotid plaque. Plaque morphology obtained by Carotid Duplex Sonography has been considered to define the plaque at risk for cerebrovascular events. The aim of this study is to find a correlation of several inflammatory markers with symptomatic carotid stenosis and signs of unstable carotid plaques in Carotid Color Coded Duplex Sonography. Material and method We investigated 65 patients (mean age: 66,29 +/- 7,77; 45 men) with internal carotid artery stenosis. 39 patients were symptomatic (26 stroke, 3 RIND, 8 TIA, 2 amaurosis fugax). With Carotid Duplex Sonography we evaluated the degree of stenosis ( we divided it in three categories: <60%, 60-80%, >80%), surface and plaque morphology. Serum levels of WBC, monocyte count, ESR, Fibrinogen and CRP were measured. Results The mean values of all inflammatory markers were higher in symptomatic vs asymptomatic group (WBC: 7,70 vs 6,36 p=0,001769; monocyte count: 0,66 vs 0,52 p=0,025037; OB.: 14,33 vs 14,27, p=0,962565; fibrynogen: 3,57 vs 3,37 g/l, p=0,613218, CRP: 30,77% elevated 19,33% elevated, p=0,22866). Patients with severe stenosis (>80%) or ulcareted plaque surface had the highest values if inflammatory markers,but the results were statistically significant only for WBC. Patients with echolucent carotid plaques had higher mean values of inflammatory markers than patients with echogenic carotid plaques (WBC: 7,77 vs 6,54 ,p=0,010705; monocyte count: 0,67 vs 0,53 , p=0,048132; OB.: 16,45 vs 12,09, p=0,018664; Fibrynogen: 3,60 vs 3,38 g/l, p= 0,206554) Conclusions Inflammatory markers can be usefull in detection of patients with carotid plaques at high risk of destabilization. The degree of inflammatory process in carotid plaque can be measured with standard inflammatory markers. Echolucent carotid plaques are correlated with inflammation in the plaque.
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P.Puz, Medical University of Silesia, Katowice, POLAND
Z.Kazibutowska   Medical University of Silesia  Katowice  POLAND
E.Motta  Medical University of Silesia  Katowice  POLAND
A.Golba  Medical University of Silesia  Katowice  POLAND
A.Bal  Medical University of Silesia  Katowice  POLAND
M.Dębski  Medical University of Silesia  Katowice  POLAND
         
         
         
         
         
         
         
         
         

Kind of presentation: poster

Etiology of Stroke  
  
Poster Session Blue
Chairs:  

Date: Thursday 28 May 2009
Time: 12:30 - 14:00
Room:  

4.
Lp-PLA2 testing usefulness among patients with symptomatic intracranial atherosclerotic disease.
BACKGROUND: Circulating lipoprotein-associated phospholipase A(2) (Lp-PLA2) has emerged as a novel biomarker for cardiovascular diseases. We investigated Lp-PLA2 among first-ever transient ischemic attack (TIA) or stroke patients with intracranial atherosclerotic disease (ICAD); its relationship with clinical onset and severity, response to secondary prevention treatments and risk of further ischemic events. METHODS: Ninety-nine consecutive patients were studied. Blood levels of Lp-PLA2 were measured 3 months after TIA or stroke by means of the PLAC Test on an automated Olympus analyzer (diaDexus). MRI including diffusion-weighted sequences was performed and long-term clinical and transcranial Doppler ultrasonography follow-up conducted. RESULTS: Several non-significant trends indicate that patients of higher risk have higher level of Lp-PLA2 [i.e. those with several brain lesions in the MRI vs those with a single lesion (p=0.2); patients with several TIAs vs those with a single TIA (p=0.2) or those with the stroke preceded by TIA (p=0.2)]. The only risk factor associated with higher Lp-PLA2 was a pathologic ankle-brachial index (p=0.05). Patients with leukoaraiosis tended to have higher level of Lp-PLA2 (p=0.1). Those receiving statins after stroke had lower Lp-PLA2 (p=0.02) and those receiving antiplatelet agents had lower Lp-PLA2 than those receiving anticoagulants (p=0.03). That was especially significant for those taking clopidogrel (p=0.001). During a median follow-up of 20 months, we found no differences in the level of Lp-PLA2 among patients that developed a new cardiovascular event (n=19, p=0.8). CONCLUSION: This preliminary data suggests for the first time that high risk TIA or stroke patients with intracranial stenosis might have higher Lp-PLA2 and that this marker is lower among those patients taking statins and/or clopidogrel. Lp-PLA2 measured three months after the qualifying event was not useful to predict a second stroke in this stroke subtype.
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A.Massot, Neurovascular Research Laboratory, Neurology Department, Vall d'Hebron Hospital., Barcelona, SPAIN
D. Pelegrí   Biochemistry Department, Vall d'Hebron Hospital.  Barcelona  SPAIN
A.Penalba  Neurovascular Research Laboratory, Vall d'Hebron Hospital.  Barcelona  SPAIN
J.Arenillas  Stroke Unit, Valladolid Hospital.  Valladolid  SPAIN
C.Boada  Neurovascular Research Laboratory, Vall d'Hebron Hospital.  Barcelona  SPAIN
D.Giralt  Neurovascular Research Laboratory, Vall d'Hebron Hospital.  Barcelona  SPAIN
M.Ribó  Neurovascular Unit, Neurology Department, Vall d'Hebron Hospital.  Barcelona  SPAIN
C.Molina  Neurovascular Unit, Neurology Department, Vall d'Hebron Hospital.  Barcelona  SPAIN
J.Alvarez-Sabín  Neurovascular Unit, Neurology Department, Vall d'Hebron Hospital.  Barcelona  SPAIN
P.Chacón  Lipids Unit, Biochemistry Department, Vall d'Hebron Hospital.  Barcelona  SPAIN
T.García  Neurovascular Research Laboratory, Vall d'Hebron Hospital.  Barcelona  SPAIN
P.Delgado  Neurovascular Research Laboratory, Vall d'Hebron Hospital.  Bareclona  SPAIN
A.Rosell  Neurovascular Research Laboratory, Vall d'Hebron Hospital.  Barcelona  SPAIN
J.Montaner  Neurovascular Research Laboratory, Neurology Department, Vall d'Hebron Hospital.  Barcelona  SPAIN
         

Kind of presentation: oral

Vascular biology  
  
 
Chairs: G. del Zoppo, USA and H. Markus, United Kingdom

Date: Thursday 28 May 2009
Time: 14:00 - 14:10
Room: A3

1.
Carotid Plaque Inflammation on FDG positron emission tomography (PET) is associated with Cerebral Microembolism in patients with recent TIA or stroke
BACKGROUND: Clinical events distal to carotid stenosis are thought to be related to embolic phenomena secondary to plaque inflammation and subsequent destabilization. Inflammation can be detected non-invasively using FDG PET. We hypothesized that microembolic signals (MES) on TCD will be associated with carotid plaque inflammation on FDG PET in recently symptomatic patients. METHODS: 16 pts presenting with recent (47 +/- 31 days) anterior circulation TIA or minor stroke and 50-99% stenosis of the ipsilateral carotid bifurcation underwent FDG PET, high-resolution ‘black-blood’ neck MRI, brain perfusion MRI and TCD detection of MES. Patients with potential cardiac source of emboli or contralateral MES were excluded. ROIs drawn on the co-registered MRI were used to measure FDG Standardized Uptake Values (SUV, with Rousset’s partial volume correction) from the index and contralateral carotid plaques/artery. At time of assessment all patients were on a single antiplatelet agent and 14/16 on a statin. RESULTS: Ipsilateral MES were detected in 7 pts (MES+ group) and absent in 8 (MES– group). The time interval from symptom onset to PET scanning and % index carotid stenosis were not different between the 2 groups (p>.05). The index-to-contralateral SUV ratio (ICR) was significantly higher in MES+ than MES– patients (Median IQR: 1.05, 0.96-1.32 vs. 0.76, 0.62-0.94, respectively; p=.005), with a significant positive correlation between the rate of MES/hr and the ICR (Kendall’s Tau=0.64, p=.003). The presence of ipsilateral hemodynamic impairment on perfusion MR was not related to the ICR (p=0.8). CONCLUSION: In this sample of recently symptomatic carotid stenosis patients, we found a strong association between in vivo plaque inflammation detected by FDG PET and the presence and frequency of MES on TCD, but not with distal hemodynamic impairment. These findings further strengthen the idea that embolic events distal to carotid stenosis are related to plaque inflammation.
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R.R.Moustafa, University of Cambridge, Cambridge, UNITED KINGDOM
D.Izquierdo-Garcia   University of Cambridge  Cambridge  UNITED KINGDOM
T.D.Fryer  University of Cambridge  Cambridge  UNITED KINGDOM
M.J.Graves  University of Cambridge  Cambridge  UNITED KINGDOM
P.S.Jones  University of Cambridge  Cambridge  UNITED KINGDOM
J.H.Gillard  University of Cambridge  Cambridge  UNITED KINGDOM
P.L.Weissberg  University of Cambridge  Cambridge  UNITED KINGDOM
E.A.Warburton  University of Cambridge  Cambridge  UNITED KINGDOM
J.C.Baron  University of Cambridge  Cambridge  UNITED KINGDOM
         
         
         
         
         
         

Kind of presentation: poster

Risk factors: manifestation, treatment and prognosis  
  
Poster Session Blue
Chairs:  

Date: Thursday 28 May 2009
Time: 12:30 - 14:00
Room:  

43.
Relative risk reduction of haemorrhagic and ischaemic stroke from antihypertensive medication
Background: Secular trends in stroke incidence suggest that age and sex standardised incidence is falling faster in primary intracerebral haemorrhage (PICH) than in acute ischaemic stroke (AIS). There is also evidence that blood pressure in many age groups has been dropping for the last 50 years. We hypothesised that blood pressure may be a more important risk factor for PICH than AIS. This study sought to determine from randomised controlled trials (RCTs) with antihypertensive drugs whether active blood pressure treatment provided better relative risk reduction in PICH compared to AIS. Methods: We examined three RCTs involving antihypertensive medication in primary and secondary prevention (PROGRESS, HOPE and SHEP). Relative risk reductions for PICH and AIS were determined for each study. Results: Relative risk reductions (RRR) in PROGRESS were 50% in PICH and 24% in AIS. In HOPE the ICH RRR was 26% compared to AIS RRR of 36%, while in SHEP the ICH RRR was 47% and the AIS RRR was 36%. Many stroke outcomes were not classified (93 in PROGRESS, 117 in HOPE and 117 in SHEP). Discussion: Outcome stroke data is poorly classified in important large antihypertensive trials. Two out of three RCTs suggest that lowering blood pressure reduces ICH more than AIS, but more data are required. We suggest that RCTs offer a way to determine the relative benefit of blood reduction in AIS and ICH if records of stroke outcome classifications are improved
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M.O.McCarron, Altnagelvin Hospital, Derry, UNITED KINGDOM
F.McVerry   Royal Victoria Hospital  Belfast  UNITED KINGDOM
P.McCarron  Queen's University Belfast  Belfast  UNITED KINGDOM
         
         
         
         
         
         
         
         
         
         
         
         

Kind of presentation: oral

Acute stroke: emergency management, stroke units and complications  
 B
 
Chairs: J. Röther, Germany and D. Toni, Italy

Date: Thursday 28 May 2009
Time: 15:20 - 15:30
Room: A2

15.
STROKE MIMICS IN rtPA-TREATED PATIENTS
Background and Purpose: Rapid recognition of acute stroke is critical for achievement of thrombolysis within therapeutic window and can potentially lead to inappropriately treat stroke mimics. Methods: Consecutive acute stroke patients admitted to a Stroke Unit and treated with IV rtPA according to ESO recommendations are prospectively registered in a stroke database. From all patients treated from June 2003 to December 2008 we retrieved patients who had a final diagnosis other than acute stroke (stroke mimic). Results: Among 240 rtPA-treated patients for presumable stroke, 9 cases of stroke mimics were identified. Stroke mimics were: conversion disorder (7 cases), acute pyelonephritis (1 case) and acute spinal hematoma (1 case). All cases had at least one vascular risk factor, 3 cases had previous psychiatric disease and 6 cases had earlier TIA/stroke. Hospital access through Stroke Green Pathway occurred in 7 cases and time stroke mimic–hospital admission was <90 min in 7 cases. Regarding time of symptoms onset: 0:00-8:00am in 2 cases, 8:00am–12:00pm in 4 cases and 12:00pm-0:00am in 3 cases. Baseline NIHSS score wide-ranged from 4 to 15. Baseline CT scan showed no acute ischaemia in all cases and an old ischaemic lesion in 1 case. Diffusion MRI was performed in 6 cases. Time onset-needle was >120min in all but one case. At 24h 5 patients were better and discharge mRankin was<=1 in 7 cases. Complications related to rtPA were: gastrointestinal hemorrhage (1 case) and epidural hematoma with spinal compression (1 case). No case had cerebral hemorrhage. Only one case had mRankin>3 at follow-up. Discussion: 3,7% of rtPA-treated patients had stroke mimics, a similar value from other series. The initial clinical diagnosis of stroke in this series had exclusively been established by neurologists. The safety of thrombolysis in acute stroke implies ist application by physicians with expertise in stroke, able of an accurate differential diagnosis.
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F.Falcão, Stroke Unit, Neurology Department, Santa Maria Hospital, Lisbon, PORTUGAL
P.Canhão   Stroke Unit, Neurology Department, Santa Maria Hospital  Lisbon  PORTUGAL
T.Melo  Stroke Unit, Neurology Department, Santa Maria Hospital  Lisbon  PORTUGAL
         
         
         
         
         
         
         
         
         
         
         
         

Kind of presentation: poster

Acute stroke: clinical patterns and practice  
  
Poster Session Red
Chairs:  

Date: Wednesday 27 May 2009
Time: 12:30 - 14:00
Room:  

8.
Frequent inappropriate and inaccurate ABCD scoring by non-vascular neurologists for risk stratification following suspected TIA
Background The ABCD score was designed by experienced Vascular Neurologists to help non-stroke specialists identify suspected TIA patients warranting urgent specialist assessment. The accuracy and appropriateness of use of this scoring system by non-stroke specialists are unknown. Methods We retrospectively and prospectively reviewed data on new referrals to the Neurology component of our Rapid Access Stroke Prevention clinic where the referring Physician completed an ABCD scoring proforma. Scoring was deemed ?appropriate? if the Vascular Neurologist subsequently confirmed a diagnosis of possible, probable or definite TIA, and ?inappropriate? if the patient had an alternative diagnosis or stroke. We calculated kappa statistics (κ) to assess inter-observer agreement between the referring doctor and (a) an experienced Vascular Neurologist and (b) 2 Vascular Neurology Residents. Results From July 2006 September 2008, 202 patients with suspected TIA were referred to our clinic. 107 had ABCD data available for analysis. 47 (44%) were deemed ?appropriate?; of the ?inappropriately? scored patients, 42/60 (70%) had another cause for symptoms, and 18/60 (30%) had a stroke. In the entire dataset (N=107), the Neurologist agreed with the referring Physician?s total ABCD score in 42% of cases [κ = 0.28]. The most unreliable individual component of the scoring system was the duration of symptoms, where the Neurologist agreed with the referring Physician in 64% of cases [κ = 0.48]. In a subset of patients who were also prospectively scored by Neurology Residents (N=21), they agreed with the referring Physician?s total ABCD score in only 43% [κ = 0.23]. Amongst the ?appropriate? referrals, the Neurologist agreed with the referring Physician?s total ABCD score in 54% of cases [κ = 0.41]. Discussion ABCD scoring is frequently inappropriate and inaccurate by non-stroke specialists in an Irish population, emphasising the importance of urgent specialist assessment of suspected TIA patients.
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J.A.Kinsella, The Adelaide and Meath Hospital, Dublin, incorporating the National Children’s Hospital, Trinity College Dublin, Ireland, Dublin, IRELAND
W.O.Tobin   The Adelaide and Meath Hospital, Dublin, incorporating the National Children’s Hospital, Trinity College Dublin, Ireland  Dublin  IRELAND
D.J.H.McCabe  The Adelaide and Meath Hospital, Dublin, incorporating the National Children’s Hospital, Trinity College Dublin, Ireland  Dublin  IRELAND
         
         
         
         
         
         
         
         
         
         
         
         

Kind of presentation: poster

Large clinical trials (RCTs)  
  
Poster Session Red
Chairs:  

Date: Wednesday 27 May 2009
Time: 12:30 - 14:00
Room:  

6.
Paramedic perspectives on participation in pre-hospital acute stroke research: a qualitative interview study in a phase III clinical trial of neuroprotective therapy
Background: Pre-hospital stroke research has been identified as a priority area for Emergency Medical Services (EMS). As a medical emergency with significant mortality and morbidity, stroke presents a major challenge to researchers. This study was conducted to determine the perspectives of paramedics about participation in a phase 3 placebo-controlled randomised clinical trial (The Field Administration of Stroke Therapy Magnesium Trial (FAST-MAG)). Methods: Semi-structured interviews with paramedics participating in the Los Angeles based FAST-MAG trial. Purposive sampling of firefighter/paramedics with high (>=4) and low (<4) patient enrolment to the trial. Analysis was conducted using a framework approach. Results: Interviews were conducted with 30 paramedics. For paramedics, the perceived advantages of involvement in research included access to a treatment that would benefit patients and enhanced professional identity. Participants reported that involving paramedics in protocol-led research was feasible. Paramedic confidence in research was limited by lack of research experience, conflicts with institutionally set performance targets (especially time); limitations on autonomous practice; and concerns related to the lack of feedback about patient outcomes. Conclusion: Training to promote evidence-based practice and support for cultural change may be valuable to increase paramedic confidence in research participation. The patient-centred paramedic culture and desire for autonomy should be recognised so that research can be conducted with sensitivity to existing practice.
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D.Burges Watson, Institute of Health and Society, Newcastle University, Newcastle Upon Tyne, UNITED KINGDOM
C.Price   Northumbria Healthcare NHS Foundation   Newcastle Upon Tyne  UNITED KINGDOM
G.Ford  Institute for Ageing and Health  Newcastle upon Tyne  UNITED KINGDOM
J.L.Saver  FAST-MAG Clinical Trial, University of California  Los Angeles  USA
S.Starkman  FAST-MAG Clinical Trial, University of California  Los Angeles  USA
S.Stratton  Los Angeles Emergency Medical Services Agency  Los Angeles  USA
M.Eckstein  University of Southern California and Los Angeles Fire Department  Los Angeles  USA
R.A.Conwit  National Institute of Neurological Disorders and Stroke  Bethesda  USA
R.Sanoff  FAST-MAG Clinical Trial, University of California  Los Angeles  USA
A.Yanes  FAST-MAG Clinical Trial, University of California  Los Angeles  USA
M.J.Murtagh  Institute of Health and Society, Newcastle University  Newcastle Upon Tyne  UNITED KINGDOM