Poster Abstracts

doi:10.1177/2396987316642909

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

HOSPITAL READMISSION FOR BLEEDING OR THROMBOEMBOLISM IN PATIENTS WITH NEW ONSET ATRIAL FIBRILLATION

D Bista ¹, L Chalmers ², G Peterson ³, L Bereznicki ²

Abstract

Background

Limited data are available on rates of, and factors associated with, hospital readmissions due to bleeding or thromboembolism (TE) among patients with atrial fibrillation (AF) in Australia.

Methods

This study was designed to follow patients with AF admitted to the three major hospitals in Tasmania, Australia, between January 2011 and June 2012. Three hundred and sixty-nine patients (≥18 years) were followed for 18 months from the discharge date of their index admission to identify any subsequent readmissions due to bleeding or TE.

Results

The rates of bleeding and TE-related readmissions within 3 months were 7.8 (95% CI 5.1–10.6) and 5.6 (95% CI 3.2–7.9) per 100 patient-years. After 18 months, the rates of bleeding and TE-related readmissions were 2.1 (95% CI 0.6–3.6) and 2.7 (95% CI 1.1–4.4) per 100 patient-years. Patients with peripheral vascular disease (PVD) (odds ratio (OR) 10.1, 95% CI 2.1–48.6) and renal impairment (OR 11.9, 95% CI 2.1–67.8) were more likely to be readmitted for bleeding while those with a history of cerebrovascular disease (CVD) (OR 3.4, 95% CI 1.0–11.3) and myocardial infarction (MI) (OR 9.7, 95% CI 3.1–29.9) were more likely to be readmitted for TE within 18 months.

Conclusions

The rates of bleeding or TE-related readmissions were high in first 3 months in this cohort. Patients with PVD and renal impairment were at higher risk of bleeding and those with CVD and MI were at higher risk of TE during long term follow-up. These patients should be a focus of interventions to reduce adverse events in AF.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ATRIAL FIBRILLATION IN TRANSIENT ISCHEMIC ATTACK - COMMON BUT SUBSTANTIALLY UNDERTREATED

F Buchwald ¹, B Norrving ², J Petersson ²

Abstract

Background

Compared to ischemic stroke (IS), the association of atrial fibrillation (AF) and transient ischemic attack (TIA) is less well established. We aimed to assess the proportion of AF in TIA patients, and these patients’ characteristics and secondary preventive treatment in comparison to IS patients.

Methods

Data on TIA and IS events, registered from July 2011 to June 2013, were obtained from the Swedish TIA and Stroke Registers (Riksstroke). A time based TIA definition (duration of symptoms <24 hours) was applied. AF was registered as present or absent, not specifying if it was previously known or newly diagnosed.

Results

AF was present in 18.6% of TIA and 30.0% of IS patients; patients with AF were older, had higher proportions of stroke risk factors, and were less likely to undergo imaging procedures than patients without AF. The proportion of AF increased with age, reaching 32.9% in TIA patients ≥85 years and 46.6% in corresponding IS patients. In contrast to ischemic stroke, AF was less common in female TIA patients than in men. On discharge 64.2% of TIA patients and 50.0% of IS patients with AF were treated with oral anticoagulants (OAC); proportions of AF patients treated with OAC decreased substantially with increasing age.

Conclusions

AF is a common, age-related, and substantially undertreated risk factor not only for IS but also for TIA. Especially in the elderly and women secondary preventive treatment after TIA is suboptimal.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

STROKE PREVENTION: COMMUNITY BASED 5 DAY SCREENING FOR ATRIAL FIBRILLATION IN HIGH RISK COHORTS

R Coary ¹, R Collins ¹, C Burke ¹, J McCourt ², T Coughlan ¹, R Kelly ³

Abstract

Background

Atrial fibrillation (AF) is detectable in 5% of the population >65 years on opportunistic ECG and is implicated in one third of Irish strokes. AF often goes undetected until the occurrence of a major stroke. AF is often paroxysmal and may not be captured by limited monitoring. AF fulfills the original WHO criteria for a screening programme.

We sought to examine the incidence of new AF in a ‘high risk’ community based population (Risk factors (RFs): hypertension, diabetes and heart failure). Group 1: 60–74 years of age with ≥2 RF; Group 2: ≥75 years of age with ≥1 RF. Patients with a history of AF, TIA or stroke were excluded.

Methods

Participants consented to a multi-functional 5 day monitor (Zensor, Intelesens) with (i) an automatic 6 hourly ECG recording (ii) algorithm programmed to record AF (iii) patient symptom triggered manual record. Two consultant physicians independently reported on the monitor results. AF was defined as >6 consecutive beats on ECG.

Results

AF was detected in 14% (n = 31) of the total cohort (n = 226, 32% female, mean age 74 years, hypertension 94%, diabetes 55%, heart failure 26%). The incidence of paroxysmal AF was 90% (n = 28). 84% (n = 26) of patients were asymptomatic of their AF.

Conclusions

These findings indicate that 5-day screening for AF is feasible in a community setting, detecting new AF in 14% of our cohort, the majority of which was paroxysmal and silent. This suggests that any screening programme should concentrate on high risk cohorts in particular.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CLINICAL PRACTICE WITH APIXABAN IN SECONDARY STROKE PREVENTION

A De Felipe-Mimbrera ¹, R Alvarez-Velasco ¹, C Matute Lozano ¹, R Vera ¹, A Cruz-Culebras ¹, A Alonso-Canovas ¹, S Sainz de la Maza ¹, C Estevez Fraga ¹, P Perez Torre ¹, J Masjuan ¹

Abstract

Background

Apixaban has been approved for stroke prevention in nonvalvular atrial fibrillation. Most data regarding efficacy and safety is driven from clinical trials; information from clinical practice in secondary stroke prevention is lacking.

Methods

We prospectively included patients starting apixaban for secondary stroke prevention at our hospital from September 2013 to June 2015. Clinical, efficacy, and safety variables were registered.

Results

Seventy-two patients were included, 61% female, mean age 79.5 (range 47–96, SD 10), mean follow-up of 4 months (range 1–19). Median CHA₂DS₂-VASc 6 (range 2–8), and HAS-BLED 2 (range 1–6). All suffered ischemic stroke, 50 % previously on warfarin, 9.7% were taking other direct oral anticoagulation (DOAC), and 40.3% anticoagulation naïve. Seven patients (9.7%) had previous history of intracranial hemorrhage (IH) due to warfarin in 3, hypertensive in the remaining. Patients were switched from DOAC due to ischemic events in 2 and systemic hemorrhage in 5. Apixaban 5 mg was prescribed in 77.8%, and 2.5 mg in the remaining. Seven patients (9.7%) suffered events during follow-up. Ischemic events (4), two transient ischemic attacks, and 2 non-disabling ischemic strokes. Hemorrhagic events (3) lead to apixaban discontinuation in all, and were a disabling IH, one lower gastrointestinal bleeding, and one soft tissue hematoma. Five patients died from causes not related to treatment and 2 were lost during follow-up.

Conclusions

Apixaban seems safe and efficacious in secondary stroke prevention. In our cohort most ischemic events were non-disabling. During follow-up there was one disabling IH in a patient with previous history of IH.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PREVALENCE OF AND RISK FACTORS FOR SILENT BRAIN INFARCTS IN PATIENTS WITH ATRIAL FIBRILLATION USING 3T-MRI

I Escudero ¹, R Ocete ², A López-Rueda ³, P Piñero ², E Fajardo ², JR Fernández-Engo ⁴, F Mancha ⁵, Á Vega ⁵, E Zapata ¹, M Prieto ¹, FJ De la Torre ¹, R Rodríguez ², F Moniche ¹, J Montaner ⁶

Abstract

Background

Atrial Fibrillation (AF) is the most common tachyarrhythmia in clinical practice, being non-valvular AF a frequent cause of cardioembolic stroke. We hypothesize that identifying silent brain infarcts (SBI) among those with non-anticoagulated AF would allow to improve stroke prevention. Therefore, we determined the prevalence of and risk factors for SBI using advanced neuroimaging techniques in patients with AF and low or moderate stroke risk according to CHADS2 score.

Methods

Patients with a history of AF who scored 0–1 in the CHADS2 were selected from Seville urban area using the Andalusian electronic healthcare database (DIRAYA). Other inclusion criteria were age older than 50 and absence of neurological symptoms at any time. A 3T brain MRI was performed to all participants.

Results

From May to September 2015,158 patients were included. Mean age was 64.3 years (range 50 to 87) and 59% were men. 99 (62.7%) patients presented hypertension and 10 (6.3%) diabetes mellitus history. 24 (15.2%) patients presented at least 1 SBI. Univariate analysis showed that an older age (70 y SBI group vs 64 y non-SBI group, p = 0.004) and diabetes mellitus (16.6% SBI group vs 4.5% non-SBI group, p = 0.024) were associated with SBI. No associtation was found with sex or hypertension history.

Conclusions

The prevalence of unknown brain infarcts is high among patients with AF and low or moderate stroke risk according to CHADS2 score. Diabetes and age were the most important risk factors associated with SBI in this cohort. Screening that population might have huge therapeutic and preventive consequences.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

SPONTANEOUS SPINAL EPIDURAL HAEMATOMA DURING APIXABAN TREATMENT

C Estevez-Fraga ¹, R Alvarez-Velasco ¹, A De Felipe-Mimbrera ¹, P Aguero-Rabes ¹, E Viedma-Guiard ¹, R Garcia-Latorre ², L Crespo-Araico ¹, V Nedkova ¹, B Escribano-Paredes ¹, A Cruz-Culebras ¹, FJ Gonzalez-Gomez ¹, J Masjuan-Vallejo ¹

Abstract

Background

About 500 cases of spontaneous spinal epidural haematoma (SSEH) have been reported. One of the risk factors associated is treatment with oral anticoagulants. Up to now no cases have been reported in patients treated with apixaban.

Methods

Case report

Results

We present a woman aged 78 whose past history included hypertension, dyslipidemia and non-valvular atrial fibrillation (CHAD₂DS₂-VASc: 4) treated with apixaban 2.5 mg/12 hours since 11 months before admission.

One hour after taking apixaban 2,5 mg she felt intense cervical pain without further symptoms. She went to another hospital’s emergency department where she received symptomatic treatment and was discharged being diagnosed with torticollis. Five hours later she had sudden cervical pain and right hemiparesis without involvement of facial region being transferred to our centre with a suspected diagnosis of stroke.

Upon arrival blood pressure was 120/60 mmHg. Neurologic examination was normal. Blood analysis revealed no alterations (GFR: 66,48 ml/min). Multimodal CT showed cervical hyperdense collection extending from C3 to C6. MRI confirmed SSEH without spinal cord signal alterations. She was hospitalized, anticoagulant treatment was withdrawn and no reversal treatment was given. Neurosurgical intervention was discarded. She was discharged home asymptomatic 4 days later without anticoagulant treatment.

Follow-up MRI performed 2 months later revealed complete resolution of SSEH.

Conclusions

We present the first case of SSEH during treatment with apixaban.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EFFICACY OF A TARGETED ANTICOAGULATION MEDICINE REVIEW CLINIC (AMC) FOR PATIENTS WITH POOR ANTICOAGULATION CONTROL ON WARFARIN

P Guyler ¹, S Shah ¹, M Ramjee ¹, T Dowling ², A Patel ², S Alam ¹, D Sinha ¹, I Grunwald ¹, L Coward ¹

Abstract

Background

UK NICE guidelines CG180 (1.5.12) in 2014 recommend that anticoagulation is reassessed for any patient with poor anticoagulation control (such as time in therapeutic range of <65%).

Previously, these patients were identified by computer from the anticoagulation service with letters generated to the GP for patient review, however, 80% were not switched to a non-vitamin K antagonist (NOAC) putting them at potentially increased risk of stroke.

Methods

The AMC delivered an anticoagulation specialist pharmacist consultation to reach a joint, informed decision regarding the best anticoagulant therapy for the patient. It supplied the first months’ treatment and managed the NOAC switching process from clinic, taking the burden away from primary care. It provided individualised treatment plans and follow up support, improving patient experience and choice whilst delivering further primary care education.

Results

87 patients were reviewed in 6 months, with an average TTR of 54% (lowest = 0%).

65 (74.7%) had their Vitamin-K antagonist (VKA) switched to NOAC, compared to 40% in primary care.

Patient Adherence to service performance standards are shown in Tables 1 & 2, with patient feedback for the service in Table 3.

56% GPs previously continued VKA at medication review which decreased to 27% in the AMC.

Conclusions

The AMC improves treatment and compliance for patients with poor anticoagulation control.

This service would be replicable in any other centralised anticoagulation service with clinical input from medical or appropriate non-medical (nurse/pharmacist) specialists.

The clinic only needs to prevent 2 strokes per year to be cost effective.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

STROKE PREVENTION STRATEGIES IN ATRIAL FIBRILLATION: BRIDGING THE GAP BETWEEN PRIMARY AND SECONDARY CARE

I Induruwa ¹, E Amis ¹, K Khadjooi ¹

Abstract

Background

Atrial fibrillation (AF) is a major cause of stroke and without appropriate preventive measures its burden will increase. We conducted a study to evaluate how primary care can be supported in initiating anticoagulation (OAC).

Methods

All acute medical admissions to Cambridge University Hospital (September 2014 to February 2015) were actively screened for AF by a stroke prevention nurse using notes and ECG (Table 1). A consultant and SpR in stroke medicine reviewed the data and notes of patients with AF as a comorbidity or new diagnosis, but not discharged on OAC. For patients felt to have no contraindications, individualised letters were sent to general practitioners, highlighting their annual stroke-risk and recommending consideration of OAC.

Results

Over 6 months 847 patients with AF were admitted: 671 (79.2%) known AF, 176 (20.8%) new diagnosis. 44% of known AF were not anticoagulated on admission, 78% of those left hospital without OAC. Only 42% of new AF patients were anticoagulated on discharge (Table 2).

Of 301 patients not discharged on anticoagulation, 112 were felt would benefit from OAC after screening, therefore, letters were sent to GPs. 102 (91%) responses were received, resulting in 43 more (38.4%) patients commenced on OAC.

Conclusions

AF is a growing comorbidity in acute admissions (11% of medical admissions based on 5 days/week screening). This is almost twice as high as previous studies by Lip and Zarifis. Hospitalised patients are a high risk group (high CHA₂DS_2–VASc scores), and secondary care can play a valuable role in screening and supporting primary care in anticoagulation decisions.

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Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

STROKE PREVENTION STRATEGIES IN ATRIAL FIBRILLATION: TACKLING THE BARRIERS TO COMMENCING ANTICOAGULATION IN PRIMARY CARE

I Induruwa ¹, E Amis ¹, K Khadjooi ¹

Abstract

Background

Atrial fibrillation (AF) is a major cause of disabling stroke, but anticoagulation rates remain suboptimal. We conducted a study to evaluate how general practitioners (GPs) can be supported in initiating anticoagulation.

Methods

Acute medical admissions to Cambridge University Hospital (September 2014 to February 2015) were actively screened for AF by a stroke prevention nurse, using ECG and notes. A stroke medicine consultant and SpR reviewed medical records of patients not anticoagulated at discharge. Individualised letters were sent to GPs of patients who were felt to be appropriate for anticoagulation, highlighting their annual stroke-risk and recommending consideration of anticoagulation.

Results

Overall 847 medical patients had AF (Table 1). 16% died in hospital and 5% were discharged for palliation.

Of 301 patients who weren’t discharged on anticoagulation, 112 letters were sent to GPs after studying medical notes (patients not reviewed). 102 (91%) responses were received, resulting in 43 more (38.4%) patients being commenced on anticoagulation.

Patient choice, bleeding risk and falls were the main reasons by GPs for not prescribing anticoagulation (Table 2).

Conclusions

Commencing anticoagulation can be challenging and numerous barriers exist which prevents this. Primary care colleagues mostly found our advice useful, as evidenced by the 91% response rate. Further support for GPs is paramount. Joint consultations together with seconday care to inform patients of stroke risk would lead to fully informed decision making. Education of GPs in the following areas can prove useful:

1) Importance of paroxysmal AF

2) Implementing measures to address falls risk and alcohol misuse

3) Regular review and reconsideraiton of anticoagulation

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Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CLINICAL FRAILTY IS A STRONG INDEPENDENT PREDICTOR OF ANTICOAGULATION PRESCRIBING HABITS FOR THE OLDER POPULATION

I Induruwa ¹, NR Evans ², A Aziz ¹, S Reddy ¹, K Khadjooi ³, R Romero-Ortuno ¹

Abstract

Background

Anticoagulation significantly reduces the risk of atrial fibrillation (AF) related stroke but there is a perceived risk of adverse effects in frail patients. Despite this, frailty measurements aren’t explicitly endorsed. Our study investigated the association between the Clinical Frailty Scale (CFS) and community anticoagulant prescribing habits in patients aged ≥75 with AF, admitted to hospital.

Methods

Data was gathered retrospectively on patients under the care of a medical team between 1/1/2014–31/3/2014 at Addenbrooke’s Hospital, Cambridge. Demographics, AF history, CHA₂DS_2-VASC and CFS scores (‘frail’ CFS 5–8, ‘non-frail’ CFS 1–4) were collected. Bivariate comparisons between anticoagulated and non-anticoagulated cohorts were analysed using Mann-Whitney U-test and Z-test of two population proportions. Multivariate analysis based on binary logistic regression included variables found to be significant (p < 0.05) at bivariate analysis. Odds-ratios were calculated for categorical data found to be significant (p < 0.05) in binary logistic regression.

Results

416 patients with known AF were included (Table 1). 215 were not anticoagulated (51.7%) on admission. Non-anticoagulated patients were older (median age 87 (IQR7) vs 83 (IQR6), p < 0.01), frailer (81.4% vs 52.2%, p < 0.01) but had lower CHA₂DS_2-VASC scores (median 4 (IQR2) vs 5 (IQR2), p < 0.01). Multivariate analysis of age, CHA₂DS_2-VASC and CFS showed all remained independently significant (p < 0.01) and that frail patients are less likely to be anticoagulated (OR:0.25 95%CI 0.16–0.39, p < 0.01).

Conclusions

Frailty is an independent predictor for anticoagulation not being prescribed. We propose that clinical frailty is an important unmeasured factor in anticoagulation decisions. The value of explicit frailty measurements in anticoagulation decisions and patient outcomes needs to be determined.

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Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ELEVATION OF NT-proBNP AND D-DIMER AS INDICATION FOR LONG-TERM HEART RHYTHM MONITORING IN PATIENTS WITH EMBOLIC STROKE OF UNDETERMINED SOURCE (ESUS)

P Jansky ¹, O Chudomel ¹, H Magerova ¹, J Paulas-Schwabova ¹, I Sarbochova ¹, M Sramek ¹, V Bulkova ², A Tomek ¹

Abstract

Background

Paroxysmal atrial fibrillation (AF) is an important cause of ESUS, however it is frequently undetected by standard examination procedures. Elevated level of D-dimer is considered a biomarker of prothrombotic state and it is connected with cardioembolic etiology in ischaemic stroke patients. N-terminal prohormone of brain natriuretic peptide (NT-proBNP) is a well-known marker of congestive heart failure. Parallel elevation of D-dimer and NT-proBNP is studied as a biomarker of AF in ischaemic stroke patients. The objective of this study is to assess the relationship of parallel elevation of NT-proBNP and D-dimer with the probability of AF detection in ischaemic stroke patients.

Methods

Retrospective monocentric analysis of consecutive ischaemic stroke patients admitted to comprehensive stroke centre in 5 months period (January to May 2015).

Results

The data of 195 patients (average age 63.3 years, 25–96) were analysed. The use of all monitoring modalities (ECG on admission, bedside ECG monitoring in ICU, telemetry on standard ward, long-term Holter and event loop monitoring) led to AF detection in 32,3% patients. Parallel elevation of NT-proBNP (>450 ng/l) and D-dimer (>250 ng/ml) was detected in 64.0% of AF patients compared to 18.8% of non-AF patients (p < 0,001). Odds ratio of AF detection in patients with parallel elevation of NT-proBNP and D-dimer was 4.084 (95% CI, 2.40–6.95, p < 0.001).

Conclusions

The probability of AF detection in ischaemic stroke patients is 4 times higher in patients with parallel elevation of NT-proBNP and D-dimer. Parallel elevation of NT-proBNP and D-dimer can be considered as a biomarker indicating prolonged ECG monitoring in ESUS patients.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EFFECT OF TYPE OF ATRIAL FIBRILLATION (PAROXYSMAL/PERSISTENT) ON INITIAL NEUROLOGICAL SEVERITY AND 3-MONTH INDEPENDENCE IN PATIENTS WITH ACUTE ISCHEMIC STROKE OR TIA: THE SAMURAI-NVAF STUDY

M Koga ¹, S Yoshimura ², T Kazunori ²

Abstract

Background

The discrimination between paroxysmal and persistent atrial fibrillations (AF) has not been considered to assess stroke outcome. We aimed to assess the differences in initial neurological severity and 3-month independence between patients with paroxysmal vs. persistent AF who had acute ischemic stroke (AIS) or TIA.

Methods

Using data of 1192 nonvalvular AF (NVAF) patients with AIS or TIA who were registered in the SAMURAI-NVAF study (a prospective, multicenter, observational study; Toyoda K, et al. Int J Stroke 2015), we divided patients into those with paroxysmal AF and those with persistent AF. We compared initial NIHSS and 3-month independence (mRS 0–2) between the 2 groups.

Results

Of the 1192 patients, 434 (191 women, 77.3 ± 10.0 y.o.) and 758 (336, 77.9 ± 9.9) were assigned to the paroxysmal AF group and persistent AF group, respectively. Of each group, 81 (18.7%) and 298 (39.3%) had been anticoagulated prior to stroke onset with warfarin or NOAC, respectively (p < 0.001), and 406 (93.6%) and 735 (97.0%) had AIS rather than TIA, respectively (p = 0.006). Initial NIHSS [7 (IQR 2–17.25) vs. 8 (3–19)] was not significantly different between the 2 groups (p = 0.115). However, 3-month independence was more commonly observed in the paroxysmal AF group (65.0%) than in the persistent AF group (55.5%) (p = 0.004). After adjusting for sex, age, prior anticoagulation, initial NIHSS, and ischemic stroke (or TIA), paroxysmal AF was independently associated with 3-month independence (adjusted OR 1.64, 95% CI 1.15–2.33; p = 0.006).

Conclusions

Patients with paroxysmal AF are more likely independent at 3 months following AIS or TIA than those with persistent AF.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

REAL INCIDENCE OF CARDIOGENIC STROKE IN PATIENTS WITH NON-VALVULAR ATRIAL FIBRILLATION BEFORE AND AFTER APPEARANCE OF NEW ORAL ANTICOAGULANTS

S Kuroda ¹, T Mori ¹, T Iwata ¹, Y Tanno ¹, S Kasakura ¹, K Yoshioka ¹

Abstract

Background

Incidence of cardiogenic stroke (CS) may decrease since non-vitamin K antagonist new oral anticoagulants (NOACs) are available.

Purpose

The aim of our retrospective study was to investigate the incidence of CS with non-valvular atrial fibrillation (NVAF) and the ratio of patients with oral anticoagulants (OACs) among them.

Methods

Included in our analysis were CS patients with NVAF who were admitted to our comprehensive stroke center between Jan 2009 and Dec 2014 within 24 hours of stroke onset, because NOAC became available at April in 2011. Patients’ features, use of warfarin (WF) or NOACs and appropriate use of OACs were evaluated. Appropriate use of OACs was defined as WF with INR of 2.0 or more and as correct dosage of NOACs.

Results

Seven hundred twenty one patients were analyzed and 195 patients (pts) (27%) took OACs, i.e. 170 pts. of WF users and 25 pts of NOACs (dabigatran in 10 and rivaroxaban in 15 pts). INR was less than 2.0 at arrival in 154 WF users. In six of 25 NOAC users, dosage was not appropriate. Most of CS pts were OACs naïve (526 pts) and inappropriate users (160 pts). There were 345 CS pts and 70 OACs users from 2009 to 2011, whereas 376 CS and 125 OACs from 2012 to 2014. NOACs users were 3 pts in 2012, 4 in 2013 and 18 in 2014.

Conclusions

Incidence of CS didn’t decrease after NOACs appearance, although OACs users increased since 2012, especially NOACs users in 2014

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

INFLUENCE OF RECENT STROKE ON PERCEPTIONS ABOUT ORAL ANTICOAGULATION THERAPY: RESULTS FROM AN INTERNATIONAL SURVEY

DA Lane ¹, J meyerhoff ², U Rohner ², GYH Lip ³

Abstract

Background

Patient’s perceptions of risk for atrial fibrillation (AF)-related stroke are likely to be influenced by experiencing a stroke. This international prospective study investigated patient perceptions of AF, stroke knowledge, preferences for oral anticoagulation (OAC) treatment decisions, and attributes of OAC affecting treatment choice.

Methods

Cross-sectional survey of 937 AF patients receiving OAC [mean(SD) age 54.3(16.6) years; 37% female] recruited from 5 countries (USA, Canada, Germany, Japan, France)]. 2 groups studied: AF and no stroke (n = 743) vs. AF with recent stroke (<6-months) (n = 194).

Results

Of those with a recent stroke, 77.2 % had slight to severe disability. All AF patients were concerned about stroke, particularly those with recent stroke. Good levels of stroke knowledge were significantly lower in recent stroke patients (9.8% vs. 22.1%). Stroke survivors reported lower adherence to OAC (p < 0.05) and preferred their doctor to choose OAC (p < 0.001). Stroke prevention was the most important factor when choosing OAC, followed by major bleeding risk, independent of a recent stroke.

Conclusions

Recent stroke survivors rate effectiveness for secondary stroke prevention as the most important factor when choosing OAC but have poorer knowledge of stroke than AF patients without recent stroke.

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Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

INFLUENCE OF ATRIAL FIBRILLATION PATIENT&RSQUO;S KNOWLEDGE OF STROKE ON PERCEPTIONS ABOUT ORAL ANTICOAGULATION THERAPY: RESULTS FROM AN INTERNATIONAL SURVEY

DA Lane ¹, J Meyerhoff ², U Rohner ², GYH Lip ¹

Abstract

Background

Patient’s knowledge about stroke is likely to influence treatment preferences in patients with atrial fibrillation (AF). This international prospective study investigated the effect of patient’s stroke knowledge on perceptions of AF, preferences for oral anticoagulation (OAC) treatment decisions, and attributes of OAC affecting treatment choice.

Methods

Cross-sectional survey of 937 AF patients receiving OAC from 5 countries (USA, Canada, Germany, Japan, France). Stroke knowledge was assessed with open-ended questions on aetiology, stroke symptoms and risk factors.

Results

Patients perceived AF as serious, particular those with good stroke knowledge. A good level of stroke knowledge was significantly lower in patients with recent stroke <6 months (9.8% vs. 22.1%). Stroke knowledge did not influence self-reported adherence to OAC. Stroke prevention was the most important factor when choosing OAC in all patients, particularly those with good knowledge, followed by major bleeding risk.

Conclusions

Stroke knowledge in AF patients influences concerns about AF. Effectiveness in stroke prevention is rated as the most important factor when choosing OAC, particularly in patients with good stroke knowledge.

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Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE ASSOCIATION BETWEEN LIPID PROFILES AND HEMORRHAGIC TRANSFORMATION IN CHINESE ACUTE ISCHEMIC STROKE PATIENTS AND IN THE SUBGROUP PATIENTS WITH ATRIAL FIBRILLATION

B Liu ¹, D Wang ¹, M Liu ¹, R Yuan ¹

Abstract

Background

The relationship between lipid profiles and hemorrhagic transformation (HT) in ischemic stroke patients was controversial and the relationship in atrial fibrillation patients was less reported.

Methods

Acute ischemic stroke patients without thrombolytic therapy were consecutively prospectively enrolled from the Chengdu Stroke Registry Database. All the included patients had emergency cranial computed tomography (CT) scan and followed magnetic resonance imaging (MRI) or CT in 2–3 days since admission. HT was detected by the followed CT or MRI after admission. Symptomatic hemorrhagic transformation (sHT) was defined as any clinical neurological deterioration with compatible HT on CT. Lipid profiles, which including total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C) and triglyceride (TG) were recorded on admission. Univariate and multivariable logistic regression analyses were used to identify the association between lipid profiles and any type HT. We identified the association between lipid profiles and spontaneous HT in stroke subgroups with with atrial fibrillation.

Results

Of the 1,643 patients enrolled, 123 (7.5%) developed spontaneous HT. 21 (1.28%) experienced sHT. High HDL-C was associated with increased risk of spontaneous HT in univariate analysis (P = 0.046). Neither statin therapy after stroke onset nor any other lipid profiles was associated with symptomatic HT. Lipid profiles and statin therapy after stroke were also not associated with increased risk of HT in the subgroup with atrial fibrillation.

Conclusions

Neither statin therapy after stroke onset nor any lipid profiles was associated with any type of HT.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

TOTAL CEREBRAL BLOOD FLOW MEASURED BY ULTRASOUND IN PATIENTS WITH CARDIOEMBOLIC STROKE. IS IT A CLINICALLY MEANINGFUL PARAMETER?

J Martí-Fàbregas ¹, S Figueroa ¹, E Martínez-Lizana ¹, I Zubizarreta ¹, D Carrera ¹, A Martínez-Domeño ¹, L Prats-Sánchez ¹, P Camps-Renom ¹, E Jiménez-Xarrié ¹, R Delgado-Mederos ¹

Abstract

Background

Most cardioembolic strokes are attributed to embolism from a cardiac thrombus. Hypoperfusion secondary to a low cardiac output or to other causes may be an alternative or complementary mechanism. We investigated whether a decreased total cerebral blood flow (tCBF) measured by Duplex ultrasound predicts vascular events in patients with cardioembolic stroke.

Methods

We studied patients with cardioembolic stroke. We excluded patients with: extracranial stenosis of ≥50% of any internal carotid or vertebral artery, technical difficulties for tCBF measurement and/or follow-up not possible.

tCBF was measured with ultrasonography. The blood flow in ml/100 g/min was the sum of the blood flow from both carotid and vertebral extracranial arteries, calculated from the time-averaged velocity and the cross-sectional area of the vessel. Patients were followed-up to assess ischemic stroke recurrence, vascular events, mortality, and vascular death. We also recorded demographic data, vascular risk factors, treatment data, echocardiographic variables, and the CHA₂DS₂-VASc-score.

Results

We studied 79 patients (age 77.9 ± 8.4 years, 31 were men). Mean tCBF was 65.5 ± 15.7 ml/100g/min. We found decreased tCBF in patients with Congestive Heart Failure, low ejection fraction and high CHA₂DS₂-VASc-score. Cox regression analysis showed that CHA₂DS₂-VASc-score (p = 0.006) and Ejection Fraction (p = 0.047) were associated with tCBF (r = 0.434). After a mean follow-up of 22 ± 8.5 months, 17 patients died (vascular death = 5), 6 (7.6%) suffered a recurrent stroke and 10 (12.7%) a vascular event. tCBF was not associated with any of these events.

Conclusions

In patients with cardioembolic stroke, tCBF is associated with the CHA₂DS₂-VASc-score and ejection fraction. Relevant clinical events were not predicted by tCBF.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

NATRIURETIC PEPTIDES AND TROPONIN IN THE CHALLENGE FOR THE NEW DIAGNOSIS OF CARDIOEMBOLISM AMONG INITIAL ESUS PATIENTS

J Molina-Seguin ¹, S Cambray ², L Colàs-Campàs ², I Benabdelhak ², J Sanahuja ¹, J Farré ³, C Gonzalez-Mingot ¹, A Quilez ¹, MP Gil-Villar ¹, R Boix ⁴, F Worner ⁵, B Campos ⁵, MI Gil ⁶, R Begue ⁶, J Valls ⁴, F Purroy ¹

Abstract

Background

Natriuretic peptides are increased in cardioembolic strokes. However, few studies asses their diagnostic value in initially undetermined stroke patients (iESUSp) with final etiological diagnosis after exhaustive work-up. We determined their clinical value in iESUSp and compared them in known persistent atrial fibrillation patients (pAF).

Methods

The concentrations of interleukin-6 (IL-6), S100β, neuron-specific enolase (NSE), high-sensitivity C-reactive protein (Hs-CRP), high-sensitivity troponin T (hsTnT), B-type natriuretic peptide (BNP) and N-terminal pro-BNP (NT-proBNP) were quantified in 246 consecutive tissular defined ischemic stroke patients. Measurements were performed within 24 h of symptoms onset and at 7 and 90 days. Clinical characteristics, neuroimaging and echocardiographic data were recorded. Association of biomarkers with AF, new diagnosis of AF (nAF) and pAF was measured calculating the area under the ROC curve (AUC) from a logistic regression model, assessing its significance.

Results

49(19.9%) patients had pAF. Among the 110(44.7%) iESUSp 40(36.4%) patients have nAF. nAF patients were significantly older, with higher volumes of lesion and non-lacunar pattern on diffusion-weighted imaging. NT-proBNP, BNP and hsTnT levels were significantly higher in all times in nAF. However, in comparison with pAF, biomarkers levels were lower with poor AUC (Table 1).

graphic file with name 10.1177_2396987316642909-img8.jpg

Conclusions

Natriuretic peptides and hsTnT were related with nAF among iESUSp, with a better clinical value when determined above basal time, although their sensitivity and specificity were lower than the observed for pAF.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE ROLE OF LOOP RECORDERS IN EMBOLIC STROKE OF UNCERTAIN SOURCE (ESUS)

I Noone ¹, MK Meagher ², C Mc Creery ³, T Cassidy ¹

Abstract

Background

Ischaemic Stroke is among the leading causes of severe disability and death, however, the cause remains unexplained in approximately 20–40% of cases resulting in the classification of ESUS. Atrial fibrillation (AF) is a well recognized cause of ischaemic stroke; the risk of further stroke is reduced by two thirds with anticoagulation(1). Implantable loop recorders (ILRs) allow continuous cardiac monitoring for up to 3 years.

Methods

In selected stroke patients (mRankin 0–3) an ILR device was inserted when no cause for their stroke had been found. This study analyses the differences between those patients who were discovered to have AF during follow-up.

Results

31 ILRs were inserted over an 18 month period. AF (>30 seconds) was detected in 15(48.3%) patients. Of those with AF, the median age was 73yrs (Range 63 – 85) and 66% were female. The mean time to detection of AF was 3 months (range 1 day to 10 months).

Comparing AF v NonAF cohort: Hypertension - 33% v 50%: Ischaemic Heart disease - 40% v 8.3%: Diabetes - 6.6% v 8.3%: Past history of stroke 46% v 66%: Hyperlipidaemia 66% v 83%

Conclusions

In this select group of stroke patients, AF was detected by ILRs in 48.3% resulting in a greater use of anticoagulants. Complication rate was low and ILRs may have a central role in the investigation of ESUS patients. Further studies are needed to determine which patients will derive the most clinical benefit from ILRs as well as the cost effectiveness of this approach.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

COMPLIANCE OF ORAL ANTICOAGULANT THERAPY IN PATIENTS WITH ATRIAL FIBRILLATION-ASSOCIATED STROKES

V Padjen ¹, D Jovanovic ¹, M Ercegovac ¹, I Berisavac ¹, P Stanarcevic ¹, M Stefanovic Budimkic ¹, L Beslac Bumbasirevic ¹

Abstract

Background

The use of oral anticoagulation therapy (OAC) reduces the risk of acute ischemic stroke in patients with atrial fibrillation (AF) by 60%. However, the use of any anticoagulant therapy in prevention of AF-associated strokes is reported to be insufficient as well as inadequate.

Methods

We performed analysis of data on stroke patients with non-valvular AF treated in the Stroke Unit in a 3-year period, as well as of OAC compliance in stroke prevention.

Results

Of 787 patients with an acute ischemic stroke, 131 had AF (16.6%, median age 70, range 62–76 years). In primary stroke prevention, from 80 (61.1%) patients who knew for previous AF, 50 (38.2%) were on previous antiplatelet therapy, 35 (26.7%) were using OAC, while 46 (35.1%) didn’t use any antithrombotic therapy. Median PT INR values for the OAC group was 1.44 (interquartile range 1.27 – 1.98). Only 5 (6.3%) patients had PT INR values within therapeutic range. In secondary stroke prevention, from 82 (62.6%) patients who survived at month-3, 51 (62.2%) used OAC, 27 (32.9%) were using antiplatelets, while 4 (4.9%) patients stopped using prescribed therapy. Median PT INR values for the OAC group was 1.7 (interquartile range 1.15 – 2.33). PT INR values within therapeutic range had only 17 (33%) patients.

Conclusions

It is alarming that, in secondary stroke prevention, only one third of patients were taking OAC properly and had PT INR values within the therapeutic range.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE ROLE OF HOLTER WEARABLE IN ATRIAL FIBRILLATION DETECTION IN CRYPTOGENIC STROKES

J Pagola ¹, F Pascual ², J juega ³, A Bustamante ⁴, M Muchada ³, S Boned ³, N Rodriguez ³, D Rodriguez-Luna ³, M Rubiera ³, M Ribo ³, J Alvarez-Sabin ³, J Montaner ⁴, A Moya ², C Molina ³

Abstract

Background

Detection of atrial fibrillation in cryptogenic strokes (CS) is essential for best treatment prevention. We tested the ability for AF detection of a newly Holter Wearable (CryptoAF) device with early (24 h-72 h) and prolonged (4 weeks) of ECG monitoring in CS patients.

Methods

CryptoAF comprised unselected patients with clinical non-lacunar ischemic stroke. We assessed the comfortability (easy to wear, self disposable and no skin damage) and the rate of good compliance (percentage of patients with >70% of monitoring time expected). To assess the efficacy of AF detection we compared CryptoAF with our best Conventional protocol (CP): 72 h of ECG telemetry + 1 week of ECG external registrator in selected patients (embolic confirmed infarction or left atria (LA) enlargement). Two healthy subjects underwent both protocols and 24 hours Holter simultaneously in order to compare the validity of the techniques.

Results

We included 33 patients in CryptoAF. The comfortability was good in 90% (30/33patients) of cases and the percentage of good compliance was 72% (24/33patients). The rate of AF detection was comparable 24.2% (8/33) CryptoAF Vs. 23.4% (11/47) CP (p = 0.931). There were no differences in age, gender, vascular risk factors and CHA2DS2VASC- score. The concordance between the techniques in healthy subjects was good (k = 1). Seventy five percent of AF detection in Crypto AF occurred in the first week of monitorization.

Conclusions

CryptoAF achieved high rate of AF detection in unselected CS patients with an early and prolonged monitorization.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PREDICTION OF ATRIAL FIBRILLATION DE NOVO IN PATIENTS WITH ACUTE ISCHEMIC STROKE

GJJ Plas ¹, PJAM Brouwers ², M Brusse-Keizer ³, MJAM van Putten ², HM den Hertog ²

Abstract

Background

The detection rate of paroxysmal atrial fibrillation (AF) after stroke is low. This may be improved by limiting monitoring strategies to a selected group of patients. We developed a prediction model to define patients with acute stroke or TIA with an increased risk of new-onset AF, using clinical data available at the emergency room.

Methods

We used clinical data and CT-scan on admission of 2555 consecutive patients with TIA or ischemic stroke admitted to our stroke unit between May 2008 and November 2014. New-onset AF was defined as AF on admission ECG or during 24-hour ECG monitoring. Patients with known AF were excluded. We identified predictors of new-onset AF with multivariable logistic regression analyses. We internally validated the model using bootstrapping. The results were expressed as multivariable Odds Ratio (mOR) and area under the ROC curve (AUC).

Results

New-onset AF was detected in 204 patients (8%). Neglect (mOR 2.3, 95% CI 1.5–3.5), loss of sulcal effacement (mOR 2.6, 95% CI 1.8–3.9), dysphasia (mOR 2.4, 95% CI 1.7–3.3), no history of statin use (mOR 1.9, 95% CI 1.4–2.7), and age per 10 years (mOR 1.9, 95% CI 1.7–2.2) were found as predictors of new-onset AF detected in the first 36 hours after admission. The prediction model had an internally validated AUC of 0.79.

Conclusions

Our internally validated risk-score, based on clinical data available at the emergency room, can be helpful to increase the detection rate of AF de novo in patients with acute ischemic stroke or TIA.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

DEFINITIVE ANTICOAGULATION FOR PATIENTS WITH NON-VALVULAR ATRIAL FIBRILLATION WHO DEVELOPED ACUTE ISCHEMIC STROKE: A MULTICENTER PROSPECTIVE COHORT STUDY

N Saji ^1,², K Kazumi ³, S Kensaku ⁴, T Inoue ², J Uemura ², J Aoki ³, Y Iguchi ⁵

Abstract

Background

The safety and efficacy of non-vitamin K oral anticoagulants (NOACs) compared with warfarin in patients with non-valvular atrial fibrillation (NVAF) who develop acute ischemic stroke or transient ischemic attack (AIS/TIA) remain unclear.

Methods

Between April 2012 and December 2014, we conducted a multicenter prospective cohort study to clarify the differences in safety and efficacy between warfarin users and NOACs users in NVAF patients who developed AIS/TIA. We divided the patients into two such groups and compared the risk of any hemorrhagic or ischemic event within one month after the onset of stroke.

Results

We analyzed 235 patients with AIS/TIA (52.3% male; mean age: 78.4 years; TIA: 8) including 73 who received tissue-plasminogen activator (tPA) therapy on admission. Oral anticoagulants were initiated within 2–4 hospital days, and 49.8% of the patients were administered NOACs. NOAC users had lower all-cause mortality (0% vs. 4.2%, P = 0.06) and lower risk of any ischemic event (6.0% vs. 7.6%, P = 0.797) compared with warfarin users. The prevalence of any hemorrhagic event was equivalent in the two groups (3.4% vs. 3.4%, P = 1.000). Early initiation of NOACs after tPA therapy was suggested to lower the risk of hemorrhagic events compared with warfarin, although the difference between the two groups was not statistically significant (0% vs. 5.6%, P = 0.240).

Conclusions

Early initiation of NOACs is safe and effective, and at least equivalent to warfarin. Furthermore, the use of NOACs after tPA therapy is suggested to have a lower risk of hemorrhagic events compared with warfarin.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

RELEVANT STRUCTURAL HEART ABNORMITIES IN YOUNG ISCHEMIC STROKE PATIENTS: TEE FINDINGS FROM THE HISTORY STUDY

D Sanak ¹, M Hutyra ², M Kral ¹, D Vindis ², T Veverka ¹, T Dornak ¹, J Precek ², D Franc ¹, A Bartkova ¹, D Skoloudik ³, M Taborsky ², P Kanovsky ¹

Abstract

Background

The cause of ischemic stroke (IS) remains often unclear in young patients. Relevant structural heart abnormities with known embolic potential may represent cause of IS also in young population. The use of transoesophageal echocardiography (TEE) allows reliable detection of most relevant structural pathologies. The aim was to assess frequency and spectrum of relevant cardiac abnormities in young IS patients.

Methods

The study set consisted of young acute IS patients <50 years enrolled in the prospective HISTORY (Heart and Ischemic STrOke Relationship studY) study registered on ClinicalTrials.gov (NCT01541163). In all patients, the brain ischemia was confirmed on CT or MRI. Admission ECG, serum specific cardiac markers, TEE with the "bubble" test, 24-hour and 3-week ECG-Holter were performed in all patients.

Results

Out of 980 patients enrolled in the HISTORY study, 143 (73 males, mean age 40.2 ± 8.1 years) were <50 years. In total, the relevant TEE abnormities were present in 49 (34%) of these patients. Patent foramen ovale with evident right-left shunt was detected in 35 (24%) patients and other significant defects of heart septum in 4 (3%) patients. Severe valve defect was present in 3 (2%) patients, cardiomyopathy in 3 (2%) patients and in 3 (2%) patients significant ventricle hypokinesis caused by ischemic coronary disease. Myxoma of left atrium was detected in one patient.

Conclusions

The relevant structural abnormities with embolic potential were detected using TEE in 34% of young IS patients. Ackowledgement: Study was supported by the IGA MH CR grant NT14288–3/2013 and by RVO FNOL 00098892.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

POST-NOAC: OBSERVATIONAL PORTUGUESE STUDY OF ISCHEMIC STROKE IN PATIENTS MEDICATED WITH NON-VITAMIN K ANTAGONIST ORAL ANTICOAGULANTS

J Beato-Coelho ¹, J Pedro Marto ², J Nuno Alves ³, C Marques-Matos ⁴, L Cunha ¹, S Calado ², J Araújo ³, J Diogo Pinho ³, E Azevedo ⁴, M Viana-Baptista ², J Sargento Freitas ¹

Abstract

Background

The non-vitamin K antagonist oral anticoagulants (NOACs) have demonstrated an effective and safe profile, at least not inferior to the vitamin K antagonists (VKAs) in patients with non-valvular atrial fibrillation. Comparing with patients not anticoagulated, preadmission medication with VKAs improves outcome in the setting of acute ischemic stroke (IS). However, the clinical impact of the NOACs in this setting has not yet been established.

Our objectives are to compare the clinical outcome of patients with IS according to the anti-thrombotic therapies prescribed at preadmission– NOACs and VKAs.

Methods

Retrospective cohort study of consecutive patients with IS admitted to 4 tertiary Portuguese hospitals. Functional status at 3 months was assessed by modified Rankin Scale (mRS) and dichotomized into good (0–2) and bad (3–6). We also evaluated haemorrhagic transformation (Ht), symptomatic intracranial haemorrhagic transformation (sICH) and mortality. We performed a logistic regression model for predictors of clinical outcome, adjusting for age, gender, coagulation level and acute recanalization therapy.

Results

359 patients were analysed, mean age 76.8 (9.93) years, 174 (48.5%) males. 256 patients (71.3%) were previously treated with VKAs and 103 (28.7%) with NOACs previous to IS. In multivariable analysis there were no significant differences for mRS at 3 months (OR: 1.254; CI95%: 0.829–1.895; p = 0.284), Ht (OR: 1.077; CI95%: 0.397–2.922; p = 0.884), sICH (OR: 0.975; IC95%: 0.253–3.760; p = 0.971), nor mortality (OR: 1.097; CI95%: 0.575–2.090; p = 0.779).

Conclusions

We found no difference in clinical outcome of IS patients with preadmission treatment with NOACs compared to VKAs.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

A STUDY TO CORRELATE THE CHA2DS2-VASC AND HASBLED SCORES IN PATIENTS WITH ATRIAL FIBRILLATION

A Sivagnanaratnam ¹, WJ Sze ¹, C Hedley ¹, R Singh ¹, J Platt ¹

Abstract

Background

Clinicians use CHA2DS2-VASC and HASBLED scores in the management of Atrial Fibrillation.

Methods

Data including patient demographics, whether or not patient was anticoagulated, recent INR and contraindications to anticoagulation were obtained using electronic patient records, discharge summaries and clinic letters. We calculated the CHA2DS2-VASC and HASBLED score for each patient.

Results

We analysed 127 patients’ data of which 17 were excluded because of incomplete data. The median age was 80(range 35–97). There were 64 males and 46 females.

64 (64/110) patients were anticoagulated with a median CHA2DS2-VASC score of 4(range 1–9) and a median HASBLED score of 2(range 1–6). Among the 24(24/64) who had a HASBLED score of ≥3, 5 had bleeding and 3 had raised INR. Among the other 40(40/64) who had a HASBLED score of <3 only 1 had bleeding.

46(46/110) patients were not anticoagulated with a median CHA2DS2-VASC score of 4(range 0–7) and a median HASBLED score of 2(range 0–4). Among the 12(12/46) who had a HASBLED score of ≥3, anticoagulation was stopped in 2 patients due to bleeding. Anticoagulation was stopped in 1 patient due to bleeding in the other 32 patients who had a HASBLED score of <3.

Conclusions

As expected a significant higher percentage(19% vs 3%) of bleeding occurred with a HASBLED score of ≥3. However all patients who had a HASBLED score of ≥3 also had a median CHA2DS2-VASC score of 5(range3–9). This study not only demonstrates the difficult decision a doctor had to take but also the need for another evidence based risk stratification tool.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

RETROSPECTIVE STUDY OF ANTICOAGULATION PRACTICE FOR ATRIAL FIBRILLATION AT A DISTRICT GENERAL HOSPITAL

WJ sze ¹, C Hedley ¹, A Sivagnanaratnam ¹, J Platt ¹, R Singh ¹

Abstract

Background

Anticoagulation in patients with Atrial Fibrillation (AF) is inadequate in both hospital and community patient populations. We aim to establish the current practice at our hospital.

Methods

We obtained a list of the last 200 hospital admissions with either established or new AF using clinical coding. We collected data using discharge summaries, clinic letters and electronic patient records. Data included patient demographics, date of diagnosis of AF, whether or not patient was anticoagulated, type of anticoagulation, recent INR and contraindications to anticoagulation. We calculated CHA2DS2-VASC and HASBLED scores for each patient.

Results

We analysed 127 patients’ data of which 17 were excluded because of incomplete data. The age ranged from 35 to 97 with a median age of 80. There were 64 males and 46 females. 90 patients were documented to have established AF of which 66% (59) were anticoagulated (76% 45/59 warfarin, 24% 14/59 novel oral anticoagulants (NOAC)). Out of the 31 patients not anticoagulated, 48% (15/31) were appropriate decisions.

20 patients were diagnosed with new AF of which 25% (5) were started on anticoagulation (60% warfarin, 40% NOAC). Of the 15 not anticoagulated, 40% (6/15) were appropriate decisions.

Only 36% of the patients on warfarin had a therapeutic INR during admission.

Conclusions

Despite awareness of thromboembolic risks associated with AF, inappropriate clinical decisions to withhold anticoagulation were made in 18% of patients with established AF. Furthermore, patients with newly diagnosed AF are not being anticoagulated immediately. Warfarin remains the anticoagulant of choice despite NOAC introduction and suboptimal INR in 64% of patients.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

USE OF NON INVASIVE CARDIAC MONITORING FOLLOWING ACUTE ISCHEMIC STROKE- A QUALITY IMPROVEMENT PROJECT AT A TERTIARY STROKE UNIT

P Thomas ¹, A Kishore ¹, D sen ¹, A fitchett ²

Abstract

Background

Paroxysmal Atrial Fibrillation (PAF) is a frequent cause of recurrent strokes and may be difficult to capture at the bedside.

A recent systematic review suggested a higher yield of PAF when monitoring over 24 hours although there is no specific guidance regarding duration, mode of monitoring or time interval following an acute stroke.

This quality improvement project reviewed existing practice and aimed to standardize methods for PAF detection.

Methods

Local Stroke Sentinel National Audit Project (SSNAP) data was used to identify appropriate patients.

We ascertained baseline data, sought opinion from stroke and cardiology consultant staff to form a local consensus policy for PAF detection, and applied tests of change to bring about improvement.

Results

Our initial retrospective audit suggested wide variation in monitoring methods; Consensus across the teams was for the use of five day event recorder (ER).

This led to development of a local protocol with repeat audit (Jan 2015-Jun 2015) suggesting interval times to intervention of about 30 d (range of 0 d-68 d); this was reduced to a median of 3 d (range 0–8 d) in Jul 2015 with acquirement of extra monitors.

New AF was detected in 7.4% (vs 3.5% historically) of monitored patients and all patients were anticoagulated.

Conclusions

In the absence of national guidance, it is necessary to develop local protocols from evidence-based consensus opinion.

Implementing this at our site has resulted in standardised practice with improvement in the use of 5 day ERs, improved PAF detection rates, and higher number of patients receiving the correct secondary preventive treatment.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

SHORT RUNS OF ATRIAL ARRHYTHMIA AND STROKE RISK: A EUROPEAN-WIDE ONLINE SURVEY AMONG STROKE PHYSICIANS AND CARDIOLOGISTS

RT Tran ¹, AJ Rankin ¹, AH Abdul-Rahim ², GYH Lip ³, AC Rankin ⁴, KR Lees ²

Abstract

Background

A recording of ≥30 seconds is required for diagnosis of paroxysmal atrial fibrillation (AF) when using ambulatory ECG monitoring. It is unclear if shorter runs of atrial arrhythmia are relevant with regards to stroke risk and variation of practice exists within Europe. We assessed current management of patients with atrial arrhythmia of <30 seconds duration detected on ambulatory ECG within Europe.

Methods

An online survey was sent to Cardiologists and Stroke Physicians within Europe, via international and national cardiac and stroke societies.

Results

Respondents included 311 clinicians from 32 countries. Regarding diagnosis of AF, 80% of responders would accept a single 12-lead ECG. In contrast, only 36% would accept a single episode lasting <30 seconds on ambulatory monitoring. Stroke physicians were twice as likely as cardiologists to accept <30 s atrial arrhythmia as being diagnostic of AF. There was ‘fair’ agreement between stroke physicians and cardiologists with regards the decision to start oral anticoagulant treatment across 8 hypothetical clinical scenarios (Kappa = 0.38 (95%CI: 0.29–0.47); p = <0.001). Stroke physicians were more likely to advocate anticoagulation for patients in lower risk categories, e.g. odd ratio, OR 1.9 (95%CI: 1.01–3.50) for a patient with CHA2DS2-VASc score of 2. The most common screening method chosen for AF post-stroke was ambulatory ECG monitoring. Whilst 89% of responders favoured implantable loop recording devices, only 50% were currently using them in clinical practice.

Conclusions

Short runs of AF create a clinical dilemma for physicians across Europe. Stroke physicians and cardiologists differ with regards to the diagnosis and management of these patients.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

DABIGATRAN PLASMA LEVELS AND RENAL FUNCTION: DOES GLOMERULAR HYPERFILTRATION ALSO MATTER?

B Volbers ¹, K Macha ¹, B Kallmünzer ¹, N Kurka ¹, L Breuer ¹, J Ringwald ², S Schwab ¹, M Köhrmann ¹

Abstract

Background

Dabigatran was shown to be effective for stroke prevention in patients with non-valvular atrial fibrillation. Decreased renal function is known to increase dabigatran plasma concentrations(DPC) which is suggested to be associated with higher bleeding rates. Recently, some authors also suggested an impact of increased renal function possibly leading to lower DPC levels. However, increased renal function in terms of glomerular hyperfiltration(GH) is scarcely recognized so far and is not addressed in most pivotal trials.

Methods

Patients taking dabigatran as secondary stroke prevention with available trough DPC at steady state and creatinine clearance(CrCl) were identified retrospectively. DPC was determined using the diluted thrombin time(Hemoclot™). Dose-normalized DPC was calculated by dividing DPC by the administered dose. CrCl was determined by measuring creatinine in plasma and 24-hour urine and was defined as increased if the threshold as suggested by the National Kidney Foundation Kidney Disease Outcomes Quality Initiative was exceeded.

Results

32 patients (16 male, 73.2(±9.7)years) were included. Mean trough DPC was 69.6(±51.8)ng/ml (dose-normalized: 0.52(±0.46)ng/ml/mg) and was taken 12.1(±1.4)h after last dabigatran intake. CrCl predicted DPC(R² = 0.18, p = 0.016). 8 patients showed increased CrCl associated with a trend towards a lower DPC(dose-normalized: 0.19(IQR 0.14–0.5)ng/ml/mg vs. 0.47(IQR 0.23–0.74)ng/ml/mg, p = 0.09).

graphic file with name 10.1177_2396987316642909-fig10.jpg

Conclusions

Not only decreased, but also increased renal function seems to have an impact on DPC. Increased renal function should also be addressed in future trials.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ASSOCIATION BETWEEN CEREBRAL LEUKOARAIOSIS AND SYMPTOMATIC HEMORRHAGIC TRANSFORMATION AFTER ACUTE ISCHEMIC STROKE WITH ATRIAL FIBRILLATION OR RHEUMATIC HEART DISEASE

C Wei ¹

Abstract

Background

Leukoaraiosis (LA) is a surrogate of cerebral small vessel disease. Symptomatic hemorrhagic transformation (sHT) is a fearful complication of ischemic stroke, particularly in patients with atrial fibrillation (AF) or rheumatic heart disease (RHD). There is scant information on the association between LA and stroke with AF or RHD.

Methods

We included ischemic stroke patients within 1 month complicated with AF or RHD. HT was identified by a base-line head computed tomography (CT) scan and post-admission magnetic resonance imaging (MRI) or a second CT. Three visual rating scales(the Fazekas scale, the Van Swieten scale (vSS), and ARWMC rating scale) focusing on different lesion regions of LA were applied to assess the LA severity based on MRI. Univariate analysis and multivariable logistic regression were performed to investigate whether the severity of LA was associated with sHT after ischemic stroke with AFor RHD.

Results

Of the 183 patients enrolled, 73(39.9%) developed HT, including 9 cases (12.3 %) of sHT. In univariate analysis, LA rated by vSS score >1 was the highest risk (OR 4.426, 95%CI 1.061–18.457) of sHT in stroke patients with AFor RHD, followed by periventricular LA with Fazekas’ score >1 (OR 4.214, 95%CI 1.107–17.469). Logistic regression analysis confirmed LA with vSS score >1, and periventricular LA were independently associated with sHT after stroke with AF or RHD.

Conclusions

Periventricular LA or LA with vSS score >1 point, reflecting at least moderate LA, may be a significant risk factor for sHT after acute ischemic stroke with AF or RHD.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

SEMI-AUTOMATIC SOFTWARE-BASED DETECTION OF ATRIAL FIBRILLATION IN PATIENTS WITH ACUTE ISCHEMIC STROKE AND TRANSIENT ISCHEMIC ATTACK

T Wienecke ¹, M Nickelsen ¹, A Snoer ¹, AM Ali ¹

Abstract

Background

Paroxysmal Atrial Fibrillation (PAF) is often asymptomatic and increases the risk of ischemic stroke. Detection of PAF is challenging but crucial because a change of treatment decrease the risk of ischemic stroke. Post-stroke investigations recommend at least 24 hours continuous cardiac rhythm monitoring. Extended monitoring detects more PAF, but is limited by costs due to manual analysis. Interpretive software might be a reasonable screening tool. We aimed to validate the performance and utility of Pathfinder SL Software compared to manual analysis.

Methods

We included 135 ischemic stroke patients with no prior history of PAF or AF and did a 7-day continuous ECG-monitoring (Holter). We compared manual analysis with Pathfinder SL software including a systematic control of registered events.

Results

Seventeen (12.6%) patients were diagnosed with PAF (Atrial Fibrillation >30 sec). Pathfinder SL Software including a systematic control of events registered 16 (94.1 %) patients with PAF. Manually we detected 15 (88.2%) patients with PAF and, Pathfinder SL had a negative predictive value of 99% and sensitivity of 94%.

Conclusions

Pathfinder SL Software including a systematic evaluation of events is an acceptable alternative compared to manual analysis in PAF detection following ischemic stroke. It is less time-consuming and therefore a reliable, cheaper alternative compared to manual analysis.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

RISK OF STROKE IN CHRONIC HEART FAILURE PATIENTS WITH PRESERVED EJECTION FRACTION, BUT WITHOUT ATRIAL FIBRILLATION: ANALYSIS OF THE CHARM-PRESERVED AND I-PRESERVE TRIALS

AH Abdul-Rahim ¹, AC Perez ¹, RL MacIsaac ¹, PS Jhund ¹, BL Claggett ², PE Carson ³, M Komajda ⁴, R McKelvie ⁵, MR Zile ⁶, K Swedberg ⁷, S Yusuf ⁵, MA Pfeffer ², SD Solomon ², KR Lees ¹, JJ McMurray ¹

Abstract

Background

The incidence and predictors of stroke in patients with heart failure and preserved ejection fraction (HF-PEF), but without atrial fibrillation (AF), are unknown. We described the incidence of stroke in HF-PEF patients with and without AF and predictors of stroke in those without AF.

Methods

We pooled data from the CHARM-Preserved and I-Preserve trials, with ejection fraction >45%. Using Cox regression, we derived a model for stroke in patients without AF in this cohort and compared its performance with a published model in heart failure patients with reduced ejection fraction (HF-REF) - predictive variables: age, BMI, NYHA class, history of stroke and insulin treated diabetes. The two stroke models were compared and cumulative incidence functions estimated. The risk model was validated in a third HF-PEF trial, TOPCAT.

Results

Of the 6701 patients, 4676 did not have AF. Stroke occurred in 125 (6.2%) with AF and in 171 (3.7%) without AF (rates 1.80 and 1.00 per 100 patient-years, respectively). There was no difference in performance of the stroke model derived in the HF-PEF cohort and the published HF-REF model (C-index 0.71, 95%CI 0.57–0.84 versus 0.73, 0.59–0.85, respectively) as the predictive variables overlapped. The model performed well in the validation cohort (0.86, 0.62–0.99). The rate of stroke in patients in the upper third of risk approximated to that in patients with AF (16.0 and 18.0 per 1000 patient-years, respectively).

Conclusions

A small number of clinical variables can identify a subset of patients with HF-PEF, but without AF, at elevated risk of stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

INCIDENCE OF STROKE IN PATIENTS WITH HEART FAILURE AND REDUCED EJECTION FRACTION: AN ANALYSIS OF OVER 40,000 PATIENTS FROM 11 RANDOMISED CLINICAL TRIALS

AH Abdul-Rahim ¹, L Shen ¹, JJ McMurray ¹, KR Lees ¹

Abstract

Background

The incidence of stroke in patients with heart failure and reduced ejection fraction (HF-REF) may have changed over time, especially with the sequential introduction of disease-modifying and oral anticoagulant therapies. We aimed to investigate the incidence of stroke within the available HF-REF trials spanning a 20 year period, according to atrial fibrillation (AF) status at baseline.

Methods

We pooled 11 randomized clinical trials in HF-REF. We analysed hazard ratios (HR, 95%CI) for stroke in each trial using Cox regression. The risks of stroke were assessed using cumulative incidence function. A Joinpoint regression was used to examine the trend in rates of stroke over time.

Results

Of the 44,122 total patients, 33,398 did not have AF. Stroke occurred in 406 patients (3.8%) with AF and in 968 patients (2.9%) without AF. Patients who experienced stroke were older and often had history of stroke and diabetes. The proportion of patients with AF who were on oral anticoagulant therapy had significantly increased over the two decades. Downward trends in stroke rates were observed across the trials, for patients with and without AF, though were not statistically significant. Compared to patients within the control arm of the earliest trial, the HR of stroke for patients with and without AF, within the treatment arm of the most contemporary trial, were 0.66 (95%CI:0.30–1.50) and 0.78 (0.51–1.19), respectively.

Conclusions

The incidence of stroke may have declined over time in patients with HF-REF enrolled in trials, consistent with a cumulative benefit of evidence-based heart failure and oral anticoagulant therapies.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

INCIDENCE OF STROKE IN PATIENTS WITH HEART FAILURE AND PRESERVED EJECTION FRACTION: A POOLED ANALYSIS OF 7,689 PATIENTS FROM 3 RANDOMISED CLINICAL TRIALS

AH Abdul-Rahim ¹, L Shen ¹, JJ McMurray ¹, KR Lees ¹

Abstract

Background

Little is known about the incidence of stroke in patients with heart failure and preserved ejection fraction (HF-PEF), which may have changed over time. We aimed to evaluate the incidence of stroke within available HF-PEF trials, according to atrial fibrillation (AF) status at baseline.

Methods

We pooled 3 randomised clinical trials in HF-PEF, conducted between 1990–2008, only including patients with ejection fraction >45%. We analysed hazard ratios (HR,95%CI) for stroke in each trial using Cox regression. The risks of stroke were assessed using cumulative incidence function. The trend in rates of stroke over time was evaluated using Jointpoint regression.

Results

Of the 7,689 total patients, 5,664 did not have AF. Stroke occurred in 124 patients (6.1%) with AF and in 202 patients (3.6%) without AF. The proportions of patients with AF who were on oral anticoagulant therapy between the trials were static, averaging at approximately 20%. Although not statistically significant, there were downward trends in stroke rates observed across the three trials, for patients with and without AF, with average rate reduction between consecutive trials of 5.9% and 13.7%, respectively. Compared to patients within the control arm of the earliest trial, the HR of stroke for patients with and without AF, within the treatment arm of the most contemporary trial, were 0.95 (95%CI:0.53–1.76) and 0.52 (0.27–1.00), respectively.

Conclusions

The incidence of stroke may have declined over time in patients with HF-PEF enrolled in trials. The cumulative benefit of evidence-based heart failure treatment may have exerted more stroke reduction effect in patients without AF.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CARDIOVASCULAR COMORBIDITY IN ACUTE POSTERIOR CIRCULATION ISCHEMIC STROKE

K Antonenko ¹, L Sokolova ¹

Abstract

Background

Heart pathology and stroke are the main leading causes of disease burden and the primary causes of death worldwide.

Objective: to analyze correlations between cardiovascular diseases and ischemic stroke in posterior circulation (PC) for more successful primary stroke prevention.

Methods

A complex clinic-neurological examination was carried out in 145 consecutive patients (85 men and 60 women) aged 32 to 85 years in acute period of ischemic PC strokes. Cardiovascular comorbidity covered the arterial hypertension (AH), atrial fibrillation (AF), ventricular extrasystole (VE), ischemic heart disease (IHD), myocardial infarction (MI), angina pectoris (AP), coronary atherosclerosis (CA), heart failure (HF). Statistical methods included ANOVA, correlation analysis and cluster analysis.

Results

There were 19.3% patients with 2 cardiovascular diseases, 26.8% – with 3 hearth diseases, 21.4% – with 4 cardiovascular pathologies. AH occurred most commonly – in 125 (86.2%), patients, followed by IHD – in 52 (35.5%), AF – in 36 (24.8%), HF – in 35 (24.1%), CA – in 23%, AP – in 25 (17.1%), VE – in 24 (16.5%), MI – in 8.3% patients, accordingly. In old patients (≥60 years) in comparison with young patients (≤59 years) we revealed more often IHD (52.1% versus 19.4%, p = 0.068) and AF (42.4% versus 6.9%, p = 0.08). Among cardiovascular risk factors correlations were detected between AF and VE (r = 0.546), AF and AP (r = −0.487), VE and AP (r = −0.392).

Conclusions

Cardiovascular pathology in patients with PC ischemic strokes is nowadays still high. Regular control and treatment of cardiovascular risk factors will help to improve the primary stroke prophylaxis.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CORONARY ARTERY CALCIUM SCORE IMPROVES THE PREDICTION OF OCCULT CORONARY ARTERY STENOSIS IN STROKE/TRANSIENT ISCHEMIC ATTACK PATIENTS

Y Beigneux ¹, JL Sablayrolles ², O Varenne ³, JL Mas ¹, D Calvet ¹

Abstract

Background

Coronary artery calcium score (CACS) has emerged as a robust and non invasive predictor of coronary events. We assessed the additional predictive value of CACS to predict the presence of severe occult coronary artery stenosis in stroke/ transient ischemic attack (TIA) patients.

Methods

We enrolled 300 consecutive patients aged 45–75 years with noncardioembolic ischemic stroke or TIA, and no prior history of coronary artery disease. The presence of coronary artery stenosis was assessed with 64-section computed tomography (CT) coronary angiography and all patients had a detailed cervicocephalic arterial work-up. CACS was determined from CT measurement of the amount of calcium in the walls of the coronary arteries using the Agatson score. The predictive value of CACS was assessed by logistic regression and reclassification table method.

Results

Among the 274 included patients who had CT coronary angiography, 50 patients (18%) had at least one stenosis ≥50%. In multivariable analysis, after adjustment for a validated score (PRECORIS score) including Framingham Risk Score and presence of cervicocephalic stenosis, CACS was strongly associated with the presence of ≥50% occult coronary artery stenosis (OR = 14.8 [1.8–120.3] for CACS (1–100) and 70.9 [8.9–562.0] for CACS > 100). When CACS was added to the standard model, model ﬁt was improved (likelihood ratio = 48.6 [p < 0.0001], AUC was 0.9 [p < 0.0001]), Net Reclassification Improvement was 28.2% [p < 0.001], and Integrated Discrimination Index was 18.2% [p < 0.001].

Conclusions

In stroke/TIA patients, CACS improves the prediction of ≥50% occult coronary stenosis beyond classical risk factors.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

BENEFIT OF PREHOSPITAL 12-LEAD ELECTROCARDIOGRAPHY IN ACUTE STROKE PATIENTS

T Bobinger ¹, B Kallmünzer ¹, M Kopp ¹, N Kurka ¹, M Arnold ², S Schwab ¹, M Köhrmann ¹

Abstract

Background

Electrocardiographic abnormalities are common in acute stroke patients and thus ECG-monitoring in prehospital care is recommended by the American Stroke Association. However, recommendations are mainly based on expert consensus and benefits of recording prehospital ECGs in patients with stroke are largely unknown.

Methods

Consecutive acute stroke patients admitted to our tertiary stroke center via Emergency Medical Service with prehospital 12-lead ECG recording were included into this study. Another baseline 12-lead ECG was recorded on admission to our hospital followed by systematic continuous ECG-monitoring on the Stroke Unit. Prehospital ECG, baseline 12-lead-ECG on admission as well as continuous Stroke Unit ECG-monitoring were assessed for all routine ECG parameters and rhythm abnormalities. Clinical data were retrieved from our prospective institutional database.

Results

Overall 259 patients were included. 2^nd or 3^rd grade AV block was observed in 5.4% of the patients, significant ST-elevation in 5.0% on prehospital ECG. In patients with atrial fibrillation (AF) on prehospital ECG recording, AF was seen in only 86.7% of 12-lead ECG recordings done on hospital admission. In two patients detection of AF was limited to prehospital ECG recording.

Conclusions

Serious electrocardiographic abnormalities are frequently found on prehospital ECG. Therefore, cardiac monitoring is an important part in prehospital stroke care. Moreover, prehospital ECG may be useful to detect paroxysmal episodes in patients with underlying AF.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CARDIAC FUNCTION IN PATIENTS WITH CEREBRAL WHITE MATTER HYPEINTENSITIES

S Elyas ¹, D Adingupu ², K Aizawa ², J Fulford ³, AC Shore ², PE Gates ², WD Strain ²

Abstract

Background

Heart failure has been associated with greater white matter hyperintensities (WMH). We aimed to explore the association of different markers of cardiac function and their interaction with mean arterial pressure (MAP) and age in patients with and without cerebral WMH.

Methods

Participants with/without history of cerebrovascular disease(CVD) were recruited. Baseline demographics, brain and cardiac- MRI were obtained for all participants. WMH volume was calculated using Freesurfer software. Measurements of cardiac function were calculated using semi-automated software and included: Cardiac output, left ventricular ejection fraction (LVEF), stroke volume, LV end systolic volume (ESV), LV end diastolic volume (EDV) and LV wall mass.

Results

73 participants with history of CVD and 39 participants with no history of CVD were recruited (age: 68 ± 9 years; SBP:130 ± 13 mmHg; DBP:74 ± 8 mmHg; 77 males). There was no association between WMH and cardiac output (R²= 0.0001, p = 0.9), LVEF (R²= 0.026, p = 0.10), stroke volume (R²= 0.018, p = 0.18), or LV wall mass (R²= 0, p = 1.0). WMH was associated with LV ESV and EDV volumes (R²= 0.06 and 0.047, p = 0.01 and 0.03, respectively). However, this association was accounted for by age and sex. In a multivariable model that included all cardiac parameters, age, sex and MAP, only age and MAP were associated with WMH (R²= 0.32, p < 0.0001 and p = 0.002 respectively).

Conclusions

We found no association between cerebral WMH and cardiac function parameters. This difference with other studies might be explained by our combined use of robust methods to assess cardiac function and WMH volume. Age and MAP were strongly associated with WMH, which emphasizes the importance of optimal BP control to reduce the progression or development of WMH.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

A WARNING SIGN HERALDS POTENTIAL CRITICAL ISCHAEMIA

P Fiori ¹, A Corbo ¹, L Iorillo ¹, A Monaco ¹

Abstract

Background

Cardiac markers are pivotal in emergencies and monitoring clinical course. The burden may be wider than expected as well as the reversibility of physiological response versus a shift toward pathological dysfunctions. Once ischaemic damage developed, the residual function is dependent on rescued penumbra. The aim of our study was to evaluate the predictive values of Troponin ths (Tro ths) and NT-Pro-Brain Natriuretic Peptide (NT-PBNP) and the correlations with clinical findings.

Methods

So far, we recruited 783 Acute Stroke (AS), 596 Chronic Cerebrovascular Diseases (CCVD) and 207 Other Neurological Diseases (OND) patients. We classified them in subgroups according to the severity of neurological and heart dysfunctions.

Results

The most significant alterations of cardiac markers were detected in class III-C, IV-C/D New York Heart Association (NYHA) / American Cardiology Association (ACA) scales, especially in AS with CCVD, and in unstable CCVD patients. Tro ths and NT-pro-BNP had predictive values. Correlations were found with echocardiographic parameters, mainly concerning NT-pro-BNP. Serial analyses showed no significant intragroup fluctuations in AS and CCVD. In normal ACA / class I NYHA OND patients, NT-PBNP levels were higher in female compared to males at admission, decreased at day 3 in both subgroups, above all in women.

Conclusions

NT-PBNP is a warning sign of atrial overload and myocardial spreading depression, which may stand for physiological preconditioning or evolve toward critical ischaemia, revealed by Tro ths elevation. We highlight features accounting for worst outcomes, restricting therapeutical effectiveness, prolonging hospitalization and predicting bounce backs, which have to be considered before decision making and discharge.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EFFECTS OF STROKE LOCALIZATION ON CARDIAC MONITORING ANOMALIES AND CARDIAC ENZYMES LEVELS IN A SPANISH STROKE UNIT

C García-Cabo Fernández ¹, L Martínez ¹, L Benavente ¹, A García-Rua ¹, S Fernández ¹, P Suárez-Santos ¹, Á Pérez ¹, P Martínez-Camblor ²

Abstract

Background

Stroke has been shown to increase the incidence of cardiac monitorization (CM) anomalies and some brain areas have been strongly associated to this fact. The aim of this study was to demonstrate the differential effects of stroke localization (SL) on CM and cardiac enzyme levels (CEL).

Methods

All patients who were admitted in our Stroke Unit from September to November 2015 were included in the study. Ischaemic stroke (IS) or haemorrhagic stroke (HS) were diagnosed according to neurological examination and Computer Tomography (CT) scan. To confirm SL and size, another CT or Magnetic resonance imaging was performed. Brain affected areas were divided according to Alberta Stroke Programme Early CT Score (ASPECTS) and Posterior Circulation-ASPECTS areas. Continous bedside CM was performed and CEL were analysed in all patients at admission.

Results

One hundred fourteen patients were included. Distribution of patients according to side and type of stroke was as follows: 43 patients (38%) right hemisphere IS,35 left hemispheric IS,9 left HS and 7 right HS. No differences in CM were found between right and left hemispheres or between HS and IS. M1 to M3, M5 and M10 areas from ASPECTS were strongly associated with abnormal MC. Patients with posterior stroke tend to have lower CEL in our sample.

Conclusions

It is known that stroke may produce changes in CM. However, SL may determine different effects. Against previous papers have proposed, in present study no differences were found between hemispheres and it was showed that insular cortex is not the only who may produce MC anomalies.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

RELATIONSHIP BETWEEN CARDIOVASCULAR AUTONOMIC DYSFUNCTION AND TROPONIN PLASMA LEVELS IN PATIENTS WITH ACUTE ISCHAEMIC STROKE

D Georgieva-Hristova ¹, S Andonova-Atanasova ¹, E Kalevska ¹

Abstract

Background

To investigate the correlation between cardiovascular autonomic dysfunction and Troponin plasma levels in patients with acute hemispheric ischaemic stroke.

Methods

This clinical study included 70 participants in total; 20 controls and 50 patients with acute stroke admitted to the Neurology Department at ‘St. Marina’ University Hospital, Varna, Bulgaria. The cardiovascular autonomic function was investigated using the Ewing’s battery of tests. According to the Ewing’s classification, the patients were separated into two groups: group one consisted of patients with mild autonomic dysfunction and group two consisted of patients with severe autonomic dysfunction. The Troponin plasma level was measured with SIEMENS-IMMULITE 2000 System for heterogeneous enzyme linked chemiluminescence immunoanalysis in samples of peripheral venous blood.

Results

The Troponin plasma levels were raised above the upper limit of the norm (0.2–0.32 ng/ml) in 16 % of the patients. In patients with severe autonomic dysfunction, the Troponin levels were approximately three times above the upper limit of the reference range. There was a significant difference between the Troponin plasma levels in patients with mild autonomic dysfunction and those with severe autonomic dysfunction, with the mean Troponin level values being significantly lower in patients with mild autonomic dysfunction (t = −1. 99, p < 0.05)

Conclusions

In patients with severe autonomic dysfunction, the Troponin plasma levels are significantly higher compared to the levels in patients with mild autonomic dysfunction. There is a relationship between the severity of cardiovascular dysfunction and plasma Troponin levels.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

RELATIONSHIP BETWEEN CARDIOVASCULAR AUTONOMIC DYSFUNCTION AND STROKE SEVERITY IN PATIENTS WITH ACUTE ISCHAEMIC STROKE

D Georgieva-Hristova ¹, S Andonova-Atanasova ¹, E Kalevska ¹

Abstract

Background

Stroke is often associated with cardiovascular autonomic dysfunction, which causes secondary heart complications. Our study explores whether stroke severity, as assessed by National Institutes of Health Stroke Scale (NIHSS) scores, correlates with the rate of cardiovascular autonomic dysfunction in patients with acute hemispheric ischaemic stroke.

Methods

This clinical study included 70 participants in total: 20 controls and 50 patients with acute stroke admitted to the Neurology Department at ‘St. Marina’ University Hospital- Varna, Bulgaria. Cardiovascular autonomic function was investigated using the Ewing’s battery of tests. According to the Ewing’s classification, the patients were separated into two groups: group one consisted of patients with mild autonomic dysfunction and group two- patients with severe autonomic dysfunction. Stroke severity was assessed with NIHSS score scale within 24 hours after stroke onset.

Results

In 50 ischaemic stroke patients, NIHSS scores ranged from 2 to 19. The results of regression and correlation analysis showed positive moderate correlation between individual NIHSS score values and the rate of autonomic dysfunction (r = 0,499; p < 0,001). The patients with mild autonomic dysfunction have a lower number of NIHSS points and those with severe autonomic dysfunction have more severe neurological deficit assessed with NIHSS scale.

Conclusions

Cardiovascular autonomic dysfunction is associated with stroke severity. The correlations seen in our patients between NIHSS scores and severity of cardiovascular autonomic dysfunction indicate a higher risk of autonomic complications in patients with more severe strokes.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

TIME LAG BETWEEN NORMALIZATION OF ELECTROCARDIOGRAPHY AND ECHOCARDIOGRAPHY OF TAKOTSUBO CARDIOMYOPATHY DUE TO SUBARACHNOID HEMORRHAGE

K Kadooka ¹, H Hadeishi ¹

Abstract

Background

Takotsubo cardiomyopathy (TCM) is caused by excessive physical and mental stress. Sometimes TCM causes fatal arrhythmia such as Torsades de Pointes(TdP). This study characterized the features of TCM due to subarachnoid hemorrhage(SAH).

Methods

Ten of 450 SAH patients treated in our hospital between January 2007 and November 2015 were noted to have TCM. We retrospectively examined these 10 patients with regard to various factor including electrocardiographic and echocardiographic parameters, duration of abnormal electrocardiographic (Te) and echocardiographic (Tt) parameters.

Results

All 10 patients were female. Mean age at diagnosis was 69.3 years (range, 40–90 years). Mean World Federation of Neurological Surgeons grading scale was 3.70. Electrocardiographic findings were as follows: inverted or flattened T waves (100%), QTc prolongation >0.45 seconds (90.0%), ST segment elevation (60.0%), and ST segment depression (20.0%). Giant diffuse negative T waves with pronounced QTc prolongation are considered to be the risk factors of TdP. Echocardiography showed typical findings of TCM in nine cases and inverted TCM in one case. In one case, a thrombus was noted in the left ventricular apex. In another case, ventral tachycardia was observed. There was a notable time lag between Te and Tt, which persisted for more than 3 weeks in at least 5 cases (50%). If follow-up of electrocardiographic parameters is discontinued at the point of normalization of wall motion, fatal arrhythmia may occur in the aftermath.

Conclusions

This study showed that there was a time lag between Te and Tt. Successive monitoring of electrocardiogram is needed, even after improvement in cardiac wall motion.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE ASSOCIATION BETWEEN COGNITIVE PERFORMANCE DURING SINGLE AND DUAL TASK CONDITION AND CARDIAC AUTONOMIC SYSTEM, AMONG PATIENTS POST STROKE AND AGE MATCHED HEALTHY CONTROLS

N Raphaely-Beer ¹, M Katz Leurer ², NM Bornstein ³

Abstract

Background

Physical exercise may improve cognitive performance by inducing an increment in cortical arousal. In the sub-acute phase post stroke many patients suffer from impaired autonomic regulation with increased sympathetic tone. Therefore, we assumed that stroke patients might not be able to show the normal increment in arousal and cognitive state in conditions of single and dual-task performance.

Methods

Study population: 15 patients in the sub-acute stage post first-ever ischemic stroke, with preserved cognitive capacity, and 15 age-matched healthy controls.

Method: Heart rate was measured continuously during rest, single-task condition (STC) and dual-task condition (DTC), using Serial three discrimination test (STDT), alone and combined with stationary pedals. Each condition was followed by a rest period. Heart rate variability (HRV), frequency and time measures were computed for each condition. Number of correct and mistake answers counted.

Results

Patients post stroke present significantly lower HRV values at rest and during STC. During DTC, normal controls present a significant reduction in HRV parameter and a significant increase in cognitive performance. No such change was noted in the stroke population. Control group answer significant higher number of answers in STDT.

graphic file with name 10.1177_2396987316642909-fig14.jpg

Figure 1: RMSSD (ms) and cognitive score (number) by study group and conditions

Conclusions

Hyper-arousal of the autonomic cardiac nerve system in patients post stroke brings a ceiling effect that prevents them from responding to stimuli

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

NEUROLOGIC COMPLICATIONS IN INFECTIVE ENDOCARDITIS. PREVALENCE AND IMPLICATIONS IN THE FINAL OUTCOME

M Rico ¹, J Fernández Suárez ², L Benavente ¹, P Oliva Nacarino ¹

Abstract

Background

Neurologic complications of infective endocarditis (IE) are common and frequently life threatening. The epidemiology of IE has changed in developed countries over the last decades, because of the increasing prevalence of surgical procedures implicating repair or replacement of the cardiac valves. We aimed to analyze the characteristics as well as the implications of neurological complications in the outcome of IE patients in our Hospital.

Methods

Patients diagnosed with IE in a third level hospital between novemeber 2007 and june 2013 were registered. Epidemiologic, clinical presentation, complications and evolution characteristics were included.

Results

102 patients were diagnosed with IE during the aforementioned time frame, 86 (84%) were men. 64% were native valves. Aortic (45%) and mitral (25%) valves were mainly affected. Staphylococcus (42%) and Streptococcus (25%) were the more frequently found microorganisms. 9% presented cerebrovascular events (all of them in patients with either involvement of the aortic or mitral valves) and 2% encephalopathy without vascular complications. Death was associated (p < 0,01) with heart failure or renal impairment of new appearance and neurological vascular complications, RR = 2, RR = 3.6 and RR = 4.7 respectively. Among the patients with cerebral vascular complications 78% died, 11% were left with sequelae and 11% were asymptomatic at discharge.

Conclusions

Findings were similar to other case series. However, prevalence of IE was higher among men and native valve IE was slightly less frequent. Although incidence of cerebrovascular complications was lower than previous reports the mortality rates were higher. Cerebrovascular complications were a determinant factor for survival, presenting with a higher RR than other risk factors.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PRESENCE AND SEVERITY OF OBSTRUCTIVE CORONARY ARTERY DISEASE AMONG ACUTE ISCHEMIC STROKE PATIENTS WITH ELEVATED CARDIAC TROPONIN UNDERGOING DIAGNOSTIC CORONARY ANGIOGRAPHY

JF Scheitz ¹, HC Mochmann ², GC Petzold ³, HJ Audebert ¹, KG Haeusler ¹, U Laufs ⁴, C Schneider ³, U Landmesser ², N Werner ⁵, B Witzenbichler ⁶, M Endres ¹, CH Nolte ¹

Abstract

Background

The aim of our study was to assess presence and severity of obstructive coronary artery disease (CAD) on coronary angiography in acute ischemic stroke (AIS) patients with elevated cardiac troponin (cTn) compared to patients with Non-ST-elevation acute coronary syndrome (NSTE-ACS).

Methods

Consecutive AIS patients at two tertiary hospitals were prospectively screened for cTn elevation (>50 ng/l, high-sensitivity cTn assay, Roche Elecsys®). Eligible AIS patients (creatinine <1.2 mg/dl, favourable premorbid status;pre-mRS < 4, no ST-segment elevation on ECG) were compared to age- and gender-matched patients with NSTE-ACS. Two cardiologists that were blinded for clinical data evaluated coronary angiograms for presence and severity of obstructive CAD (at least one stenosis >=50%).

Results

AIS patients (n = 29, median age 76, 52% male, median NIHSS 5) underwent coronary angiography within a median of 48 h after hospital admission. CTn on presentation was not different in patients with AIS or NSTE-ACS (95 ng/l versus 94 ng/l, p = 0.55). Compared to NSTE-ACS patients, AIS patients were less likely to have any obstructive CAD (15/29 versus 25/29, p = 0.02) and frequency of multivessel CAD (>=2 diseased vessels) was lower (8/29 versus 18/29, p = 0.01). Older age, ischemic findings on admission ECG (other than ST-elevation), wall motion abnormalities on left ventricular (LV) angiogram and reduced LV function were associated with presence of CAD in patients with AIS.

Conclusions

Frequency and severity of CAD are significantly lower in AIS patients compared to age- and gender-matched patients with NSTE-ACS despite similar baseline cTn levels. Nearly half of AIS patients with elevated cTn have no evidence of CAD. Non-coronary causes should be considered in these patients.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PREVALENCE OF AND FACTORS ASSOCIATED WITH SYSTOLIC DYSFUNCTION IN ISCHEMIC STROKE PATIENTS- THE SICFAIL (STROKE INDUCED CARDIAC FAILURE IN MICE AND MEN) COHORT STUDY

S Wiedmann ¹, D Mackenrodt ², V Rücker ¹, P Kraft ³, C Morbach ⁴, S Störk ⁴, C Kleinschnitz ³, P Heuschmann ⁵

Abstract

Background

Cardiac diseases including systolic dysfunction (SD) are established risk factors for ischemic stroke (IS) and SD itself is associated with a higher morbidity. Reliable data on the frequency of SD in IS are lacking. We investigated prevalence of SD and identified factors associated with it in acute IS patients.

Methods

Data were collected within the ongoing prospective observational hospital-based SICFAIL cohort study assessing the natural course of cardiac function after IS. Patients were assessed for baseline cardiac function including clinical cardiac examination, echocardiography performed by an expert sonographer, and detailed cardiac medical history. SD was defined as left ventricular ejection fraction (LVEF) <=55%. Logistic regression was performed to identify factors associated with SD prevalence.

Results

Between January 2014 and February 2015 the first 264 subjects with complete information on echocardiography were included in the study. 14.4% (95% CI 10.7–19.1%) showed evidence for SD (range LVEF 26–55%). In multivariate analysis, men had a higher probability of SD (OR 3.2, 95% CI 1.3–8.4); pre-stroke diagnosis of myocardial infarction (OR 2.7, 95% CI 0.9–4.4) and more severe stroke (NIHSS > =4) (OR 2.0, 95% CI 0.9–8.0) showed a trend to increase probability of SD. 6.8% of IS patients reported evidence for symptomatic heart failure pre-stroke.

Conclusions

SICFAIL is the first study providing reliable data on the prevalence of SD in subjects with IS and identifying factors associated with its prevalence. The impact of SD regarding longer-term prognosis of IS is currently being studied in an ongoing follow-up.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

REPORTING CT AND MR SCANS OF HEAD BY NEURORADIOLOGISTS IN ACUTE STROKES: AIMING TOO HIGH?

S Andole ¹, S Shah ²

Abstract

Background

Neurologists and Radiologists) ability to recognize and reliably identify changes on CT scans is very variable, they did not reliably identify patients with early infarct signs. This audit was undertaken to see if the head scans for patients admitted to our hyperacute stroke units are all interpreted and reported by neuroradiologists (NR)? If not, how many are not reported by them? Should the guidelines be more pragmatic?

Methods

A list of all patients admitted to the hyperacute stroke unit in a month were obtained from the unit. PACS was checked for all the patients to check how many head scans the patient had, how many were CT scans, how many MRI head and who the reporting doctor was. The date and time of the scans was also recorded.

Results

Out of a total of 127 patients, a NR reported the presentation CT head in 87 (68%). 26 (21%) were reported by a consultant radiologist. 14 (11%)by middle grade doctor. A total of 75 (59%)scans were done out of hours. During working hours 84% scans were reported by a NR, whereas this figure dropped considerably to 58% during non working hours Middle Grades reported 6 and 10 percent during working hour and non working hours. Out of a total 30 patients, who had a repeat CT; 22 (73%) were reported by a neuroradiologist. MRI's were reported by a neuroradiologist in 89%.

Conclusions

Scans can be reliably reported by various grades in acute stage and guidelines should be altered to reflect the actual practice.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

OUTCOME AFTER ENDOVASCULAR MANAGEMENT OF ANTERIOR CIRCULATION ACUTE ISCHEMIC STROKE IN OCTOGENARIANS

M Barral ¹, J Labreuche ², D Smadja ³, H Redjem ¹, S Samdja ¹, G Ciccio ¹, R Blanc ¹, M Piotin ¹

Abstract

Background

Endovascular treatment option for anterior circulation large vessels acute ischemic stroke (AIS) improves functional outcome at three months. However, elderly patients (≥80 years) are a growing and fragile population for whom data are scarce.

The objective of this study was to evaluate the factors associated with a favorable functional outcome after endovascular treatment for anterior circulation AIS in elderly patients.

Methods

All patients aged ≥80 years old with anterior circulation AIS, and a primary functional independence (mRS ≤ 2) referred for endovascular treatment were included. The primary endpoint was functional outcome at 3 months. The secondary endpoint was the angiographic success of endovascular recanalization. Mortality, symptomatic intracranial hemorrhage (SIH). Initial NIHSS, gender, age, AIS and coronaropathy anteriority, glycemia, hypertension, time to thrombolysis, time to groin puncture, successful recanalization, general anesthesia, DWI-ASPECTS, favorable collaterality, 24 h intracranial hemorrhage, location of occlusion and thrombolysis were evaluated as prognostic factors associated with a favorable functional outcome (mRS ≤ 2) using uni- and multivariate analysis.

Results

A total of 143 patients were treated for anterior circulation AIS with a recanalization rate of 80.4%. We found a SIH rate of 7.7% and mortality was 34.9%. At 3 months 23.1% of patients were functionally independent (mRS ≤ 2) and 18.9% had moderate disability (mRS = 3). Age (p = 0.04), DWI-ASPECTS (p = 0.009), NIHSS (p = 0.01), glycemia (p = 0.04) and recanalization (p = 0.0063), were associated with a favorable functional outcome. Age, NIHSS and reperfusion were associated with a favorable outcome in bivariate analysis.

Conclusions

Endovascular management of anterior circulation AIS is effective and safe. Age, NIHSS and reperfusion are significant prognostic factors.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PRELIMINARY RESULTS OF THE TREVO RETRIEVER REGISTRY

B Bartolini ¹, RF Budzik ², J English ³, B Baxter ⁴, R Gupta ⁵, RG Nogueira ⁶, E Veznedaroglu ⁷

Abstract

Background

To assess real world performance of the Trevo retriever in patients experiencing acute ischemic stroke (AIS).

Methods

A total of 1000 patients at a maximum of 75 sites internationally will be enrolled and analyzed in a prospective open-label, consecutive enrollment international registry. The primary end point is the recanalization status at the end of the procedure using modified TICI score. Data regarding key time points of the processes, reperfusion grade, adverse events and 90 days mRS were collected.

Results

As of August 12, 2015 a total of 500 patients were enrolled. The median NIHSS at admission was 16. The majority of patients (65%) were treated under 6 hours from last known normal with a mean procedure time of 62 minutes. The occlusion site was M1 or M2 for the majority of patients (76%). General anesthesia was employed in 53% of procedures. The rate of TICI 2b or 3 was 91% with an average of 1.7 passes with the device. At 24 hours, median NIHSS was 7. At 3 months, 54% of patients presented a mRS ≤ 2 and the overall mortality rate was 18%.

Conclusions

The Trevo Retriever Registry represents the first look at the real world data with stent retriever use in clinical trials showing overwhelming benefit of the stent retrievers to treat AIS. Future subgroup analysis that includes the newly revised AHA/ASA inclusion criteria will provide better insights to identifying areas of improved clinical outcomes with this treatment modality.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE CLINICAL IMPACT OF LEUCOCYTE SUBPOPULATIONS IN HUMAN STROKE THROMBI

T Boeckh-Behrens ¹, J Kleine ¹, C Zimmer ¹, H Poppert ²

Abstract

Background

There is strong evidence for an important role of inflammatory processes in the development of tissue damage caused by acute ischemic stroke. Such processes may have both detrimental and protective effects. Specifically, neutrophils tend to be associated with a worse outcome, whereas higher counts of CD34+ cells seem to be associated with a better clinical course. Aim of this study was to determine, if subpopulations of leucocytes inside the stroke-inducing thrombus tissue are associated with the course of ischemic stroke after mechanical thrombus extraction.

Methods

In 108 consecutive patients with acute anterior circulation stroke treated by mechanical thrombectomy, the retrieved vessel-occluding thrombi were retained and processed for histological analyses containing CD31-, CD34- and neutrophil-elastase-immunostainings. The different cells were quantified and correlated with clinical data, including NIHSS at discharge and mRS after 90 d as outcome parameters.

Results

There was no clear association between neutrophil- as well as CD34+-count and outcome parameters. The amount of CD31+-cells showed no relation to the NIHSS on admission, but a significantly positive correlation with patient improvement until discharge (difference NIHSS, p = 0,02).

Conclusions

The relation between CD31+ cells and patient improvement is in line with recent reports showing immunmodulatory and neuroprotective effects of the CD31-molecule, suggesting CD31 as possible promising neuroprotective agent in stroke patients.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

GENERAL ANESTHESIA EFFECTS ON OUTCOMES WITH MECHANICAL THROMBECTOMY: OBSERVATIONS FROM THE SWIFT PRIME TRIAL

A BONAFE ¹, M Goyal ², R Jahan ³, O Eker ¹, EI Levy ⁴, RG Nogueira ⁵, DR Yavagal ⁶, JL Saver ⁷

Abstract

Background

General anesthesia (GA) may adversely impact patients undergoing thrombectomy for acute ischemic stroke, but studies often have not accounted for confounding by indication (sicker patients needing GA).

Methods

We analysed efficacy and safety outcomes in the multicentre SWIFT PRIME trial in 4 patient groups: 1) received GA for any reason, 2) did not receive GA; 3) treated at hospital with policy of GA for all patients; 4) treated at hospital with policy of conscious sedation preferred, GA only when required. Multivariate models compared outcomes adjusting for 14 variables, including age, sex, NIHSS, ASPECTS, clot location, glucose level, BMI, hypertension, diabetes, hyperlipidemia, atrial fibrillation, myocardial infarction, peripheral artery disease, and smoking status.

Results

Among 97 patients, 35 (36%) received GA, including 29 by hospital policy and 6 due to patient-specific factors. GA patients were more frequently hypertensive, had similar baseline ASPECTS and mean imaging to groin time. In multivariate analysis, efficacy outcomes with non-GA vs GA were: TICI 2b/3 - 89% vs 86%, OR 1.5 (95CI 0.2–9.9); 90 d mRS 0–2- 63% vs 57%, OR 3.6 (95CI 0.9–13.4). For patients at GA-all vs GA-selective hospitals, outcomes were: TICI 2b/3 - 81% vs 91%, OR 4.3 (95CI 0.6–31.0); 90 d mRS 0–2- 48% vs 66%, OR 3.9 (95CI 1.1–14.0). Safety outcomes, including SAH and ICH were similar among groups.

Conclusions

Use of GA did not delay imaging to groin time significantly. Revascularization rates, functional independence at 3 months and safety outcomes were similar among groups. These findings require confirmation in larger, randomized studies.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ANESTHESIA TYPE DURING ENDOVASCULAR ACUTE ISCHEMIC STROKE TREATMENT AND CLINICAL OUTCOMES IN THRACE STUDY

S Bracard ¹, F Guillemin ², X Ducrocq ³

Abstract

Background

A number of studies have suggested that anesthesia type (local anesthesia or conscious sedation versus general anesthesia) during intra-arterial treatment for acute ischemic stroke has implications for patient outcomes, with usually worse outcomes with general anesthesia compared with conscious sedation.

Methods

We evaluated the following outcomes: recanalization rate, good functional outcome (mRS ≤ 2), asymptomatic and symptomatic intracranial hemorrhage, death, vascular complications, time to thrombectomy and procedure time for patients included in THRACE trial. THRACE is a French randomized, multicentre, controlled trial on mechanical thrombectomy for large cerebral arteries acute occlusions

Results

412 patients were included in THRACE trial. Among them, 143 were treated with thrombectomy, 69 under general anesthesia (GA) and 74 under local anesthesia or conscious sedation. Median NIHSS was 19, stroke was due to intracranial ICA occlusion in 14% and M1 occlusion in 86% without any difference between both groups. Time to thrombectomy and duration of thrombectomy were similar. Thrombectomy achieved a good revascularization (mTICI 2 b-3) in 51 patients (77.2%) with GA and 43 (62.3%) with local anesthesia or conscious sedation.

At 3 months the rate of favorable outcome (mRs 0–2) was 52.2% in GA group vs 48.6% in conscious sedation group, not significatively different (OR = 0.87 95%CI: 0.45–1.68). Similarly, there were no significant differences in rates of deaths, intra cranial hemorrhages or adverse events.

Conclusions

In THRACE study, anesthesia type did not interfere significatively with clinical outcomes.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EMBOLI DURING MECHANICAL THROMBECTOMY FOR STROKE WITH STENT RETRIEVERS. SINGLE OPERATOR, SINGLE CENTER EXPERIENCE

G Chater-Cure ¹, P Correira ¹, SH Aghamiri ¹, S Wegener ², G Baltsavias ¹

Abstract

Background

Mechanical thrombectomy using stent retrievers has proved to be efficient forintracranial large vessel occlusion but iatrogenic distal or new territory emboli may occur in 3.7% to 18.9% of cases. Protective devices like proximal balloon occlusion and distal access catheter have been proposed to decrease the incidence of thrombectomy-related emboli (TRE).

Methods

We retrospectively reviewed 87 consecutive cases of stent retriever mechanicalthrombectomy by a single operator without the use of protective devices for anterior circulation large vessel occlusion. We evaluated the frequency, distribution and outcome of cases with TRE. Two groups of patients with and without emboli were compared using univariate analysis and the analyzed variables included age, sex, admission NIHSS, site of occlusion, time from symptom onset to treatment, operation duration, number of passes, recanalization (mTICI score), hemorrhage and outcome (3 month mRS). The data were compared with the literature.

Results

Twelve (13.8%) cases had emboli. The two groups were comparable in terms of allvariables including age and admission NIHSS score. The 3 months mRS was not different between groups. The group with emboli had a significantly greater use of intra-arterial lysis and distal thrombectomy. The incidence of TRE without use of protective device was comparable to the literature of stent retriever thrombectomy with protective devices.

Conclusions

In view of the highly similar characteristics of groups with and without emboliand comparable incidence of emboli in series with use of protection devices, there is still insufficient evidence to recommend using additional protective devices during mechanical thrombectomy with stent retrievers.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE TIME OF ENDOVASCULAR TREATMENT FOR ACUTE ISCHEMIC STROKE

A Ciccone ¹, C Motto ², E Ciceri ³, L Valvassori ⁴, M Nichelatti ⁵, ML De Lodovici ⁶, G Craparo ⁷, A Zini ⁸, S Vallone ⁹, N Checcarelli ¹⁰, M Guidotti ¹¹, G Torgano ¹², M Isalberti ¹³, M Magoni ¹⁴, R Gasparotti ¹⁵, L Malfatto ¹⁶, M Balestrino ¹⁶, L Castellan ¹⁷, M Russo ¹⁸, P Amistà ¹⁹

Abstract

Background

The objective was to assess the impact of time to treatment on outcome in a post-hoc analysis of the SYNTHESIS Expansion trial.

Methods

SYNTHESIS Expansion was a randomized trial, to test whether fast- track endovascular treatment (i.e. intra-arterial thrombolysis with t-PA alone and/or mechanical clot disruption and/or retrieval) increases the proportion of independent survivors (modified Rankin scale 0–1) at three months, compared with standard i.v. t-PA. Patients had to be randomized within 4 h: 30 min from stroke onset and treated as soon as possible. We did a per- treatment post-hoc analysis of the effect of time on outcome in the two groups.

Results

A total of 163 patients were treated with the endovascular approach and 177 with i.v. t-PA. The median time from stroke onset to end of treatment was 4 h: 46 min in the endovascular group (IQR 4 h: 00 min-5h: 30 min) and 3 h: 50 min (IQR 3 h: 20 min-4h: 20 min) in the i.v. t-PA group (P < 0.001). The proportion of endovascular patients with modified Rankin scale 0–1 at three months was related to the duration of treatment (p = 0.04) more than the delay to the start (p = 0.38). The effect of treatment on primary outcome was assessed in patients who started treatment within 3 h or later than 3 h from symptom onset: the corresponding odds ratios, adjusted for the main prognostic variables, were 0.88 (95% CI 0.32–2.40) and 0.79 (95% CI 0.39–1.61) (P = 0.37).

Conclusions

Duration of the procedure is more important than time to treatment; the endovascular procedure should be completed as early as possible in order to maximize the clinical benefit.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

IMPACT OF RECANALIZATION IN PATIENTS WITH PRETREATMENT DWI-ASPECTS ≤ 6 TREATED WITH ENDOVASCULAR THERAPY

JP Desilles ¹, A Consoli ², S Escalard ¹, H Redjem ¹, R Blanc ¹, P Guedin ², O Coskun ², G Ciccio ¹, S Smajda ¹, C Ruiz Guerrero ¹, P Sasannejad ¹, G Rodesch ², M Piotin ¹, B Lapergue ³

Abstract

Background

In acute ischemic stroke (AIS) patients, a diffusion-weighted imaging (DWI) Alberta Stroke Program Early Computed Tomography Score (ASPECTS) is correlated with infarct volume and is an independent factor of functional outcomes. Patients with pretreatment DWI-ASPECTS ≤ 6 were excluded or under represented in the recent randomized EVT trials. Our aim was to assess the impact of recanalization in patients with pretreatment DWI-ASPECTS ≤ 6 treated with EVT.

Methods

We analyzed data collected between January 2012 and August 2015 in 2 prospective clinical registries of AIS patients treated with EVT. Every patient with a documented internal carotid artery or middle cerebral artery occlusion with pretreatment DWI-ASPECTS ≤ 6 was eligible for this study. The primary outcome was a favorable outcome defined by modified Rankin Scale of 0 to 2 at 90 days.

Results

Two hundred twenty five patients were included in this study. Among them, 152 (67%) had a good recanalization (TICI ≥ 2b) at the end of EVT. There was no statistically difference in the baseline clinical characteristics between recanalized and non-recanalized patients. Recanalized patients had an increased rate of favorable outcomes (38,8% vs 16,6%, p = 0,003) and a decreased rate of mortality at 3 months (23% vs 43%, p = 0,007) compared with non-recanalized patients. The symptomatic intracerebral hemorrhagerate was not different in the 2 groups (8,6% vs 11,8%, p = 0,51).

Conclusions

Patients with a pretreatment DWI-ASPECTS ≤ 6 may still benefit of EVT when a good recanalization is achieved. In particular, EVT-induced recanalization was associated with a reduced rate of mortality without increased risk of symptomatic intracerebral hemorrhage.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

SONOTHROMBOLYSIS POTENTIATED BY MICROBUBBLES IN ACUTE ISCHEMIC STROKE: A PROSPECTIVE RANDOMIZED PILOT STUDY

L Dinia ¹, L Prats-Sánchez ², D Carrera ³, R Delgado-Mederos ², R Marín-Bueno ², P Camps-Renom ², J Martí-Fàbregas ²

Abstract

Background

Sonothombolysis (ST) increases recanalization rates in acute ischemic stroke patients. Adding common diagnostic microbubbles (MB) induces further enhancement of sonothrombolysis, leading to a more complete and faster arterial recanalization in non-randomized studies. This pilot randomized study aimed to investigate the safety and efficacy of the combined treatment (ST + MB + rtPA) compared with standard systemic thrombolysis.

Methods

Double blind, prospective, randomized, phase II trial (www.clinicaltrials.gov, NCT01678495). Acute ischemic stroke patients with documented arterial occlusion of anterior circulation and treatable within 4,5 hours, were randomized to one of two arms: combined treatment with sulphur hexafluoride-filled MB, transcranial Doppler (TCD) and systemic rtPA (MB group) compared to systemic rtPA alone with brief TCD vessel diagnostic assessments (control group). Study endpoints: recanalization rate (according to the TIBI grading system), hemorrhagic transformation rate, clinical improvement (NIHSS at 6–24 h) and mortality (24 h and 3 months), 3 months clinical outcome (Rankin scale score 0–2).

Results

A total of 24 patients were randomized (MB 11, controls 13). Complete recanalization rates (MB 54,5% vs controls 46,2%), were similar in both groups. No differences were found in terms of clinical improvement at 24 hours (MB 9% vs controls 9%) and 90 days (MB 27,3% vs controls30,8%) nor in terms of symptomatic (MB 0% vs controls 7,7%) and asymptomatic (MB 27,3% vs controls 38,5%) intracranial bleeding. There were 2 deaths in each group, none related to the treatment under investigation.

Conclusions

Sonothrombolysis potentiated by microbubbles is safe in our small pilot study. Efficacy on recanalization rates and outcomes needs to be confirmed in larger randomized series.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

INFLUENCE OF DEVICE CHOICE ON EFFECT OF INTRA-ARTERIAL TREATMENT FOR ACUTE ISCHEMIC STROKE IN MR CLEAN

D Dippel ¹, OA Berkhemer ², P Fransen ¹, LA Van den Berg ³, D Beumer ⁴, A Van der Lugt ⁵, YB Roos ³, H lingsma ⁶, R Van Oostenbrugge ⁴, W van Zwam ⁷, CBLM Majoie ²

Abstract

Background

Intra-arterial treatment by means of retrievable stents has been proven safe and effective. Whether treatment effect is similar for all types of stent is a matter of ongoing debate. The aim of this study is to explore differences in functional outcome, neurological recovery and adverse events according to stent type and brand, within the MR CLEAN trial.

Methods

The primary outcome was functional outcome at 90 days, assessed with the modified Rankin Scale (mRS). Secondary outcome measures included NIHSS at one week, Barthel Index at 3 months, occlusion on CTA and mTICI score. Safety outcomes included death, any symptomatic intracerebral hemorrhage and periprocedural events. Treatment effects were adjusted for patient age, stroke severity, and collateral score. We examined treatment effect modification by center type (academic or not) and use of general anesthesia.

Results

Of the 500 patients included in the trial, 233 were allocated to intervention. Of these, 124 (53%) were first treated with the TREVO device (adjusted common Odds Ratio (acOR) for shift on the mRS: 1.98 (95% CI: 1.30–2.92), 31 (13%) with the Solitaire device (acOR 1.90 (95% CI: 0.97 to 3.73), 40 (17%) with other retrievable stents or mechanical devices and 38 (16.3%) not. There was no interaction between device and treatment effect on functional outcome, mTICI score, persistence of occlusion on CTA, infarct volume and other secondary and safety outcomes.

Conclusions

In the MR CLEAN trial, we found no evidence for a differential treatment effect by stent type or brand.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

MECHANIC THROMBECTOMY IN ANTICOAGULATED PATIENTS, EXPERIENCE OF 58 CASES IN A HOSPITAL

E García Molina ¹, E Carreón Guarnizo ¹, C Sánchez-Vizcaíno Buendía ¹, J Díaz Pérez ¹, G Valero López ¹, AE Baidez Guerrero ¹, J Zamarro Parra ², M Espinosa De Rueda ², F Marin Ortuño ³, MD Antonio ², AM Morales Ortiz ¹

Abstract

Background

The objetive is to analyze the anticoagulated patients undergoing mechanical thrombectomy and compare them with not anticoagulated patients with the same procedure.

Methods

We performed a descriptive cross-sectional study of 58 anticoagulated patients undergoing thrombectomy gathered in our data base of 405 thrombectomy, analyzing demographic and clinical characteristics and outcomes , and verifying whether there were any differences with the not anticoagulated group.

Results

From the 58 patients analyzed, 4 were treated with heparin, 5 DOACs and 49 acenocoumarol, of which 22 had an INR > 1.7, being the average 1.65 (SD 0.39). The median age was 71.5 years, 36 (62.1%) were women, 47 (81%) had atrial fibrillation, 44(76%) hypertension, and 18 (31%) Diabetes, the main artery affected was the middle cerebral in 30 (56%), and intravenous thrombolysis was performed in 5 (8.6%). In terms of outcomes: achieved recanalization in 94.2%, 24 h CT scan showed bleeding in 12 (20.7%); at 90 days, 16 patient (32,7%), had a modified Rankin scale (mRS) score of 0 to 2, and the mortality were 32.7%.

Compared to not anticoagulated patients we observed significant differences as follow: mostly women, more frequency of atrial fibrillation and mostly cardioembolic strokes in anticoagulated, although intravenous thrombolysis was most frequent in not anticoagulated. Nevertheless, we didn´t find any differences in recanalization, hemorrhage (21.1% anticoagulated vs 19.2% not anticoagulated; P 0.93), mRS score at 90 days, or mortality.

Conclusions

The anticoagulated patients undergoing thrombectomy, presented distinct clinical variables, but in outcomes we did not observe differences in hemorrhage or prognosis compared with non-anticoagulated.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

MECHANICAL THROMBECTOMY IN THE MANAGEMENT OF ACUTE ISCHEMIC STROKE: PATIENT OUTCOME FOLLOWING THE OBLIGATIONAL TRANSPORT TO ANOTHER FACILITY

Z Goldenberg ¹, P Siarnik ¹, I Vulev ²

Abstract

Background

Mechanical thrombectomy on top of or without intravenous thrombolysis has been considered a first-line treatment of acute ischemic stroke due to acute occlusion of extra- and intracranial vessels.

Methods

We performed a retrospective analysis of door-to-needle time and outcome of patient with acute ischemic stroke, admittted to the 1st Department of Neurology, University Hospital Bratislava who were, after confirmation of large vessel occlusion and meeting the criteria, referred to the Department of diagnostic and interventional radiology of the National Institute of Cardiovascular Diseases. This required an obligational transportation by ambulance.

Results

Till December 31, 2015 this interventional procedure was performed in 15 patients. Intravenous thrombolysis prior to procedure was initiated in 13 patients. TICI 0 was achieved in 14 patients. Favourable outcome (mRS 1–2) after 24 hours, 7 days and 90 days was observed in all but 2 patients. Obligational transportation affected the door-to-needle time, however had no unfavorable effect on the patient outcome.

Conclusions

Mechanical thrombectomy on top of or without intravenous thromobolysis achieved favourable outcome in a vast majority of acute stroke patients meeting the indication criteria. Obligational transportation to a different facility had no deletrious effect on the patient outcome.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PRE-HOSPITAL NIHSS SCORE, ONSET TO GROIN AND DOOR TO GROIN PUNCTURE TIMES IN MOBILE STROKE UNIT PATIENTS GOING TO THROMBECTOMY: YEAR 1 DATA

J Grotta ¹

Abstract

Background

Mobile Stroke Unit (MSU) management may facilitate identification of thrombectomy (IAT) candidates and reduce onset to groin (OTG) and door to groin (DTG) times.

Methods

Patients treated with tPA on the MSU who went to IAT. NIHSS with sensitivity and specificity for IAT treatment. OTG and DTG puncture times.

Results

Eighteen of 75 (24%) tPA patients on the MSU went to IAT. NIHSSs in IAT patients ranged 5–26. NIHSS cutoff >16 had optimal sensitivity and specificity (.72 and .81) but missed 5 of 18 candidates. Other cutoffs/sensitivity/specificity: >9/.83/.58 and >4/1.0/.10 (Figure 1). In 12 patients at one CSC, OTG was 175 min (faster than any of the positive trials); DTG ranged 66–240 min; when the patient went direct to CTA, DTG were 66 and 80 min. Over the year, IAT frequency increased and DTG decreased (Figure 2). To detect a 30 minute reduction vs standard management, 46 patients will be needed per group.

graphic file with name 10.1177_2396987316642909-fig17.jpg

graphic file with name 10.1177_2396987316642909-fig18.jpg

Conclusions

Prehospital NIHSS is imprecise in identifying IAT candidates; cutoff >9 will identify 83% of cases. MSU management reduces OTG, but further study is needed on shortening DTG.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EFFECT OF INTRAVENOUS THROMBOLYSIS IN STROKE PATIENTS TREATED WITH BRIDGING THERAPY

S Jung ¹, L Mueller ², P Frauke ³, S Gerhard ², M Pasquale ³, H Mirjam ², F Urs ², M marie-luise ², B monika ², A Marcel ², M Heinrich ², G Jan ³, EK Marwan ³

Abstract

Background

The additional effect of IVT in bridging concept remains questionable. The aim was to determine the recanalization rate and thrombus dislocation rate before endovascular treatment (EVT) in patients treated within the bridging concept.

Methods

We reviewed our single center database and identified all patients in whom bridging therapy was intended since 2008. Thrombus dislocation and aggravation and reperfusion between initial and control imaging were scored retrospectively. Relevant recanalization was defined as TICI 2b/3 or partial recanalization plus distinct symptom improvement.

Results

319 patients were included. Relevant recanalization occurred in 9.1% and thrombus dislocation in 8.8% of the patients before EVT. Recanalization rates were significantly higher in distal compared to proximal occlusions (occlusion of internal carotid artery: 5.4%, middle cerebral artery M1: 8.1%, M2: 17.6%, basilar artery: 13.6%) and in patients treated with the drip-and-ship paradigm compared to those treated with the mother-ship paradigm. In multivariable regression analysis only the occlusion location was an independent predictor of relevant recanalization before EVT (p = 0.046).

Conclusions

Recanalization in bridging therapy prior to EVT is highly dependent upon the occlusion location and treatment paradigm. We had to treat 19 patients with ICA occlusions and 12 patients with M1 occlusions with bridging therapy for one relevant recanalization before EVT in contrast to only 6 patients with M2 occlusions and 7 patients with BA occlusions. The results of our study suggest that future randomized controlled trials may consider the treatment paradigm, occlusion location and thrombus dislocation to specify patients that benefit most from bridging therapy in comparison to EVT alone.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

REPEATED INTRAVENOUS THROMBOLYSIS IN PATIENTS WITH EARLY RECURRENT ISCHEMIC STROKE

T Kahles ¹, ML Mono ², MR Heldner ², RW Baumgartner ³, H Sarikaya ², A Luft ⁴, S Bohlhalter ⁵, C Traenka ⁶, ST Engelter ⁶, N Kurka ⁷, M Köhrmann ⁷, S Curtze ⁸, T Tatlisumak ⁸, P Michel ⁹, K Nedeltchev ¹

Abstract

Background

Intravenous thrombolysis (IVT) given within 4.5 hours from symptom onset is effective and safe in patients with acute ischemic stroke. Its use in patients with prior infarct within the preceding 3 months is contraindicated due to an assumed higher risk of intracerebral hemorrhage (ICH). In addition, apart from the beneficial thrombolytic effects, tissue plasminogen activator itself is capable of aggravating ischemic damage by promoting neurotoxicity and blood-brain barrier disruption. However, as patients with early (<3 months) recurrent stroke (ERS) have largely been excluded from thrombolysis randomized controlled trials (RCT), effectiveness and safety of repeated IVT is essentially unknown in these patients. We here report the largest case-series of repeated IVT in ERS.

Methods

We retrospectively searched the databases of eight European stroke centers for patients with ERS, who received IVT for both strokes. Demographics, clinical and radiological data, bleeding complications and functional outcome were analyzed.

Results

We identified 19 ERS patients receiving repeated IVT. Mean age was 68 ± 12 years and 37% were female. Mean inter-thrombolysis interval was 33 days (range: 2–82). Functional independence (mRS ≤ 2) was achieved in 79% of patients after the first and in 47% after the repeated IVT, respectively. There was no symptomatic ICH.

Conclusions

Our data challenges the current acute treatment paradigms and strongly encourages reconsideration of the IVT exclusion criterion “prior stroke within 3 months”. As RCTs for these rare cases are not likely, larger registries might serve to identify selection criteria for the safe use of repeated IVT in ERS.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

TRANSBRACHIAL ENDOVASCULAR CLOT REMOVAL THERAPY USING BALLOON GUIDE CATHETER FOR ACUTE ISCHEMIC STROKE

S Kasakura ¹, T Mori ¹, T Iwata ¹, Y Tanno ¹, K Yoshioka ¹

Abstract

Background

Since the acute recanalization endovascular therapy with the stent retriever spread, the balloon guide catheter (BGC) has been widely used. The transfemoral approach is a common technique in the acute clot removal therapy using the BGC. When aortic or peripheral arterial conditions limit the transfemoral approach, the transbrachial approach can be an option. The BGC of 9 Fr outside diameter can be safely inserted into the brachial artery by direct insertion without a sheath.

Methods

We retrospectively analyzed patients who underwent the acute clot removal therapy using the BGC via the brachial artery. Patient characteristics, procedure time, TICI grade, distal emboli and periprocedual complication were evaluated.

Results

We have tried to navigate the BGCs via the brachial artery in 14 cases of acute ischemic stroke and succeeded in 10 cases. The BGCs were successfully positioned at the right common carotid artery (CCA) in 6 cases and at the left CCA in 4 cases. The median time from puncture to the BGC balloon dilatation was 21 minutes (interquartile range: 12–28). Recanalization of TICI 2b or 3 was achieved in 8 of 10 cases. No distal emboli or periprocedural complication occurred.

Conclusions

The transbrachial navigation of the BGC without a sheath may be an option for the clot removal therapy in acute ischemic stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PRELIMINARY RESULTS FROM THE RACER STUDY: A MULTICENTER CLINICAL EXPERIENCE WITH THE ACE64 ASPIRATION CATHETER AS FRONT-LINE THERAPY IN ACUTE STROKE

A Kowoll ¹, A Moreno ², J Weber ³, C Loehr ⁴, G Gal ⁵, H Korner ⁶, A Berlis ⁷, W Weber ¹, T Lo ⁸, JR Masso ⁹, S Peschillo ¹⁰

Abstract

Background

With a narrow treatment window required for good outcome, large vessel occlusions (LVOs) in acute stroke pose serious challenges. The Penumbra ACE64, a large bore aspiration catheter, was designed as a novel tool to rapidly restore flow by A Direct first Pass Aspiration Technique (ADAPT), enabling decreased procedural times leading to good outcome. This study aims to assess safety and effectiveness of the ACE64 as front-line therapy.

Methods

The RACER study retrospectively collected data in 125 patients from 9 centers treated with ACE64 with ADAPT as front-line therapy, December 2014 to May 2015. Eligible patients must present with a mTICI 0–1 score and be treated with ACE64 within 6 hours following stroke onset. Effectiveness was defined by a core-laboratory adjudicated mTICI 2b/3 score, while complication rates determined safety.

Results

Patients presented with a median age of 73 years and a median NIHSS of 14.5. Prior to thrombectomy, thrombolytic therapy was administered in 66.4%. Post procedure, 84.0% of patients were revascularized to mTICI 2b/3. Median time from arterial puncture to reperfusion was 34 minutes with a median of 2 passes [IQR 1–2]. To remove persistent occlusion, a stent retriever was used as adjunctive therapy in 8.0%. Functional independence was reported in 49.2% of patients at 90 days. Complications included embolization to new territory (1.6%), dissection (3.2%), vasospasm (1.6%) and perforation (0.8%). Symptomatic intracranial hemorrhage was noted in 12 patients.

Conclusions

Results from the current analysis suggest the ACE64 with ADAPT as front-line appears to be safe and effective for acute stroke secondary to LVO.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

BILATERAL CORTICAL HIPPOCAMPAL INFARCTION FOLLOWING ACUTE BASILAR THROMBOSIS

N Lummel ¹, S Wunderlich ², C Zimmer ¹, K Justus ¹

Abstract

Background

Different phenotypic lesion patterns can be distinguished in hippocampal ischemia. In this study, frequency and clinical consequences of ischemic lesions concerning the entire, lateral hippocampal cortex on both sides (BHI), following acute basilar thrombosis and mechanical recanalization, were evaluated.

Methods

All patients with acute basilar thrombosis subjected to mechanical recanalization between 01/2012 and 12/2015 were identified. Available magnetic resonance images (MRI) (1–7 days following recanalization) including diffusion-weighted-imaging (DWI) were reviewed. In patients with BHIs, presence and distribution of additional ischemic lesions in the posterior circulation territories were recorded. Clinical records were evaluated regarding National Institutes of Health Stroke Scale (NIHSS) and clinical symptoms at discharge.

Results

68 patients with acute basilar thrombosis treated with mechanical recanalization were identified, 42 of which had follow-up MRI. In four cases (9.5%) BHIs were detected on DWI. In all four patients, additional patchy ischemic lesions were found in the posterior circulation territories (right/ left occipital lobe: 3/ 3, right/ left thalamus: 2/ 2, right/ left cerebellum: 3/ 2, brainstem: 2). NIHSS at discharge was 1 in three patients and 4 in one patient. All four patients showed relevant mnestic deficits at discharge. One patient additionally exhibited dysarthria, mild left hemiataxia and vertigo.

Conclusions

Bilateral cortical hippocampal ischemia is a rare, but important finding following basilar thrombosis, associated with severe clinical impairment. Selective vulnerability to hypoxia and/ or deficient collateralization seem to play a major role in this phenomenon.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

BRIDGING-THERAPY WITH INTRAVENOUS RECOMBINANT TISSUE PLASMINOGEN ACTIVATOR DOES IMPROVE FUNCTIONAL OUTCOME IN PATIENTS WITH ENDOVASCULAR TREATMENT IN ACUTE STROKE

I Maier ¹, D Behme ², M Schnieder ¹, I Tsogkas ², K Schregel ², A Kleinknecht ¹, K Wasser ¹, M Bähr ¹, M Knauth ², M Psychogios ², J Liman ¹

Abstract

Background

Although endovascular treatment for proximal vessel occlusion is very effective, it remains controversial if iv-rtPA therapy prior to endovascular treatment is superior compared to endovascular treatment alone. In this study we compared functional outcomes and recanalization rates of endovascularly treated stroke patients with and without bridging iv-rtPA therapy.

Methods

Patients with acute proximal occlusion in the anterior and posterior circulation eligible for intraarterial emergency revascularization with and without prior iv-rtPA were included in this monocentric, prospective observational study. Modified ranking scale (mRS) and National Institute of Health Stroke Scale (NIHSS) have been determined at baseline, discharge and 90 d follow up after stroke. Successful reperfusion was defined as a Thrombolysis in Cerebral Infarction (TICI) scale 2b-3.

Results

Of the 112 patients included, 83 (74%) received bridging therapy with iv-rtPA prior to endovascular treatment, 29 (26%) received endovascular treatment alone. Mean decrease of the NIHSS was 8 points (SD; ±8) in the bridging-group and 2 points (SD, ±7) in the non-bridging-group (p = 0.004). Number of patients with discharge mRS 0–2 (35 vs 5; p = 0.011) and 90-days mRS 0–2 (33 vs 5; p = 0.047) was higher in the bridging-group compared to the non-bridging-group. There was a trend towards a higher reperfusion rate in patients with bridging-therapy (61 vs 16 patients, p = 0.057), while there was no difference in groin-to-reperfusion time between the groups (60 ± 32 vs 66 ± 40 minutes (mean ± SD); p = 0.432).

Conclusions

Bridging therapy with iv-rtPA prior to endovascular treatment seems to improve functional outcome in acute stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

USE OF GENERAL ANESTHESIA FOR MECHANICAL THROMBECTOMY IS NOT ASSOCIATED WITH TIME TO TREATMENT OR REVASCULARIZATION RATE IN THE STRATIS REGISTRY

N Mueller-Kronast ¹, MA Aziz-Sultan ², MT Froehler ³, R Jahan ⁴, RP Klucznik ⁵, JL Saver ⁶, OO Zaidat ⁷, DR Yavagal ⁸

Abstract

Background

STRATIS is an ongoing, prospective, multi-center, non-randomized, observational registry of mechanical thrombectomy with Solitaire for acute ischemic stroke due to large vessel occlusion.

Methods

The registry plans to enroll 1000 patients treated with Solitaire device within 8 hours from symptom onset. Anesthesia type is analyzed with time to treatment and revascularization rate.

Results

Of 346 subjects enrolled to date, 226 patients (65%) had conscious sedation (CS), 20 (6%) required conversion to general anesthesia (GA), and 100 (29%) had pre-planned GA. In the GA group, patients were significantly younger (66.3 vs. 69.9 years; p = 0.04) and baseline NIHSS was higher (18.2 vs. 16.7; p = 0.02). There was no difference in rate of IVtPA use (60% in GA, 62% in CS). Door to groin time was short in both groups and did not differ between GA and CS (mean 93.1 vs. 106.5 min). The mean onset to groin and groin to reperfusion times also did not differ (237.3 vs. 231.3, and 48.6 vs. 54.1 minutes). GA did not result in higher TICI 3 (49% vs. 55%) or TICI ≥ 2b scores (84% vs. 87%).

Conclusions

In general, time to treatment was short regardless of anesthesia type, and there was no significant delay with initiation of GA. Time to revascularization and rate of revascularization were also unaffected by anesthesia type. The relatively low percentage of patients treated with GA may represent a shift in the practice pattern. The low rate of conversion to GA suggests that CS can be safely performed in the majority of patients undergoing mechanical thrombectomy.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EFFECTIVENESS OF INTRA-ARTERIAL TREATMENT IN PATIENTS WHO ARE TREATED WITH ANTIPLATELET AGENTS: MR CLEAN SUBGROUP ANALYSIS

M Mulder ¹, O Berkhemer ², P Fransen ¹, D Beumer ³, LA Van den Berg ⁴, H Lingsma ⁵, Y Roos ⁴, R Van Oostenbrugge ³, W Van Zwam ⁶, C Majoie ², A Van der Lugt ⁷, D Dippel ⁸

Abstract

Background

It is unknown whether antiplatelet treatment (APT) modifies the effect of intra-arterial treatment (IAT) in patients with acute ischemic stroke. In order to explore the interaction between APT and IAT, we analyze the safety and effectiveness of IAT in patients on APT compared with patients not taking this medication.

Methods

All 500 MR CLEAN patients were included and we distinguished between patients who were on APT (acetyl-salicylic acid, carbasalate calcium, clopidogrel, prasugrel etc.) and those who were not. We estimated the effect of IAT on the shift on the modified Rankin Scale with ordinal logistic regression analysis, and tested for interaction of antiplatelet treatment with IAT.

Results

The 144 patients (29%) on APT were older, more often were men and more often had vascular comorbidity. After adjustments for age, sex, NIHSS, collateral score and vascular comorbidity, the common odds ratio of IAT in patients on APT was 1.67 [95% Confidence Interval (CI): 0.88–3.16], and 1.78 [95% CI: 1.21–2.63] in patients not on APT. There was no interaction between APT and intervention (p = 0.777). We observed more symptomatic intracranial hemorrhages in the APT subgroup, but there was no difference between the treatment groups (Table 1).

graphic file with name 10.1177_2396987316642909-img9.jpg

Conclusions

Intra-arterial treatment for patients with acute ischemic anterior circulation stroke caused by intracranial large vessel occlusion is equally effective and safe in patients with and without prior antiplatelet use.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

DWI-ASPECTS AND NIHSS AT BASELINE PREDICT GOOD RECOVERY BY MECHANICAL ENDOVASCULAR THROMBECTOMY AFTER THROMBOLYSIS FOR ACUTE ISCHEMIC STROKE

S Nogawa ¹

Abstract

Background

Recent multicenter randomized control trials have demonstrated that mechanical endovascular thrombectomy (EVT) after intravenous infusion of recombinant tissue plasminogen activator (IV rt-PA) might improve functional outcome of patients with acute ischemic stroke, although it could trigger hemorrhagic transformation. We, therefore, tried to elucidate factors which determined their outcome.

Methods

Sequential 17 patients (68.4 ± 12.6 year old) with acute ischemic stroke who underwent IV rt-PA followed by EVT were enrolled. According to the change in NIHSS after EVT, we divided these subjects into good recovery (GR) group (>4, n = 5) and poor recovery (PR) group (<3, n = 12), and compared these two groups in various measures.

Results

1) Duration from the onset to the puncture in the PR group (4:08 + 1:24) was not different from that in the GR group. 2) At infusion of rt-PA, NIHSS in the GR group (13.0 + 6.7) was significantly (p < 0.05) lower than that in the PR group (20.2 + 7.8). 3) DWI-ASPECTS in the GR group (8.6 + 1.7) was significantly (P < 0.05) higher compared with that in the PR group (5.9 + 2.2). 4) The recanalization rate (>TICI 2b) in the GR group was 100%, while that in the PR group was 67%. 5) NIHSS at the discharge and mRS at 3 months after the onset in the GR group were significantly lower than those in the PR group.

Conclusions

DWI-ASPECTS at the baseline (>6) and NIHSS at the initiation of IV rt-PA (<20) may predict good recovery by the mechanical EVT after thrombolysis.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

INCREASED ADMISSION GLUCOSE AND IMPAIRED FASTING GLUCOSE ARE ASSOCIATED WITH UNFAVOURABLE SHORT-TERM OUTCOME AFTER INTRA-ARTERIAL TREATMENT OF ISCHAEMIC STROKE IN THE MR CLEAN PRETRIAL COHORT

E Osei ¹, HM den Hertog ¹, OA Berkhemer ², PSS Fransen ³, YBWEM Roos ⁴, D Beumer ⁵, RJ van Oostenbrugge ⁵, WJ Schonewille ⁶, J Boiten ⁷, AAM Zandbergen ⁸, PJ Koudstaal ³, DWJ Dippel ³

Abstract

Background

Acute hyperglycaemia has been associated with unfavourable outcome in patients with acute ischaemic stroke treated with recombinant tissue plasminogen activator. Limited data are available on the impact of glucose on outcome after intra-arterial treatment. We studied whether increased admission serum glucose is associated with unfavourable outcome after intra-arterial treatment of acute ischaemic stroke.

Methods

Patients were derived from the pretrial registry of the MR CLEAN-trial. All patients with available serum glucose values on admission and/or fasting glucose levels on day 1–7 were included. Acute hyperglycaemia was defined as acute glucose values >7.8 mmol/L. Impaired fasting glucose (IFG) was defined as fasting glucose ≥ 5.6 mmol/L. Primary outcome measure was poor outcome defined as modified Rankin Scale score >2 on discharge. The relationship between serum glucose on admission, hyperglycaemia or IFG on the one hand and poor outcome on the other were expressed as odds ratios. Adjustments for potential confounders were made with a multivariable logistic regression model.

Results

Eighty-eight patients of the 348 patients (25%) were classified as acutely hyperglycaemic, and 142 of the 227 patients (63%) had IFG in the first week of admission. Median admission serum glucose was 6.8 mmol/L (IQR 6–8). Admission serum glucose (aOR 1.3, 95%CI 1.1–1.6), acute hyperglycaemia (aOR: 2.4; 95% CI 0.9–6.1) and IFG (aOR 2.8; 95%CI 1.2–6.8) were associated with poor outcome on discharge.

Conclusions

Increased serum glucose on admission and IFG in the first week after stroke onset are associated with unfavourable short-term outcome after intra-arterial treatment of acute ischaemic stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ADMISSION GLUCOSE AND EFFECT OF INTRA-ARTERIAL TREATMENT IN PATIENTS WITH ACUTE ISCHAEMIC STROKE IN THE MR CLEAN COHORT

E Osei ¹, HM den Hertog ¹, OA Berkhemer ², PSS Fransen ³, YBWEM Roos ⁴, D Beumer ⁵, RJ van Oostenbrugge ⁵, WJ Schonewille ⁶, J Boiten ⁷, AAM Zandbergen ⁸, PJ Koudstaal ³, DWJ Dippel ³

Abstract

Background

Hyperglycaemia on admission is common after ischaemic stroke and is associated with unfavourable outcome after treatment with recombinant tissue plasminogen activator and intra-arterial treatment. Hence, patients with hyperglycaemia may be less responsive to intra-arterial treatment. We assessed whether increased admission serum glucose modifies the effect of intra-arterial treatment in the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) trial.

Methods

Hyperglycaemia was defined as admission serum glucose >7.8 mmol/L. The primary effect measure was the adjusted common odds ratio (acOR) for a shift in the direction of a better outcome on the modified Rankin scale (mRS), estimated with ordinal logistic regression. Secondary outcome variable was symptomatic intracranial haemorrhage. Treatment effect modification of hyperglycaemia and continuous admission serum glucose levels was assessed with multiplicative interaction variables and adjusted for prognostic factors.

Results

Four hundred and eighty-seven patients were included. Median admission serum glucose was 6.7 mmol/L (IQR 5.8–7.8). Fifty-seven of 226 patients (25%) assigned to intra-arterial treatment were hyperglycaemic, compared with 61 of 261 patients (23%) in the control group. The interaction of either hyperglycaemia or admission serum glucose levels and treatment effect on mRS scores was not significant (acOR 1.3; 95%CI 0.6–2.9 and acOR 1.0; 95%CI 0,9–1.2, respectively). The same applied for symptomatic haemorrhages (aOR 2.0; 95%CI 0.4–9.1 for hyperglycaemia, aOR 1.1; 95%CI 0.9–1.5 for admission serum glucose).

Conclusions

We found no evidence for effect modification of intra-arterial treatment by admission serum glucose in patients with acute ischaemic stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

RETRIEVABLE STENT THROMBECTOMY IN ACUTE ISCHEMIC STROKE: IS IT BENEFICIAL IN THE ELDERLY?

F Perren ¹, L Puke ², C Kremer ³, V Mendes Pereira ⁴

Abstract

Background

Thrombectomy in acute ischemic stroke is used in case of systemic thrombolysis failure or contraindication. Stent retrievers were showed to be safe and efficient. However, little is known about the effect of this therapy in the elderly.

Methods

In ischemic stroke due to acute proximal MCA occlusion treated with stent retrievers’ thrombectomy only, outcome and safety of elderly (≥75years) and younger patients were analyzed.

Results

In 48 consecutive acute ischemic stroke patients ineligible for systemic thrombolysis, outcomes of elderly patients (14/25 women, mean age 82.6; 11/23 men, mean age 80.2) were compared to those of younger (<75years) patients (11/23 women, mean age 53; 12/23 men, mean age 59). Admission NIHSS was 13.6 in younger patients and 17 in the elderly (t = 2.08; p = 0.0429). Recanalization was completely achieved in 37 cases (77%) and was not significantly different between younger and older patients (Fisher’s exact p > 0.05). NIHSS improvement before and after stent retriever recanalization was highly significant in younger (t = 7.41; p < 0.0001) and in older patients (t = 5.78; p < 0.0001). However, the size of improvements did not differ significantly between younger and older patients (t = 1.37; p = 0.17). Good functional outcome (mRS 0–2) was significantly worse in the elderly (Fisher’s exact p > 0.0006), but there were no gender differences (Fisher’s exact p > 0.05). Hemorrhagic transformation occurred in 45.8%, but was symptomatic in only 10% and did not differ significantly in the elderly.

Conclusions

These results suggest that stent-based thrombectomy in selected patients for acute MCA occlusion is safe, very effective in terms of recanalization and associated with improved neurological outcome and should be considered in elderly patients.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ENDOVASCULAR TREATMENT OF TANDEM OCCLUSION IN ANTERIOR CIRCULATION: OUTCOMES IN ACUTE ISCHEMIC STROKE PATIENTS TREATED WITHIN 6 HOURS OF SYMPTOM ONSET

D Sanak ¹, R Havlicek ², M Kocher ³, L Loudova ², T Veverka ¹, M Lacman ⁴, M Cerna ³, T Belsan ⁴, M Kral ¹, P Maly ², V Prasil ³, M Tinkova ², T Dornak ¹, L Ceprova ², S Burval ³, J Kleckova ², D Franc ¹, F Charvat ⁴

Abstract

Background

Early recanalization of symptomatic cerebral occlusion is crucial for clinical improvement and recovery after acute ischemic stroke (AIS). Mechanical thrombectomy (MT) with stent-retrievers showed positive clinical effect and high recanalization rate in treatment of middle cerebral artery (MCA) occlusion. In tandem occlusion of MCA and internal carotid artery (ICA), the effect of MT has been still not yet enough established. The aim was assess the safety and efficacy of MT in AIS patients treated within first 6 hours of symptom onset.

Methods

Study set consisted of consecutive AIS patients from our stroke database with tandem ICA + MCA occlusion treated with combination of extracranial ICA angioplasty or MT in case of distal ICA occlusion and MT with stent-retrievers for MCA occlusion. Stroke severity was assessed using the NIHSS and 90-day clinical outcome using the mRS. Recanalization was rated using the TICI scale.

Results

Out of 494 AIS patients treated with MT (stent-retrievers) in both centers, 42 (67% males, mean age 67.2 ± 8.9 years) were treated for ICA + MCA occlusion and had a baseline median NIHSS of 19.0. 48% of these patients were treated with combination of angioplasty and MT and 52% with MT only. Overall recanalization was achieved in 90% of patients and complete (TICI 3) in 62% of patients. No symptomatic intracerebral hemorrhage was occurred. The median mRS was 3 and 45% of patients had mRS 0–2 after 90 days.

Conclusions

Stent-retrievers seems to be safe and effective treatment option also in tandem occlusion in anterior circulation. Acknowledgement: Study supported by RVO FNOL 00098892.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THROMBOLYSIS WITHIN THE “GOLDEN HOUR” IN “REAL LIFE”: DATA FROM THE AUSTRIAN STROKE REGISTRY

P Santer ¹, S Krebs ², K Matz ¹, L Seyfang ³, Y Teuschl ³, W Lang ², M Brainin ¹

Abstract

Background

Intravenous thrombolysis performed within 90 minutes has a two-fold better outcome than thrombolysis performed at 3 hours or thereafter. In clinical practice, only a minority is treated within the Golden Hour.

Aims were to study the timing of thrombolysis and to analyse variables related to outcome differences.

Methods

A uni- and multivariate analysis of stroke patients treated with thrombolysis that had been registered in the Austrian Stroke Registry and had received either a personal or telephone 90 day follow-up.

Results

3.254 thrombolysed cases of which 793 received thrombolysis within 90 min were included. The median admission NIHSS was higher in the 90-min-group (12 (Q_0.25: 7, Q_0.75: 17) versus 7(Q_0.25: 5, Q_0.75: 13)). These patients showed more TAC syndrome (34.9%) as an etiology and fewer had previous stroke events (11.5% versus 18.6%). Patients had a shorter DNT (median 30 min, (Q_0.25: 23 min, Q_0.75: 42 min)) in this group than in the group of later thrombolysis (median 54.5 min, (Q_0.25: 35 min, Q_0.75: 85 min)). There was a poor outcome for patients receiving thrombolysis later than 90 min with an OR of 1.58 (95% Cl 1.29–1.94). Multivariate analysis showed that admission without accompanying emergency physician was faster (46.8% versus 39.5%).

Conclusions

Real-life registry data confirm the results from randomized studies that the Odds Ratio for good outcome increases two-fold when thrombolysis is performed within 90 minutes after stroke onset compared to 3 hours or later. Efforts to shorten the preclinical and intra-hospital phase before thrombolysis are needed.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THROMBOLYSIS IN PATIENTS WITH VERY MINOR STROKE (NIHSS 0 AT PRESENTATION)

C Schulte ¹, N Hubert ¹, R Backhaus ², G Hubert ¹, R Haberl ¹

Abstract

Background

Intravenous thrombolysis (IVT) is beneficial in reducing disability even in patients with minor acute ischemic stroke (NIHSS < 4). Given presumed small infarct size, rate of intracerebral hemorrhage (ICH) is suspected to be low. However safety of IVT-administration in patients with NIHSS = 0 has not been studied. Aim of this study was to analyze safety of IVT and rate of stroke mimics in patients with NIHSS = 0 at presentation.

Methods

The TeleStroke Unit network TEMPiS has set up a thrombolysis registry that includes all consecutive patients receiving IVT in 19 hospitals. Data from 01/2010 to 10/2015 were searched for patients with NIHSS = 0 at presentation. Outcome measures were thrombolysis-associated complications (ICH, major extracranial hemorrhage requiring intervention, allergic reaction) and in-hospital mortality.

Results

22 patients who received IVT were identified with stroke-like symptoms, but NIHSS = 0 at hospital presentation, 16 patients (72.7%) had ischemic stroke as final diagnosis. Six patients (27.3%) obtained other diagnoses at demission. Most common symptoms were dizziness (86%), gait disorder (64%) and nausea (41%). One patient (4.5%) suffered symptomatic ICH due to an unknown preexisting cerebellar arteriovenous malformation. This patient had a stroke mimic as final diagnosis. In the subgroup with definite stroke no patient had ICH. No other thrombolysis-associated complications appeared, noone died. 64% were discharged without deficits.

Conclusions

Rate of IVT related complications in patients with NIHSS = 0 was low, but symptomatic ICH did occur in one case. Given the high rate of stroke mimics in this subgroup and the usually small deficits, IVT may not be indicated.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

REVASCULARIZATION THERAPY IN ACUTE STROKE PATIENTS TREATED WITH NOAC SHOULD BE SAFE

K SUZUKI ¹, J AOKI ¹, T NAGAO ², K KIMURA ¹

Abstract

Background

The safety of intravenous thrombolysis (IVT) and endovascular therapy (EVT) in patients treated with NOACs is unclear. We investigated whether recanalization therapy in patients treated with NOACs is safe.

Methods

A nationwide, multicenter, retrospective cohort questionnaire survey was conducted to investigate the: (1) frequency of intracerebral hemorrhage (ICH) after recanalization therapy in patients treated with NOACs; (2) independent factors related to ICH; (3) relationship between last intake time of NOACs and ICH; and (4) comparison of ICH frequency between patients treated with NOACs, vitamin K antagonist (VKA), and no-anticoagulation (no-ACT) (control).

Results

One hundred eighteen of 205 stroke centers returned the questionnaire and 100 patients (56 IVT alone, 29 EVT alone, and 15 both IVT and EVT) on NOACs were registered. The frequency of asymptomatic and symptomatic (≥4-point NIHSS score increase) ICH within 24 hours in NOACs patients were 18% and 2%, and were not different compared with the VKA and no-ACT groups (p = 0.728; and p = 0.626). On multivariate analysis, systolic blood pressure (OR, 1.04; p < 0.001) and blood glucose (OR, 1.02; p = 0.019) were independent factors for ICH. Among the 52 patients with a known last intake time of NOACs, the rate of ICH was higher in patients ≤4 hours from last intake than those >4 hours (38% vs. 10%, p = 0.033).

Conclusions

Risk of ICH after revascularization therapy in patients treated with NOACs should be low. Systolic blood pressure, glucose level, and NOACs intake time appear to be factors for ICH

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

STROKE TEAM RHEIN MAIN - SIMULATOR-BASED STROKE TEAM TRAINING FOR A REGIONAL STROKE NETWORK IMPROVED NETWORK-WIDE DOOR-TO-NEEDLE TIMES AND STAFF SATISFACTION

D Tahtali ¹, W Pfeilschifter ¹, H Steinmetz ¹, F Bohmann ¹

Abstract

Background

Acute stroke care is delivered by interdisciplinary teams. It is a general principle of emergency medicine that while the individual experience of every single professional is valuable, good communication and a well-rehearsed team-based workflow ultimately enhance safety and lead to better outcomes. “STROKE TEAM Rhein Main” was a one-year project to implement the Frankfurt University Hospital STROKE TEAM algorithm with regular simulator-based team trainings (SBTs) in our regional stroke network comprised of 7 certified stroke units and test its transferability.

Methods

In the first 3 months, baseline door-to-needle times (DNTs) in the participating hospitals were recorded and staff satisfaction was evaluated via a standardized questionnaire. In the following intervention phase we organized workshops in which we mapped out individual stroke algorithms tailored to each hospital’s local conditions. Then we conducted SBTs in the participating hospitals and offered a train-the-trainer workshop and distributed standardized teaching materials. We then conducted a second round of data acquisition.

Results

The STROKE TEAM intervention significantly reduced the median DNT of our regional stroke network by 12 minutes from 42 to 31 minutes and noticeably increased work satisfaction of emergency room employees.

The SBTs became highly popular with nurses, doctors and trainees of all professions and significantly increased the feeling of safety and well-preparedness in acute stroke care.

Conclusions

The Frankfurt University Hospital STROKE TEAM algorithm proved to be well-transferable to different hospital settings and simulator-based training is a powerful tool to enhance team dynamics in acute stroke care.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

FACTORS RELATED TO FLAIR LESION EXPANSION AFTER SUCCESSFUL THROMBECTOMY FOR ACUTE ISCHEMIC STROKE

S Takaishi ¹, D Tokuura ¹, H Mizukami ¹, T Fukano ¹, T Yoshie ¹, S Nogoshi ¹, T Takada ¹, T Ueda ¹

Abstract

Background

Change of MRI findings after mechanical thrombectomy for acute ischemic stroke has yet to be revealed. The purpose of this study is to evaluate high intensity lesion volume changes of FLAIR imaging in subacute stage after successful thrombectomy and predictive factors for lesion changes.

Methods

52 patients were enrolled, who operated mechanical thrombectomy for acute ischemic stroke between April 2010 and December 2015 with internal carotid artery or middle cerebral artery obstruction and with successful TICI2b-3 recanalization. Measurements high intensity lesion volume in MRI on admission, day2 and day7 were performed. Evaluation of basic disease, reperfusion time, measurement of each CT perfusion’s parameters and clinical outcome were performed and assessed relation with change of MRI findings.

Results

In this study Compared with FLAIR high intensity lesion on day 7 expanded in 19 patients (36.5%) and diminished in 9 patients (17.3%) on day2. In lesion-expanded cases TICI2b cases were 15 (78.9%) TICI3 cases were 4 (21.1%), good clinical outcome (modified Rankin scale 0–2) patients were 7 (36.8%). In lesion-expanded cases bad outcome (modified Rankin scale 5–6) patients were 3 (15.8%). In lesion expansion cases, Enhance volume in CT imaging immediately after recanalization was larger than non-expanded cases (P < 0.05), moreover in diminished cases CT enhance volume tended to be small. Lesion enhancement in CT imaging was also associated to hemorrhagic infarction.

Conclusions

In conclusion, FLAIR lesion expansion associates with and lesion enhance volumes in CT imaging immediately after recanalization. CT enhancement associates with not only lesion expansion but also hemorrhagic infarction.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

SAFETY OF INTRAVENOUS THROMBOLYTICS IN STROKE ON AWAKENING (SAIL-ON)

V Urrutia ¹, R Faigle ¹, S Zeiler ¹, E Marsh ¹, M Bahouth ¹, M Cerdan Trevino ¹, J Dearborn ¹, R Leigh ¹, S Rice ¹, M Saheed ², P Hill ², R Llinas ¹

Abstract

Background

Up to 25% of acute stroke patients first note symptoms upon awakening, and are ineligible for treatment with intravenous tissue plasminogen activator (IV tPA). We hypothesize that patients awaking with stroke symptoms may be safely treated with IV tPA if they meet all other standard criteria.

Methods

A prospective, open label, single treatment arm, safety trial of standard dose IV tPA in patients who presented with stroke symptoms within 0–4.5 hours of awakening. From January 30, 2013, to September 1, 2015, twenty consecutive wake-up stroke patients selected by non-contrast head CT (NCHCT). The Primary outcome was symptomatic intracerebral hemorrhage (sICH) in the first 36 hours. Secondary outcomes included NIH stroke scale (NIHSS) at 24 hours; and modified Rankin Score (mRS), NIHSS, and Barthel index at 90 days.

Results

The average age was 65 years (range 47–83); 35% were women; 45% were African American. The average NIHSS was 6 (range 4–11). The average time from wake-up to IV tPA was 205 minutes (range 114–270). The average time from last known well to IV tPA was 580 minutes (range 353–876). The median mRS at 90 days was 1 (range 0–5). There was no sICH; two of 20 (10%) had asymptomatic ICH on routine post IV tPA brain imaging.

Conclusions

Administration of IV tPA in wake-up stroke patients was feasible and safe in this pilot study of IV tPA administration in wake-up stroke patients presenting within 0–4.5 hours from awakening and screened with NCHCT. An adequately powered randomized clinical trial is needed.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EARLY RECANALIZATION RATE AFTER IV-TPA AND TREATMENT RESULTS OF ADDITIONAL INTRA-ARTERIAL THROMBOLYSIS IN LARGE ARTERY INTRACRANIAL OCCLUSION DISEASE PATIENTS

DS Yoo ¹, L Sang-Bock ¹, W Tae-Yeon ¹, J Won-Il ¹, L Tae-Kyu ¹, H Phi-Woo ¹, J Shin-Soo ¹, C Kyung-Suck ¹

Abstract

Background

Intravenous tissue plasminogen activator administration (IV-tPA) is the only standard treatment for acute ischemic stroke patients, but its therapeutic effect on in large artery intracranial occlusive disease (LAICOD) is questionable. We attempted to analyze the recanalization rate of IV-tPA in LAICOD patients and clinical results of additional intra-arterial thrombolysis (IA-Tx) on non-recanalized patients after IV-tPA.

Methods

We included 212 patients who treated IV-tPA and/or IA-Tx. CT-angiography (CTA) was taken as an initial imaging study and acute stroke MRI was performed immediately after IV-tPA administration. We analyzed the recanalization rate, favorable clinical outcomes (mRS: 0–2) and the hemorrhagic complication rate based on additional IA-Tx and perfusion/diffusion (P/D)-mismatching.

Results

Thirty-four patients were recanalized after IV-tPA but 178 patients were not. 118 patients were treated with IV-tPA only and 60 patients were treated with additional IA-Tx. The overall recanalization rate of LAICOD after IV-tPA was 16.0%, among these recanalized patients 82.4% had favorable outcomes. The recanalization rate after additional IA-Tx was 80.0%, and favorable outcome was significant better than who treated IV-tPA only (p = 0.049). In patients who treated additional IA-Tx, P/D-mismatched patients led to fewer hemorrhagic complications (p = 0.046) and better clinical outcomes (p = 0.000) than P/D-matched patients.

Conclusions

The recanalization rate after IV-tPA in LAICOD patients was low. Additional IA-Tx for non-recanalized patients after IV-tPA could improve the patient outcomes. And P/D-mismatch on acute stroke MR, which taken before the IA-Tx. was good indicator for the safety and effectiveness for additional IA-Tx.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

COMPARE THE PROGNOSTIC VALUE BETWEEN THE DIFFUSION VOLUME AND THE PERFUSION/DIFFUSION MISMATCHING FINDING

DS Yoo ¹, W Tae-Yeon ¹, L Sang-Bock ¹, J Won-Il ¹, L Tae-Kyu ¹, H Phi-Woo ¹, J Shin-Soo ¹, C Kyung-Suck ¹

Abstract

Background

Diffusion (DWI) change area regard as cytotoxic edema and ischemic core. And perfusion/diffusion mismatching (P/D-mismatch) is regard as ischemic penumbra and targeted tissue to ischemic stroke treatment. Exact diffusion volume may be important to speculate the patient prognosis. But there were no studies which compare the clinical significance of the diffusion volume and P/D-mismatch.

Methods

57 patients whom treated additional IA-Tx, non-recanalized after IV-tPA with anterior circulation and major vessel occlusion, were analyzed retrospectively. Diffusion volume was calculated from MR graphic program and P/D-mismatch was evaluated by radiologist who was not involved in patient treatment. Statistical analysis were done according to the DWI volume and P/D-mismatch, in recanalization, favorable outcome, and significant hemorrhagic.

Results

P/D-mismatch was statistical significant prospect on favorable outcome (c2, p = 0.000), neurologic improvement (c2, p = 0.000), significant hemorrhage (c2, p = 0.043), extravascation (c2, p = 0.000) and decompressive surgical incidence (c2, p = 0.007). But diffusion volume, evaluated cording to 30 cc, 60 cc, 100 cc grading analysis, not predict neurologic outcomes, hemorrhagic complications.

Conclusions

In this study, diffusion volume calculation is impossible to calculate without computerized program and clinical significance of diffusion volume was questionable. P/D-mismatch was more significant prognostic indicator than diffusion volume in acute stroke patient management.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

COMPARE THE CHEMICAL AND MECHANICAL INTRA-ARTERIAL THROBOMBOLYSIS

DS Yoo ¹, W Tae-Yeon ¹, L Sang-Bock ¹, J Won-Il ¹, L Tae-Kyu ¹, H Pil-Woo ¹, J Shin-Soo ¹, C Kyung-Sock ¹

Abstract

Background

Recent clinical trials concerned, intraarterial thrombolysis (IA-Tx) used retrieval stent (Solitair or Trevor) in patients who are not recanalized after iv-tPA or not indication for iv-tPA, reported that IA-Tx is effective treatment modality. Authors tried to compare the clinical results between chemical and mechanical IA-Tx.

Methods

Data from 132 patients whom treated IA-Tx, anterior circulation with major vessel occlusion, were analyzed retrospectively. Treatment group were divided into a chemical thrombolysis group (n = 78: Urokinase, Rheopro, etc) and mechanical thrombolysis group (n = 54: Solitair devices). And clinical data were analyzed according to the tPA used prior to IA-Tx and perfusion/diffusion mismatch (P/D-mismatching). Treatment results were compared by recanalization rate (TIMI grade 2 and 3), clinical outcomes, mortality, and significant intra-cerebral hemorrhage rate.

Results

Recanalization rate was 56.4% in chemical thrombolysis group and 85.2% in the mechanical thrombolysis group (χ², p < 0.000). Favorable outcome (modified Rankin Scales score of 0–2), mortality and significant intra-cerebral hemorrhage were similar in the two groups (χ², p > 0.05). P/D-mismatching checked before the IA-Tx, was significant good prognostic indicator for IA-Tx (χ², p < 0.05).

Conclusions

In our study, mechanical thrombolysis shows better recanalization rate compared with chemical thrombolysis group. But clinical outcomes show no difference in both treatment groups. P/D-mismatching was constant significant prognostic indicator in our analysis. Proper combination of the advanced neuroradiologic evaluation and intraarterial treatment might improve the clinical outcomes of the major larger artery intracranial occlusion patients.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

INTRAINFARCT FLAIR HYPERINTENSITY PREDICTS INTRACEREBRAL HAEMORRHAGE AFTER ENDOVASCULAR REPERFUSION THERAPY IN ACUTE ISCHEMIC STROKE PATIENTS

T Yoshimoto ¹, M Hayakawa ², K Seki ², Y Miyazaki ², H Yamagami ³, T Satow ⁴, J Takahashi ⁴, K Toyoda ², K Nagatsuka ⁵

Abstract

Background

In acute ischemic stroke (AIS) patients, intrainfarct fluid-attenuated inversion recovery (FLAIR) hyperintensity on pretreatment magnetic resonance imaging (MRI) is reported to be associated with intracerebral haemorrhage (ICH) after intravenous thrombolysis. We analysed whether the existence of intrainfarct FLAIR hyperintensity predicts the development of ICH after endovascular therapy (EVT).

Methods

Among consecutive 117 AIS patients treated with EVT in our hospital from October 2012 to August 2015, patients with large vessel occlusion of the anterior circulation were examined. FLAIR hyperintensity within the area of diffusion restriction was determined on baseline MRI, and the patients were divided into two groups (FLAIR-positive and -negative). ICH was defined as a low intensity signal on MRI T2* weighted images in the infarct area within 36 hours after EVT, and symptomatic ICH (sICH) was defined as ICH with any neurological deterioration. The incidence of ICH and sICH were compared between the two groups.

Results

This study included 90 patients (74 ± 11 years, 56 men). Intrainfarct FLAIR hyperintensity was present in 59 patients (67%). Age, baseline NIHSS score, onset-to-MRI time, DWI-ASPECTS, onset-to-reperfusion time, rate of intravenous thrombolysis were not significantly different between the groups. However, the incidence of ICH and sICH of FLAIR-positive group were higher than those of FLAIR-negative group (68% vs 35% (P < 0.01), and 29% vs 10% (P = 0.02), respectively. In multivariate analysis, intrainfarct FLAIR hyperintensity was independently associated with ICH (odds ratio 4.4, 95% confidence interval 1.4 – 16.3).

Conclusions

Intrainfarct FLAIR hyperintensity predicts ICH after EVT in AIS patients.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CLOPIDOGREL LOADING DOSE VERSUS MAINTENANCE DOSE TO TREAT ACUTE ISCHEMIC STROKE IN CHINA: A DOUBLE BLIND RANDOMIZED CLINICAL TRIAL (CLASS-CHINA)

Y Zhao ¹, Y Wanyong ¹, T Zefeng ¹, W Wenmin ², X Weimin ³, Z Jinsheng ⁴, X Anding ¹

Abstract

Background

To evaluate the efficacy and safety of clopidogrel with loading dose in treating acute non-cardiogenic ischemic stroke.

Methods

CLASS-China was a prospectively, randomized, double-blinded, placebo-controlled trial in mainland China. Patients with partial anterior circulation cerebral infarction due to acute non-cardiogenic ischemic stroke had been enrolled. The onset time must within 48 hours, and the patients with thrombolysis were excluded. Patients were divided into loading dose group and routine dose group. The primary outcome was the incidence of recurrence of stroke or stroke in progression (SIP) with 7 days. Life-threatening bleeding was defined as the primary safety outcome. An intension-to treat analysis was used for the statistic analysis.

Results

From Feb. 28, 2008 to Mar. 2010, 16 centers and 303 patients were recruited into this study. The demographic characteristics and baseline data showed no significant differences between the two groups. The total primary outcome was 15.5%, and there was no difference between the two groups (loading dosage group 16.1% (24/149) and control group 14.9% (22/148), respectively, P = 0.782). The non-dependence rate in loading dose group (80.4%) was slightly higher than that in controlled group (76.6%). Fatal bleeding was found in 2 cases (1.3%) in loading dose group and 4 cases (2.7%) in control group. There was no significant difference in adverse events or severe adverse events in both groups.

Conclusions

This trial failed to show benefit of loading dose over standard dose of clopidogrel in patients with acute non-cardiogenic ischemic stroke. Further study about the use of clopidogrel in acute ischemic stroke patients is needed.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

TRANSBRACHIAL GUIDE-SHEATH SPECIFICALLY DESIGNED FOR DIRECT COMMON CAROTID ARTERY CANNULATION IN COMMON CAROTID ARTERY STENTING

S Kasakura ¹, T Mori ¹, T Iwata ¹, Y Tanno ¹, K Yoshioka ¹

Abstract

Background

The transfemoral approach is a common technique for the carotid artery stenting (CAS) and that involves the risk of distal embolism when high-grade stenosis exists at the common carotid artery (CCA). We have used the originally designed guide sheath for direct cannulation to the CCA without any guide-wire or coaxial catheter in the CAS.

Methods

We retrospectively analyzed patients who underwent the CAS for CCA with the transbrachial guide-sheath specifically designed for direct cannulation to the CCA, between January 2012 and March 2014 in our institution. Technical success, procedure time, periprocedual complications and 30-day major cardiovascular events (stroke, myocardial infarction, and death) were evaluated.

Results

Six patients were analyzed. Three of them underwent the transbrachial CAS for the right CCA stenosis and the other three for the left CCA lesion. In all cases, we were successful in direct cannulation to the target CCA with the guide-sheath and achieved the CAS safely. The median time from the arterial picture to the end of procedure was 59 minutes (interquartile range: 54–62.5). No periprocedural complication or cardiovascular event within 30 days following the CAS occurred.

Conclusions

We successfully and safely performed the CAS for the CCA stenosis with the specifically designed transbrachial guide sheath for direct cannulation to the CCA.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CLINICAL CHARICTERISTICS OF YOUNG AGE STROKE IN RECENT LOCAL CITY OF SOUTH KOREA: SINGLE CENTER STUDY

S Kim ¹, K Jinsoo ¹

Abstract

Background

To evaluate the characteristics of young age stroke in chuncheon, korea

Methods

We retrospectively studied 90 patients with acute ischemic stroke aged between 18 to 55 years who were admitted to kangwonregional cerebrovascular center. All patients underwent brain CT/MRI and, echocardiography and laboratory studies for coagulopathy and vasculitis, PFO study with TCD. Stroke subtypes were classified according to TOAST criteria.

Results

In our study, prevalence of young age stroke was 5.4% in all stroke patients in our registry. Men (86.3%) was significantly more than women. Stroke subtypes were: large artery atherosclerosis 22.7%, small artery occlusion 22.7 %, cardioembolism 18.1 %, undetermined causes 27.2%, and other determined etiologies 9.0%. PFO was positive in 21.6 % The prevalence of hypertension, cigarette smoking and habitual alcohol consumption was signifcantly higher in men than in women.

Conclusions

In our study, sex ratio deviation and relative proportion of large artery atherosclerosis/small artery occlusion were significant different with other past study of young age stroke. Our study show that classical risk factor of stroke is most important risk factor of young age stroke in recent korean stroke patients.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

STROKE IN KAZAKHSTAN

A Kondybayeva ¹, S Kamenova ¹, K Kuzhibaeva ¹, M Zhanuzakov ², A Sharaphanova ¹

Abstract

Background

In numerous researches, which were conducted in developed countries, identified a clear link between the organization and the quality of care for patients with stroke and mortality and disability. In this regard, we have conducted research related to the study of epidemiological indicators of stroke in different regions of Kazakhstan, which showed a high level of incidence of stroke.

Methods

We conducted a population-based research and get an objective picture of stroke in Kazakhstan, as well as evaluated risk factors for stroke, depending on the age and gender.

Results

Risk factors.

We have defines the main risk factors.

Stroke types and subtypes in Kazakhstan.

The structure of stroke have occupied 83% ischemic stroke and 17% hemorrhagic stroke and subarachnoid hemorrhage. Among ischemic stroke atherothrombotic 61%, cardioembolic 24% and lacunar 15%.

Future stroke research.

In order to reflect the structural features of stroke in Kazakhstan according to the pathogenetic mechanisms and to explore the interaction of genetic characteristics of the population and the risk factors, we began work on research of genetic risk assessment for different subtypes of ischemic stroke using the polymorphism associated with inflammation.

The first publication of this research is scheduled for the end of 2016.

Conclusions

Prevalence of stroke in Kazakhstan.

Our researches have shown that the incidence of stroke in different regions of Kazakhstan amounts to 2.5–3.7 cases per 1000 population per year, the death rate from 1 to 1.8 cases per 1000 population per year. The incidence among the male population is higher than women's.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EFFECT OF LOW-DOSE STATINS FOR PRIMARY PREVENTION ON FUNCTIONAL OUTCOMES IN CHINESE SOUTHWESTERN PATIENTS WITH FIRST-EVER ISCHEMIC STROKE

C Liu ¹

Abstract

Background

Moderate-intensity statin pretreatment reportedly was effective for westerners on lowering initial severity and improving functional outcomes after ischemic stroke. However, the Asians commonly use low-dose statins. And a Japanese study have showed that treatment with a low dose of pravastatin for primary prevention

reduced the risk of coronary heart disease. This study was to evaluate the association of low-dose statins for primary prevention and functional outcomes in Chinese southwestern patients with first-ever ischemic stroke.

Methods

We retrospectively enrolled 1260 patients with first-ever ischemic stroke between 2010 and 2015. According to whether with pre-existing statin therapy, patients were divided into two groups. We evaluated the functional outcomes at discharge after 3 months using the modified Rankin Scale. Favourable outcome was defined as grades 0–2, while poor outcome was 3–5.

Results

At the end of study, 321 patients of the statin group (n = 432) had favorable outcomes compared to 552 patients of the group not taking statins (n = 828). The logistic regression analysis showed it had statistical significance (OR = 1.384, 95% CI 1.054 to 1.819, p = 0.02).

Conclusions

Low-dose statins for primary prevention in Chinese southwestern patients with first-ever ischemic stroke was associated with favorable functional outcomes.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

LONG-TERM OUTCOME FOLLOWING LESION-SPECIFIC WINGSPAN-STENT TREATMENT FOR INTRACRANIAL ARTERIAL DISEASES

T Mori ¹, T Iwata ¹, Y Tanno ¹, S Kasakura ¹, K Yoshioka ¹, S Kuroda ¹

Abstract

Background

Clinical and angiographic outcome (CAO) following balloon angioplasty (bA) for an intracranial artery stenosis (iAS) depends on its angiographic characteristics. Mori’s type B (length of 5 mm or longer and less than 10 mm, severe eccentricity, or strong angle) or C (diffuse length of 10 mm or longer, chronic complete occlusion of 3 months or longer) lesions are refractory to bA, because abrupt occlusion or restenosis after pBA is anticipated. The aim of this study was to investigate if Wingspan-stent treatment (W-st) can improve CAO of type B or C lesions.

Methods

Included were patients who underwent elective W-st for symptomatic intracranial type B or C lesions between July and November 2014. Evaluated were success rate, procedural complications, angiographic restenosis (aR) rate at 3 months after stenting, recurrent ischemic symptoms (riS) within 6 months or repeat bA or stenting rate within 6 months.

Results

Seven patients matched our criteria. Two patients underwent W-st for the middle cerebral artery (MCA), three for the intracranial carotid artery (iCA) and two for the vertebro-basilar artery (VBA). Four patients had type B and three patients type C lesions. All patients underwent transbrachial W-st. Gateway balloon in 6 cases and Shiden in one case were used for initial dilatation. Successful W-st was achieved in all cases. No procedural complications occurred. Asymptomatic aR occurred in 4 cases (57%), but no riS. No repeat angioplasty was done.

Conclusions

Wingspan provided safe dilatation even in type B or C lesions and prevented riS. However, asymptomatic restenosis remains problematic.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

BURDENS OF AORTIC ATHEROMAS AND CEREBRAL SMALL VESSEL DISEASES IN ISCHEMIC STROKE PATIENTS

TJ Song ¹, YD Kim ², J Yoo ², J Kim ², D Song ², JH Heo ², HS Nam ²

Abstract

Background

Association between aortic atheromas (AAs) and other large vessel disease are well known. However, the relationship between AAs and small vessel diseases (SVD) is uncertain. We investigated the association between AAs and cerebral SVD.

Methods

We enrolled 737 patients who performed transesophageal echocardiography (TEE) and brain MRI for acute stroke evaluation in a prospective stroke registry. AA subtypes were classified as complex aortic plaque (CAP) and simple aortic plaque (SAP). Presence, burden and distribution of cerebral microbleeds (CMBs), existence of high-grade white matter hyperintensities (WMHs), and asymptomatic lacunar infarctions (ALIs) were investigated.

Results

Three hundred sixty patients (48.8%) had AAs. Two hundred sixty nine patients (36.4%) had one or more SVDs including 161 CMBs (21.8%), 218 high-grade WMHs (29.5%), and 230 ALIs (31.2%). Burdens of SVD including number of CMBs, degree of WMHs, and presence of ALIs were highest in patients with CAPs, followed by SAPs compared to those without AAs (p for trend <0.001, respectively). In multivariable analysis, presence of CMBs (odds ratio [OR] 4.68), high-grade WMHs (OR 3.13), high-grade PVSs (OR 3.35), and ALIs (OR 4.24) were more common in patients with AA than in those without AA.

Conclusions

We found that patients with AAs frequently had cerebral SVDs. Burdens of both AAs and SVDs were well correlated. Therefore, evaluation of TEE in patients with a high burden of SVDs might reveal AA, an important cause of stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CHRONIC KIDNEY DISEASE IS INDEPENDENTLY ASSOCIATED WITH SUBACUTE RECURRENT ISCHEMIC STROKE IN PATIENTS WITH ATRIAL FIBRILLATION

K Sakuta ¹, K Sakai ¹, Y Terasawa ¹, T Hirai ¹, S Omoto ¹, H Mitsumura ¹, C Toyoda ¹, Y Iguchi ¹

Abstract

Background

Background and Purpose: The present study aimed to determine the frequency and time of recurrent ischemic stroke (RIS) in patients with acute ischemic stroke (AIS) and atrial fibrillation (AF), and to clarify associated factors.

Methods: Methods

We retrospectively assessed and compared the clinical features of 79 consecutive patients (male, n = 56; median age, 75 y; median baseline NIHSS, 4) who were hospitalized due to AIS accompanied by AF, and who did or did not develop RIS between January 2012 and March 2015.

Results: Results

Non-vitamin K antagonist oral anticoagulants were administered to 60% of the patients after a median of two days from the onset of the index stroke. Stroke recurred in 10 (13%) of the 79 patients about 5 days after admission. The proportion of men was lower (30% vs. 77%, P = 0.005) and the patients were older (82 vs. 75 y, P = 0.049) in the group with RIS. Chronic kidney disease was significantly more prevalent in the group with RIS (50% vs. 16%, P = 0.025) and independently associated with RIS (OR, 8.20; 95%CI, 1.30–51.56; P = 0.025).

Conclusions: Conclusions

We found that RIS frequently develops about 5 days after admission in patients with AIS and AF and that chronic kidney disease is independently associated with RIS.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EPIDEMIOLOGICAL, SOCIO-ECONOMIC AND LIFE-STYLE CHARACTERISTICS OF YOUNG ISCHEMIC STROKE PATIENTS: COMPARISON WITH YOUNG MYOCARDIAL INFARCTION PATIENTS

Z Eichlova ^1,², D Sanak ², M Hutyra ³, A Kuncarova ², L Sikorska ³, M Kral ², S Klimosova ¹, T Veverka ², J Precek ³, A Bartkova ², M Taborsky ³, P Kanovsky ²

Abstract

Background

The occurrence of ischemic stroke (IS) in young adults (<50 years) ranges about 10–15% and myocardial infarction (MI) about 6–10%. Recent reports showed also the decrease of age of ischemic event onset in this population in contrast to most other diseases. The aim of our study was to assess significant differences of epidemiological, socio-economic and risk factors in young patients with acute IS and MI.

Methods

The prospective study set consisted of young acute IS and MI patients <50 years admitted at our hospitals. All enrolled patients completed uniform anonymous structured multiple-choice questionnaire involving all important epidemiological, socio-economic and life-style characteristics including known vascular risk factors and conditions

Results

In total, 150 patients were enrolled; 98 (54 males, mean age 38.6 ± 8.1 years) were IS patients and 52 (37 males, mean age 39.8 ± 9.3 years) IM patients. Out of all studied parameters, significant difference was found only between female subgroups; higher number of smokers in MI patients (72% vs. 27%, p < 0.05) and higher number of users of contraception pills in IS patients (68% vs. 19%, p < 0.05) were detected. Observed lower number of MI patients without regular sport activities (25% vs. 50%) and living in urban areas (20% vs. 61%) were non-significant.

Conclusions

The higher number of users of contraception in female IS patients and higher number of smokers in female MI patients were the only two significant differences found in studied parameters. Study supported by the IGA MH CR grant NT14288–3/2013 and by RVO FNOL 00098892.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PREDICTORS OF GOOD FUNCTIONAL OUTCOME IN PATIENTS WITH INTRACEREBRAL HAEMORRHAGE

I Šarbochová ¹, H Magerová ¹, M Hořejší ¹, A Tomek ¹

Abstract

Background

The knowledge of the important factors that affect prognosis of intracerebral haemorrhage (ICH) is necessary for the clinician to make a reasonable prediction for individual patients to provide a rational approach to patient management. Widely used predictive tools are ICH score (ICHs) - mortality at 30 days and SMASH-U etiology classification - mortality at 3 months.

Aim: The purpose of the study was to determine significant predictors of good functional outcome at 3 months in ICH patients using a combination of ICHs and SMASH-U.

Methods

Retrospective monocentric study of 130 consecutive ICH patients treated at comprehensive stroke centre ICU. Included patients were scored with ICHs on admission and the etiology was classified using SMASH-U after complete diagnostic examinations. The primary outcome was mRS 0–2 at 3 months.

Results

Good outcome was achieved in 49 (37.7%) patients. Structural lesion ICH was a predictor of good outcome independently on degree of ICHs (OR = 13,33, 95% CI 1,59–112, p = 0,02). Hypertonic ICH was predictor of good outcome only in combination with ICHs 0 (OR = 1.55, 95% CI 0.76–3.20, p = 0.23). The lowest chance of good outcome was in following categories: medication (OR = 0,42,95% CI 0,11–1.57, p = 0,2), underlying lesion (OR = 0.63,95% CI 0.24–1.67, p = 0.34), amyloid angiopathy (OR = 0.65,95% CI 0.22–1,98, p = 0.45) and ICH of undetermined etiology (OR = 0.69,95% CI 0,17–2,8, p = 0,6).

Conclusions

ICH from structural lesion was a significant predictor of good outcome irrespective of entry ICHs, hypertensive ICH predicted good outcome in ICHs 0 patients compared to other etiologies. The combination of both tools is useful to more accurately predict ICH outcome.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ASSOCIATION OF SLEEP DISORDERED BREATHING WITH WAKE-UP ACUTE ISCHEMIC STROKE

P Siarnik ¹, Z Carnicka ¹, K Klobucnikova ¹, B Kollar ¹, P Turcani ¹

Abstract

Background

Sleep disordered breathing (SDB) is a frequent in stroke patients. SDB is one of the independent risk factors for ischemic stroke. Multiple mechanisms underlying SDB might be responsible for the development of stroke. The aim of this study was to compare polysomnographic, clinical, and laboratory characteristics of wake-up (WUS) and non-wake-up acute ischemic strokes (NWUS).

Methods

We enrolled 88 patients with acute ischemic stroke. Clinical characteristics of the population were recorded on admission, and blood samples were obtained in the fasting condition following morning. SDB was assessed using standard overnight polysomnography in the acute phase of the stroke.

Results

WUS were present in 16 patients (18.2%), and NWUS in 72 patients (81.8%). In WUS compared to NWUS, we observed significantly higher values of apnea-hypopnea index (24.8 vs. 7.6, p = 0.007), desaturation index ([DI] 26.9 vs. 8.8, p = 0.005), arousal index (22.6 vs. 13.1, p = 0.035), diastolic blood pressure (91.6 mm Hg vs. 85.2 mm Hg, p = 0.039), triglyceride levels ([TG] 1.9 mmol/L vs. 1.2 mmol/L, p = 0.049), and significantly lower levels of D-dimer (0.4 µg/L vs. 0.7 µg/L, p = 0.035). DI (CI: 1.003–1.054, p = 0.031) and TG (CI: 1.002–1.877, p = 0.049) were the only independent variables significantly associated with WUS in binary logistic regression model.

Conclusions

Although the design of our study does not prove the causal relationship between SDB and WUS onset, higher severity of SDB parameters in WUS supports this hypothesis.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE CARNITINE-BUTYROBETAINE-TRIMETHYLAMINE-N-OXIDE PATHWAY AND PREDICTION OF CARDIOVASCULAR MORTALITY IN PATIENTS WITH CAROTID ATHEROSCLEROSIS

K Skagen ¹, M Troseid ², T Ueland ³, S Holm ³, A Abbas ⁴, I Gregersen ³, V Bjerkeli ³, F Reier-Nilsen ⁵, D Russell ¹, A Svardal ⁶, TH Karlsen ⁷, P Aukrust ³, RK Berge ⁶, M Kummen ³, J Hov ³, B Halvorsen ³, M Skjelland ¹

Abstract

Background

γ-butyrobetaine (γBB) is a metabolite from dietary Carnitine, involved in the gut microbiota-dependent conversion from Carnitine to the pro-atherogenic metabolite trimethylamine-N-oxide (TMAO). Orally ingested γBB has a pro-atherogenic effect in experimental studies, but γBB has not been studied in relation to atherosclerosis in humans. The aim of this study was to evaluate associations between serum levels of γBB, TMAO and their common precursors Carnitine and trimethyllysine (TML) and carotid atherosclerosis and adverse outcome.

Methods

Serum γBB, Carnitine, TML and TMAO were quantified by high performance liquid chromatography in patients with carotid artery atherosclerosis (n = 264) and healthy controls (n = 62).

Results

Serum γBB (p = 0.024) and Carnitine (p = 0.001), but not TMAO or TML, were increased in patients with carotid atherosclerosis. Higher levels of γBB and TML, but not TMAO or Carnitine were independently associated with cardiovascular death also after adjustment for age and eGFR (adjusted HR [95%] 3.3 [1.9- 9.1], p = 0.047 and 6.0 [1.8–20.34], p = 0.026, respectively).

Conclusions

Patients with carotid atherosclerosis had increased serum levels of γBB, and elevated levels of γBB and its precursor TML were associated with cardiovascular mortality. Long-term clinical studies of γBB, as a cardiovascular risk marker, and safety studies regarding dietary supplementation of γBB, are warranted.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

HAVIER DISEASE BURDEN OF YOUNGER STROKE PATIENTS IN A POOR DISTRICT OF BUDAPEST

I Szőcs ¹, I Vastagh ¹, A Ajtay ¹, A Folyovich ², D Bereczki ¹

Abstract

Background

Hungary has a single payer health insurance system, offering a potential of uniform quality of healthcare. The economic power of the districts of Budapest is far less than uniform, leading to substantional regional differences in socioeconomic status.

Methods

Based on the national database of the health insurance fund, we found 4779 patients hospitalized for their first-ever stroke between 2002 and 2007, dwelling in the least and the most wealthy districts of Budapest (the poorest being district 8, n = 2618, the most wealthy district 12, n = 2161). They were followed up for case fatality of any causes, associated diseases and stroke recurrence until 2013.

Results

Global case fatality was higher in the younger age-groups in district 8 than in district 12 (e.g. 41–50 years, 33% vs. 16%, p = 0.004). This difference diminished with age, but was detectable throughout all ages.

Disease burden (i.e. the mean of the number of associated diseases per patient for the respective group) was significantly higher in younger patients of district 8, this difference between the two districts vanishing by the age of 70. The prevalence of nutritional diseases (diabetes and hyperlipidaemia) was higher for district 8 regardless of age. The prevalence of vascular diseases in district 12 patients reached that of district 8 at a significantly older age (12 years delay for patients below 70 years).

Conclusions

Patients belonging to a lower socioeconomic group of a universal healthcare system show higher stroke fatality and heavier disease burden, particularly in younger age groups.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

RISK FACTORS OF CEREBRAL INFARCTION FOLLOWING TRAVEL ACROSS DIFFERENT CLIMATE ZONES

QC Tan ¹, JT Zhang ¹, XW Xing ¹, QG Xu ¹, C Rong-Tai ¹, SY Yu ¹

Abstract

Background

Limited studies reported the risk of cerebral infarction associated with the change of climate. Our aim is to investigate the risk factors of cerebral infarction occurred after travelling across different climate zones.

Methods

Subjects travelled from northeast, northwest and north of China to Sanya during September 1st 2012 to February 28th 2013 were reviewed. Subjects who developed cerebral infarct (Group I) or did not (Group II) were compared and risk factors were identified. Logistic regression models was used to identify the risk factors of cerebral infarction following climate zone change.

Results

Two hundred and ninety one subjects (Group I: 144; Group II: 147) were analyzed. Group I patients have higher prevalence of history of cerebral vascular disease, hypertension, abnormal glucose metabolism, and carotid arterial stenosis, hyperhomocysteinemia. Group I also experienced a bigger change of temperature between the place of departure and Sanya. A lower mean arterial blood pressure travel upon arrival to Sanya, and a bigger blood pressure difference before and after travel were observed in Group I. Cox regression analysis showed that male gender (OR = 1.522, p = 0.025), abnormal glucose metabolism (OR = 4.617, p < 0.001), cerebral arterial stenosis (OR = 3.48, p < 0.001), hyperhomocysteinemia (OR=1.417, p = 0.040), bigger temperature difference between the place of departure and Sanya (each 10°C) (OR = 1.423, p < 0.001), low blood pressure before travel (OR = 0.979, p = 0.025) were independent risk factors of cerebral infarction following travel.

Conclusions

Cerebral infarction following travel across different climate zones is a newly recognized etiology of stroke, and maybe associated with hemodynamic changes.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ACID URIC IN THROMBOLYSED STROKE PATIENTS: THE SUB-ANALYSIS OF THE URICIS STUDY

S Vidale ¹, A Consoli ², F Galati ³, P Postorino ³, M Arnaboldi ¹, D Consoli ³

Abstract

Background

Uric acid (UA) is an antioxidant agent and for this reason it could have neuroprotective effects. In previous studies high blood levels of UA were associated with poor clinical outcome in ischemic stroke patients. Aim of this sub-analysis was to investigate the prognostic role of UA on clinical outcome in thrombolysed stroke patients.

Methods

Consecutive thrombolysed patients admitted to two Italian stroke units between 2012 and 2013 have been enrolled. Demographical data, vascular risk factors, admission and follow-up clinical features have been registered. Uric acid, creatinine, blood glucose have been tested for each patient. Statistical analysis was performed using chi-square and t-test for univariate analysis. A conditional logistic regression was applied to determine the significant prognostic negative factors.

Results

211 patients were enrolled (Median age: 73 years; males: 51.4%). High blood pressure was the main vascular risk factor (70.1%). Median NIH value at admission was 11. Median UA value was 5.9 mg/dL and hyperuricemia was present in 28.9% of patients. While 64% of patients with normal uricemia had good outcome, 83% of hyperuricemic subjects had poor outcome (p < 0.001). At multivariate analysis, previous stroke, clinical syndrome and severity at admission were significantly related to poor clinical outcome (p < 0.001). A poor outcome was also associated to hyperuricemia condition (RR: 3.484; 95%CI: 2.168 – 5.601; p < 0.001).

Conclusions

In the sub-analysis of this study we observed a negative effect of hyperuricemia on functional outcome in thrombolysed patients. This condition could benefit for a prompt treatment, also in the acute phase of ischemic stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

RISK OF BLEEDING AND RECURRENCE BY TIME TO RECRUITMENT: DATA FROM THE TRIPLE ANTIPLATELETS FOR REDUCING DEPENDENCE AFTER ISCHAEMIC STROKE (TARDIS) TRIAL

L Woodhouse ¹, J Appleton ¹, N Sprigg ¹, P Bath ¹

Abstract

Background

Stroke and TIA are associated with an increased risk of recurrence. Antiplatelet treatment is often given in order to reduce this risk. However, the use of this treatment to prevent recurrence can increase the risk of bleeding events.

Methods

TARDIS is comparing intensive vs guideline antiplatelet therapy in patients with acute ischaemic stroke or TIA. Information on bleeding and recurrence is collected up to day 90. The outcomes of interest are recurrent stroke or TIA and bleeding at day 90, ordered by severity. The effect of time to recruitment on recurrence and major/fatal bleeding rates will also be assessed.

Results

By 21^st December 2015, 2973 patients had been recruited to the TARDIS trial; mean age 69, male 1867 (62.8%). By day 90, the distribution of outcome in ischaemic events was: fatal 0.5%, mRS 4/5 0.6%, mRS 2/3 1.5%, mRS 0/1 1.2%, TIA 2.4% and none 93.6%. The distribution of outcome in bleeding was: fatal 0.3%, major 1.3%, moderate 1.0%, minor 10.0% and none 87.4%. The distribution of recruitment, recurrence and major/fatal bleeding by time can be seen in Figure 1.

graphic file with name 10.1177_2396987316642909-img10.jpg

Conclusions

Patients recruited earlier into TARDIS have a higher rate of recurrence. Fatal recurrent events are more common than fatal bleeds.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

FUNCTIONAL OUTCOME IN PATIENTS SUFFERING A RECURRENCE OR A MODERATE/MAJOR BLEED AFTER STROKE/TIA: DATA FROM ‘TRIPLE ANTIPLATELETS FOR REDUCING DEPENDENCY AFTER ISCHAEMIC STROKE’ (TARDIS) TRIAL

L Woodhouse ¹, J Appleton ¹, N Sprigg ¹, P Bath ¹

Abstract

Background

After ischaemic stroke (IS) or TIA, recurrence and moderate/major bleeding are each associated with worse outcome. We compared baseline characteristics and outcomes for patients who did and did not have recurrence or bleeding using data from the ongoing TARDIS trial.

Methods

TARDIS is assessing the safety and efficacy of intensive vs guideline antiplatelet agents in 4,100 patients with acute non-cardioembolic IS or TIA. Information on bleeding is collected up to day 90. Recurrent IS and TIA events and functional outcome are assessed centrally with blinding to treatment assignment at day 90. Data are unadjusted odds ratio (OR) or mean difference (MD) with 95% confidence interval (CI).

Results

In 2973 patients (recruited up to 21 December 2015), recurrent events (192) were more common in patients with a qualifying event of TIA (p = 0.008). However, there was no difference in the number of people with moderate/major bleeding (87) in patients with either a qualifying event of stroke or TIA. Patients with a recurrent or moderate/major bleeding event had worse outcomes at day 90 than those without such events, with: more deaths (both p < 0.001), dependency (modified Rankin Scale, both p < 0.001), disability (Barthel Index, both p < 0.001), cognitive impairment (TICS-M, both p < 0.001), worse quality of life (EQ-5D HUS, both p < 0.001) and more mood disturbance (Zung depression scale, both p < 0.001).

Conclusions

Recurrent events are more common after TIA. Both recurrent ischaemic and significant secondary bleeding events are associated with a worse outcome.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

OUTCOMES ASSOCIATED WITH OFF-LABEL DOSING OF RIVAROXABAN IN THE XANTUS STUDY

P Amarenco ¹, AGG Turpie ², P Kirchhof ³, S Hess ⁴, S Kuhls ⁵, M van Eickels ⁴, S Haas ⁶, AJ Camm ⁷

Abstract

Background

XANTUS, a prospective, real-world study using rivaroxaban for stroke prevention in patients with non-valvular atrial fibrillation (NVAF) showed low rates of stroke and major bleeding. According to the label the approved rivaroxaban dose is 20 mg once daily (od) with 15 mg od used only for patients with creatinine clearance 15–49 ml/min.

Purpose

XANTUS provides an opportunity to assess outcomes associated with off-label rivaroxaban dosing in patients with NVAF.

Methods

Patients with NVAF newly started on rivaroxaban were followed up for 1 year or until 30 days after stopping treatment. Baseline characteristics and outcomes were compared in patients dosed in accordance with the label with those in whom the label was not followed.

Results

Of 6784 patients included in XANTUS, 2320 were classified as unknown in terms of dosing in accordance with the label, mainly because creatinine clearance was not recorded. Of the remaining patients, the majority (3608) received doses in accordance with the label, 856 were not dosed in accordance with the label. Patients receiving off-label doses of rivaroxaban had worse outcomes, with a composite of treatment-emergent adjudicated major bleeding, death, stroke or non-central nervous system systemic embolism of 7.5%/year compared with those treated on label (4.8%/year) (Table). Major bleeding occurred at a rate of 2.6%/year in patients treated on-label and 3.7%/year in those treated off-label. Corresponding rates for stroke/systemic embolism were 0.9%/year and 1.4%/year.

graphic file with name 10.1177_2396987316642909-img11.jpg

Conclusions

In XANTUS, dosing outside of the recommended label was associated with less favourable outcomes, potentially related to the inappropriate dosing and/or baseline patient characteristics.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

SYNCOPE AND NEUROLOGICAL SIGNS: DOUBLE TROUBLE?

E Campos Costa ¹, E Guevara ², M Rodrigues ¹

Abstract

Background

Transient loss of consciousness results from impaired cerebral perfusion, frequently from cardiac, neurocardiogenic or hemodynamic causes.

Methods: Results

A seventy-year-old male with no medical history presented with 3-month history of episodes characterized by malaise, blurred vision, faintness and dizziness, with postural changes and resolving spontaneously in seconds. Two days before admission the episodes became longer and more frequent. Neurological examination was unremarkable along with blood work, ECG and brain-CT. During observation he suddenly became obtunded with eye closure, left gaze deviation, facial asymmetry, severe dysarthria, left hemiparesis and bilateral Babinski sign (NIHSS:21). Emergent CT-angiography revealed possible bilateral V4 vertebral artery stenosis. After thirty minutes the patient recovered spontaneously (NIHSS:0) and antiplatelet therapy was started. Brain-MRI uncovered recent bilateral cerebellar, paramedian pontine and left cerebral peduncle infarctions, MRI-angiography and Doppler-ultrasonography confirmed bilateral vertebral stenosis and medical therapy was optimized. Cerebral angiography revealed severe right vertebral artery stenosis and an intracranial stent was placed. The transthoracic echocardiography was normal but Holter-monitoring revealed complete atrioventricular block pattern, leading to cardiac pacemaker implantation. Multifactorial etiology for the episodes was considered (cardiac conduction impairment and arterial stenosis). The patient had a favorable clinical course and remains asymptomatic.

Conclusions

The clinical features suggested postural hypotension. Neverteheless the latest episodes and symptoms witnessed by a neurologist led to other diagnosis. Careful evaluation of these patients with cardiac exams and vertebrobasilar artery imaging, may have important therapeutic and prognostic implications. Vertebrobasilar arteries stenting is controversial, but the consequences of a recurrent event may be serious or lethal.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CEREBRAL VENOUS THROMBOSIS - A RETROSPECTIVE STUDY

I Carmezim ¹, R Oliveira ², C Oliveira ², A Nunes ², A Gomes ², M Miranda ², A Monteiro ²

Abstract

Background

Thrombosis of the dural sinus and cerebral veins (CVT) are an uncommon form of stroke, usually affecting young individuals, representing 0.5% to 1% of all strokes.

Our purpose was characterization of CVT cases diagnosed at our hospital from 2004 to 2015.

Methods

Retrospective and descriptive study through assessment of the patient clinical files.

Results

The study population consisted of 27 patients, all Caucasians, with an average age of 43,5 years, wherein 24 (88,9%) were female.

All patients presented at least one thrombotic risk factors and the most frequent was oral contraceptives (55,6%), being the only one in four cases (14,8%).

The most frequent initial symptom was headache (88,9%), being the only symptom in 33,3% patients. The following usual initial symptoms were vomiting (29,3%), focal neurological deficits (25,9%) and seizures (18,5%).

Diagnosis was made by CT in 20 cases (74,1%). Initial head Computerized Tomography (CT) was normal in seven cases, in which the diagnosis was achieved by Cerebral CT-Venography in three cases (11,1%) and by Magnetic Resonance in four cases (14,8%).

Average time from onset of symptoms to diagnosis was 4,9 days.

The most frequent location of thrombosis was superior sagittal sinus (40,7%) and right transverse sinus (40,7%).

Treatment was made with anticoagulants in 92,6% and full recovery occurred in 24 (88,9%) of patients and 1 (3,7%) died.

Conclusions

CVT is a pathology with clinical nonspecific symptoms, requiring a large clinical suspicion for its diagnosis. It is important to emphasize that a negative head CT does not exclude the presence of CVT.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PRECISE DIAGNOSTIC SCORE (PREDISC) IMPROVES ACCURACY OF TRANSIENT ISCHEMIC ATTACKS (TIA) DIAGNOSIS

C Cereda ¹, P George ², M Mlynash ², GW Albers ²

Abstract

Background

To facilitate biomarker and genetic studies on TIA, a reliable tool for distinguishing brain ischemic events from non-vascular mimics is needed. A recently developed Precise Diagnostic Score (PREDISC) combines clinical features with advanced imaging to accurately achieve TIA identification.

Methods

Patients with TIAs were prospectively enrolled. A candidate serum biomarker, platelet basic protein (PBP), was evaluated between clinically diagnosed TIAs versus control patients. Alternatively, RNA expression in blood of TIA patients was performed. Subsequently, a blinded rater applied the PREDISC to further classify these patients and include those with probable to very likely TIA (PREDISC > =3) while excluding possible/unlikely to be TIA (PREDISC = 0–2). The student’s t-test was used for comparison of PBP samples to controls, and hierarchical cluster analysis was used to identify patterns in the RNA expression cohort.

Results

Utilizing the PREDISC, we excluded 12 patients from the PBP analysis that had been diagnosed clinically with a TIA (n = 22 with clinical diagnosis compared to n = 10 with PREDISC > =3). PREDISC improved the statistical significance of PBP to accurately diagnose TIAs compared to controls (p = 0.004 with PREDISC versus p = 0.019 with clinical diagnosis). Utilizing PREDISC on the RNA expression cohort, hierarchical cluster analysis of the identified genes suggested the presence of 2 patterns of RNA expression in patients with TIA (n = 10). The 2 patients excluded by PREDISC in this population had the same expression as controls.

Conclusions

PREDISC allows us to more accurately diagnose and select patients with "true" TIAs in the studied population and is promising for integration into future biomarker/genetic trials.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

IMMUNOHISTOCHEMICAL STAINNING OF 54 FRESH INTRACRANIAL THROMBI: HIGH CONTENT OF CD3+ CELLS MAY REPRESENT A NEW BIOMARKER OF ATHEROTHROMBOTIC STROKE

V Costalat ¹, C Dargazanli ¹, V Rigaud ¹

Abstract

Background

Approximately 30% of strokes are cryptogenic despite an exhaustive in-hospital work-up. Analysis of clot composition recently made routinely available by endovascular treatment could provide insights into stroke etiology. T Cells already have been shown to be a major component of vulnerable atherosclerotic carotid lesions. We therefore hypothesize that T-cell content in intracranial thrombi may also be a biomarker of atherothrombotic origin.

Methods

We histopathologically investigated 54 consecutives thrombi retrieved after mechanical thrombectomy in acute stroke patients. First, thrombi were classified as fibrin-dominant, erythrocyte-dominant or mixed pattern. Then, we performed quantitative analysis of CD3+ cells on immunohistochemically-stained thrombi and compared T-cell content between “atherothrombotic”, “cardioembolism” and “other causes” stroke subtypes.

Results

Fourteen (26%) thrombi were defined as fibrin-dominant, 15 (28%) as erythrocyte-dominant, 25 (46%) as mixed. The stroke cause was defined as “atherothrombotic” in 10 (18.5%), “cardioembolism” in 25 (46.3%), and “other causes” in 19 (35.2%). Number of T-cells was significantly higher in thrombi from the “atherothrombotic” group (53.60 ± 28.78) than in the other causes (21.77 ± 18.31; p < 0.0005) or the “cardioembolism” group (20.08 ± 15.66; p < 0.0003).

Conclusions

The CD3+ T-cells count in intracranial thrombi was significantly higher in “atherothrombotic” origin strokes compared to all other causes. Thrombi with high content of CD3+ cells are more likely to originate from an atherosclerotic plaque.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

HISTOLOGICAL ANALYSIS OF THROMBI RETRIEVED FROM PATIENTS WITH ACUTE ISCHEMIC STROKE AND CORRELATION WITH CLINICAL, ETIOLOGICAL AND RADIOLOGICAL FEATURES

A De Felipe-Mimbrera ¹, A Alonso-Canovas ¹, JC Mendez ², E Fandiño ², R Vera ¹, A Cruz-Culebras ¹, C Matute Lozano ¹, S Sainz de la Maza ¹, R Alvarez-Velasco ¹, H Pian ³, P Perez Torre ¹, B Fernandez Felix ⁴, J Masjuan ¹

Abstract

Background

Thrombus composition may relate with stroke etiology and radiological features. Our aim was to analyze the relation between histological components of thrombi retrieved in acute ischemic stroke (AIS) with etiology, clinical, and radiological features.

Methods

Histological analysis of thrombi retrieved from patients with AIS by endovascular mechanical extraction at our Hospital since January 2013-December 2015. We recorded histological composition (% of fibrin and red blood cells), clinical variables, baseline cranial tomography (CT) features and etiological subtype (TOAST classification). Statistical analysis was made using ANOVA, t-student, chi-square, Wilcoxon and Pearson´s linear correlation when applicable.

Results

Eighty-three patients were included, 53% male, mean age was 61 ± 10.2 (range 39–86). Etiology was cardioembolic in 51, atherothrombotic in 15, arterial dissection in 3, undetermined in 14. Hyperdense artery sign (HAS) was observed in 36 (43.4%). Previous intravenous thrombolysis in 38 (45.8%). Median retraction maneuvers 2 (1–6). Recanalization rates were 85.5% (TICI2b/3). Symptomatic hemorrhagic transformation was observed in 9 %, 48.2% were independent at 3 months (mRS 0–2). Mean red blood cell proportion was 59.8% ± 21.4, and mean fibrin proportion 40.2% ± 21.4 (cardioembolic: 41.6 ± 22.7, atherothrombotic: 38.7 ± 15.3, artery dissection: 37.9 ± 21.4, undetermined 36.7 ± 37.9). No association was found between fibrin fraction and etiology, mRS at 3 months, retraction maneuvers, recanalization rate or hemorrhagic transformation. HAS was significantly less frequent in fibrin dominant clots (p 0.032).

Conclusions

Thrombi composition does not appear to relate to stroke etiology. HAS on baseline CT is less frequent in fibrin dominant thrombi.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

INTIMAL HYPERPLASIA CAROTID PATCH ENDARTERECTOMY WITH GoreTeX AND PTFT PATCH

M Goertler ¹, L Poser ¹, A Oldag ¹, Z Halloul ²

Abstract

Background

To assess postoperative risk of intimal hyperplasia after carotid patch endarterectomy with GoreTex patches and PTFE patches.

Methods

Patients with symptomatic and asymptomatic carotid stenosis were subjected to patch CEA. Within an period of 20 years from 1994 to 2013 GoreTex patches and PTFE patches were used for patch closure. All patients underwent routine colour duplex follow-up investigations after 4 days, 6 weeks, 3 months and thereafter every 6 months to detect restenosis. Intimal hyperplasia was defined as low echogenic arterial wall thickening, detected not before the 6 weeks follow-up and not later than 18 months after endarterectomy.

Results

884 patients (75 men, mean age 67 years, SD 9 years) underwent carotid endarterectomy. Intimal hyperplasia occurred in 93 patients (10.5 %) and was found in 68 of 567 patients (12.0 %) with GoreTex patches and 25 of 317 % of patients (7.9 %) with PTFE patches (chi square test 0.056).

Conclusions

Intimal hypoplasia can be detected in a substantial number of patients after patch carotid endarterectomy. Its occurrence was not significantly different in patients with GoreTex patches compared to those with PTFE patches, although there was a trend to more frequent intimal hypoplasia after GoreTex.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

QUANTITATIVE VIDEO-OCULOGRAPHY: A NEW OPTION IN THE DIFFERENTIAL DIAGNOSIS OF THE VERTEBROBASILAR STROKE

M Guillán ¹, JC Fernandez-Ferro ¹, N Barbero ¹, MA Aranda ¹, S Bellido ¹, MM Medina ², J Pardo ¹

Abstract

Background

Most of acute vestibular syndromes (AVS) are due to benign peripheral causes (vestibular neuritis or labyrinthitis) but a 5% are the result of a vertebrobasilar stroke (VBS), a missdiagnosed entity. Recent studies have used the portable video-oculography device "VHIT" (Video Head Impulse Test) to measure the vestibular function as a highly sensitive test in the differential diagnosis between these two diseases. We tried to reproduce these results in our population.

Methods

We prospectively analyzed all patients with AVS attended by neurologist on call in our emergency department from June 2014 to June 2015. AVS was defined as dizziness/vertigo with or without unsteady gait, nystagmus or vegetative symptoms but without other focal neurological symptoms, lasting 1–7 days. In all cases cranial magnetic resonance imaging (MRI) with diffusion-weighted imaging was performed within 72 hours and study by VHIT.

Results

We identified 15 patients; 8 men and 7 women, mean age: 66 ± 18.8 (range: 19–86). 9 patients had a normal MRI and a VHIT compatible with peripheral vertigo (PV). 4 patients had a pathological MRI with VBS (3 cerebellar stroke (2 PICA, 1 ASCA), 1 brainstem stroke) and VHIT not compatible with PV. 2 patients had normal both MRI and VHIT, resulting in a final diagnosis of non vascular cerebellar syndrome after complete study.

Conclusions

The number of patients with AVS evaluated by neurologist was low. Innovative devices more accessible and affordable than MRI, based on the physiology of AVS, may help in the differential diagnosis between PV and VBS.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

VALIDITY OF PLASMA D-DIMER LEVEL IN DIAGNOSIS OF ISCHEMIC STROKE OF OTHER DETERMINED ETIOLOGY

MU Jang ¹, CH Kim ¹, JH Sohn ¹, HC Choi ¹

Abstract

Background

D-dimer is product of fibrin degradation and suggestive of predictor of stroke lesion volume and early neurologic outcome. However it has been controversial about correlation d-dimer and stroke subtype. We aimed to investigate plasma d-dimer level by TOAST classification in large cohort registry.

Methods

Based on prospective stroke registry, consecutive series of 2168 patients are included between January 2007 and December 2014. We collected demographics, stroke characteristics, and clinical outcomes. All hospitals participating in stroke registry use same algorithm for classification of stroke type.

Results

Among 2168 patients. 732 (34%) patients were identified by large artery atherosclerosis, 377 (17%) patients by small vessel occlusion, 579 (27%) patients by cardioembolic stroke, 92 (4%) patients by other determined etiology like cancer related stroke, and rest of them by others. Mean plasma level of d-dimer was highest in the other determined etiology group , followed by cardioembolic stroke, and it was statistically significant by ANOVA methods.

Conclusions

Plasma d-dimer level was higher in subgroup of other determined etiology by TOAST classification. Ischemic stroke patients with high d-dimer level should be considered for comprehensive cancer work up.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CRYPTOGENIC ISCHEMIC STROKE DEFINED BY COMPUTERIZED SSS-TOAST CLASSIFICATION: CHARACTERISTICS AND PROGNOSIS: A STUDY OF 490 CASES FROM THE BREST STROKE REGISTRY

M Kieffer ¹, D Hervé ², FM Merrien ¹, A Jourdain ¹, I Viakhireva-Dovganyuk ¹, P Goas ¹, F Rouhart ¹, S Timsit ¹

Abstract

Background

Cryptogenic ischemic stroke (CIS) have unidentified mechanisms despite a complete assessment, the definition however is not standardized and therefore unreliable. SSS-TOAST is a recent automated classification that may provide a reliable classification for CIS. The goal of this study was to analyze the characteristics and prognosis of well defined-CIS in a population-based registry.

Methods

Patients in the Brest Stroke Registry (France) were collected from 2008 to 2010 for demographic data, clinical presentation, vascular risk factors and early (28-days) and late mortality (5 years) and classified according SSS-TOAST. CIS were compared to non-CIS by univariate and multivariate analyzes (p < 0.05).

Results

2087 IS were collected, 490 had CIS. In univariate analysis, CIS were younger (75 years versus 79), had less coronary artery disease (10.1 % versus 17.0%), peripheral artery disease (5.8% versus 8.9%), cardiac arrhythmia (2.7% versus 29.4%), but more dyslipidemia (39.3% versus 34.0%). CIS patients had a lower median NIHSS score (2 versus 3), less lacunar syndrome (18.9% versus 36.1%), a higher Glasgow Coma scale (87.1% versus 89.3%) and were more frequently “at home without help” (55.0% versus 38.9%). Multivariate analysis confirmed predictors of CIS for GCS (3.00; 95%CI [1.54–5.86]), “home without help” (1.68; [1.29–2.19]) and lacunar syndromes (OR = 0.30; [0.22–0.40]). Early and late mortality was lower in the CIS compared to non-CIS: 2.26% vs 11.68% and 24.79% vs 42.95% respectively.

Conclusions

CIS represented 25% of IS, were younger, had less vascular diseases, a milder clinical severity and a better early and late prognosis suggesting that atherosclerosis is not the main mechanism involved.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CEREBROSPINAL FLUID β-AMYLOID LEVELS IN CEREBRAL AMYLOID ANGIOPATHY-ASSOCIATED HEMORRHAGIC STROKE

A Lago ¹, M Campins ², R López-Cuevas ², C Nieves ², A Wicht ², L Morales ², H Argente ², JI Tembl ², G Fortea ², M Baquero ²

Abstract

Background

According to the modified Boston criteria, cerebral amyloid angiopathy (CAA) can present with lobar hematoma (LH) or superficial siderosis (SS). Our aim was to analyze cerebrospinal fluid (CSF) biomarkers as a diagnostic tool for CAA as potential contributors to improve the diagnosis of CAA in life.

Methods

We retrospectively analyzed CSF levels of Aβ42, total tau (t-tau), and phosphorylated tau (p-tau) of 15 patients with LH or SS. Concentrations expressed in nanograms per liter (ng/L) were determined with ELISA (Innogenetics). Normal cutoff values were established: Aβ42 < 700 ng/L, t-tau > 350 ng/L, p-tau > 85 ng/L.

Results

15 patients were included. Mean age was 72 years (60–81); 40% were female, 60% had hypertension, 33% had dementia, 33% had history of previous hemorrhagic stroke and 40% were on antithrombotic treatment. Mean levels of biomarkers were: Aβ42: 578.7 ng/L (301–1225); t-tau: 474.4 ng/L (128–1240); p-tau 54.2 ng/L (22–131). 73% had amyloid B42 < 700 ng/L, 33.3% t-tau < 350 ng/L, 80% p-tau < 85 ng/L.

Conclusions

Amyloid biomarkers in CSF have a potential role in the diagnosis of CAA associated cerebral hemorrhage, as a large number of cases have abnormal values of amyloid in CSF. Questions remain about their usefulness such as best timing for sample collection, appropriate cutoff values for the diagnosis and issues about sensibility and specificity.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PREDICTION OF PATENT FORAMEN OVALE IN YOUNG ADULTS WITH CRYPTOGENIC STROKE

V Larrue ¹, A Jaffre ¹, B Guidolin ¹, N Nasr ¹

Abstract

Background

The probability of discovering a patent foramen ovale (PFO) in a patient with cryptogenic stroke can be estimated with the RoPE score. However, the predictive value of the RoPE score may be reduced in young adults, because of the weight of age in its calculation. In the present study, we sought to determine the predictive value of a new score using the presence of non-obstructive carotid atherosclerosis on vascular imaging rather than age and traditional vascular risk factors.

Methods

Patients aged 18–54 years, consecutively treated for first-ever cryptogenic ischemic stroke in a stroke unit, were included in this analysis. Cryptogenic stroke was diagnosed using the ASCOD classification system. PFO was diagnosed on TEE. Non-obstructive (<50% stenosis) carotid atherosclerosis was assessed using ultrasound imaging.

Results

A total of 164 patients [mean age (SD) = 43.7 (8.5) years; 104 men] were included. A PFO was diagnosed in 79/164 (48.2%) patients. In logistic regression analysis including the components of the RoPE score and carotid atherosclerosis, only carotid atherosclerosis (OR = 0.22, 95% CI 0.09–0.52, P < 0.001) and cortical infarct (OR = 2.18 95% CI 1.03–4.60, P = 0.04) were significantly associated with PFO. A 4-point (0 to 3) score was derived based on these ORs. This Atherosclerosis-Cortical infarct (AC) score significantly predicted PFO (c-statistic = 0.66, 95% CI 0.58–0.74). The c-statistic for the RoPE score was inferior (0.60, 95% CI 0.52–0.69).

Conclusions

The AC score is calculated using imaging data collected during the initial evaluation of stroke. The present study suggests that this simple score can predict the probability of PFO in young individuals with cryptogenic stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

IMPACT OF SIDE BRANCHES ON COMPUTATION OF FRACTIONAL FLOW IN INTRACRANIAL ARTERIAL STENOSIS USING COMPUTATIONAL FLUID DYNAMICS METHOD

H Liu ¹, L Lan ¹, X Leng ¹, HL Ip ¹, J Abrigo ², TW Leung ¹, D Wang ³, KS Wong ¹

Abstract

Background

Computational ﬂuid dynamics (CFD) allows noninvasive computation of fractional flow(FF) in intracranial arterial stenosis (ICAS). Removal of small branches in cerebral arteries is necessary in CFD simulation. The impact of the simplification on the measurement of FF needs to be judged.

Methods

Idealized vascular model was built with 70.8% focal luminal stenosis. A branch with 1/3 or 1/2 radius of parent vessel was added at distances of 5, 10, 15 and 20 mm to the lesion, respectively. CFD was computed with assumptions of rigid vessel wall, blood as Newtonian fluid, incorporating pressure at inlet boundary, and flow rate at outlet boundary. Assignment of flow rate at bifurcation follows Murray’s law. Five intracranial arteries reconstructed from patient-specific imaging were used to test the impact of simplification by including or removing side branches. Relative difference of FF within 5% between paired models (branches included and removed) is considered no impact of the branches on FF assessment

Results

Compared with control models without branch, the relative differences of FF in models with side branches of 1/3 or 1/2 radius of parent vessels located at different distances to the stenosis, were less than 2%. In the five pairs of cerebral arteries (branches included and removed), FF were 0.876/0.877, 0.853/0.858, 0.874/0.869 0.865/0.858 and 0.952/0.948 respectively. The relative difference in each pair was less than 1%.

Conclusions

Removal of side branches with radius <50% of parent vessel has little impact on the accuracy of FF assessment in ICAS.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ASCOD CLASSIFICATION OF ACUTE ISCHAEMIC STROKE AMONG YOUNG ADULTS IN A GENERAL HOSPITAL

M McCarron ¹, J McKee ², F McVerry ¹

Abstract

Background

Most young patients with acute ischaemic stroke (AIS) are investigated and managed in general hospitals. We evaluated the aetiology of young AIS patients in a general hospital using the ASCOD (atherosclerosis, small vessel disease, cardiac source, other cause and craniocervical dissection) classification system.

Methods

Risk factors and investigations were recorded in consecutive AIS patients aged from 14 to 45 years admitted to a general hospital over a 10 year period.

Results

82 consecutive patients (47 men, 35 women, mean age 36.7 (SD 8.62) years) with AIS were assessed. The most common risk factors were cigarette smoking (52%), hypertension (27%), excess alcohol (22%) and family history of stroke in a first degree relative (21%). A definite cause of stroke (ASCOD grade 1) was identified in 41 patients (50%). An uncertain cause of stroke (ASCOD grade 2) was found in nine patients (11%). No cause for stroke was identified (A0S0C0O0DO) in 22 patients (27%). Cryptogenic stroke patients were less thoroughly investigated (grade 9) than patients with other ASCOD grades, but this was not statistically significant (7 of 22 or 32% versus 13 of 75 or 22%, p = 0.23). In five patients (4.8%) with recurrent AIS over a mean follow-up of 5 years (1.2% per year), definite causes were identified in four patients - mitral valve lesion, moyamoya, MELAS and small vessel disease.

Conclusions

The ASCOD classification system encourages investigation of young AIS patients. A general hospital can identify similar phenotyping results in young AIS patients as larger tertiary stroke centres.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ACUTE POSTERIOR MULTIFOCAL PLACOID PIGMENT EPITHELIOPATHY (APMPPE) DIAGNOSIS AFTER RECURRENT STROKES IN YOUNG PATIENT: CASE REPORT

M Ranieri ¹, A Bersano ¹, L Caputi ¹, M Carriero ¹, G Boncoraglio ¹, G Cammarata ², S Sacco ³, E Parati ¹

Abstract

Background

Acute posterior multifocal placoid pigment epitheliopathy (APMPPE) is a rare, immune-mediate chorioretinal disease, affecting typically young people, characterized by the simultaneous or sequential onset in both eyes of multiple cream-colored lesions located in the posterior pole leading to visual impairment. These lesions progressively fade and are replaced by areas of depigmentation. However, the disease is typically self-limiting with a good prognosis.

Neurological complications are uncommon and can include headache, transient hearing loss, optic neuritis, meningoencephalitis and stroke. Cerebrovascular complications usually occur simultaneously or within a few weeks after the ocular presentation, even if delayed strokes more likely mediated by vasculitic-mechanism are reported years after APMPPE onset.

Methods

Herein we report a 18 years old male patient who developed multiple ischemic strokes in different vascular territories within few weeks, without complaining any visual symptoms. He underwent a comprehensive diagnostic assessment in order to rule out other cerebrovascular etiology, such as primary and secondary autoimmune disorders

Results

Brain MRI confirmed bilateral cerebellar, pontine and left white matter periventricular recent ischemic lesions.

Angiographic and CSF evaluation resulted normal. An ophthalmologic evaluation disclosed the typical APMPPE ocular features.

Conclusions

This represents the first case of APMPPE in which neurological manifestations precede ocular symptoms. Our report underlines the utility of a complete ophthalmological evaluation as part of cerebrovascular assessment, in young-onset cryptogenic stroke, even when no clear visual disturbance are complained. Although not always supported by cerebral angiogram and CSF findings, vasculitic process is probably the mechanism underlying stroke in APMPPE, representing a kind of “uveocerebral vasculitic syndrome”.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

LOW UTILITY OF SCREENING FOR HYPERCOAGULABILITY IN ARTERIAL ISCHEMIC STROKE

J Schaafsma ¹, L Kalman ¹, N Rashkovan ², R Selby ³, E Elamin ¹, R Swartz ², L Casaubon ¹

Abstract

Background

The yield of hypercoagulability screening in patients with arterial ischemic stroke is unknown whereas costs of screening are substantial. We evaluated whether hypercoagulability screening changes clinical management for our stroke patients.

Methods

We identified all patients with arterial ischemic stroke tested for hypercoagulability at the Toronto Western Hospital and the Sunnybrook Health Science Centre between July 2012 and July 2015. We separated screening for antiphospholipid antibodies (APLA) from inherited thrombophilia testing (protein C/S or antithrombin deficiency, Factor-V Leiden mutation, prothrombin gene mutation) and assessed the number needed to screen to change clinical management.

Results

220 stroke patients, mean age 53 (IQ-range 43–63), were tested for hypercoagulability: 213/220 patients (97%) were screened for APLA and 187/220 patients (85%) for inherited thrombophilia. 47/220 patients (21%) had abnormal test results: 8 patients (4%) had APLA, 37 patients (17%) had positive screening for inherited thrombophilia, and 2 patients (1%) had both. Management changed in 1/220 patient (0.5%, 95%-CI: 0.1–2.5%; number needed to screen: 220). This patient had SLE and presented with a third stroke. She was prescribed warfarin after APLA were confirmed on repeat testing. For the other 46 patients with abnormal hypercoagulability tests clinical management did not change. Reasons were: marginally abnormal results considered clinically irrelevant (n = 31), known thrombophilia and already on anticoagulation (n = 1), or identification of other stroke etiology (n = 14).

Conclusions

We found a low yield from APLA screening and no yield from inherited thrombophilia testing for patients with arterial ischemic stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

DEVELOPING A NOVEL ALGORITHM TO HELP IDENTIFY ACUTE STROKE MIMICS

F Siddiqui ¹, N Khan ¹, C Goehl ¹, L Endris ¹, A Elias ²

Abstract

Background

Stroke is the leading cause of disability and death. However ≈ 30% of patients with stroke like symptoms do not have stroke. Due to time sensitivity and established safety of intravenous tissue plasminogen activator (tPA), a significant number of stroke mimics receive tPA resulting in unwarranted stay, unnecessary diagnostic testing, and a significant financial burden to the hospitals, and patients. We proposed a novel algorithm derived from multiple studies looking at common predictors of acute stroke mimics.

Methods

We performed a review of previously published articles on acute stroke mimics and identified several factors that are positively or negatively associated with these patients. We measured the strength of association by utilizing Odd’s ratios. We identified major negative or positive predictors (Age, hypertension, hyperlipidemia, diabetes, atrial fibrillation, migraine, epilepsy and psychiatric illness) that are easy to acquire in emergency setting and formulated a nine point scoring system. The patients with highest scores would most likely be stroke mimics. We applied this algorithm on retrospectively collected patients that received IV tPA in our hospital.

Results

Our study included 106 patients. 26 (24.5%) patients were stroke mimics. 50% of stroke mimics were women. Only 7% stroke mimics had atrial fibrillation as compared to 43% with real strokes. After application of the algorithm, patients who scored >5 points have 100 % specificity for being stroke mimics.

Conclusions

We proposed a novel algorithm to identify stroke mimics that can be utilized in emergency setting to triage a patient for acute stroke imaging/management.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

TROPONIN T PREDICTS THE CARDIOEMBOLIC ETIOLOGY AND CLINICAL OUTCOME IN THE HYPERACUTE STROKE PHASE

M Terceño ¹, J Serena ¹, Y Silva ¹

Abstract

Background

High cardiac troponin (cTn) levels are detected in stroke patients. Nevertheless is not well stablished the role that cTn plays in stroke and its utility. The aim of this study is to know whether basal cTnT determination in the hyperacute phase can predict the cardioembolic etiology and clinical outcome in stroke patients.

Methods

We prospectively studied 112 patients with undetermined acute ischemic stroke. cTnT levels were determined at hospital arrival. Small vessel disease, large vessel occlusion and cardioembolic subetiologies at admission were ruled out for this study. All patients were subjected to a complete etiology evaluation. The follow up was at least 12 months. Classification of subtype ischemic stroke was made by TOAST criteria. We stablished two groups: patients cTnT ≥ 14 ng/L (group A) and <14 ng/L (group B).

Results

Patients of group A were significantly older (77 vs 63), had higher baseline NIHSS (8 vs 4), higher left atrial diameter (41,7 vs 36,9 mm), lower ejection fraction (57% vs 62%), had more frequently major cardioembolic sources after echocardiography evaluation (15,6% vs 6,5%), had more previously unknown atrial fibrillation (38,1% vs 7,1%), more frequently cardioembolic etiology (76,2% vs 28,5%), lower glomerular filtration (GF) (63,6 vs 90,4), higher 3 months NIHSS (3 vs 1), were less frequently independent at 3 months [mRS 0–2](47,55 vs 89,4%) and had higher mortality at follow-up (17,5% vs 1,5%). After multivariate analysis cardioembolic etiology and GF remained statistically significant.

Conclusions

Determination of basal cTnT in undetermined strokes during the hyperacute phase predicts cardioembolic TOAST subtype and long-term prognosis.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

IS ROUTINE ECHOCARDIOGRAPHY NECESSARY IN PATIENTS WITH A TIA?

S Tyebally ¹, A Chandna ¹, D Turner ¹, R Simister ¹

Abstract

Background

Cardioembolism is implicated in approximately 15% of ischaemic strokes with transthoracic echocardiography (TTE) being the primary mode of cardiac imaging. There have been no studies specifically investigating the utility of TTE in Transient Ischaemic Attacks (TIAs). In this study we aim to quantify the yield of TTEs in TIA patients.

Methods

We performed a retrospective review of the use of TTE in the population of patients seen between 2011 and 2014 who presented to a specialist stroke service in London, UK, with an acute neurological event diagnosed as TIA, Amaurosis Fugax, or Branch Retinal Artery Occlusion. Out of these 1150 patients, 317 patients had a routine TTE performed in the same hospital and available for analysis. The TTE reports were subsequently analysed. Electronic clinic letters of these patients were also analysed to determine whether the TTE findings changed the clinical management of the patient.

Results

Of the 317 TTEs performed, Patent Foramen Ovale (PFO) was identified in 21 (6.6%), heart failure in 11 (3.5%), valve disease in 26 (8.2%) and mixed pathology in 15 (4.7%). Other various pathology (e.g. pericardial effusion) was found in 20 (6.3%). A normal study was reported in 224 (70.7%). The TTE changed the clinical management in 8 patients (4 PFO closure procedures, 4 were referred for anticoagulation).

Conclusions

We identified that routine TTE performed in a population of TIA patients changed the clinical management in only 2.5%. An abnormal TTE was reported in 29.3% demonstrating a significant level of cardiac disease in this population.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE A-S-C-O CLASSIFICATION IDENTIFIES CARDIOEMBOLIC PHENOTYPES IN A HIGH PROPORTION OF EMBOLIC STROKES OF UNDETERMINED SOURCE (ESUS)

M Vales Montero ¹, A García Pastor ¹, B Chavarría Cano ¹, P Sobrino García ¹, AM Iglesias Mohedano ¹, F Díaz Otero ¹, P Vázquez Alén ¹, E Luque Buzo ¹, N Redondo Ráfales ¹, P Salgado Cámara ¹, MÁ Martín Gómez ¹, P Simón Campo ¹, Y Fernández Bullido ¹, JA Villanueva Osorio ¹, A Gil-Núñez ¹

Abstract

Background

To compare the distribution of A-S-C-O phenotypes in patients with ischemic stroke meeting ESUS criteria with the rest of stroke subtypes.

Methods

We analyzed patients with ischemic stroke admitted to a stroke unit during 2010. Stroke etiology was determined according to TOAST and A-S-C-O classification. Retrospectively, we identified patients that met ESUS criteria and compared the A-S-C-O phenotype in the ESUS group with the rest of stroke subtypes (non-ESUS group).

Results

The study included 318 patients. According to TOAST criteria, cryptogenic stroke accounted for 22.3% of all ischemic strokes. Most of cryptogenic strokes fulfilled ESUS criteria (85.7%). None of the patients classified in the ESUS group scored 1 (defined cause) in any of the A-S-C-O phenotypes. 31.7% of ESUS were categorized as C2 ("cardioembolic, uncertain causality") compared with 10.9% of non-ESUS (p < 0.001) and 35.0% of ESUS were classified as C3 ("cardioembolic, unlikely a direct cause of stroke, but disease is present") compared with 20.2% of non-ESUS (p = 0.01). Conversely, 3.3% of ESUS were classified as S2 ("small vessel disease, uncertain causality ") in contrast to 21.3% of non-ESUS (p = 0.001). There were no statistically significant differences in patients who obtained scores 2 or 3 in the rest of A-S-C-O phenotypes.

Conclusions

The TOAST classification categorizes a high proportion of ischemic strokes as cryptogenic, of which a significant part fulfills ESUS criteria. The A-S-C-O classification identifies potential cardioembolic sources in patients classified as ESUS. Our results support that a significant proportion of strokes meeting ESUS criteria could have a cardioembolic mechanism.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

RACE-ETHNIC DISPARITIES AMONG ICH PATIENTS IN THE FLORIDA-PUERTO RICO COLLABORATION TO REDUCE STROKE DISPARITIES (FL-PR CReSD)

M Ayodele ¹, K Wang ¹, C Dong ¹, MA Ciliberti-Vargas ¹, C Gutierrez M, S Oluwole ¹, EJ Perez ¹, N Asdaghi ¹, S Koch ¹, JG Romano ¹, DZ Rose ², WS Burgin ², EJ Garcia ³, U Nobo ⁴, M Robichaux ⁵, SP Waddy ⁶, MF Waters ⁷, JC Zevallos ⁸, RL Sacco ¹, T Rundek ¹

Abstract

Background

Race-ethnic disparities among patients with intracerebral hemorrhage (ICH) have previously been described. We evaluated for race-ethnic disparities in incidence, risk factors, and outcomes among ICH patients in the FL-PR CReSD Study.

Methods

Race-ethnicity were categorized as follows: Puerto Ricans (PR-H), Florida non-Hispanic White (FL-W), non-Hispanic Black (FL-B), and Hispanic (FL-H). 11,208 patients with ICH (62% FL-W, 18% FL-B, 14% FL-H, 6% PR-H) were included from 76 sites (67 FL; 9 PR) from 2010 – 2015. Age was compared using ANOVA and logistic regression was used to evaluate for differences in risk factors and in-hospital mortality.

Results

Overall, FL-B were younger (60 ± 14 vs. FL-W 71 ± 15, FL-H 68 ± 16, PR-H 70 ± 14; p < 0.0001), and compared to FL-W, had higher rates of smoking (14.9% vs 12.4%, p < 0.0001), diabetes (27.7% vs. 19.8%; p < 0.0001), and hypertension (73.7% vs. 63.9%; p < 0.0001). Compared to FL-H, PR-H had higher rates of diabetes (40.6% vs. 24.6%; p < 0.0001) and hypertension (81.4% vs. 58.6%; p < 0.0001). Age-adjusted in-hospital mortality was lower for FL-B compared to FL-W (OR 0.85, 95% CI 0.75 – 0.97) and higher for PR-H compared to FL-H (OR 1.34, 95% CI 1.07 – 1.69).

Conclusions

Among ICH patients in the FL-PR CReSD Study, FL-B were significantly younger with higher rates of comorbidities despite lower in-hospital mortality compared to FL-W. PR-H had both higher rates of vascular risk factors and in-hospital mortality compared to FL-H. Further analyses are planned to examine the effects of severity and process of care on these outcomes.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CLINICAL OUTCOME OF PATIENTS WITH PRIMARY INTRACEREBRAL HEMORRHAGE IN A SPECIALIST STROKE CENTRE IN UNITED KINGDOM- RETROSPECTIVE CASE SERIES

P Boovalingham ¹, L Brawn ², M Blake ³, D O'Kane ³, V Srinivasan ³

Abstract

Background

Intracerebral hemorrhage (ICH) is the most devastating type of stroke with the greatest mortality rate. Primary intracerebral hemorrhage, accounting for 78 to 88 percent of cases, originates from the spontaneous rupture of small vessels damaged by chronic hypertension or amyloid angiopathy.

Methods

Our aim is to look at the clinical outcome of patients with primary intracerebral hemorrhage (ICH) admitted to Northampton General Hospital NHS Trust, a specialist stroke centre in United Kingdom from September 2014 to August 2015. Neuroimaging in the form of cranial CT scan was done in all patients to confirm diagnosis. Functional outcomes were assessed using modified Rankin scale (mRS) after discharge and at 6 months after discharge.

Retrospective case analysis; All the data iwere analyzed using multivariate logistic regression.

Results

A total of 279 ICH patients(average age 77.25 ± 14.50years) were included with men(64.11%)significantly be more than women(P < 0.002). Most common ICH location was basal ganglia (60%)followed by cortical lobar area(21.8%),thalamus(10%),cerebellum(4.2%)and brainstem(4%). Ventricular extension was noted in13.9% of patients.ICH volume was mostly below15 cc (39%) as computed by Kothari method. ICH score upon admission varied but mostly with a score of 0 and 2. Seven percent of patients had surgical intervention. All-cause mortality during admission was at 17%. There was improvement in the modified Rankin Scale (mRS) scores of patients upon discharge and at6 months in ICH survivors.

Conclusions

Outcome of patients with primary intracerebral hemorrhage varied greatly and dependent upon several factors. Older age, high ICH score and volume upon admission were identified to be important factors of poor outcome.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

SMALL VESSEL DISEASE MARKERS AND INTRACEREBRAL HEMORRHAGE VOLUME AND EXPANSION

G Boulouis ¹, E Van Etten ^1,², A Charidimou ¹, E Auriel ^1,³, A Morotti ¹, M Pasi ¹, HB Brouwers ^1,⁴, AM Ayres ¹, A Vashkevich ¹, M Jessel ¹, KM Schwab ¹, A Viswanathan ¹, J Rosand ¹, JN Goldstein ^1,⁵, SM Greenberg ¹, ME Gurol ¹

Abstract

Background

Hematoma expansion is an important determinant of outcome in spontaneous intracerebral hemorrhage (ICH). We investigated the impact of MRI markers of small vessel disease (SVD) on hematoma volume and growth in patients with lobar and deep ICH.

Methods

ICH Volumes at presentation and closest to 48 h post symptoms onset were measured in 370 patients with primary ICH (not related to anticoagulation) and expansion was calculated. Microbleeds (MBs), cortical superficial Siderosis (cSS) and white matter hyperintensity (WMH) volume were assessed on MRI. Associations between SVD markers and ICH volume as well as expansion were investigated using multivariable models.

Results

We analyzed 232 subjects with primary lobar (mean age 74.9 ± 11, 55% female) and 138 subjects with deep ICH (mean age 67.1 ± 13, 44% female). Lobar ICH was significantly larger than deep ICH even after adjusting for age and gender (p < .001).

Presence of cSS was an independent predictor of ICH volume in the lobar group [TABLE]. Absence of MBs was a predictor of larger ICH volume in both deep and lobar ICH and of expansion in lobar ICH. WMH volumes were not associated with acute ICH features.

graphic file with name 10.1177_2396987316642909-img12.jpg

Conclusions

Hemorrhagic markers of SVD on MRI are associated with ICH volume and expansion suggesting a broader prognostic role for acute phase MRI in spontaneous ICH.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PRIOR ANTIPLATELET THERAPY IS ASSOCIATED WITH LARGER HEMATOMA VOLUME AND HEMATOMA GROWTH IN PATIENTS WITH INTRACEREBRAL HEMORRHAGE: RESULTS FROM AN OBSERVATIONAL STUDY AND A META-ANALYSIS

P Camps-Renom ¹, A Alejaldre-Monforte ¹, R Delgado-Mederos ¹, A Martínez-Domeño ¹, L Prats-Sánchez ¹, E Pascual-Goñi ¹, J Martí-Fàbregas ¹

Abstract

Background

Large baseline Hematoma Volume (HV) and Hematoma Growth (HG) are both related to poor outcome in patients presenting with intracerebral hemorrhage (ICH). Whether prior antiplatelet therapy (APT) influences baseline HV, HG and the outcome following an ICH, remains controversial.

Methods

We collected clinical and radiological data from a prospective cohort of patients diagnosed of spontaneous ICH within 24 hours from the onset of symptoms. Prior APT was recorded by clinical history. In patients in whom a follow-up CT scan was available within 72 hours we assessed HG, defined as an increase of >33% in the HV. We assessed mortality and functional outcome during follow-up with the Rankin scale. We also searched for published studies reporting HG according to previous APT and pooled the available data to perform a meta-analysis.

Results

We included 223 patients (mean age 72.5 ± 13 y, 54.3% were men). Previous APT was reported in 74 patients (33.2%). The linear regression model showed that prior APT was independently associated with larger baseline HV. HG was detected in 49 out of 130 patients (37.7%) and no differences were observed according to prior APT in our cohort. However, after pooling our results with the available data of seven studies in the meta-analysis, prior APT showed an increase in HG frequency (OR 1.56 95% CI 1.17–2.07). Patients under APT tended to present with worse outcome during the follow-up, though this difference was not significant (p = 0.06).

Conclusions

Prior APT is related to greater HV at admission and a higher risk of HG in patients with spontaneous ICH.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

TRENDS IN CASE FATALITY, ANTICOAGULANT USAGE AND LOCATION OF INTRACEREBRAL HAEMORRHAGE OVER A 12 YEAR PERIOD

S Murphy ¹, MT Cooney ¹, S O'Callaghan ¹, P Moloney ¹, I Noone ¹, M Crowe ¹, T Cassidy ¹

Abstract

Background

Intracerebral haemorrhage (ICH) is associated with worse outcomes than ischaemic stroke. Counter- intuitively this has not improved in recent years. We postulated that increasing age of the population and usage of anticoagulants represents a possible explanation.

Methods

St Vincent’s University hospital is a tertiary referral hospital serving a population of 300,000 in Dublin, Ireland. We excluded ICH associated with trauma or other secondary causes. We analysed changes in age distribution, clinical characteristics, medication usage and case fatality (30 day mortality) over the 12 year period. Fisher’s exact test was used to assess for significant differences between percentages.

Results

3,547 stroke patients presented between 2003 and 2014; 11.1% (394) were due to ICH. Median age was 77.2 years. ICH patients aged ≥90 years increased from 1.9% in 2003–2006 to 7.5% in 2010–2014. Anticoagulation use in this group increased from 0% in 2003–2006, to 11% in 2007–2010 to 19% in 2011–2014, NS. There was no change in case fatality or location of ICH over the 12 years. There was an increase in case fatality with increasing age; 11% in under 75 s, 24% in 75–89, 38% in over 90 s, p < 0.001. Lobar ICH was associated with higher case fatality than deep ICH; lobar 40%, deep 14%.

Conclusions

Conclusion: We have shown no decrease in case fatality, despite advances in management of ICH over this period. Potentially this is related to the increasing usage of anticoagulation and age in ICH patients. Further research will focus on identifying factors associated with short-term mortality and longer term functional outcome.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

INTRACEREBRAL HEMORRHAGE AFTER THROMBOLYSIS: REPORT FROM A TERTIARY CARE HOSPITAL, NORTH INDIA

B Das ^1,², D Khurana ¹, C Ahuja ³, V Lal ¹, S Prabhakar ^1,⁴

Abstract

Background

Intracerebral hemorrhage (ICH), a potential life threatening complication of thrombolysis. A hemorrhagic transformation (HI) of ischemic brain tissue can occurs with or without use of intravenous recombinant tissue plasminogen activator (rtPA) although it is clearly high in treated group. There is limited data of from Indian subcontinent. Hence we aim to address the frequency and outcome of thrombolysis related ICH and more importantly symptomatic ICS (sICH) from a North Indian public tertiary hospital.

Methods

A retrospective review of our prospective acute ischemic stroke database from January 2011 to December 2015, who received intravenous rtPA within 4.5 hours of symptom onset, were analyzed. European Cooperative Acute Stroke Study (ECASS) II and Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST) criteria were used in defining thrombolysis related ICH (HI-1, HI-2, PH-1, PH-2 and sICH). Data sub-analysis was done to look for the trend of thrombolysis related complication and associated factors.

Results

Out of 190 patients who received rtPA within 4.5 hours of symptom onset, 10 (5.2%) patients had sICH and HI was noted in 29 (15.2%) patients whereas 5 (2.6%) had inhospital mortality. Increased trend of simultaneous use of mechanical thrombectomy had impact on HI. Delay in shifting to stroke care unit due to resource-limitation had abated the expected outcome. With improving stroke care, we observed improved trend of sICH complication.

Conclusions

In a resource-limited setting, we observed improving trend of thrombolysis related complication signifying a prudent case selection, early diagnosis and more aggressive treatment might improve outcome.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ORAL ANTICOAGULATION AFTER INTRACRANIAL HAEMORRHAGE: RESULTS OF SURVEYS AMONG STROKE PHYSICIANS

E Forfang ¹, S Bell ², E Berge ³, R Al Shahi-Salman ⁴

Abstract

Background

It is unknown whether patients with an indication for taking an oral anticoagulant (OAC) for prevention of ischaemic events should start OAC after intracranial haemorrhage (ICH). Observational studies suggest that OAC is beneficial after ICH, but there are no completed randomised-controlled trials.

Methods

We performed a web-based survey among investigators in the REstart or STop Antithrombotics Randomised Trial (RESTART, ISRCTN71907627) in UK and in the STudy of Antithrombotic Treatment after IntraCranial Haemorrhage (STATICH) in the Scandinavian countries.

Results

In the UK, 145 of 153 respondents (95%) were uncertain whether or not to give OAC in patients who survive ICH and have an indication for OAC. The majority of respondents would prefer to randomise patients with atrial fibrillation and CHA₂DS₂-VASc score >1 (n = 127, 88%), recurrent venous thromboembolism (n = 111, 78%) or other cardiac indications (n = 116, 80%) in a trial of long-term OAC vs. control after ICH. 109 respondents (75%) would prefer a new OAC rather than warfarin. The survey in the Scandinavian countries is on-going and will be presented at the conference.

Conclusions

Stroke physicians in the UK were uncertain whether or not to give OAC after ICH, and would include patients with an indication for OAC after ICH in a RCT comparing starting vs. avoiding OAC. Complete results, including data from the Scandinavian countries, will be presented at the conference.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

VERTEBROBASILAR DOLICHOECTASIA IS ASSOCIATED WITH CEREBRAL MICROBLEEDS AND INTRACEREBRAL HEMORRHAGE IN THE POSTERIOR CIRCULATION

A Förster ¹, H Wenz ¹, M Al-Zghloul ¹, C Groden ¹

Abstract

Background

Vertebrobasilar dolichoectasia (VBD) is a dilatative arteriopathy related to the risk of intracerebral hemorrhage. In the present study we sought to evaluate the frequency of cerebral microbleeds (CMB) and intracerebral hemorrhage (ICH) in VBD.

Methods

We analyzed MRI findings in 77 VBD patients with special emphasis on CMB and ICH on T2*-weighted gradient echo images (GRE) in relation to the established diagnostic MRI criteria of VBD. CMB/ICH location was categorized into anterior/posterior circulation.

Results

Overall, 63 (81.1%) patients (median age 72.0 years, 72.7% male) were included in the analysis. CMB were observed in 28/63 (44.4%) patients, the number ranged from 1 to 84. In the posterior circulation CMB were observed more frequently (27/28 (96.4%)) in comparison to the anterior circulation (15/28 (53.6%)). For an example see Figure 1. The number ranged from 1 to 32. ICH was observed in only 3/63 (4.8%) patients. All of these were located in the posterior circulation. No significant differences with regard to basilar artery (BA) diameter (p = 0.74), height of BA bifurcation (p = 0.18), or lateral position of the BA (p = 0.50) between patients with and without CMB were observed.

graphic file with name 10.1177_2396987316642909-fig33.jpg

Conclusions

Vertebrobasilar dolichoectasia is associated with CMB and ICH in the posterior circulation. This posterior dominance of CMB and ICH in VBD might imply a specific underlying vascular patholology.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

DEFINITION OF SYMPTOMATIC INTRACRANIAL HEMORRHAGE SUBSTANTIALLY IMPACTS COMPLICATION RATES

D Frei ¹, A Yoo ², O Zaidat ³, R von Kummer ⁴, P Khatri ⁵, R Gupta ⁶, D Lopes ⁷, H Shownkeen ⁸, D Meyer ⁹, H Buell ⁹, V Bach ⁹, S Kuo ⁹, A Bose ⁹, SP Sit ⁹, J Mocco ¹⁰

Abstract

Background

Symptomatic intracranial hemorrhage (sICH) is a major complication of reperfusion therapy in acute stroke patients. However, there is no standardization in how sICH is defined, with recent intra-arterial therapy trials utilizing varying definitions. Herein we report the impact of 4 different definitions on sICH rates of the THERAPY trial.

Methods

The multicenter prospective THERAPY trial randomized patients to either combined IA therapy with IV rtPA or IV rtPA alone. Rates of patients experiencing sICH, defined in THERAPY as 24 hr CT evidence of an ECASS defined intracranial hemorrhage and a worsening of ≥4 on the NIHSS scale, were evaluated and compared to relating trial sICH definitions.

Results

A total of 105 THERAPY patients were evaluated for sICH. Study definition A (Table) expressed the highest level of sICH complications for the combined IV rtPA and IA treated THERAPY patients (9.5%, 10/105). Subjecting the THERAPY cohort to sICH analysis of relating trial definitions yielded varying results. In general, the highest reported rates of sICH among the trials were observed for definition A. Under more narrow definitions (B and C), the rate of sICH declined to as low as 0.0% for the THERAPY IA arm.

graphic file with name 10.1177_2396987316642909-img13.jpg

Conclusions

The rates of sICH in ischemic stroke therapy are apparently high when hemorrhagic infarctions (HI1 and HI2) are considered as the cause of neurological deterioration. Our findings indicate rates of sICH are substantially impacted by the definition employed. To better understand between-trial differences in sICH rates, criterion standardization is mandatory. Further data are needed to identify the most clinically relevant definition.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EFFECT OF LOW LEVELS OF LDL-CHOLESTEROL IN THE OUTCOME OF HEMORRHAGIC STROKE

AM García Gallardo ¹, M Alonso de Leciñana Cases ¹, Y Herrero Infante ¹, J Rodríguez Pardo De Donlebún ¹, G Ruíz Ares ¹, P Martínez-Sánchez ¹, B Civantos Martín ², E Díez Tejedor ¹, B Fuentes Gimeno ¹

Abstract

Background

The relationship between LDL-Cholesterol levels and outcomes after intra cerebral hemorrhage (ICH) has been suggested but it has not been firmly established so far.

Our objective is to assess the influence of LDL-Cholesterol serum levels in the prognosis of patients with spontaneous ICH.

Methods

Retrospective observational study involving patients diagnosed with ICH in both the Stroke Unit and the Intensive Care Unit. Patients who did not have a serum lipid profile available were excluded. Demographics, medical history, vascular risk factors, NIHSS at onset, volume of CH on CT-scan and blood tests were recorded. Outcome measures were independency (mRS < 3) and mortality at 3 months.

Results

Of 347 patients with ICH during the study period, a total of 125 were included: 64% men, age 67 years (SD = 16), systolic blood pressure 164 mmHg (SD = 37), glucose 132,5 mg/dl (SD = 43), LDL-Cholesterol 118 mg/dl (SD = 36), mean hemorrhage volume 27 cc (SD = 34), median NIHSS: 5 (IQR 2; 9). At 3 months 57% were independent. Mortality was 18%. There was an inverse association between LDL-Cholesterol level and hemorrhage volume (Coef −0,172; 95% CI: −0,339 to – 0,004; p = 0,045). After adjustment for covariates the multivariate analysis showed an independent inverse relationship between LDL-Cholesterol and hemorrhage volume (Coef −0,190; 95% CI: −0,352 to −0,028; p = 0,022), as well as with the probability of dependency (OR 0.98; 95% CI: 0.97–0.99, p = 0.019) and mortality at 3 months (OR 0.98; 95% CI 0.96–0.99, p = 0.041).

Conclusions

Higher serum LDL-Cholesterol level appears to predict smaller hemorrhage volume and lower probability of dependency and mortality at 3 months in patients with spontaneous ICH.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

MISTIE III - MINIMALLY INVASIVE SURGERY AND rT-PA FOR ICH - RECRUITMENT UPDATE THE FIRST 260 PATIENTS

B Gregson ¹, AD Mendelow ¹, K Lane ², N McBee ², I Awad ³, K Lees ⁴, J Dawson ⁵, D Hanley ²

Abstract

Background

Pilot studies of minimally invasive surgery (MIS) for spontaneous supratentorial intracerebral haemorrhage (ICH) have suggested that when combined with recombinant tissue plasminogen activator (rt-PA) applied directly to the clot improved recovery is seen. MISTIE III aims to establish whether MIS plus rt-PA in selected patients with ICH improves outcome compared with conventional medical management.

Methods

An international multicentre randomised open label trial funded by US NIH, recruiting 500 patients who must have a stable ICH of >30ml with a GCS ≤14 or an NIHSS ≥6, and SBP <180 for six hours prior to randomisation. Patients randomised to surgery have a CT to confirm correct location of the catheter prior to dosing and 1 mg of rt-PA is administered every 8 hours for up to 9 doses. All patients have daily CT scans during the acute period to monitor for rebleeding. Outcome is measured at 30, 180 and 365 days using video recorded mRS assessment. The study is powered for a 12% increase in the modified Rankin Scale score (mRS) of 0–3 at 180 days compared to medical management.

Results

Recruitment commenced in the USA in December 2013 and in Europe in December 2014. By the end of December 2015 260 patients had been recruited, 215 in USA, 18 in UK, 11 in Spain, 7 in Israel, 3 in Hungary and 5 in Asia. Germany was just opening to recruitment. These patients had a median age of 63 (range 28–84) and 58% were male.

Conclusions

European sites are essential to reach target on time.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ADDITION OF ORAL ANTICOAGULANT USE TO ICH SCORE TO PREDICT HOSPITAL MORTALITY IN INTRACEREBRAL HEMORRHAGE

R Houben ¹, FHBM Schreuder ¹, RJ van Oostenbrugge ¹, J Staals ¹

Abstract

Background

Background and purpose –the ICH score is a commonly used prediction model for mortality in intracerebral haemorrhage (ICH), based on five independent predictors (ICH volume, location, Glasgow Coma Scale score, age, intraventricular extension). Use of oral anticoagulants (OAC) is also associated with mortality but it is unknown whether addition of OAC use to the ICH score increases the prognostic performance.

Methods

Methods – We retrospectively selected all consecutive adult non-traumatic ICH cases (region South-Limburg, the Netherlands 2004–2009). Using univariable and multivariable logistic regression, association between OAC use and hospital mortality was tested. We created a New ICH score by adding OAC use to the ICH score. We calculated correlation between hospital mortality and ICH score and New ICH score using Spearman correlation test and we then computed ROC curves and calculated the area under the curve (AUC).

Results

Results – We analysed 1256 cases, 286 (22.8%) were OAC-ICH. Hospital mortality was 37,2%. OAC use was independently associated with hospital mortality (OR 2.02, 95%-CI 1.42–2.89; p < 0.001), corrected for the 5 predictors of the ICH score. The ICH Score and the New ICH Score were both significantly correlated with hospital mortality (rho 0.602, p < 0.001 and 0.603, p < 0.001 respectively). The AUC for the ICH Score was 0.851, for the New ICH Score 0.853. This difference was not significant.

Conclusions

Conclusion – Although OAC use proofs to be an independent predictor of hospital mortality, addition of OAC use to the existing ICH score does not increase the prognostic performance of this score.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE EFFECT OF CONCOMITANT EXPOSURE TO ANTIPLATELETS AND STATINS ON HEMATOMA EXPANSION AND OUTCOME IN INTRACEREBRAL HEMORRHAGE

VA Lioutas ^1,², MM Salem ¹, C Feigert ^1,², M Selim ^1,²

Abstract

Background

Statins possess antiplatelet properties. The role of statins and antiplatelets (APL + STAT) in hematoma expansion (HE), a major determinant of outcome, in intracerebral hemorrhage (ICH) is controversial. We explored whether concomitant exposure to statins and antiplatelets has an additive effect on HE compared to either drug alone

Methods

Retrospective review of data from 328 consecutive patients with acute spontaneous ICH. We divided the patients into 4 groups; those taking antiplatelets alone, statins alone, both drugs, or none. We examined separately the relationship between exposure to antiplatelets, statins, or the combination and HE and functional outcome, stratifying our analyses by ICH location.

Results

Fifty-nine (18%) patients were on antiplatelets alone at presentation; 36 (11%) were on statins; 69 (21%) were on APL + STAT. Exposure to either drug alone had no effect on HE or 90-day outcome (p > 0.05). Concomitant exposure to APL + STAT was associated with substantial HE, defined as relative increase ≥33% in hematoma volume between baseline and 24-hour CT scans; unadjusted p = 0.04; OR 2.8 [1.19–6.5] and p = 0.02 after adjustment for initial hematoma volume, serum glucose, coagulopathy, and systolic blood pressure. This association was driven by the combination’s effect on lobar hemorrhages (p = 0.02). We observed a non-significant increase in in-hospital mortality and poor functional outcome at 3 months (mRS > 2

Conclusions

Concomitant exposure to APL + STAT, but not either agent alone, was associated with substantial HE in our cohort of ICH patients. This finding might have important practice implications. Larger studies are necessary to delineate the effects of these medications on ICH outcome.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

30-DAY MORTALITY PREDICTORS IN PATIENTS WITH NONTRAUMATIC INTRACEREBRAL HEMORRHAGE

H Magerova ¹, I Sarbochova ¹, J Schwabova Paulasova ¹, M Horejsi ¹, A Tomek ¹

Abstract

Background

Mortality of patients with intracerebral hemorrhage (ICH) is usually predicted using ICH score (ICHs) with predicted mortality 100% if the score of ≥5 is achieved. However, there are factors not included in the ICHs but suspected to worsen the outcome. The aim of our study was to determine the effect of variables (included and not included in the ICHs) on the 30-day mortality.

Methods

130 patients with nontraumatic ICH were included in the study. Evaluated factors were: age ≥80, ≥70 and ≥60 years, Glasgow coma scale (GCS), hematoma volume ≥30 ml, hematoma localization, hemocephalus, anticoagulation, antiplatelet therapy, hypertension, diabetes, serum glucose ≥8 mmol/l and coronary artery disease (CAD).

Results

We confirm age, GCS, hemocephalus and hematoma volume being independent predictors of 30-day mortality. Stronger association was found for age ≥70 years than for age ≥80 years (OR = 30.233, p < 0.001 and OR = 4.427, p = 0.003 respectively). No patient <60 years died. Infratentorial localization did not increase mortality (p = 0.37) and no patient with cerebellar hematoma died. Mortality risk was further increased in patients with CAD (OR = 6.043, p = 0.001) and antiplatelet therapy (OR = 3.667, p = 0.014) although only weak correlation between these factors was found (r = 0.21, p = 0.017). Other variables were not statistically significant mortality predictors.

Conclusions

Our data suggest that the risk of 30-day mortality is significantly increased already in age ≥70 years. On the other hand, infratentorial localization may not predict unfavorable outcome. Further, some comorbidities and chronic medication may increase the risk of mortality. These should be considered when (mortality) outcome of patient with ICH is predicted.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

POST-NOAC: OBSERVATIONAL PORTUGUESE STUDY OF INTRACRANIAL HEMORRHAGE IN PATIENTS MEDICATED WITH NON-VITAMIN K ANTAGONISTS ORAL ANTICOAGULANTS

C Marques-Matos ¹, JN Alves ², JP Marto ³, JA Ribeiro ⁴, A Monteiro ¹, J Araújo ², F Silva ⁴, F Grenho ⁵, J Pinho ², E Azevedo ¹, M Viana-Baptista ³, J Sargento-Freitas ⁴

Abstract

Background

Introduction: Recent phase III trials showed a reduction in stroke incidence in atrial fibrillation patients treated with new oral anticoagulants (NOAC) compared to vitamin K antagonists (VKA) mainly driven by a reduction in intracranial hemorrhage (ICH). However, there is few data on prognosis of NOAC-associated ICH. The aim of this study is to compare functional prognosis and mortality in NOAC and VKA-associated ICH.

Methods: Methods

Retrospective cohort study of consecutive patients with non-traumatic ICH admitted between January 2013 and June 2015 to 4 tertiary portuguese hospitals. Functional outcome at 3 months was assessed using the modified Rankin Scale (mRS) and dichotomized into favourable (0–2) and poor (3–6). Clinical and imagiological variables were collected. Univariate and multivariate binary logistic regression analysis were performed to compare outcome in both groups.

Results: Results

Among the 246 patients (median age 77 years, IQR 69–82; 46.7% women) 24 (9.8%) were anticoagulated with a NOAC and 222 (90.2) with a VKA. The majority of ICH patients had parenchymal hemorrhages (65.0%). NOAC patients were significantly older (median age 81.5 vs 76 years, p = 0.048) and more often had parenchymal hemorrhages (83.3% vs. 63.1%, p = 0.048). Regarding other demographic and clinical variables there were no differences between groups. Multivariate analysis adjusted for age, CHA₂DS₂VASc and HAS-BLED scores, showed no association between type of anticoagulant treatment and favourable outcome (OR = 0.621, 95%CI = 0.190–2.026, p = 0.430) or mortality (OR = 1.200, 95%CI = 0.490–2.942, p = 0.690) at 3 months.

Conclusions: Conclusions

This study shows no significant differences regarding 3-month functional outcome or death between NOAC and VKA-treated patients with intracranial hemorrhage.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

SERUM CALCIUM AND EXTENT OF BLEEDING IN INTRACEREBRAL HEMORRHAGE

A Morotti ¹, A Charidimou ¹, M Jessel ¹, K Schwab ¹, A Ayres ¹, J Romero ², A Viswanathan ¹, E Gurol ¹, SM Greenberg ¹, C Anderson ¹, J Rosand ¹, J Goldstein ¹

Abstract

Background

Calcium is a key cofactor of the coagulation cascade. We hypothesized that low serum calcium is associated with the extent of bleeding in ICH as measured by baseline ICH volume and risk of ICH expansion.

Methods

We performed a retrospective analysis of a prospective cohort of consecutive patients with primary ICH ascertained between 1994 and 2015. Subjects were included if ionized calcium measurement was obtained on admission. Hypocalcemia was defined as ionized calcium <1.13 mmol/L. Baseline and follow-up hematoma volume on non-contrast CT (NCCT) were measured using a computer-assisted semi-automatic analysis. Hematoma expansion was defined as increase >30% or 6 mL from baseline ICH volume. Association between serum calcium, baseline hematoma volume and ICH expansion were investigated in multivariable linear and logistic regression models respectively.

Results

526 patients met the inclusion criteria (mean age 69.1 + 12.7 years, 57.8% males), of whom 348 (66.2%) had hypocalcemia on admission. Low ionized calcium levels were independently associated with higher baseline ICH volume (β = − 0.22, standard error = 0.06, p = 0.002). A total of 317 patients had a follow-up NCCT available and were included in the ICH expansion analysis. In this subgroup, the presence of admission hypocalcemia was associated with increased risk of ICH expansion (OR 2.4,95% CI 1.02–5.86, p = 0.044), after adjusting for other confounders.

Conclusions

Hypocalcemia is common in ICH patients and correlates with extent of bleeding. Low calcium may be associated with a subtle coagulopathy predisposing to increased bleeding and might therefore be a promising therapeutic target for acute ICH treatment trials.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

LEUKOCYTE COUNT AND INTRACEREBRAL HEMORRHAGE EXPANSION

A Morotti ¹, CL Phuah ¹, C Anderson ¹, M Jessel ¹, K Schwab ¹, A Ayres ¹, E Gurol ¹, A Viswanathan ¹, SM Greenberg ¹, J Goldstein ¹, J Rosand ¹

Abstract

Background

While acute leukocytosis is a well-established response to intracerebral hemorrhage (ICH), leukocytes, because of their interaction with platelets and coagulation factors, may in turn play a role in hemostasis. To test this hypothesis, we investigated whether admission leukocytosis was associated with reduced bleeding following acute ICH. We measured this extent of bleeding as hematoma expansion.

Methods

Consecutive patients with primary ICH were prospectively collected from 1994 to 2015 and retrospectively analyzed. We included subjects with a follow-up CT scan available and complete white blood cells (WBC) count performed within 48 h from onset. Baseline and follow-up hematoma volumes were calculated with a semi-automated software and expansion was defined as ICH growth >30% or 6 mL. The association between WBC count and ICH expansion was investigated with multivariate logistic regression.

Results

1302 subjects met eligibility criteria (median age 74.6 years, 55.8% males), of whom 207 (15.9 %) experienced hematoma expansion. Higher leukocyte count on admission was associated with reduced risk of ICH expansion (Odds Ratio [OR] 0.91, p = 0.001). The risk of hematoma growth was inversely associated with neutrophil count (OR 0.90, p = 0.001) and directly associated with monocyte count (OR 2.71, p = 0.034). The association between lymphocyte count and ICH expansion was neutral (OR 0.96, p = 0.718).

Conclusions

Higher admission WBC count is associated with lower risk of ICH expansion. This highlights a potential role of the inflammatory response in modulating the coagulation cascade following acute ICH.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

DETERMINANTS AND SIGNIFICANCE OF WITHDRAWAL OF TREATMENT IN THE INTERACT2 STUDY

P Munoz Venturelli ¹, X Wang ¹, P Lavados ², C Stapf ³, T Robinson ⁴, R Lindley ¹, E Heeley ¹, C Delcourt ¹, J Chalmers ¹, CS Anderson ¹

Abstract

Background

In INTERACT2, a small but significant number of patients had a decision to withdraw active treatment (WAT) in the intensive BP lowering group.

Aims: To describe the characteristics of WAT patients in INTERACT2 cohort, and determine the association of this variable on management and prognosis.

Methods

Post-hoc analysis of the INTERACT2 study cohort. Multivariable models created to identify factors associated with decision for WAT within 7 days and 90-day mortality.

Results

Of 2779 patients, WAT occurred in 121 (4%). Baseline variables of age, admission NIHSS score, hematoma volume, intraventricular extension and randomization to intensive BP lowering were independently associated with WAT. Higher 90-day mortality occurred in those with WAT compared to non-WAT patients (81/120 [68%] vs 205/2624 [8%]) respectively, P < 0.001). WAT patients died earlier than non-WAT patients (P < 0.001), and they had shorter hospital length of stay (P < 0.001). However, among 90-day survivors, 19/39 (49%) patients in the WAT group were disabled (mRS 4–5) compared to 695/2419 (29%) in non-WAT group.

Conclusions

In this non-comatose acute ICH cohort, WAT was undertaken in patients with a poor prognosis. Despite receiving more intensive treatment strategies, they had higher mortality and residual disability.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

VARIATION IN MANAGEMENT OF PATIENTS WITH ISCHEMIC STROKE OR INTRACEREBRAL HAEMORRHAGE WITH RESPECT TO NOACS IN THE NETHERLANDS. A NATIONWIDE SURVEY STUDY

TTM Nguyen ¹, MC Visser ¹, EJ van Dijk ², CJM Klijn ²

Abstract

Background

The risk of intracranial bleeding in patients using non-vitamin K antagonist oral anticoagulants (NOACs) is lower than in those using vitamin K antagonists (VKAs). The neurologist is one of the first in line to be confronted with these complications in the acute setting. Experience with treatment of complications is limited and protocols have only recently been adjusted, which leaves room for practice variation. The purpose of this study was to investigate variation in management of patients with ischemic stroke or intracerebral haemorrhage with respect to NOACs in Dutch hospitals.

Methods

A web based survey with a maximum of 39 questions were asked with respect to initiation of NOACs after an ischemic stroke, restarting NOACs after an intracerebral haemorrhage (ICH) and thrombolytic procedures.

Results

58 of the 91 (64%) neurologists completed the survey. There was considerable variation in the initiation of NOACs after an ischemic stroke. In case of restarting a NOAC after a NOAC associated ICH, 18% would restart after 7–14 days and 72% after 2–10 weeks. 22% would never consider IV thrombolysis in NOAC-users, while a large majority would consider it under certain circumstances. All neurologists express a need for more education regarding this topic.

Conclusions

We found considerable variation, especially in the initiation of NOACs after an ischemic stroke, restarting a NOAC after an intracerebral haemorrhage and thrombolytic procedures in Dutch hospitals. Sharing clinical experience and education helps to reduce this variation and improve care. Further research is needed to investigate implications of this variation for the quality of care.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

QUALITY IMPROVEMENT TO DELIVER OUTSTANDING OUTCOMES IN INTRACEREBRAL HAEMORRHAGE (QUIDD-ICH): DELIVERING AN ICH ACUTE CARE BUNDLE AT A UK COMPREHENSIVE STROKE CENTRE

K Paroutoglou ¹, M Massyn ¹, V O'Loughlin ¹, L Harrison ¹, A Worthington ¹, L Hood ¹, H Patel ², A Parry-Jones ³

Abstract

Background

Optimal acute blood pressure (BP) management, rapid treatment of anticoagulation-associated intracerebral haemorrhage (ICH) and appropriate access to neurosurgery and critical care can improve outcomes after ICH. Using the Model for Improvement, we began implementing an ICH acute care bundle targeting these processes at our UK comprehensive stroke centre from June 2015, aiming for a 10% absolute reduction in death and severe disability.

Methods

Using intravenous glyceryl trinitrate first-line, we first sought to effectively deliver intensive BP lowering. We are now using point-of-care INR and keep prothrombin complex concentrate in the Emergency Department to optimise rapid reversal of anticoagulation. These changes are accompanied by a programme of education for relevant staff. All data are given as median and interquartile range.

Results

We admitted 182 ICH patients from 1/6/2015 to 9/1/2016. Prior to BP protocol changes, needle-to-target (<140 mmHg) time for intensive BP lowering was 258 min (147.5 – 369.5; n = 12) but improved to 48.5 min (27.5 – 74.3; n = 28) after changes (Figure). Door-to needle time for PCC is 198 min (145 – 254; n = 13). Unadjusted 30-day case fatality was 33.3% (n = 252;1/5/14–31/5/15) before our project and 27.0% (n = 162;1/6/15–10/12/2015) after.

graphic file with name 10.1177_2396987316642909-fig37.jpg

Conclusions

We have achieved improvements in BP management in acute ICH care at our centre. Work is ongoing to improve speed of anticoagulation reversal and implement a new ICH care pathway.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

TOPOGRAPHY OF SUBCLINICAL DWI LESIONS IN PATIENTS WITH INTRACRANIAL HEMORRHAGE

T Phan ¹, S Singal ¹, J ly ¹, R chandra ¹, H Ma ¹, B Clissold ¹, V Srikanth ¹

Abstract

Background

Subclinical ischemic lesions on diffusion weighted MR imaging (DWI) were recently described in patients with spontaneous intracerebral hemorrhage (ICH) and convexity subarachnoid hemorrhage (cSAH), possibly related to amyloid angiopathy. The topography of these lesions may provide clue regarding their pathogenesis with investigators suggesting preference of these lesions in watershed infarct location. The aim is to study the topography of these lesions.

Methods

Patients presenting to Monash Medical Centre between 2011–2014 with ICH and cSAH were included in the absence of aneurysm, arteriovenous malformation, hemorrhagic infarction, or contra-indication for Magnetic Resonance Imaging (MRI). Diffusion weighted imaging (DWI) lesions were segmented and registered to stereotactic coordinates. Their locations were compared to digital maps of arterial territory and watershed areas.

Results

There were 114 eligible patients; mean age was 69.6 ± 12.3 years (male 53.9%). The distribution of patients were cSAH 16 (14.0%), lobar ICH 48 (42.1%) and deep ICH 50 (43.9%). Among 30 patients (26%) who had DWI positive lesions, 16 (53.3%) occurred within 7 days and 29 (96.7%) by 6 months. The predominant locations were frontal 15/30 (50.0%), parietal 10/30 (33.3%) and subcortical 7/30 (23.3%). These locations and the haemorrhage types are displayed in Figure 1 [convexity subarachnoid hemorrhage (red), lobar hemorrhage (blue) and deep hemorrhage (yellow)]. There were no statistical association between the DWI lesion locations and the type of intracranial haemorrhage.

graphic file with name 10.1177_2396987316642909-fig38.jpg

Conclusions

Subclinical ischemic lesions are widely distributed in the brain. This pattern may be due to underlying amyloid angiopathy.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

NEW ONSET ATRIAL FIBRILLATION FREQUENCY AND RISK FACTORS IN PATIENTS WITH ACUTE INTRACEREBRAL HEMORRHAGE

L Prats-Sánchez ¹, C Painous Marti ¹, F Fayos Vidal ¹, E Pascual Goni ¹, R Delgado-Mederos ¹, A Martínez-Domeño ¹, P Camps-Renom ¹, J Martí-Fàbregas ¹

Abstract

Background

The incidence and risk factors for new-onset atrial fibrillation (nAF) after acute intracerebral hemorrhage (ICH) are uncertain. By analogy with ischemic stroke, we hypothesized that insular cortex damage may be a risk factor for nAF. We investigated the frequency and risk factors for nAF in patients with ICH.

Methods

We studied consecutive patients with spontaneous ICH. All patients underwent continuous bedside EKG monitoring for at least 24 hours. We excluded patients with previous history of AF, known triggers of AF and previous stroke. Demographic (age, sex), vascular risk factors, NIHSS score, vital signs, laboratory and radiological (intraventricular/subarachnoid hemorrhage, localization, cause and volume of the hematoma) data were registered prospectively, including detection of nAF. Damage of the insular cortex was assessed by a blind evaluator using an interactive brain atlas (http://www.imaios.com/en/e-Anatomy/). Bivariate and multivariate regression analyses were performed.

Results

From 226 patients, 132 fulfilled the inclusion/exclusion criteria (mean age, 69.8 ± 14.8 years; median NIHSS = 7, 53% men). nAF was detected in 10 (7.5%) patients. Male gender (9/10 vs 61/122, p = 0.019), insular cortex damage (6/10 vs 19/122, p = 0.003) and sylvian fissure subarachnoid hemorrhage (5/10 vs 15/122, p = 0.007) were associated with nAF. In the multiple regression analysis male gender (OR 8.9; 95%CI 1.0–75.5, p = 0.012) and insular cortex damage (OR 8; 95%CI 1.9–33.3, p = 0.003) were associated with nAF.

Conclusions

We observed nAF in 1 out of 13 patients with ICH. Male gender and insular damage, probably due to damage to the central autonomous nervous system, are associated with nAF. This finding may be important for hemodynamic and antithrombotic management.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ELDERLY PATIENT, MULTIMORBIDITY AND INTRACEREBRAL HAEMORRAGE. EBRICTUS STUDY

ML Queralt-tomas ¹, MA Gonzalez-henares ¹, A Panisello-tafalla ¹, JL Clua-espuny ², R Ripolles-vicente ¹, J Lucas-noll ¹, VF Gil-guillen ³, T Forcadell-arenas ¹

Abstract

Background

The demographic evolution has been characterized by the ageing associated to multimorbidity and polimedication. The aim of this study was to assess the association between the incidence ICH and the prevalence of known associated factors (avoidable incidence).

Methods

It’s a prospective study of population-based cohort of a first episode ICH since 01/04/2006 to 30/06/2015 in primary care area. We analyzed demographics, clinical, co-morbidities, prescription, disability, mortality and temporal trends. The avoidable cases were calculated according the Unnecessarily Premature and Sanitarily Avoidable Mortality (MIPSE) classification.

Results

240 cases were included (143 M 97 W). The cumulative incidence was 26.3/10⁵/year. 43.7% occurred ≥80 years. Women were older (77.12 ± 12.47 vs. 73.3 ± 12.4, p = 0.02). The associated comorbidities were age ≥75 years (OR 9.59 IC95% [7.4–12.44]), alcoholism (OR 5.1 IC95% [2.85–9.40]), antidepressant selective serotonin (SSRI) reuptake inhibitor (OR 3,7 IC95% [2,13–6,44]), male (OR 2.81 IC95% [1.56–5.05]), hypertension (OR 2,26 IC95% [1,19–4,30]) and polimedication (OR 2,20 IC95% [1,19–4,05]).

40% were associated to avoidable factors, being the hypertension or the traumatism presented in 89.7% of these patients. The avoidable ICH incidence would be 66.6% <75 year-old and 22.7% ≥75 year-old. The risk of mortality changes according to associated factor and age (Table 1). Associated with poor outcomes were: age (OR 1.18/year [CI95% 1.07–1.29], p < 0.001), OAC (OR 4.65/year [CI95% 1.10–19.6], p 0.036), polimedication (OR 1.08 [CI95% 1.03–1.13], p 0.001), and SSRI (OR 9.71 [CI95% 1.23–76.68], p 0.031).

Conclusions

Just 22.7% of those ones ≥75 year-old could be avoidable. The MIPSE classification doesn’t include relevant risk factors.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

MINIMALLY INVASIVE NECROSECTOMY ALTERNATIVELY TO CRANIECTOMY IN STROKE

KDM Resch ¹

Abstract

Background

In the series of 170 hematoma evacuations some cases were hamorrhagic infarctions. In these cases additional to the hematoma the center oft he necrosis was evacuated also. As these patients made a much better recovery than craniectomy cases we developed a novel concept.

Methods

Hemorrhagic infarctions were operated through key-holes (burr-hole, 1€ approach) under ultrasound control (burr-hole probe, Alpha 7, ALOKA) and by mouth-switch tracked microscope. Before surgery CTA or TCD was made to see if the infarction showed reperfusion, because in the latter condition the operation may be more difficult. Perfusion CT determined the center of the necrosis.

Results

In all cases we saw a much better course of recovery than in craniectomy cases. The patient were not disabled additionally by stigmata like large craniectomy defect, big scarf, loss of hair and psychological trauma. The beginning of rehabilitation therapy could start within one week only. The wound of 3 cm was not visible and during rehabilitation there was no fear by the rehabilitation teams to soon start the full training program. We did not see any complications due to the MIN strategy.

Conclusions

In stroke decompression our results of MIN concept application seam logical regarding pathophysiology. It is worthwhile to study this novel concept by trials. The operative technique, however is much more sophisticated and also much faster and more economic than a simple craniectomy.

file://localhost/Users/kdmresch/Desktop/ESOC2016%20Barcelona/Folie1.jpg

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

INTRA-CEREBRAL HEMORRHAGE(ICH) EVACUATION BY MINIMAL INVASIVE NEUROSURGERY

KDM Resch ¹

Abstract

Background

STICH I and II trials did not take notice of minimal invasive neurosurgery (MIN) strategies and techniques. EndoSTICH trial and MISTIE trial are studying two minimally invasive techniques (endoscopic evacuation and katheter-lysis) which however do not compete the needs of the majority of hemorrhages. We elaborated a MIN technique with high effectiveness and applied it up to now in 170 cases. We present a retrospectively analysis of this first series.

Methods

This MIN concept combined several techniques to assist microsurgery: High-end neurosonography with small probes („burr-hole-probe/ALOKA) and mouth tracking of the microscope, both mandatory. Additionally we added endoscopy (Wolf, Aesculap, Storz) and LASER (Th-YAG Revolix).

170 patients underwent this application within 10 years by the presenting author. The approaches varied from burr-hole to 1€ or 2€ in size depending from the imaging findings and expected difficulties.

Results

In nearly all cases it was possible to evacuate the hematoma within 1 hour and the hematoma evacuation decreased the ICP to normal levels. Clinical results were excellent in lobar bleedings with isochoric before surgery. Large and deep-seated hemorrhages needed longer recovery time but in all cases postop CT showed fast reduction of perifocal edema.

Conclusions

Combination of ultrasound, mouth tracking, endoscopy and LASER enabled evacuation of all type of hematoma minimal invasively and very effectively in less than one hour. Ultrasound real-time control detected all types and locations of bleeding causes. The evacuation amount and the reaction of the brain were under visual control. Mouth tracking enables free hands for fast acting and safe control.

file://localhost/Users/kdmresch/Desktop/Folie1.jpg

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PATIENTS TRANSFERRED TO AN INTENSIVE CARE UNIT WITHIN SEVEN DAYS OF STROKE: DATA FROM THE ONGOING TRANEXAMIC ACID FOR HYPERACUTE PRIMARY INTRACEREBRAL HAEMORRHAGE (TICH-2) TRIAL

N Sprigg ¹, K Robson ¹, J Appleton ¹, P Bath ¹

Abstract

Background

Intracerebral haemorrhage is a medical emergency and can lead to reduced consciousness. Some patients may require support in intensive care units (ICU).

Methods

TICH-2 records whether participants have been transferred to ICU by day 7. Baseline characteristics and outcomes were compared between those that had been transferred and those that had not.

Results

Of 1116 participants, at day 90, in TICH-2, 117 (10.5%) had been transferred to ICU. The percentage of patients going to ICU ranged from 2% to 100% across all centres, median [IQR] 14.3% [7.7%, 20%]. Patients going to ICU were younger, male and had more severe strokes with lower GCS. Over 40% patients who went to ICU were also transferred for surgery and almost 60% received invasive ventilation. Day 90 modified Rankin Scale, Barthel Index and Euroqol-5D were significantly worse for the people who were transferred (all p-values < 0.0001); however, 11.1% of people that went to ICU had a mRS of 2 or less and 16.2% were home alone or home with family/carers at discharge. Deaths by day 90 were also significantly higher for those who had been transferred (p-value: 0.0005).

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Conclusions

The proportion of patients going to ICU varies widely across centres. Only half have ventilation. Those going to ICU were more likely to have more severe strokes and worse outcomes, but some patients survive and live independently.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

LARGER VOLUME HAEMATOMA AND FEMALE SEX PREDICT LOWER GCS AFTER PRIMARY INTRACEREBRAL HAEMORRHAGE

D Gill ¹, A Rossiter ¹, B Lonergan ¹, R Lobo ¹, A Kar ¹

Abstract

Background

Glasgow Coma Scale (GCS) on presentation predicts neurological and functional outcome in patients with primary intracerebral haemorrhage (ICH). We aimed to explore what factors predict GCS on presentation in patients with primary ICH.

Methods

This was a single-centre retrospective study on consecutive patients presenting to Imperial College Healthcare NHS Trust (United Kingdom) between 2010 and 2014 with spontaneous lobar or deep ICH. Haematoma volume was determined using the ABC/2 method. Ordinal logistic regression analysis was used to explore the relationship between GCS (ordinal dependent variable) and the following predictor variables: sex (male or female), hematoma volume (cm³), intraventricular extension (present or absent), and haematoma location (deep or lobar). Coefficients and 95% confidence intervals were used as measures of effect size; a p value < 0.05 was used to indicate statistical significance.

Results

Data was available for a total of 392 patients. Ordinal logistic regression analysis revealed that of the considered predictor variables, only female sex (coefficient −0.48, CI −0.10 to −0.86, p = 0.01) and haematoma volume (coefficient −0.02, CI −0.02 to −0.01, p < 0.01) were statistically significant in predicting lower GCS on presentation, with the presence of intraventricular extension just missing the cut off (coefficient −0.42, CI −0.84 to 0.00, p = 0.05). Haematoma location (lobar or deep) did not appear to play a role in predicting GCS (p = 0.312).

Conclusions

Patients presenting with primary ICH that are female or have larger volume bleeds have lower GCS and thus worse functional outcomes.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

NATIONAL INSTITUTES OF HEALTH STROKE SCALE SCORE PREDICTS VOLUME OF INTRACRANIAL HEMORRHAGE

T Schneider ¹, A Frölich ¹, G Thomalla ², J Fiehler ¹, JH Buhk ¹

Abstract

Background

Direct imaging examination of patients with high National Institutes of Health Stroke Scale (NIHSS) scores ad potential candidates for thrombectomy in the angiography suite would reduce time to groin puncture. Sensitivity of new imaging methods such as flat-panel computed tomography (FP-CT) in the detection of small intracerebral hemorrhages (ICH) is poorly defined. We compared NIHSS scores and ICH volumes in order to determine whether higher NIHSS scores are helpful to clinically rule out small hematomas.

Methods

This monocentric study analyzes 70 patients diagnosed with spontaneous first-ever ICH. CT- or MRI-based volumetric analysis was performed with a 3D-segmentation tool. Spearman’s rank-order correlation was used for statistical testing.

Results

NIHSS score at admission were recorded in 48 patients (group 1). The remaining 22 patients were intubated (group 2). Median NIHSS was 9 (range 0–19, IQR 8.75) in group 1. Correlation between ICH volume and NIHSS score was moderate (rs = 0.524, p < 0.001). Mean ICH volume was 31.5 cm³ (range 0.2–188.0 cm³) for group 1 and larger in group 2 (81.0 cm³, range 3.9–239.0 cm³, p = 0.001). ICH volumes ≤1 cm³ were neither found in patients with an NIHSS score of ≥5 nor in intubated patients.

Conclusions

NIHSS is correlated with the ICH volume. This finding might be helpful in the further evaluation of FP-CT as a new imaging technique.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

SILENT BRAIN HEMORRHAGES IN TERM NEWBORNS: MECHANISMS AND PROGNOSTIC MARKERS

O Semyachkina-Glushkovskaya ¹

Abstract

Background

Intracranial hemorrhages (ICH) in newborns is a major problem of future generation’s health due to the high rate of death (up 25%), cognitive disability (50–85%) of infants and significant limitation of knowledge about reasons, mechanisms and prognosis of neonatal ICH.

Methods

We analyzed mechanisms preceding and accompanying ICH in newborn rats using a model of stress-induced ICH (sound stress, 120 dB, 370 Hz) and an interdisciplinary approach based on a morphological analysis of brain tissues, coherent-domain optical technologies for visualization of the cerebral blood flow, monitoring of the cerebral oxygenation and the deformability of red blood cells (RBCs).

Results

We found that latent period of ICH is accompanied by a progressive reduction of blood flow in the cerebral venous system and cerebral oxygenation that was accompanied by an increase in RBCs deformability as well as a significant depletion of the molecular layer of the cortex and the pyramidal neurons, which are crucial for associative learning and attention. The incidence of ICH is characterized by a progression of these changes, which are accompanied by the irreversible cell death apoptosis process in the “intellectual zones” of the brain.

Conclusions

Our results suggest that the progressive relaxation of cerebral veins, hypoxia and increased RBCs deformability are the important mechanisms and prognostic markers of ICH and serious injures of “intellectual zones” of the brain during the first days of life.

This work was supported by Grant of Russian Science Foundation № 14–15-00128.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

LEUKOARAIOSIS AND HEMATOMA GROWTH IN PATIENTS WITH INTRACEREBRAL HEMORRHAGE

M Sykora ¹, C Herweh ², T Steiner ³

Abstract

Background

The role of leukoaraiosis in intracerebral hemorrhage remain unclear. We investigated the influence of white matter changes on initial hematoma volume, hematoma growth and clinical outcome in patients with supratentorial intracerebral hemorrhage.

Methods

Computed tomography scans of 264 patients included in a placebo arm of a prospective, multicenter trial were used for a semi-quantitative analysis of white matter changes. A logistic regression analysis was used to explore the effects on hematoma volume, volume changes and clinical outcome after 90 days.

Results

The degree of leukoaraiosis was not associated with initial hematoma volume, absolute and relative hematoma growth or hematoma growth >33%. However, leukoaraiosis significantly increased the odds for mortality (adjusted OR 1.4, CI 1.03–1.9, p = 0.03) and decreased the odds for favorable outcome after 90 days (adjusted OR 0.7, CI 0.56–0.88, p = 0.02).

Conclusions

Leukoaraiosis is not associated with hematoma volume or growth. It rather seems to be associated with poor outcome and mortality after intracerebral hemorrhage independently.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THREE-MONTHS MORTALITY IN PATIENTS WITH SPONTANEOUS INTRACEREBRAL HEMORRHAGE AND THE BLEND SIGN

H Tejada Meza ¹, J Artal Roy ¹, P Seral Moral ², LF Ángel Ríos ², GJ Cruz Velásquez ¹, A Fernández Sanz ¹, P Ruiz Palomino ¹, J Marta Moreno ¹

Abstract

Background

Intracerebral hemorrhage (ICH) is associated with high mortality rates. Early hematoma growth is an independent predictor of poor functional outcome and the Blend sign has shown to be a predictor of early hematoma growth. The purpose of this study was to determine if the Blend sign correlates with mortality in the first three months after an ICH.

Methods

By a retrospective follow-up study we assessed the mortality rate at three months of all patients with non-traumatic ICH who arrived to our hospital and underwent baseline CT scan within 6 hours after onset of symptoms between 2010 and 2015. Logistic regression analysis was used to assess the relationship between the presence of blend sign and mortality in the first three months after a ICH.

Results

In the 125 patients assessed we found the Blend sign in 16.0%. Those with the Blend sign had a higher mortality in comparison with those who didn’t (50% vs 26.7%) (p = 0.038), but the multivariable analysis found that only hematoma volume was an independent predictor of mortality at three months.

Conclusions

Blend sign is associated with a higher mortality rate in the first three months after ICH, but this association is lost when we consider hematoma volume in the multivariate analysis.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

UTILITY OF DIFFUSION AND PERFUSION MRI FOR PREDICTING PERIHEMORRHAGIC EDEMA GROWTH IN THE ACUTE PHASE OF INTRACEREBRAL HEMORRHAGE

M Terceño ¹, J Serena ², J Puig ³, G Blasco ³, J Daunis i Estadella ⁴, V Cuba ³, G Carbo ³, S Pedraza ⁵, Y Silva ²

Abstract

Background

Intracerebral hemorrhage (ICH) is a devastating disease. ICH volume is the main predictor of poor outcome, but growing evidence suggests that perihematomal edema (PHE) contributes to secondary brain injury. Methods for predicting PHE growth in clinical scenarios are lacking. We aimed to determine the utility of diffusion (DWI) and perfusion (PWI) MRI indexes for predicting PHE growth in patients with ICH.

Methods

We prospectively studied 25 patients with spontaneous ICH admitted within 12 hours of symptom onset. Patients underwent MRI including DWI and PWI sequences on admission and at 72 hours. We measured ICH and PHE volumes on fluid-attenuated inversion recovery images; we used Olea Sphere V.3.0 to determine apparent diffusion coefficient (ADC), cerebral blood volume (CBV), cerebral blood flow (CBF), mean transit time (MTT), and time to peak (TTP). To measure ICH and PHE growth, we calculated the difference between volumes on baseline and 72-hour follow-up studies. We also considered age, sex, blood pressure, National Institutes of Health Stroke Score (NIHSS), and Rankin Scale score.

Results

PHE growth correlated with NIHSS at baseline (r = 0.430; p = 0.036), PHE-MTT values (r = 0.486; p = 0.026), and PHE-ADC values (r = 0.632; p = 0.001). We found no significant correlations for ICH growth. Multivariate linear regression identified baseline PHE-ADC as an independent predictor of increased PHE volume at 72 hours (p = 0.024).

Conclusions

Our preliminary results suggest that DWI can be useful for predicting PHE growth in the first 72 hours and should therefore be further evaluated as a potential imaging biomarker to guide therapeutic strategies in ICH.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

AMYLOID-β 40 AND 42 IN CEREBROSPINAL FLUID: BIOMARKERS FOR PRECLINICAL CEREBRAL AMYLOID ANGIOPATHY

E van Etten ¹, M Verbeek ², J van der Grond ³, R Zielman ¹, S van Rooden ³, E van Zwet ⁴, A van Opstal ³, J Haan ¹, SM Greenberg ⁵, M van Buchem ³, M Wermer ¹, G Terwindt ¹

Abstract

Background

Hereditary forms of cerebral amyloid angiopathy (CAA) are unique resources to investigate preclinical amyloid pathology. We investigated cerebrospinal fluid (CSF) biomarkers in presymptomatic and symptomatic mutation carriers with Hereditary Cerebral Hemorrhage with Amyloidosis Dutch type (HCHWA-D).

Methods

HCHWA-D-mutation carriers and controls were enrolled in the cross-sectional EDAN (Early Diagnosis in Amyloid Angiopathy Network) study. The HCHWA-D group was divided into symptomatic carriers with a previous intracerebral hemorrhage (ICH) and presymptomatic carriers. CSF concentrations of amyloid-β₄₀ (Aβ₄₀), amyloid-β₄₂ (Aβ₄₂), total tau (t-tau), and phosphorylated tau₁₈₁ (p-tau₁₈₁) proteins were compared with similar aged control subjects. Correlations between CSF markers and MRI markers were investigated with multivariate linear regression analyses.

Results

We included ten symptomatic HCHWA-D patients (mean age 55 ± 6), five presymptomatic HCHWA-D-mutation carriers (mean age 36 ± 13), 31 controls < 50 years (mean age 31 ± 7), and 50 controls ≥50 years (mean age 61 ± 8). After correction for age, CSF Aβ₄₀ and Aβ₄₂ were significantly decreased in symptomatic carriers vs controls (median Aβ₄₀: 1386 vs 3867 ng/L p < 0.001; median Aβ₄₂: 289 vs 839 ng/L p < 0.001) and in presymptomatic carriers vs controls (median Aβ₄₀: 3501 vs 4684 ng/L p = 0.011; median Aβ₄₂: 581 vs 1058 ng/L p < 0.001). Among mutation carriers, decreasing CSF Aβ₄₀ was associated with higher lobar microbleed count (p = 0.010) and increased white matter hyperintensity volume (p = 0.008).

Conclusions

Decreased levels of CSF Aβ₄₂ and Aβ₄₀ occur before HCHWA-D-mutation carriers develop clinical symptoms of CAA. CSF Aβ₄₂ and Aβ₄₀ concentrations may serve as preclinical biomarkers for CAA pathology.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

WHETHER SERUM MAGNESIUM, CALCIUM AND PHOSPHORUS ASSOCIATED WITH THE SHORT AND LONG TERM OUTCOME OF INTRACEREBRAL HEMORRHAGE

Y Xiong ¹

Abstract

Background

We explore whether admission serum magnesium, calcium and phosphorus and these concentration change have relationship with intracerebral hemorrhage(ICH) patients prognosis.

Methods

A total of 848 patients from January 2012 to June 2014 of the National Key Technology R&D Programme of the 12th Five-Year Plan ‘Study on Etiology and Minimally Invasive Neurosurgery for Hemorrhagic Stroke’ were included for baseline analysis and survival analysis. Finally, 761 patients finished the 1 year follow up. According theadmission serum ions level, patients were divided into 4 quartiles separately. And on the basis of serum ions change, patients were divided into 5 to 6 groups.

Results

During 3 month follow up, ICH patients with serum calcium level ≥2.21 mmol/L have significant lower mortality (p = 0.033) compared with ICH patients with serum calcium level <2.21 mmol/L after adjusted prognosis relative factors. Serum magnesium increased between 0 to 0.1 mmol/L within 6 to 24 hours associated greater function outcome (p = 0.028) compared with no concentration change group and so did serum calcium decrease 0 to 0.2 mmol/L (p = 0.007). As for 1 year follow up, ICH patients with serum P level ≥0.84 mmol/L had significant better function outcome (p = 0.041) compared with ICH patients with serum phosphorus level <0.84 mmol/L.

Conclusions

For ICH patients, higher serum calcium on admission may associated with lower mortality and serum magnesium increase within 0.1 mmol/L and serum calcium decrease within 0.2 mmol/L during 6 to 24 hours after ICH onset may contribute patients function outcome at short term. Higher serum phosphorus on admission may associate with better patients’ function outcome in long term. But serum magnesium on admission shows no relationship with patients’ prognosis.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

MULTIPLE BIOMARKERS INCLUDING CARDIAC TROPONIN AND THE INCIDENCE OF CEREBRAL HERNIATION AFTER INTRACEREBRAL HEMORRHAGE AND THE SEVERITY OF STROKE

M Xu ¹, J Lin ¹, D Wang ¹, M Liu ¹, Z Hao ¹, C Lei ¹

Abstract

Background

Cerebral herniation is a devastating complication following intracerebral hemorrhage. Little is, however, known about the biomarkers which was associated with cerebral herniation. We therefor aimed to explore a panel of biomarkers including serum troponin which had the predictive value for the incidence of cerebral hernia.

Methods

A retrospective cohort study of all patients with acute intracerebral hemorrhage admitted to West China Hospital from May 1, 2014 to September 1, 2015 was performed (n = 188). Fourteen biomarkers including serum troponin were measured in those 188 patients. Basic characteristics were obtained from the prospective database of the National Key Technology R&D Programme of the 12th Five-Year Plan.

Results

Among the fourteen biomarkers, we found that elevated troponin was independently associated with cerebral herniation (adjusted odds ratio [OR] 5.19; 95% confidence interval [CI], 1.08–24.93). In addition, troponin elevations were associated with the hematoma location in deep, hypertension-related hemorrhage and in-hospital mortality, as well as a lower Glasgow Coma Scale (GCS) score and a higher National Institutes of Health Stroke Scale (NHISS) score. After adjusting for confounding factor, elevated troponin was significantly associated with lower GCS score and higher the NHISS score (OR 2.34; 95% CI, 1.17–4.68, P = 0.016; OR 2.06; 95% CI, 1.06–4.01, P = 0.033, respectively.)

Conclusions

Troponin elevations among fourteen biomarkers, along with large hematoma volume, even after adjusting potential confounders, is associated with an almost 5-fold increased risk of cerebral herniation. The possibility of a cerebral herniation should be considered when intracerebral hemorrhage patients with large hematoma volume and elevated troponin.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

SERUM CALCIUM AND PHOSPHATE LEVELS AND SHORT- AND LONG-TERM OUTCOMES IN ACUTE INTRACEREBRAL HEMORRHAGE PATIENTS

S YOU ¹, Q Han ², J Xu ¹, C Zhong ³, H Liu ¹, Y Zhang ¹, C Liu ¹, Y Cao ¹

Abstract

Background

We investigated whether admission serum calcium and phosphate levels are associated with short- and long-term outcomes in patients with acute intracerebral hemorrhage.

Methods

A total of 365 patients with acute intracerebral hemorrhage were enrolled in this study. Participants were classified into 4 subgroups according to serum calcium or phosphate quartiles. Demographic characteristics, lifestyle risk factors, medical history, and other clinical characteristics were recorded for all participants. Excellent outcome was defined as discharge or 3-month modified Rankin scale (mRS) scores of 0–1.

Results

Univariate analysis comparing the highest and lowest quartiles indicated that elevated calcium level was associated with 2.26-fold and 2.28-fold increases in the odds for discharge and 3-month excellent outcome, respectively. After adjustment for age, sex, and other potential risk factors, patients in the highest quartile still had significantly increased odds of discharge and 3-month excellent outcome, the corresponding odds ratios (ORs) were 3.54 (95% confidence interval [CI], 1.09–11.56) and 5.36 (95% CI, 1.69–16.99). When calcium was divided into two groups, the ORs of higher calcium were 3.01 (95% CI, 1.16–7.82) and 2.78 (95% CI, 1.14–6.78) for discharge and 3-month excellent outcome, respectively. However, no significant association was observed between serum phosphorus and excellent outcome.

Conclusions

Elevated admission serum calcium level but not phosphorous is positively associated with excellent outcome at discharge or 3-month in acute intracerebral hemorrhage patients.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ASSOCIATION OF SERUM TOTAL BILE ACID LEVELS WITH HEMATOMA VOLUME, STROKE SEVERITY, AND CLINICAL OUTCOMES IN PATIENTS WITH ACUTE INTRACEREBRAL HEMORRHAGE

S You ¹, Y Zhang ¹, C Zhong ², J Xu ¹, X Zhang ¹, H Liu ¹, Y Cao ¹, C Liu ¹

Abstract

Background

This study aimed to investigate whether serum total bile acid levels at the time of admission were associated with hematoma volume, stroke severity, and clinical outcomes in patients with acute intracerebral hemorrhage.

Methods

A total of 335 patients with acute intracerebral hemorrhage were prospectively included. Patients were divided into four groups, according to the quartiles of serum total bile acid levels. Multivariate linear regression models and non-conditional logistic regression models were used to evaluate the association between serum total bile acids levels and hematoma volume, admission severity, or prognosis of acute intracerebral hemorrhage.

Results

The median hematoma volumes for the quartiles of total bile acid levels (Q1 to Q4) were 12.0, 12.3, 10.0, and 6.7 mL (P < 0.001), and the median National Institutes of Health Stroke Scale scores were 8, 8, 6, and 5 (P = 0.002), respectively. In the multivariate-adjusted models, patients in Q4 had smaller hematoma volumes (P = 0.039) and lower NIHSS (P = 0.037) than patients in Q1. After 3 months, 136 poor outcomes (mRS ≥ 3) and 46 all-cause deaths were documented. However, compared with patients in Q1, those in Q4 were not associated with poor outcomes (odds ratio, 0.81; 95% confidence interval, 0.29–2.31; P-trend = 0.739) or all-cause mortality (odds ratio, 0.53; 95% confidence interval, 0.08–3.52; P-trend = 0.380) after adjusting for age, sex, hematoma volume, and baseline NIHSS.

Conclusions

High serum total bile acid levels were associated with smaller hematoma volumes and lower NIHSS at the time of admission. However, there were no significant relationships between serum total bile acid levels and 3-month clinical outcomes among patients with ICH.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

LDL-C/HDL-C RATIO AND RISK OF ALL-CAUSE MORTALITY IN PATIENTS WITH INTRACEREBRAL HEMORRHAGE

S You ¹, C Zhong ², J Xu ¹, Q Han ³, Y Zhang ¹, J Shi ¹, Z Huang ¹, Y Cao ¹, C Liu ¹

Abstract

Background

The low-density lipoprotein cholesterol/high-density lipoprotein cholesterol (LDL-C/HDL-C) ratio has been recognized as a strong risk predictor of cardiovascular diseases. However, the association between the LDL-C/HDL-C ratio and the prognosis of acute intracranial hemorrhage (ICH) is unclear. Thus, we prospectively investigated whether a low LDL-C/HDL-C ratio could predict all-cause mortality in Chinese patients with acute ICH.

Methods

A prospective cohort study of 356 patients with acute ICH was conducted, and the mean follow-up time point was 80.4 days. Participants were divided into four categories, based on LDL-C/HDL-C ratio quartiles. Three-month outcomes were evaluated by in-person or telephone interviews with patients or their family members. The end point was 3-month mortality from all causes.

Results

Forty-seven deaths from all causes were documented. The Kaplan-Meier curves show that patients in the lowest quartiles had the highest cumulative incidence rates (log-rank P = 0.027). After adjusting for covariates, a low LDL-C/HDL-C ratio was associated with a 3.55-fold increase in the risk of all-cause mortality (hazard ratio, 3.55 [95% confidence interval, 1.04–12.14]; P-trend = 0.011) when the highest and lowest quartiles were compared. The C-statistic of the LDL-C/HDL-C ratio was significantly larger than that of LDL-C (0.638 vs. 0.548, P = 0.012).

Conclusions

A low LDL-C/HDL-C ratio was independently associated with an increased risk of all-cause mortality at 3 months in patients with ICH. Moreover, the LDL-C/HDL-C ratio appeared to be a better predictor of all-cause mortality than serum LDL-C.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PREDICTORS OF DIFFUSION-WEIGHTED IMAGING AND ACUTE BRAIN INFARCTS IN SPONTANEOUS INTRACEREBRAL HEMORRHAGE

Q Zhang ¹, Y Yang ², D Liebeskind ³, Y Zhang ¹, J Saver ³

Abstract

Background

Intracerebral Hemorrhage (ICH) has the highest rates of dependence or death among stroke. The goal of this study is to identify clinical predictors of acute brain infarcts detected by diffusion-weighted imaging (DWI) in patients with Spontaneous ICH, in combination with clinical characteristics and risk factor of patients.

Methods

We collected data on patients with spontaneous ICH admitted to UCLA Medical Center between Jan 1, 2006 and Dec. 31, 2012 and in whom DWI was performed within 7 days of admission. The patients concurrent MRI were performed within 7 days of symptom onset. Logistic models probed the relation with the risk factor of acute brain infarcts in sICH.

Results

Among 149 spontaneous ICH patients (mean 63.17 years, 43.62% female, and 16.89% black) who also underwent MRI, DWI abnormality was observed in 89.26%. Among the location of abnormalities, any ipsilateral and no contralateral to ICH in 94.74%, contralateral and no ipsilateral to ICH in 0.76%, both ipsi and contra in 5.26%. A multiple logistic regression model identified 5 categories of independent predictors of DWI positivity.

Conclusions

We found that acute brain infarction is relatively common after acute spontaneous ICH. Several factors including aggressive blood pressure highering, may be associated with acute ischemic infarcts after ICH. These preliminary findings require further prospective study.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

INFECTION PREDICTION FOR ANEURYSMAL SUBARACHNOID HEMORRHAGE PATIENTS AT HOSPITAL ADMISSION: COMBINED PANEL OF SERUM AMYLOID A AND CLINICAL SCALES

L Azurmendi ¹, A Sarrafzadeh ², N Tiberti ³, P Sanchez Pena ⁴, V Degos ⁴, L Puybasset ⁴, S Richard ⁵, N Turck ¹, JC Sanchez ¹

Abstract

Background

Aneurysmal subarachnoid hemorrhage (aSAH) is associated with high rates of mortality/morbidity. Nosocomial infections, such as pneumonia or urinary tract infections, are some of the main causes of outcome worsening and death. This study evaluated the performance of panels composed of clinical parameters (GCS, WFNS, Fisher, and age) and/or blood biomarkers (serum amyloid A (SAA), C-reactive protein (CRP), neopterin, and white blood cells (WBC)) for predicting the risk of infection of aSAH patients at hospital admission.

Methods

The present study included 104 patients from two independent European cohorts. Biomarker concentrations were evaluated from plasma samples taken at hospital admission, and receiver operating characteristic curves were used to assess their predictive power. The best panel combination was obtained using the PanelomiX tool.

Results

At hospital admission, the most sensitive parameters for the stratification of patients at risk of developing an infection were SAA and the WFNS. A specificity value set at 100% (95% CI, 100–100), resulted in sensitivity values of 26.98% (95% CI, 15.87–38.1) for SAA and 31.88% (95% CI, 21.74–43.48) for WFNS. Moreover, the panel combination of SAA, WBC, WFNS, and age significantly improved (p < 0.004) this performance, resulting in a sensitivity value of 64.3% (95% CI, 50–78.6).

Conclusions

At hospital admission the diagnostic test panel combination of SAA, WBC, WFNS, and age is a promising tool for predicting infections that will develop during hospitalization in aSAH patients. This could lead to better management of patients, faster administration of antibiotherapy, reductions in the number of nosocomial infections, and improvement in the associated outcome.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE BURDEN OF UNDER RECOGNISED COGNITIVE IMPAIRMENT IN THE HYPERACUTE STROKE UNIT

A Chandratheva ¹, G Christofi ¹, C Walters ², E Bretherton ², V Yeardley ², D Lally ², R Brealey ², H Warwick ², R Simister ¹

Abstract

Background

Cognitive assessment is routinely performed on the hyperacute stroke unit (HASU). However, this may not provide a comprehensive profile. On an acute neurorehabilitation step-down unit linked to the HASU, we assessed cognition using stroke-specific screening tools, functional tasks and detailed collateral history.

Methods

On a 7-bedded acute neurorehabiliation step-down unit developed as a winter pressures project, January 26^th-May 27^th 2015, we accepted patients assessed by a neuro-navigator on HASU and spoke acute stroke units (ASU). Patients were medically stable and deemed ready or ‘nearly ready’ for early supported discharge (ESD). We used standardized stroke specific screening tools: Oxford cognitive score (OCS) or Birmingham cognitive screen (BCOS). Detailed collateral histories and more comprehensive functional tasks were performed. Where significant cognitive impairment was identified patients had neuropsychological assessment to inform signposting on discharge.

Results

Of 76 screened patients 41(54%) male, mean age 73yrs (SD 16.7), 30 (39%) age ≥80yrs, 28(58%) had premorbid cognitive impairment. 36(47%) had new or a deterioration in cognitive function. More detailed functional assessments of extended activities of daily living were required in 52 (68%). Further collateral history was obtained in 48 (63%). 30 (39%) were living alone. Neuropsychological intervention was undertaken in 12(16%) patients. Average length of stay for patients with cognitive impairment was non significantly greater (8.40 vs 7.1 days, p = 0.25).

Conclusions

Approximately half of patients referred to ESD had cognitive impairment. This may be under recognised in the hyperacute phase and may require further clinical scoring, functional assessment and more detailed collateral history.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

STABILITY OF TEST OF PRE-MORBID IQ (NATIONAL ADULT READING TEST, (NART)) OVER 3 YEARS AFTER MILD STROKE

V Cvoro ¹, CA McHutchison ¹, F Chappell ¹, K Shuler ¹, S Makin ², M Dennis ¹, J Wardlaw ¹

Abstract

Background

Adjustment for prior cognitive ability is important to assess cognitive impact of stroke. The NART is validated for assessing premorbid intelligence of English-speaking ageing subjects even with early dementia, but not after stroke. NART assesses language (word recognition) ability, which, is thought to be ‘crystallised’ and therefore spared following neurological injury or decline. We tested stability of NART over time after stroke.

Methods

We followed up patients over 3 years, assessing the NART at one, 12 and 36 months after mild (ie non-disabling) lacunar or cortical ischaemic stroke. We assessed stability of NART over the 36 months using Bland Altman analysis.

Results

91 patients, mean age 68.3, SD 11, range 39–94; mean NIHSS 1.2, SD 1.2, range 0–7 had NART at all 3 time points. Mean IQ was 116.6, range 94.8–128, SD 8.36 at one, 117.2 range 89.8–128 SD 9.74 at 12, and 113.5 range 92.3–128 SD 8.83 at 36 months after stroke.

graphic file with name 10.1177_2396987316642909-fig42.jpg

Conclusions

NART remained stable to 36 months after mild stroke providing a useful test of pre-morbid IQ. However, there may be a downward trend in IQ after 12 months. A larger sample and longer follow up are required to determine if particular stroke characteristics affect stability of NART after stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

A PROSPECTIVE STUDY OF CHARACTERISTICS OF POST STROKE APHASIA AMONG PERSIAN SPEAKING INDIVIDUALS

S Heidari ¹, A Rahimi Jaberi ², R Nilipour ³, SK Saraj-Zadehfard ⁴, A Borhani-Haghighi ⁵, J Rahimian ⁶

Abstract

Background

This study was undertaken to assess the severity of post stroke aphasia as well as noun and verb impairment in Persian speaking patients as it relates to the site of lesion.

Methods

30 Persian aphasic patients aged 34 to 78, with lesions in both left and right hemisphere, were evaluated prospectively within one year post onset. Based on Aphasia Quotient (AQ) values derived from validated Persian Version of Western Aphasia Battery (P-WAB 1, Nilipour 2014), patients were divided into four groups of severity as mild, moderate, severe and very severe. The Persian Object and Action Naming Battery(Nilipour 2015) was used to measure noun and verb impairment. Lesion locations were classified as cortical or subcortical, and were determined by magnetic resonance imaging. The cortical group was categorized as anterior, posterior and anterior-posterior.

Results

The mean AQ was 79.3 with a range of 30–96. Of the 30 subjects, 13.4% had severe, 13.4% had moderate and 73.2% had mild aphasia. Severity of aphasia in patients with cortical lesions was significantly higher than those with subcortical lesions (P = 0.031). However the mean AQ of patients with LH infarctions (73.61) was lower than those with RH infarctions (87.9), no significant statistical relationship was seen between the occurrence of lesion in either hemisphere and the severity of aphasia. The assessment of noun- verb impairment indicated that regardless of lesion site, the average response to object naming was higher than action naming.

Conclusions

These findings revealed that cortical lesions were more likely to affect language function than subcortical lesions.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EXTRA AND TRANSCRANIAL COLOR-CODED SONOGRAPHY FINDINGS IN APHASIC PATIENTS WITH IPSILATERAL INTERNAL CAROTID ARTERY, AND/OR MIDDLE CEREBRAL ARTERY STENOSIS OR OCCLUSION

DC Jianu ¹, SN Jianu ², F Dan ¹, L Petrica ³

Abstract

Background

Large artery disease (LAD) is presumed in aphasics with ischemic stroke and significant stenosis (>50%) or occlusion of the ipsilateral ICA/MCA. However, the existing data on the distribution of the steno-occlusive diseases in aphasics is scarce.

Aims To investigate the role of Transcranial Color Coded Sonography (TCCS) in the determination of abnormalities affecting intracranial, and/or extracranial arteries in aphasics with acute ischemic stroke.

Methods

A total of 166 consecutive patients (pts) with a first acute ischemic stroke (LAD type) and aphasia were examined. Their language function was evaluated by means of the Romanian modified version of the Western Aphasia Battery. They received extracranial color Doppler sonography (ECDS) and TCCS examinations in the first 12 hours of stroke onset. There was no brain DWI MRI findings of an earlier stroke.

Results

The main aphasic syndrome at admission was Broca’s aphasia (55%). In 75.3% of cases (125 pts) the lesions were located at classical language centers. TCCS and ECDS results were: 1) 65 pts (39.1%) with no changes in the intracranial hemodynamics; 2) 101 pts (60.9%) with the following changes: a) 25 pts (15.1%) with MCA, siphon or terminal ICA (C1) stenosis/occlusions; b) 76 pts (45.8%) with hypoperfusion of the left MCA; 34 of them had a severe stenosis/or occlusion of the extracranial ipsilateral ICA, with collateral circulation.

Conclusions

TCSS was a reliable method for the evaluation of the intracranial ICA and MCA stenosis/occlusion and helped identify the intracranial hemodynamic impairment in the extracranial ICA diseases causing post-stroke aphasia.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

GALANTAMINE ADMINISTRATION IN CHRONIC POST-STROKE APHASIA

B Muinjonov ¹, E Giyazitdinova ²

Abstract

Background

To investigate the influence of galantamine on linguistic function, any associated factors in patients with chronic post-stroke aphasia were analysed.

Methods

45 patients younger than 75 years with chronic aphasia ($1 year since onset) were prospectively enrolled in the study. Language testing was performed at weeks 0 and 16. Initial galantamine dose was 8 mg/day for 4 weeks, and 16 mg/day for the following 12 weeks. Efficacy was evaluated by the sum of four domains (spontaneous speech, comprehension, repetition and naming) on the aphasia quotient (AQ) of the Western Aphasia Battery from baseline to endpoint .

Results

Mean age was 60.4 years (22e74) and 14 patients were female. Mean duration of aphasia was 2.261.5 years. There was a significant increase in the total AQ score in the galantamine group (n¼23, 48.5e57.0 percentile; p¼0.007) but not in the control group (n¼22, 54.3e54.9 percentile; p¼0.308). The AQ2 score was independently associated with AQ1, galantamine administration and Mini-Mental State Examination (MMSE) score in multiple linear regression models. With the galantamine group, the good responders (vs poor responders) had a higher level of education (p¼0.048), higher baseline MMSE score (p¼0.009) and a subcortical dominant pattern (p¼0.030). After adjusting for potential variables, subcortical dominant lesion was the independent determinant for galantamine responsiveness (OR 30.3; 95% CI 1.1 to 805.9, p¼0.041).

Conclusions

Administration of galantamine had a beneficial effect on chronic post-stroke aphasia, and was more prominent in subcortical dominant lesions.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

NON-FOCAL TRANSIENT NEUROLOGICAL ATTACKS ARE ASSOCIATED WITH COGNITIVE IMPAIRMENT IN PATIENTS WITH CAROTID OCCLUSIVE DISEASE

E Oudeman ¹, L Onkenhout ¹, K Klijn ², A Algra ¹, J Kappelle ¹

Abstract

Background

Hemodynamic failure of the brain is associated with an increased risk of cognitive decline and probably also with an increased risk of transient neurological attacks (TNAs). We investigated whether a history of non-focal TNAs was associated with decreased cognitive functioning in patients with carotid occlusive disease.

Methods

Fifty-three patients with internal carotid artery occlusion or high-grade stenosis, aged >50 years and no dementia, underwent standardized history taking and neuropsychological testing. Non-focal TNA was defined as one or more of the following transient symptoms: blurry vision, positive visual phenomena, decreased consciousness, confusion, amnesia, unsteadiness, non-rotatory dizziness, paresthesias or bilateral weakness of legs. Neuropsychological testing included MMSE, tests on attention, visuospatial function, information processing, language, executive function and memory. We calculated z-scores for the MMSE, each cognitive domain and all domains combined and analyzed the association between non-focal TNAs and cognition with linear regression analysis, adjusted for age and education level.

Results

Twenty-four patients (45%) had experienced non-focal TNAs in the preceding six months. Patients with non-focal TNAs had a lower MMSE (mean 27.2, SD 3.1) than those without non-focal TNAs (mean 27.8, SD 1.5), but we found no differences in z-scores based on neuropsychological testing, either by domain or overall. After adjustment for age and level of education the association between non-focal TNAs and zMMSE remained (beta = −0.54, 95% CI −.99 to −.08, P = 0.02).

Conclusions

In patients with carotid occlusive disease, non-focal TNAs are associated with a lower MMSE, but not with impairment in specific cognitive domains.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

COLLATERAL CIRCULATION AND COGNITIVE FUNCTION IN STROKE PATIENTS WITH SYMPTOMATIC CAROTID STENOSIS

S Pires-Barata ¹, R Garcia ², V Ladera ², MV Bartolome ², S Mateus ³, I Mendes ³, V Pós-de-Mina ³, C Corzo ⁴, L Rebocho ⁴

Abstract

Background

Collateral circulation has not been a well-documented variable when considering cognitive function among stroke patients with symptomatic carotid stenosis. The aim of the present study is to characterize the cognitive function considering the presence or absence of collateral circulation mechanisms.

Methods

74 participants were eligible for inclusion and divided in three groups (14 ischemic stroke with symptomatic internal carotid stenosis, 30 ischemic stroke without stenosis and 30 stroke free participants), matched by gender, age and scholar grade. A comprehensive neuropsychological assessment and a MRI with perfusion and diffusion study, was conducted during the first two weeks after the vascular event, before being subjected to carotid revascularization treatment.

Results

70% of the participants were male, mean age 65.3 ± 13.9 and 34% had [4–6[years of scholar education. More than half had a right side lesion and 46% were classified has PACI. In the stenosis group, 50% had a moderate to severe stenosis and 57% had no collateral circulation mechanism. Considering the screening tests, attention tests, learning and memory, no statistical difference was observed. It was observed that patients without collateral circulation mechanisms performed worst when considering an executive function – shifting (TMT B; p < ,010).

Conclusions

Patients with symptomatic stenosis without collateral circulation mechanisms tend to be slower when compared to those with collateral circulation in shifting abilities. More research is needed to understand the mechanism behind these findings.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ACUTE STROKE: A COGNITIVE FUNCTION CHARACTERIZATION

S Pires-Barata ¹, M Duarte ², S Lourenço ³, C Corzo ³, L Rebocho ³

Abstract

Background

Cognitive function in acute stroke is not a well documented identity; however it is important to establish the cognitive pattern in this early stage. The aim of the present study is to characterize the cognitive function of acute ischemic stroke patients.

Methods

195 acute ischemic stroke patients full field our inclusion criteria. All patients were evaluated by a neuropsychologist or a trained psychologist, using our stroke unit neuropsychological protocol - CogUAVC (O-LOG/C-LOG, language, praxis, clock drawing test, house drawing copy test and Neuropsychiatric Inventory).

Results

More than half of the patients were man, with mean age of 66.64 ± 12.02. More than half of the patients were evaluated between 48 and 72 h. A right hemispheric stroke was observed in 52%, 15% had an NIHSS of 3 at entrance, 46% were classified as PACI and 42% had a MCA stroke. Orientation was impaired in 13% and 61% presented impairment in at least one of the cognitive domains studied. Executive function was impaired in 64% and recall also in 64%. Considering humour, 24% presented depressive symptoms and 19% anxiety.

Conclusions

The results suggested that, even in early phases, only few patients were disorientated, but more than half showed impairment in executive function and recall domains, with the presence of depressive symptoms. These findings may be of great importance in order to define a more adjusted rehabilitation plan, since early phases.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE NEUROPSYCHOLOGICAL PROFILE OF TIA AND STROKE MINOR PATIENTS

A Carnes-Vendrell ¹, J Deus ², J Molina-Seguin ¹, J Pifarré ³, F Purroy ¹

Abstract

Background

To determine the neuropsychological profile of transient ischemic attack (TIA) and minor stroke (MS) patients during the acute phase of the brain ischemia

Methods

We included 74 consecutive patients (NIHSS ≤ 4 or TIA). All patients underwent diffusion-weighted magnetic resonance imaging (DWI). We classified the neuropsychological tests into eight cognitive domains[f1]. We correlated age, sex, family status, socio-demographic environment, employment status, level of education, manual dominance, etiology, vascular risk factors, abuse of substances, previous psychiatric disease, patient’s family history, and DWI findings with the neuropsychological profile.

Results

Mean age was 66.4 (SD 11.0) years, 72% male. We included 22 DWI negative TIA, 15 DWI positive TIA and 37 MS subjects. We observed disturbances in up to 72 (97.3%) patients. The domains that best discriminated cognitively impaired from unimpaired patients were verbal memory, attention/information processing speed (IPS), executive functions, visuospatial integration and psychomotor ability. We found significant correlations between abuse of substances and verbal (p = .038) and visual memory (p = .032). Level of education correlate with attention (p = .025), visuospatial integration (p = .026) and shows a trend towards significance with executive functions (p = .059). Atherosclerosis and small-vessel disease correlate with praxis performance (p = .043). Hypertension was related to attention (p = .020). No differences were observed according to the presence or absence of DWI abnormalities.

graphic file with name 10.1177_2396987316642909-fig43.jpg

Conclusions

Beside minimum or complete resolution of neurological symptoms, TIA and MS patients did have cognitive impairment, especially in verbal memory, attention/IPS, executive functions, visuospatial integration and psychomotor ability. These deficits correlate with multiple variables, such as abuse of substances, level of education, etiology and vascular risk factors.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

DUAL -TASK TRAINING AND STATIN TREATMENT NORMALIZE C-REACTIVE PROTEIN AND LIPID LEVELS AND IMPROVE POSTURAL AND COGNITIVE FUNCTIONS IN PATIENTS WITH VASCULAR MILD COGNITIVE IMPAIRMENT

E Sidorovich ¹, S Likchachev ¹, N Klishevskaiya ¹, A Sidorovich ²

Abstract

Background

There is growing evidence that balance-cognitive dual – task training may improve postural and cognitive functions in the patients with Vascular Mild Cognitive Impairment (VaMCI).

The aim of our study was to evaluate the effect of balance-cognitive dual –task training and statin treatment combination on C-reactive protein levels, lipid content and cognitive and postural functions.

Methods

Fifty nine patients with VaMCI were randomly divided into 2 groups. The 1st group (n = 26) received simvastatin of 40 mg/d or atorvastatin of 20 mg/d, antihypertensive and antiplatelet treatment. Along with this treatment the 2nd group (n = 33) underwent ten sessions of balance training on the static and dynamic stabiloplatforms accompanied by cognitive tasks

Results

The decrease in hsCRP (from 2,0; 0,8–3,4 to 1,1; 0,4–2,4 mg/l and from 2,2; 0,9–3,8 to 1,6; 0,8–3,3 mg/l, Р < 0,05) was found in both groups of the patients 30 days after the onset of the treatment. In the 2nd group there was also increase in HDL-C from 1,1; 0,8–1,6 to 1,6; 1,2–2,0 mmol/l, Р < 0,05.

The patients of the 2nd group demonstrated improved attention in Shulte’s tables test, trail making test, semantic and phonemic fluency (Р < 0,05). In the static stabiloplatform examination the training group had significant improvement in body sway and the gravity center displacement radius, and decrease in the average postural response time in the dynamic stabiloplatform examination (р < 0,054).

Conclusions

This study suggests that the combination of balance-cognitive dual-task training and statin treatment helps improve cognitive and postural function and reduce the severity of systemic inflammation and dyslipidemia in the VaMCI patients.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ACQUIRED AMUSIA AFTER STROKE - THE NEURAL BASIS

A Sihvonen ¹, P Ripollés ², V Leo ¹, A Rodríguez-Fornells ², S Soinila ³, T Särkämö ¹

Abstract

Background

Acquired amusia, the inability to perceive or produce music, is a relatively common disorder after stroke to the middle cerebral artery territory. However, while abnormalities in the structure, function, and connectivity of right superior temporal and inferior frontal brain areas have been implicated as the neural cause of congenital amusia, the precise neuroanatomical basis of acquired amusia has to date not been systematically explored.

Methods

To evaluate crucial changes in the brain associated with acquired amusia and its recovery, a longitudinal study with 77 subacute stroke patients and 6-month follow-up was conducted. Music perception was evaluated with the Montreal Battery of Evaluation of Amusia (MBEA) and structural MRIs were acquired to carry out voxel-based lesion symptom-mapping (VLSM), voxel-based morphometry (VBM), and tract-based spatial statistics (TBSS) analyses comparing amusic and non-amusic patients.

Results

Preliminary results from VLSM analyses indicate that acquired amusia is specifically associated with damage to the right temporal areas, insula, and putamen. Similarly, tentative results from TBSS of white matter tracts suggest that reduced connectivity within the right frontotemporal pathways is closely linked to amusia. Additionally, in VBM analyses, patients with persistent amusia showed further grey matter volume decrease in the superior temporal areas in the right hemisphere.

Conclusions

Overall, these findings implicate the right temporal and subcortical regions and the right frontotemporal pathway as the crucial neural substrate of acquired amusia and its recovery after stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

DISTINCT ANATOMICAL CORRELATES OF ORIENTATION TO TIME REVEALED BY LESION-SYMPTOM MAPPING STUDY IN CHINESE POPULATION

W Liu ¹, L Zhao ¹, JM Biesbroek ², L Shi ¹, A Wong ¹, HJ Kuijf ³, GJ Biessels ², VCT Mok ¹

Abstract

Background

Orientation to time, an important domain assessed by Mini-Mental State Examination (MMSE), is a strong predictor of subsequent cognitive decline in elderly. However, the underlying neural substrate is still uncertain. We assessed which key cerebral regions were associated with time orientation in one year after stroke in Chinese population.

Methods

272 patients (age, 67.8 ± 10.1; female, 47.2%) with acute ischemic lesions (AIL) received MMSE in one year after stroke. We applied voxel-based lesion-symptom mapping (VLSM) to investigate the spatial relation between AIL locations on brain magnetic resonance imaging (MRI) and time orientation. Secondly, we performed a region of interest-based (ROI) analysis to validate the significant clusters derived from VLSM analyses using a multivariable linear regression model based on the automated anatomical labeling (AAL) atlas and ICBM DTI-81 white matter tract atlas.

Results

VLSM analyses identified that MMSE score in one year after stroke was significantly associated with AIL in the left basal ganglia, angular gyrus, superior temporal gyrus and corpus callosum. Orientation to time was only related to key regions in the left basal ganglia: caudate, putamen, pallidum and anterior limb of internal capsule.

graphic file with name 10.1177_2396987316642909-img15.jpg

graphic file with name 10.1177_2396987316642909-img16.jpg

Conclusions

These findings identify that the left basal ganglia is a critical substrate for deficits in orientation to time after stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EVALUATION OF CAROTID ANGIOPLASTY WITH STENT IN A SERIES OF PATIENTS USING A DISTAL PROTECTION SYSTEM- A DESCRIPTIVE STUDY

J Abril Jaramillo ¹, MÁ Gamero-García ¹, R De Torres Chacón ¹, M Iglesias Blanco ², C Carrascosa Rosillo ², S Pérez ¹, S Eichau ¹, A Domínguez Mayoral ¹, MA Quesada ¹, G Izquierdo ¹, R Ruiz Salmerón ²

Abstract

Background

Atherosclerotic disease favors the handling of the plate during angioplasty and generate increased risk of stroke, which is required of protective devices, although its use is currently controversial.

Methods

Descriptive study, single-center (Virgen Macarena Hospital, Seville, Spain). The data was analyzed with 51 patients undergoing CAS from October 2012 to August 2015, with distal protection system Twin-one. Angioplasties were performed in patients with symptomatic stenosis ≥50% and asymptomatic stenosis ≥70% previously assessed by doppler or/and CT angiography. Clinical events was evaluated at 30 days (death, stroke, heart attack) also device tolerance and control of stent with carotid doppler.

Results

From the series of 51 patients, 78% were male, 80% HTA, 55% DM, DLP 59%, tobacco 74%. 86% had affected the symptomatic artery; 43% had subtotal stenosis. After the intervention the mean percent stenosis decreased from 65.7 ± 17.2 to 23.0 ± 16.2 (p < 0.001). The minimum luminal diameter (in internal carotid artery) increased from 1.6 ± 0.8 to 3.9 ± 0.7. The rate of clinical events at 30 days was 7.8% (3 strokes, 1 patient died). The implant failure rate was 5.9 %.

Conclusions

Success rate:>90%, with a residual lesion <50% in all patients. The event rate was 7.8%, still acceptable considering a symptomatic population. No restenosis was observed in the doppler at 30 days. We consider the use of twin-one system a viable and secure alternative during angioplasty, but must be corroborated with new studies in the same line or in a comparative with other distal protection systems.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

RESTENOSIS OF SUCCESSFUL RECANALIZATION AFTER MECHANICAL THROMBECTOMY IN HYPERACUTE ISCHEMIC STROKE: COMPARISONS BETWEEN LARGE ARTERY ATHEROSCLEROSIS AND CARDIOEMBOLISM

SJ An ¹, TJ Kim ¹, CK Kim ¹, Y Kim ¹, KW Nam ¹, HJ Mo ¹, CH Sohn ², BW Yoon ¹

Abstract

Background

Mechanical thrombectomy is an effective revascularization treatment for acute intracranial large artery occlusion. However, outcomes of stent retrieval and recanalization may differ between mechanism of acute arterial occlusions due to large artery atherosclerosis (LAA) and those due to cardioembolism (CE). The purpose of this study was to assess the association between restenosis following intraaterial mechanical thrombectomy and stroke subtypes.

Methods

We reviewed 65 consecutive patients with acute ischemic stroke who had the occlusion of major anterior circulation arteries and underwent mechanical thrombectomy using solitaire stent between October 2010 and March 2013. MRA follow-up was performed at 24 hours ± 6 hours after recanalization. The ischemic stroke subtypes of these patients had previously been established with the TOAST classification system.

Results

Forty of eligible 65 patients were male with a median age [IQR] of 70 years [65–77]. Fifty-four (84.6%) of 65 all eligible patients achieved successful recanalization (thrombolysis in cerebral infarction grade 2b-3) at end-of-procedure. Twenty-eight (66.7%) of 42 patients who underwent a follow-up MRA had complete recanalization. Thirteen (24.0%) of 54 patients successful recanalization at end-of-procedure changed to incomplete recanalization on follow-up MRA. Eight (61.5%) of 13 patients is LAA subtype and five (38.5%) of 13 patients is CE subtype. LAA subtype was statistically significant correlation with higher restenosis rate of recanalized vessel after thrombectomy (P = 0.041).

Conclusions

Our finding suggest that LAA subtype of TOAST classification was characterized by a significantly higher risk for restenosis of sussessful recanalization after mechanical thrombectomy.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

SAFETY AND EFFICACY OF REVIVE THROMBECTOMY DEVICE IN SEVERE ACUTE ISCHEMIC STROKE

R Gandini ¹, F Sallustio ², S Merolla ¹, F Chegai ³, S Pizzuto ², D Konda ¹, S Abrignani ¹, P Stanzione ²

Abstract

Background

Very few studies have investigated the Revive thrombectomy device in acute ischemic stroke (AIS).

Methods

We retrospectively analyzed data of patients treated by mechanical thrombectomy in addition or not to IV rtPA administration. Demographic, clinical, and procedural times of patients treated by RD were compared to those observed in patients treated by the Solitaire FR or Trevo devices (other stentrievers, i.e. OS). Successful reperfusion was defined as TICI score ≥2; favorable clinical outcome was defined as a modified Rankin scale (mRS) score ≤2 at 3 months; rate of symptomatic intracranial hemorrhage (sICH) and mortality were collected.

Results

between November 2010 and February 2015 39 RD and 19 OS treated patients were performed. There were no differences in age, sex, stroke etiology based on TOAST criteria and classic vascular risk factors. Median baseline NIHSS and ASPECT score were similar (19 vs 20; p = 0.7; 9 vs 8; p = 0.5) as well as the rate of fair pial collaterals on pretreatment angiography (58% vs 60%). Successful reperfusion was obtained in 77% of RD and 89% of OS group (p = 0.3). Median number of device passages was significantly lower in the RD group (1.8 ± 1.2 vs 2.8 ± 1.8; p = 0.01). The rate of 3 months favorable outcome (mRS 0–2) did not differ between the two groups (36% vs 37%), whereas 3 months mortality was slightly lower in the RD as compared to OS group (26% vs 37%; p = 0.5).

Conclusions

RD seems to be safe and effective in the treatment of severe acute ischemic stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PRESENCE OF MICROINFARCTS AND CONTROL OF STENT RESTENOSIS IN CARTID STENTING USING TWIN ONE AS PROTECTION DEVICE

MR de Torres Chacón ¹, MÁ Gamero García ¹, J Abril Jaramillo ¹, M Iglesias Blanco ², C Carrascosa Rosillo ², S Pérez Sánchez ¹, S Eichau Madueño ¹, A Domínguez Mayoral ¹, MA Quesada García ¹, G Izquierdo Ayuso ¹, R Ruiz Salmerón ²

Abstract

Background

Twin One is a device used in carotid stenting (CAS) that combines distal protection and angioplasty balloon on the same device. We report the results in CAS patients using Twin One, according to the degree of stenosis and the presence of stent restenosis and silent microinfarcts on MRI.

Methods

Patients undergoing CAS using Twin One, at Virgen Macarena Hospital in Seville. Baseline characteristics (hypertension, diabetes…) are analyzed. Degree of stenosis is measured during arteriography. Stent restenosis is monitorized using doppler ultrasound at 1, 6 and 12 months after stenting. Silent microinfarcts are detected on MRI.

Results

51 patients (23.5% women, 76.5% men). A subgroup of 33 patients with complete study (Doppler ultrasound and MRI Cranial) is analyzed. 4 patients (12 %) had mild stenosis (<50%), of them 1 patient (25 %) presented microinfarcts. 15 patients (46%) had moderate stenosis (50–70%), 3 of them had microinfarcts (20%). 14 patients (42 %) had severe stenosis (>70 %), with microinfarcts in 6 of them (43%). There was no stent restenosis a month after implantation. There were 2 moderate restenosis (6%) at 6 months and 3 (9%) at 12 months. One moderate restenosis, that was detected at 6 months, evolved severe in 12 months control; rest remained stable.

Conclusions

In our sample Twin One is a device with an acceptable rate of microinfarcts during CAS but has been detected a higher incidence of these in the most severe stenosis. The tendency toward restenosis is low after using this device.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

RATES, TIMES, AND EARLY NEUROLOGICAL OUTCOMES OF ENDOVASCULAR TREATMENT IN CONSECUTIVE PATIENTS WITH ISCHAEMIC STROKE

B Drumm ^1,², S Murphy ¹, J Thornton ³, E Kavanagh ⁴, T Lynch ¹, K O'Rourke ¹, S Smyth ¹, E Dolan ⁵, P Brennan ⁶, A O'Hare ⁶, P MacMahon ⁴, D Hayden ¹, P O'Donoghue ¹, H Leona ¹, P Kelly ¹

Abstract

Background

Recent estimates of the proportion of ischaemic stroke patients eligible for thrombectomy have varied from 2.6–10%. Studies may under-estimate the true eligibility rate if CT angiography (CTA) is not routinely performed. Over-estimation may occur if selected cases are included from other hospitals, or if the total number of stroke cases is under-counted. Accurate data is required from consecutive hospitalised stroke cohorts with high CTA rates. We investigated the rate of referral for thrombectomy for consecutive ischaemic stroke cases in 2015.

Methods

We included all admitted patients with new ischaemic stroke (including in-hospital stroke) from 1^st January to 31^st December 2015, using our hospital discharge register and stroke database, with clinical verification. We excluded those with TIA and haemorrhagic strokes and those originally referred from other hospitals.

Results

290 new ischaemic stroke cases were identified. Mean arrival NIHSS was 15.3(SD 6.2), and median arrival Rankin was 5[IQR:4–5]. 166(57.2%) had CTA at presentation. 73(25.2%) had intravenous alteplase and 32(11.0%) were referred for thrombectomy via a ‘drip-and-ship’ model. Median door-to-CT time was 16 minutes and door-to-CTA was 28 minutes. 18(56.2%) of those sent for thrombectomy received intravenous alteplase. Median presentation-to-groin puncture time was 121 minutes. 6 had TICI 2b/3 recanalisation at angiography. Thrombectomy and/or stenting was performed in 23 patients. 3 were unsuccessful. Mean 24-hour NIHSS was 8.3 (SD 6.8) (p = 0.001), the median 30-day Rankin was 4[IQR:2–5].

Conclusions

With routine CTA for acute stroke, we found higher rates of eligibility for acute endovascular treatment than previously estimated. Our data will guide planning for stroke endovascular services.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

HEALTH ECONOMIC AND CLINICAL OUTCOMES IN THROMBECTOMY-ELIGIBLE ACUTE ISCHAEMIC STROKES: IMPLICATIONS FOR COST-EFFECTIVENESS STUDIES

A Ganesh ^1,², R Luengo-Fernandez ³, RM Wharton ¹, SA Gutnikov ¹, LE Silver ¹, Z Mehta ¹, PM Rothwell ¹, OBO the Oxford Vascular Study ¹

Abstract

Background

Mechanical thrombectomy for proximal intracranial occlusion has been shown to increase good 3-month functional outcome (modified Rankin Score [mRS] 0–2) in acute ischaemic stroke, but reliable cost-effectiveness analyses are required to support clinical service development. It is therefore necessary to understand how short-term mRS in thrombectomy-eligible ischaemic stroke translates into long-term disability, death and healthcare costs.

Methods

We studied a population-based cohort of incident ischaemic strokes (OXVASC – 2002–2014) who were potentially eligible for thrombectomy, defined pragmatically as those with NIHSS ≥5 seeking medical attention within 6 hours of onset. We related 1-month mRS to 5-year death, disability, and healthcare cost in the 3-month survivors using multivariate models adjusted for age and sex, and compared them to trends in other inpatients and all ischaemic strokes.

Results

Among 1,409 ischaemic stroke survivors, 180 (12.8%) were potentially thrombectomy-eligible and a further 654 received emergency/hospital inpatient care. Long-term outcomes in thrombectomy-eligible cases were similar to the other inpatient and overall populations when stratified by 1-month mRS. In thrombectomy-eligible cases, mRS > 2 was a strong predictor of 5-year death/disability (adjusted OR = 5.0, 1.65–15.81, p = 0.005), with similar results for other inpatient strokes (aOR = 9.41, 4.58–19.33, p < 0.0001) and for all ischaemic strokes (aOR = 8.85, 5.73–13.67, p < 0.0001). Similar results were obtained for analyses of 5-year mortality and long-term healthcare costs.

Conclusions

Patients with thrombectomy-eligible ischaemic stroke show a similar relationship between short-term outcome and long-term mortality, disability, and costs as other ischaemic strokes. Therefore, local published overall disability-stratified long-term outcome data can be used in regional cost-effectiveness analyses of thrombectomy

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE COLLATERAL CIRCULATION IN CT PERFUSION, A NEW PREDICTOR OF CLINICAL OUTCOME IN STROKE PATIENTS TREATED WITH THROMBECTOMY

S Bashir ¹, S Trillo ¹, C Aguirre ¹, E Barcena ², G Zapata ¹, L Perez ¹, JL Caniego ², A Barbosa ², F Nombela ¹, Á Ximénez-Carrillo ¹, J Vivancos ¹

Abstract

Background

The collateral circulation (CC) has a great importance in the prognosis after stroke. We try to evaluate the relationship between the CC estimated in CT perfusion source images (CTPSI) of patients who underwent thrombectomy and their outcome. We also investigated the correlation with the CC evaluated with single phase CTA (CTA-CC) and DSA (DSA-CC).

Methods

Retrospective study of consecutive patients with acute ischemic stroke in MCA territory treated with thrombectomy in our center with successful revascularization. The images were evaluated by a neurologist blind to the clinical data. The CC was scored using several scales in the CTPSI. We use a comparative scale between both hemispheres (CoPerS) with a punctuation of 1 to 4 (1 if CC greater than healthy hemisphere, 2 similar, 3 around 50% and 4 scarce). These variables were correlated with the mRS3m using the Spearman method.

Results

66 patients. Mean age: 69 years (SD: 10.2). Women 55.5%. Median ASPECTS 8 (7;10), median NIHSS 18 (15;23). There was a direct and statistically significant correlation between the punctuations in the CoPerS (p < 0.001) with the mRS3m, (Spearman coefficient of correlation = 0.54). We also found statiscally significant correlation between CoPerS with CTA-CC and DSA-CC.

Conclusions

The punctuation of CoPerS relates with the outcome of patients with acute ischemic stroke of the MCA, being an easy tool with predictive utility in patients treated with thrombectomy.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

SEVERE INTRACEREBRAL HEMORRAGHE: A DESCRIPTIVE STUDY, ANALYSIS AND THE ROLE OF SURGERY

A Gutiérrez García ¹, JR Penanes Cuesta ², F Monasterio Chicharro ¹, G Vega González ¹, P Pulido Rivas ², E Díaz Rodríguez ¹, A Bardal Ruiz ¹

Abstract

Background

To study mortality and evolution of patients with spontaneous cerebral hemorrhage (SCH), comparing surgical and conservative treatment, and define which variables have prognostic value on the evolution of patients.

Methods

Prospective observational study of incident cases. We included 164 adult patients with SCH admitted to the neurocritical unit at La Princesa University Hospital from 2009 to 2013. Aneurysmal hemorrhage was excluded. Variables related to baseline patient characteristics, hematoma, previous treatment received and complications were collected. Outcome variables were mortality and neurologic outcome using the modified Rankin Scale (mRS).

Results

The most common cause of SCH was hypertensive. The most common sites were the cerebral cortex and the basal ganglia. 85 patients (52%) underwent surgical treatment: craniotomy with evacuation, decompressive craniectomy, external ventricular drainage and / or intraventricular fibrinolysis. The most frequent complications observed in our study were the presence of intracranial hypertension (ICH), systemic infection and rebleeding. The variables associated with mortality were age (CI 1.8 to 51.7), admission GCS <9 (CI 1.8–30.5), hematoma volume >30 mL and brainstem compression (CI 1–28.5). Surgery was a protective factor for mortality (CI 0.06 to 0.9). The variables related to poor neurological outcome (mRS) were age (CI 2–59.4), admission GCS <9 (CI 1–31.56), brainstem compression (CI 2.3–94.56) and ICH (CI 1.47–16).

Conclusions

The indication of surgical treatment in brain hemorrhage remains controversial. The variability in patient characteristics makes this decision difficult. In our study, surgery was shown to reduce mortality in patients with SCH, but not to improve functional outcome.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EFFICACY AND SAFETY OF THE TREATMENT WITH NECK-REMODELING STENTS FOR HIGH-RISK INTRACRANIAL ATHEROSCLEROTIC STENOSIS

F Hernández-Fernández ¹, JD Molina-Nuevo ², O Ayo-Martín ¹, J García-García ¹, E Juliá ², MJ Pedrosa ², T Segura ¹

Abstract

Background

Intracranial atherosclerotic disease is a common cause of ischemic stroke, with a high rate of recurrences. Endovascular treatment is controversial, since two randomized trials have failed to ensure superiority of intracranial stenting and angioplasty versus aggressive medical therapy. The aim of our study is to analyze the rate of recurrences and clinical complications for the treatment with self-expanding, neck-remodeling stents for high-grade intracranial stenosis with severe clinical recurrences despite best medical therapy.

Methods

Prospective registry of a single-center conducted during 2015. Inclusion criteria were the presence of intracranial high-grade stenosis (>70%) causing neurological, severe fluctuations despite double antiplatelet therapy and statins. Minimum follow-up of three months was completed in all the patients, recording clinical data, post-procedural safety outcomes (stroke, death, intracranial hemorrhage), technical success, restenosis rate, modified Rankin scale and clinical recurrences at three months.

Results

Five patients were selected, with preeminence of male sex (80%) and a medium age of 62 years (range 52–82). With the use of neck-remodeling, self-expanding stents (Solitaire AB in four cases, Enterprise in one case) technical success was achieved in all the patients(100%). In three cases undersized balloon angioplasty was necessary to get appropiate recovery of vascular lumen. No more fluctuations neither post-procedural adverse events (0%) were registered. During follow-up period (median 5.8, range 3–12 months), one case of asymptomatic restenosis (20%) and no more recurrences (0%) were recorded.

Conclusions

In our series endovascular treatment with self-expanding stents (mainly Solitaire AB) and undersized angioplasty was technically feasible and free of complications in the short and medium term.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

GOOD BASELINE ANGIOGRAPHIC COLLATERAL FLOW CORRELATES WITH SUCCESSFUL RECANALIZATION AND CLINICAL OUTCOME AFTER ENDOVASCULAR TREATMENT FOR ACUTE ISCHEMIC STROKE WITHIN 24 HOURS FROM ONSET

JH Seo ¹, HW Jeon ², HW Jeong ³

Abstract

Background

To evaluate the relationships among angiographic collateral flow, successful recanalization, and clinical outcome after endovascular treatment (EVT) in patients experiencing acute ischemic stroke (AIS) within 24 hours of onset

Methods

We assessed patients experiencing acute anterior circulation ischemic stroke who underwent EVT between 2011 and 2015. Patients with large artery occlusion of anterior circulation and clinical diagnosis of AIS, within 24 hours of first found abnormal time (FAT), were included in the study.

Results

One hundred seventy-three patients met the inclusion criteria. Mean age was 68.3 ± 12.6 years and median National Institutes of Health Stroke Scale score was 14 (range, 5–29). Median time from FAT to arrival was 92 minutes. Overall successful recanalization, defined by the Modified Thrombolysis In Cerebral Infarction scale grade 2b-3, was achieved in 65.3% of patients, and good clinical outcome, as defined by the modified Rankin Scale (mRS 0–2), was achieved in 47.4% of patients. For successful recanalization, angiographic collateral grade was the independent factor. In multiple logistic regression analysis, angiographic collateral grade was independently associated with clinical outcome after adjusting for other variables (odds ratio, 5.96; 95% CI, 1.76–20.19).

Conclusions

Our data showed that angiographic collateral grade was a strong independent predictor of successful recanalization after EVT and good clinical outcome in AIS patients when applied up to 24 hours from FAT. Consequently, good angiographic collateral flow may help predict successful recanalization and better clinical outcomes after EVT in patients with AIS.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PREDICTOR OF EARLY DRAMATIC RECOVERY FOLLOWING CEREBRAL ARTERY RECANALIZATION BY ENDOVASCULAR TREATMENT IN PATIENTS WITH ACUTE ISCHEMIC STROKE

DH Kim ¹, HW Nah ¹, HS Park ², JH Choi ², MJ Kang ², SW Kim ³, SM Jun ⁴, JK Cha ¹

Abstract

Background

Endovascular treatment significantly increased recanalization rate and improved functional outcomes in acute ischemic stroke. However, many patients did not have early dramatic recovery after cerebral artery recanalization by endovascular treatment. We assessed clinical factors and magnetic resonance imaging findings associated with early dramatic recovery following recanalization by endovascular treatment in anterior circulation infarction.

Methods

We included acute ischemic stroke patients with anterior circulation occlusion who received endovascular treatment between January 2007 and July 2015. Patients with ischemic stroke meeting the following criteria were analyzed: NIHSS score ≥6, lesion volume of pre-treatment diffusion-weighted imaging <70 cm³ and Thrombolysis in Cerebral Ischemia scores (2b-3) after endovascular treatment. Early dramatic recovery was defined as a ≥8-point reduction or NIHSS score of 0 to 1 at 24 hours. Logistic regression analysis identified factors associated with early dramatic recovery.

Results

Among 106 patients successfully recanalized by endovascular treatment, early dramatic recovery was achieved in 48 patients (45.3%). Median onset-to-recanalization time was 320 minutes (interquartile range, 270–415 minutes). Median pretreatment lesion volume was 12 cm³ (interquartile range, 12–25 cm³). Initial high NIHSS score (OR 1.14, 95% CI 1.01–1.29) and early recanalization time (OR 0.99, 95% CI 1.28–8.45) were independently associated with early dramatic recovery. Patients with early dramatic recovery more frequently had a modified Rankin Scale score ≤1 (P < 0.01).

Conclusions

This study demonstrated that early recanalization time of an occluded artery and high NIHSS are associated with early dramatic recovery after successful endovascular therapy in patients with anterior circulation infarction.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CENTRALIZING INTRA-ARTERIAL THROMBECTOMY MAY HINDER RAPID TREATMENT DUE TO LONG INTER-HOSPITAL TRANSFER DELAYS

F Kraus ¹, GJ Hubert ¹, G Schulte-Altedorneburg ², RL Haberl ¹

Abstract

Background

Introduction

Since publication of five intra-arterial thrombectomy (IAT) trials in the first half-year of 2015 there is compelling evidence that patients with ischemic stroke (AIS) due to large vessel occlusion (LVO) in the proximal anterior circulation make large profit of mechanical clot retrieval. On the other hand, there is still a major shortage of neurointerventionalists.

Hence, stroke patients in rural regions have to put up with long transfer times to be supplied to IAT.

Aim

To analyse workflow concerning identification and transfer of patients eligible for IAT within a TeleStroke network in a rural area and to identify major delays.

Methods

The Telemedical Project for Integrative Stroke Care (TEMPiS) is a TeleStroke Unit network with 2 hub and 19 spoke hospitals in Bavaria/Germany.

We retrospectively analysed data of all eligible IAT-patients within the TEMPiS-network from 06/2014 to 10/2015 transferred to the hub’s neurointerventional centers.

Results

In total, 47 patients were transferred. Detailled workflow data was available for 27 patients.

After clinical/radiological reevaluation in the hub hospital, 11 patients finally underwent IAT, from whom 5 have been pretreated with ivTPA.

Median onset-to-needle time for ivTPA in TEMPiS and published IAT-trials was 100 and 85–145 min, median onset-to-groin puncture time 277 min and 200–269 min, respectively.

Major delay in workflow was due to long decision-to-groin puncture times of median 170 min.

Conclusions

Analysis of workflow parameters in our TeleStroke network (TEMPiS) shows an extensive delay of almost 3 h for transfer to the closest interventional site.

Main reasons for delay are long transfer times and time-consuming procedures for preparing patients for transport.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THROMBECTOMY IN ACUTE ISCHEMIC STROKE - ESTIMATIONS OF A FLOOD TO COME

Å Kuntze Söderqvist ^1,², T Andersson ^1,², N Ahmed ^2,³, N Wahlgren ^2,³, M Kaijser ^1,⁴

Abstract

Background

New recommendations for mechanical thrombectomy in acute ischemic stroke, supported by several European professional organisations, have recently been published. The new recommendations suggest that thrombectomy should be considered for eligible patients with a large artery occlusion in the anterior circulation within six hours of stroke onset. Today the resources are unevenly spread and in order to be able to meet a potentially increased demand we have estimated the future need of thrombectomy.

Methods

We have compared our local thrombectomy data (2009–2011) with data from the Swedish National Stroke Register. We have calculated the proportion of thrombectomies performed at our hospital according to level of stroke severity by NIH Stroke Scale score (0–5, 6–11, 12–19 and 20–35) and then estimated the total number of thrombectomies expected in Sweden if the recommendations were implemented broadly.

Results

The number of thrombectomies would have been more than 5 times higher (1247 estimated compared to the 232 actually reported in the national stroke registry) if the new recommendations for thrombectomy in acute ischaemic stroke had been implemented in 2013 (the year from which we have the most recent available data from the Swedish Stroke Register).

Conclusions

When the new recommendations are implemented broadly, there will be a substantial increase in demand of thrombectomies. Our study highlights the need for policymakers and health care professionals to prepare for the increasing demands on stroke care.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

STENT RETRIEVER BASED ENDOVASCULAR REPERFUSION THERAPY IN OCTOGENARIANS

R Leker ¹, M Gomori ², J Cohen ³

Abstract

Background

Background and Purpose: Endovascular reperfusion therapy (ERT) may be beneficial in patients with large hemispheric stroke. Previous studies concluded that favorable outcomes are far less frequent in older patients but have not explored outcomes in the era of newer generation stent-retrievers.

Methods

Materials and Methods: Consecutive patients with large hemispheric stroke treated with stent-retriever based ERT (SERT) were included. We compared neurological and functional outcomes between patients younger and older than 80.

Results

We included 16 patients older than 80 (22.5%, mean age 84.1 ± 4.4, 56% females) and compared them to 55 patients that were younger than 80 (77.5%, mean age 63.1 ± 12.5, 51% females). Risk factor profile, admission neurological severity, stroke etiology and procedure related variables including excellent target vessel recanalization did not differ between the groups. Favorable outcome at 90 days (modified Rankin Score ≤2) was more common in younger patients (77% vs. 23%; p = 0.031). In contrast mortality rates were higher in octogenarians (40% vs. 7%; p = 0.01). Logistic regression analysis adjusting for neurological severity and collateral state identified age over 80 (OR 0.15 95% CI 0.03–0.75; p = 0.02) and reperfusion state (OR 7.4 95% CI 1.1–49.9; p = 0.04) as significant modifiers of favorable outcome. Similarly, age over 80 was identified as a positive predictor of mortality (OR 8.1 95% CI 1.8–36.7; p = 0.007).

Conclusions

Very old patients have higher chances of mortality and lower probability of achieving functional independence even after SERT. Nevertheless, because some elderly patients do achieve favorable outcomes the cost-effectiveness of SERT in this population needs to be further studied.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE EFFECT OF INTRA-PROCEDURAL HEPARIN DOSE ON ANGIOGRAPHIC RECANALIZATION AND OUTCOME IN ACUTE ISCHEMIC STROKE: ANALYSIS FROM INTERVENTIONAL MANAGEMENT OF STROKE (IMS) III CLINICAL TRIAL

S Majidi ¹, M Saleem ², A Qureshi ²

Abstract

Background

Intra-procedural heparin dose may affect the rate of post-treatment intracranial hemorrhage (ICH) and recanalization in ischemic stroke patients undergoing endovascular treatment.

Methods

Subjects who underwent endovascular treatment in Interventional Management of Stroke (IMS) III clinical trial were analyzed. The effect of heparin infusion rate (IU/kg) were analyzed on study endpoints included recanalization(TICI score of 2a-3), ICH(within 24 hours) and favorable 90-day outcome(modified Rankin scale of 0–2). The analysis was adjusted for time interval from randomization to groin puncture.

Results

Total of 188 subjects had recanalization (TICI score 2a, 2b or 3) following intra-arterial therapy which comprised 73% of 258 subjects analyzed. There was no difference in age, gender, race and presence of comorbid conditions, baseline NIHSS, and the type of endovascular device between subjects with recanalization and those without recanalization. There was no significant different in the rate of heparin infusion between subjects with recanalization and those without recanalization (33.40 ± 15.34 IU/kg versus 33.20 ± 12.62 IU/kg, p = 0.92). Total of 119 subjects had ICH in 24-hour CT scan and rate of heparin infusion was not different in these subjects (34.01 ± 15.83 IU/kg versus 32.78 ± 13.55 IU/kg, p = 0.51). There was no association between heparin rate and favorable 90-day outcome (31.88 ± 15.44 IU/kg versus 35.20 ± 13.29 IU/kg, p = 0.11).

There was no difference in the rate of recanalization, ICH and poor 90-day outcome among different tertiles ( < 20 IU/kg, 21–40 IU/kg, and >40 IU/kg) of heparin infusion rate.

Conclusions

There was no association between heparin infusion rate and angiographic recanalization, post-procedural ICH or 90-day outcome in acute ischemic stroke patients undergoing endovascular treatment.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

STENTING OF ACUTE CAROTID ARTERY DISSECTION - GOOD OUTCOMES BOTH WHEN INDICATED BY HEMODYNAMIC INSUFFICIENCY AND WHEN PERFORMED AS ADJUNCT TO MECHANICAL THROMBECTOMY

F de Wahl ¹, S Holmin ¹, T Moreira ¹, O Aspegren ², O Sveinsson ¹, T Andersson ¹, M Söderman ¹, M Mazya ¹

Abstract

Background

Carotid artery dissection (CAD) may lead to severe arterial stenosis/occlusion or on-site thrombus formation resulting in hemodynamic or thromboembolic stroke, respectively. The former may be treated with primary endovascular stenting; the latter may be stented as an adjunct to mechanical thrombectomy. We aimed to compare clinical characteristics, functional outcome and intracranial hemorrhage (ICH) in patients treated with CAD stenting for hemodynamic and thromboembolic stroke.

Methods

We reviewed medical records and neuroradiological images from CAD patients treated with endovascular stenting between 2006 and 2015 at the Karolinska University Hospital, Stockholm, Sweden.

Results

20 patients were stented for CAD in the acute phase: 12 for hemodynamic insufficiency and 8 adjuvant to thrombectomy for acute thromboembolic stroke. All hemodynamic patients had a grossly insufficient Circle of Willis. Functional independence (mRS 0–2) at 6 months as determined by an independent neurologist was seen in 83% of the hemodynamic and 75% of the thromboembolic patients, with no patients having an mRS score of 5–6. One asymptomatic parenchymal hematoma occurred in the thrombectomy group.

graphic file with name 10.1177_2396987316642909-img17.jpg

Conclusions

Endovascular stenting of CAD at an experienced centre is safe and associated with a high proportion of functionally independent patients when indicated by cerebral hemodynamic insufficiency, as well as when performed as an adjunct to stroke thrombectomy.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ASSESSING THE IMPACT OF CARE IN A TELEMEDICINE-BASED STROKE NETWORK USING PATIENT-CENTERED HEALTH-RELATED QUALITY-OF-LIFE OUTCOMES

M McAdams ¹, J Murphy ¹, M DePrince ², R Reehill ³, J Badolato ⁴, C Glodek ⁵, F Gordon ⁶, S Jara ⁷, J Human ⁸, R Rosenwasser ¹, R Bell ⁹, F Rincon ¹

Abstract

Background

Robotic-Telepresence-based Telemedicine Networks (RTPTN) deliver time-sensitive interventions for acute ischemic stroke (AIS) to underserved healthcare settings at higher rates – and with greater accuracy – than other models of telemedicine-based care.

To elucidate the impact of RTPTN models on patient outcomes, the present research prospectively examines the feasibility of using validated, health-related quality-of-life (HRQoL) measures (i.e. NIH/NINDS PROMIS and Neuro-QoL tools) as novel alternatives to a standard measure of neurologic disability (i.e. modified Rankin scale [mRS]).

Methods

Patients receiving telemedicine-based diagnoses of AIS were identified using StrokeRESPOND®: an Internet database comprising names of all telemedicine candidates across 28 regional community hospitals in the Jefferson Neuroscience Network. For each consenting participant, personal health information and HRQoL-questionnaire responses were captured by a consolidated electronic database, at 3-month intervals.

This preliminary analysis compares first-round/3-month assessment scores (i.e. mRS, NeuroQOL, and PROMIS) from Jefferson RTPTN patients who received recombinant tissue plasminogen activator (IV-tPA) (n = 13) with 3-month assessment scores from Jefferson RTPTN patients who did not (n = 11). We performed an univariate analysis, using a t-test for parametric data (p < 0.05) and the Mann-Whitney U-test for nonparametric data.

Results

MRS scores were lower (med. = 1, IQR = 2 vs. med. = 3, IQR = 3, p = 0.1) and NeuroQoL (75 ± 23 vs. 57 ± 26, p = 0.1) and PROMIS (43 ± 12 vs. 34 ± 12, p = 0.046) scores were higher in the IV-tPA-treated group than the no-IVtPA group.

Conclusions

We predict HrQoL endpoints will appropriately measure patient outcomes. Results should inform novel approaches to classic patient outcomes research while advancing the field of telemedicine and its potential role in stroke care.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

NON THERAPEUTIC ANGIOGRAMS IN ACUTE ISCHEMIC STROKE PATIENTS BEING CONSIDERED FOR ENDOVASCULAR TREATMENT DOES NOT ADVERSELY AFFECT PATIENT OUTCOMES

AI Qureshi ¹, MA Saleem ¹, MS Miran ¹, AA Malik ¹

Abstract

Background

There are concerns regarding risks of unnecessary angiograms (non therapeutic angiogram that does not lead to therapeutic intervention) in acute ischemic stroke patients who are considered for endovascular treatment.

Methods

We determined the risk of acute kidney injury, symptomatic intracranial hemorrhage (ICH) and death and disability at 3 months among subjects who underwent a non therapeutic angiogram as part of being considered for endovascular treatment in a multicenter randomized clinical trial. We compared the rates with acute ischemic stroke patients who did not undergo any angiogram after adjusting for age and baseline National Institutes of Health Stroke Scale (NIHSS) score strata (<20, 11–20, and 21 or greater) using logistic regression analyses.

Results

A total of 89 subjects (mean age 67.02 ± 11.24; 48 were men) underwent a non-therapeutic angiogram after being randomized to endovascular treatment. Compared with subjects who did not undergo any angiogram (n = 222), subjects who underwent a non-therapeutic angiogram had similar rates of neurological deterioration within 24 hrs (odds ratio [OR] 1.45; 95% confidence interval [CI] 0.34–6.11) and symptomatic ICH (OR 1.64; 95% CI 0.37–7.23). The rates of death and disability at 3 months (defined by modified Rankin scale of 3–6) was significantly lower among the patients who received an angiogram (OR0.44; 95% CI 0.23–0.83) after adjusting for potential confounders.

Conclusions

Non therapeutic angiograms in acute ischemic stroke patients who are being considered for endovascular treatment does not adversely affect patient outcomes

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

HYPERPERFUSION SYNDROME POST-CAROTID ANGIOPLASTY AND STENTING (HISPANIAS STUDY): RESULTS FROM A NATIONAL PROSPECTIVE MULTICENTER STUDY

F Moniche ¹, J Montaner ², F Mancha ², F Delgado ³, JJ Ochoa Sepulveda ⁴, M Ribo ⁵, A Tomasello ⁶, E Murias ⁷, M Gonzalez Delgado ⁸, JA De las Heras ⁹, GS Juan Carlos ¹⁰, L Fernandez ¹¹, JM Ramirez-Moreno ¹², S Mosteiro ¹³, MD Fernandez Couto ¹⁴, J Zamarro ¹⁵, G Parrilla ¹⁵, J Gil ¹⁶, R Gil ¹⁷, A Gonzalez ¹⁸

Abstract

Background

Cerebral hyperperfusion syndrome (CHS) is a rare but severe complication of carotid revascularization. Prospective studies about CHS are scarce and few data is known about the incidence, risk factors and pathophysiology. We present preliminary data from a national prospective study in Spain.

Methods

A national prospective multicenter study is ongoing with twenty-four recruiting hospitals. Baseline characteristics, transcranial Doppler sonography and CAS procedure data are registered. Follow-up is done to detect CHS up to 30 days after CAS. Clinical and neuroimaging characteristics of CHS and outcomes are analyzed.

Results

Two hundred ninety five carotid angioplasty and stenting procedures have been included from Jan/15 to Jan/16 from 24 different hospitals. Of them, 61.8% were symptomatic stenosis. Mean age was 70.4 and 81% were men. Impaired cerebral vasorreactivity was detected in 37.2%. Fourteen patients developed CHS after CAS (4.7%). Of them, 64% had cephalea, 28.6% had impaired level of consciousness and 14.3% had neurological deficit. Brain edema was detected in 3 patients and 3 patients had intracranial hemorrhage. Only one patient had permanent neurological deficit and there was no deaths.

Conclusions

CHS seems to be more frequent than previous series shown but with a more benign course. This ongoing prospective study will give some light about the real incidence of CHS, outcomes and pathophysiology of this complication of carotid revascularization.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EFFICACY OF ACTIVE MANAGEMENT OF THE TARGET P2Y12 REACTION UNIT RANGE IN PATIENTS UNDERGOING ANEURYSMAL NEUROINTERVENTIONAL PROCEDURES

I Nakagawa ¹, HS Park ¹, K Fukutome ¹, S Yokoyama ¹, S Yamada ¹, Y Hironaka ¹, Y Motoyama ¹, YS Park ¹, H Nakase ¹

Abstract

Background

Optimal antiplatelet inhibition is essential in patients undergoing neurointerventional procedures, however, variability in response to clopidogrel can contribute to thromboembolic and hemorrhagic complications. In the present study, we evaluated the impact of active management of antiplatelet reactivity in patients undergoing aneurysmal neurointerventional procedures.

Methods

Between 2013 and 2015, 48 consecutive patients (male; 10, mean age; 56) underwent aneurysmal coil embolization and received clopidogrel (75 mg daily) and aspirin (100 mg daily) before the treatment. Patients underwent prospective assessment of preoperative platelet function using VerifyNow assay and received adjunctive cilostazol (200 mg daily; triple antiplatelet therapy) in case of clopidogrel hypo-response. Patient with clopidogrel hyper-response underwent clopidogrel dose reduction according to the protocol (clopidogrel, 12.5–50 mg daily).

Results

Successful coil embolization was performed in all patients. Stent-assisted coil embolization was performed in 24 patients (50%). Preoperative clopidogrel resistance was noted in 5 patients (10%) and clopidogrel hyper response was noted in 18 patients (38%). In active management of platelet reactivity resulted in optimization of P2Y12 reaction units (PRU) value within the target range during and after the treatment. There were no symptomatic thromboembolic or hemorrhagic events.

Conclusions

Active management of clopidogrel dosing for clopidogrel hyper-response and adjunctive cilostazol for clopidogrel hypo-response resulted in an adjustment of PRU value to within a target range, and there were no hemorrhagic complications after the treatment.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

LEPTOMENINGEAL COLLATERALS PREDICT GOOD CLINICAL OUTCOME FOLLOWING MECHANICAL RECANALIZATION OF MAJOR ARTERIES IN ANTERIOR CEREBRAL CIRCULATION

T Peisker ¹, P Vasko ¹, B Koznar ², P Widimsky ², I Stetkarova ¹

Abstract

Background

Introduction: Mechanical thrombectomy of major artery occlusion in anterior cerebral circulation was proved to significantly improve clinical outcome of patients with acute ischemic stroke. Yet in spite of successful recanalization a part of patients do not demonstrate clinical improvement. Except time factor a collateral supply is considered to impact viability of the brain tissue.

Methods: Methods

We selected 38 patients who underwent a successful mechanical recanalization of acute occlusion of distal internal carotid artery and/or middle cerebral artery. It was registered a delay from stroke onset to groin puncture and presence of leptomeningeal collaterals on initial CTA. Subsequently we correlated these parameters with final clinical outcome according to Rankin scale (mRS). Good clinical outcome was considered as mRS 0–2.

Results: Results

Time elapsing to groin puncture shoves non-significant inverse relationship with final clinical status (R = − 0,27, P = 0,19). Collateral leptomeningeal supply on CTA has in our cohort significant relationship with clinical outcome of the patients (P = 0,03). In five patients the therapy was initiated beyond the therapeutic window (wake-up stroke in three). Leptomeningeal collaterals on CTA were seen in all of them. Three of these patients reached good clinical outcome.

Conclusions

Conclusion: Presence of leptomeningeal collateral supply on CTA might determine the patients with acute major cerebral artery occlusion who could benefit from revascularization therapy even after exceeding of the therapeutic window.

The study is supported by Research project PRVOUK P34.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

MECHANICAL THROMBECTOMY ON AN OUTPATIENT BASIS IS FEASIBLE AND SAFE

M Piotin ¹, H Redjem ¹, G Taylor ², G Ciccio ¹, S Smajda ¹, A Godier ², R Blanc ¹

Abstract

Background

With the clear Class I, Level of Evidence A indication that thrombectomy for acute stroke is beneficial, the intervention community must, along with the refinement of thrombectomy techniques, work to improve patient triage and workflow. Comprehensive stroke center (CSC) are now at risk of saturation due to augmented patient admission load. Mechanical thrombectomy (MT) on an outpatient basis may be a solution to avoid congestion in CSC. The question is to determine if MT on an outpatient basis is as safe and effective as conventional hospitalization.

Methods

Based on our prospectively gathered database we extracted patients who were admitted for MT for anterior circulation ischemic strokes in our CSC since 2012. Due to practical reasons of organization and workflow, many of these patients were readdressed to the referring stroke centers immediately or within 24 hours after mechanical thrombectomy. We dichotomized patients for which the stay was <24 h (outpatients) and those whose stay was >24 h (inpatients) and compared their characteristics and outcomes.

Results

The baseline characteristics of both groups are detailed in Table 1. Both patient groups were comparable for gender, lateralization of occlusion, intravenous lysis prior to MT, time elapsed from stroke onset to femoral puncture, quality of reperfusion. Outpatients were older but with lower NIHSS at admission, had more frequently isolated MCA than carotid siphon/MCA or tandem occlusions, better DWI-ASPECTS, less often general anesthesia, less procedural complications and better functional outcomes at 3-month.

graphic file with name 10.1177_2396987316642909-img18.jpg

Conclusions

MT on an outpatient basis is safe and feasible.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

STROKE COMPLICATIONS AT BRADFORD ROYAL INFIRMARY, BRADFORD, UK

H Ramadan ¹, C Patterson ¹, S Maguire ¹, I Melvin ¹, K Kain ², E Teale ³, A Forster ³

Abstract

Background

Complications after stroke can hinder functional recovery and are associated with poorer outcomes. We aimed to determine the type and frequency of early complications after the first week following admission to an acute stroke unit until death or discharge from hospital.

Methods

Single-centre, prospective observational study recording symptomatic complications occurring in patients admitted with acute stroke (TIA excluded) from 01/05/2013 to 30/04/2014.

Results

657 individuals were diagnosed with acute stroke. 361(55%) patients were excluded from analysis (43 not admitted, 254 and 64 patients discharged and died respectively within 7 days of admission). For the 296 patients surviving beyond 7 days, average length of hospital stay was 36.6 days. Complication rate were dysphagia 28%, urinary tract infection 10%, chest infection 9.5%, urinary retention 2.7%, seizure 2.3%, delirium 2.3%, recurrent stroke 2%, symptomatic haemorrhagic transformation of infarct 2%, depression requiring treatment 1.3%, pulmonary embolism 1.3%, deep venous thrombosis 0.7%, acute coronary syndrome 0.6%, and others 8%. Overall 71% of patients experience a complication from their stroke

Conclusions

Complications are common during acute and sub-acute phases of stroke despite all the advances in clinical stroke care. Prevention protocols, improved awareness, early recognition and treatment are key in ameliorating these events during hospital stay

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

STENT-RETRIEVER THROMBECTOMY FOR ACUTE ISCHEMIC STROKE WITH TANDEM OCCLUSION: A SYSTEMATIC REVIEW OF CLINICAL OUTCOMES

R Riva ¹, R Sivan-Hoffman ¹, B Gory ¹, X Armoiry ², M Goyal ³, PE Labeyrie ¹, F Turjman ¹

Abstract

Background

Acute strokes secondary to acute tandem occlusion involving both the extracranial internal carotid artery and an intracranial artery are associated with extremely poor prognosis. Stent-retriever thrombectomy (SRT) is now the reference therapy, in association with thrombolysis, for proximal intracranial occlusion. However, the benefit in functional outcome and safety of SRT are not yet well known in case of tandem occlusions. The aim of this study was to assess efficacy and safety of SRT in tandem occlusion stroke patients.

Methods

Using the PubMed database, we conducted a systematic review and meta-analysis of all studies that included patients with acute ischemic stroke attributable to tandem occlusion treated with SRT between November 2010 and May 2015.

Results

The literature search identified 11 previous studies with a total of 237 subjects, of whom 202 were treated with stent placement for proximal ICA occlusion. Mean initial NIHSS score was 17, and median time from onset to recanalization was 283.5 minutes. Mean intravenous thrombolysis rate was 63.8%. In the meta-analysis, the recanalization rate reached 75.9% (95% CI, 68.2–82.2), and clinical outcomes showed a pooled estimate of 40.9% (95% CI, 33.5–48.8; 10 studies) for favorable outcome, 16.8% (95% CI, 11.7–23.4; 10 studies) for mortality and 11.4% (95% CI, 7.3–17.4; 8 studies) for symptomatic intracranial hemorrhage.

Conclusions

SRT with carotid stenting is associated with acceptable safety and efficacy in stroke patients with tandem occlusion compared to natural history, and should be the first therapeutic option in association with intravenous thrombolysis.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EARLY VERSUS LATE CAROTID ARTERY STENTING. DOES THE SOONER THE BETTER?

N Rodriguez-Villatoro ¹, D Rodriguez-Luna ¹, M Ribó ¹, A Flores ¹, P Coscojuela ², J Pagola ¹, M Muchada ¹, S Boned ¹, L Seró ¹, JM Juega ¹, C Vert ², M Rubiera ¹, A Tomasello ², CA Molina ¹

Abstract

Background

There is no clear evidence of the timing of internal carotid artery (ICA) revascularization within 2 weeks after stroke. We aimed to study the differences in restenosis, complications, and recurrences between those stents implanted in the ICA within 72 hours after stroke and beyond this time.

Methods

Prospective study of consecutive patients who underwent symptomatic extracranial ICA stenting within 2 weeks after stroke between April-2013 and January-2015. We compared in-stent restenosis, clinical and hemodynamic complications, and stroke recurrences between those stents implanted within 72 hours and those implanted between 72 hours and 2 weeks. We evaluated the stent viability by carotid ultrasound at 24 hours, 3 months, and 1 year after the procedure. The minimum follow-up period was 1 year.

Results

From 103 patients who underwent stenting, 51 patients fulfilled inclusion criteria. Mean age was 70.2 ± 11.4 years. Twenty-one (42.3%) stents were implanted within 72 hours (median time 49[25–64] hours) and 30 (57.7%) beyond 72 hours (median time 6[5–7] days). Both groups were homogeneous in demographic data, vascular risk factors, and previous treatment. Restenosis rate at 3 months was similar between the two groups (11.7% vs 13.4%, p > 0.05). Similarly, severe (including intracranial hemorrhage) and non-severe complications were similar in both groups (p > 0.05), even in those patients with contralateral ICA stenosis >50% or occlusion (n = 15).

Conclusions

Carotid artery stenting within 72 hours after stroke does not increase the restenosis rate, complications, and stroke recurrence risk compared to those stents implanted beyond 72 hours, even in the presence of contralateral estenosis or occlusion.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

REAL LIFE AFTER THE TRIALS ON MECHANICAL THROMBECTOMY FOR ISCHEMIC STROKE

J Schaafsma ¹, V Pereira ², E Elamin ¹, F Silver ¹, T Krings ², A Pikula ¹

Abstract

Background

Clinical trials demonstrated that thrombectomy improves outcome in selected patients with acute ischemic stroke caused by an intracranial proximal arterial occlusion. We aimed to evaluate clinical outcome of patients offered thrombectomy who do not meet the ESCAPE-trial criteria.

Methods

We retrospectively identified all patients who underwent thrombectomy after the ESCAPE-trial terminated. We compared short-term modified Rankin scores (mRS) at discharge and/or at 3 months of patients meeting the trial criteria with the mRS of patients with exclusion criteria. We considered mRS ≤ 3 as good outcome with rehabilitation potential.

Results

Fifty patients underwent thrombectomy between 11/2014 and 07/2015. Thirty-two patients (64%) had exclusion criteria: premorbid impairment (Barthel < 90) (n = 14), large infarct core and/or poor collaterals (n = 10), distal occlusion (n = 10), non-disabling stroke (n = 4), and/or late presentation (n = 2). 15/32 patients (47%) with exclusion criteria had an mRS ≤ 3 versus 14/18 patients (78%) meeting trial criteria (OR0.3;95%CI:0.1–0.9). Distal occlusions were associated with mRS ≤ 3 (OR9.0;95%CI:1.04–77.8), whereas premorbid impairment (OR9.5;95%CI:2.2–42) and/or large infarct core/poor collaterals (OR21.0;95%CI:2.39–185) were associated with mRS > 3. Complications of thrombectomy causing clinical deterioration were observed in 2/32 patients with exclusion criteria versus 1/18 patients meeting trial criteria (OR1.1;95%CI:0.1–13.4).

Conclusions

A substantial number of patients with exclusion criteria for the ESCAPE-trial had good outcome after thrombectomy, particularly patients with distal occlusions, whereas the eventual harm caused by thrombectomy was not higher than in patients meeting trial criteria. A prospective registry is needed to enable direct comparison between patients who are offered thrombectomy versus those who are not, to select patients who truly benefit from this treatment.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

IMPROVEMENT IN CORTICAL VERSUS SUBCORTICAL PERFUSION AFTER SUPERFICIAL TEMPORAL ARTERY- MIDDLE CEREBRAL ARTERY (MCA) BYPASS IN PATIENTS WITH SEVERE STENOSIS OF INTRACRANIAL CAROTID AND MCA

V Sharma ¹, N Bolem ², HL Teoh ¹, B Chan ¹, L Wong ¹, TT Yeo ², C Ning ², A Sinha ¹

Abstract

Background

The role of superficial temporal artery-middle cerebral artery (STA-MCA) bypass in patients with symptomatic intracranial steno-occlusive disease has been evaluated scarcely. We have recently reported the improvement in clinical and various cerebral hemodynamic parameters after STA-MCA bypass surgery for severe steno-occlusive disease of intracranial internal carotid (ICA) or middle cerebral artery (MCA) and impaired cerebral vasodilatory reserve (CVR). Using acetazolamide challenged hexamethylpropyleneamine-oxime single-photon emission computed tomography (HMPAO-SPECT), we evaluated the differential improvement in metabolic perfusion in cortical and subcortical structures after STA-MCA bypass surgery.

Methods

Patients with severe steno-occlusive disease of intracranial ICA or MCA underwent transcranial Doppler (TCD) for CVR assessment using breath-holding index (BHI). Patients with impaired BHI (<0.69) were further evaluated with acetazolamide-challenged SPECT and STA-MCA bypass surgery was offered to patients with impaired CVR on SPECT. All patients underwent SPECT at 4 ± 1 months. Using automated image analyzer, we evaluated differences in metabolic perfusion in cortical and subcortical regions.

Results

Of the 126 patients (80 male, mean age 56yrs; range 23–78yrs) that fulfilled our inclusion criteria, 84 (67%) showed impaired CVR on SPECT. Fifty (60%) of them underwent STA-MCA bypass surgery. HMPAO-SPECT repeated 4 ± 1 months after surgery showed significant improvement in all cases. Significantly better improvement (14.5%) in cerebral perfusion was noted in the cortical regions as compared to the subcortical regions (4.5%, p < 0.005).

Conclusions

STA-MCA bypass surgery in carefully selected patients with symptomatic severe intracranial steno-occlusive disease results in significant improvement in cerebral perfusion, especially in the cortical regions.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE USEFULNESS OF DWI CORTICAL INFARCTION GRADE FOR THE TREATMENT OF ACUTE ISCHEMIC STROKE

S Shindo ¹, M Shirakawa ², K Uchida ², Y Sugiura ¹, S Saito ², S Yoshimura ^1,²

Abstract

Background

The endovascular thrombectomy (EVT) for acute ischemic stroke is performed by reference to the radiological diagnosis such as the Alberta Stroke Program Early CT Score (ASPECTS) and cases with low ASPECTS tend to be avoided EVT. However, some cases show significant neurological improvement after EVT against the low ASPECTS. We advocate Diffusion Weighted Image cortical infarction grade (DWI-CI grade) by the infarction pattern of M4–6 at DWI-ASPECTS, and examine the clinical characteristics and usability of it.

Methods

75 consecutive patients with acute anterior circulation ischemic stroke who were performed EVT were enrolled. DWI-CI grade was defined as follows. Grade 1 was assigned if no high signal intensity was found at M4–6 of DWI ASPECTS. Grade 2 was assigned if the high signal intensity was found at only the cortex of M4–6. Grade 3 was assigned if the high signal intensity was found at M4–6 subcortex as well.

Results

Patients with higher DWI-CI grade had lower DWI-ASPECTS (p < 0.01) and less cortical collateral flow (p < 0.01). Adjusting for other factors, regression analysis models indicated that the age (odds ratio, 0.89; 95% CI, 0.82–0.96), the admission NIHSS score (odds ratio, 0.87; 95% CI, 0.78–0.95), DWI-ASPECTS (odds ratio, 2.26; 95% CI, 1.24–4.66), and the difference of DWI-CI grade between Grade 2 and 3 (odds ratio, 14.7; 95% CI, 0.82–0.96) were independently associated with the good clinical outcome.

Conclusions

DWI-CI grade is affected by collateral flow. Grade 2 has the possibility to show more neurological improvement after EVT than Grade 3.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

DO CLOT CHARACTERISTICS CORRELATE WITH RECANALIZATION RATE AND OUTCOME IN ACUTE BASILAR ARTERY OCCLUSION TREATED WITH ENDOVASCULAR THERAPY?

L Shu ¹, C Riedel ¹, J Meyne ², O Jansen ¹, U Jensen-Kondering ¹

Abstract

Background

Whether clot characteristics (thrombus length and thrombus density) correlate with recanalization rate and outcome in patients with basilar artery occlusion (BAO) treated with endovascular therapy (EVT) is still controversial. Previous studies were based on one method, such as CTA to evaluate thrombus length or absolute HU to calculate thrombus density, which might underestimate the potential predictive value of clot characteristics.

Methods

We retrospectively assessed 40 BAO patients treated with thrombectomy whose thrombus lengths measured on non-enhanced cranial CT (NECCT) and CTA were matched (Figure 1). Thrombus length and thrombus density (in absolute/relative HU) were measured on NECCT before treatment. Thrombolysis In Cerebral Infarction grade (TICI) 2 to 3 was considered a successful recanalization. 3-month mRS 0 to 2 was considered a favorable outcome. We evaluated the correlation of clot characteristics with recanalization rate and outcome.

Results

Neither thrombus length nor thrombus density showed association with recanalization rate (odds ratio [OR] 1.04, 95% confidence interval [CI] 0.94–1.16, P = 0.45; OR 1.02, 95% CI 0.86–1.22, P = 0.81). However, higher HU value of thrombi was correlated with more favorable outcome (OR 1.20, 95% CI 0.99–1.44, P = 0.05) (Figure 2), whereas thrombus length was not (OR 0.98, 95% CI 0.92–1.05, P = 0.57).

graphic file with name 10.1177_2396987316642909-fig50.jpg

graphic file with name 10.1177_2396987316642909-fig51.jpg

Conclusions

Although thrombus length and thrombus density didn’t independently correlate with recanalization rate, high density of thrombi was a significant predictor of favorable outcome in BAO patients undergoing EVT.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

MECHANICAL THROMBECTOMY IN ACUTE ISCHEMIC STROKE: A SINGLE CENTER EXPERIENCE IN POLAND

A Ferens ¹, J Chrzanowska-Wasko ¹, A Golenia ¹, D Wloch-Kopec ¹, P Brzegowy ², B Lasocha ², T Popiela ², A Slowik ¹

Abstract

Background

Recent clinical trials have shown a beneficial effect of mechanical thrombectomy in acute ischemic stroke.

Methods

We present a prospective series of 66 consecutive patients (mean age: 65 ± 13 years) treated by mechanical trombectomy within 8 hr after stroke onset from January 2013 to December 2015 at the Center of Interventional Therapies of Acute Stroke in Krakow, Poland. The treatment protocol was accepted by the Local Ethical Committee.

Results

Mechanical thrombectomy was proceeded by rt-PAIV in 40 patients (60,6%); rt-PA was not given for other patients because of: exceeding of the therapeutic window for rt-PAIV (22.7%); INR ≥ 1.7 (10.6%) and risk of bleeding (3.3%). Acute thrombus location was as follows: ICA: 12(18,2%); MCA-M1: 37(56.1%); MCA-M2: 10(15.2%); MCA- M3: 3(4.5%) and BA: 4(6.1%). Rt-PAIA was introduced in 4 cases, carotid stenting before the procedure was required in 4 cases. Mean time from stroke onset to groin puncture was 267 ± 91.2 minutes. Solitaire device was used in 80.1% of cases. TICI results after the procedure were as follows: 0: 9(13.6%); 1: 6(9.1%); 2a: 17(25.8%); 2b: 11(16.7%); 3: 23(34.8). Twelve patients (18.2%) died within 90 days after stroke onset (5 – severe brain hemorrhage, 2 – brain edema and herniation, 3 – pulmonary infection; 2 – circulatory insufficiency). 90-day independence was measured by the Barthel Index: 35 (64.8%) scored 80–100 points; 6 (11.1%) scored 60–79; 6 (11.1) scored 40–59 points; 2 (3.7%) – 20–39 points and 5 (9.3%) scored 0–19 points.

Conclusions

We show similar data to recently published results in the endovascular-treated arms of clinical trials.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

SOCRATES-LIKE SUBPOPULATIONS IN THE TIAregistry.org

E Meseguer ¹, L Sissani ¹, J Labreuche ², E Vicaut ³, P Amarenco ¹

Abstract

Background

SOCRATES (NCT01994720) was a randomized controlled trial evaluating benefits/risks of treatment with aspirin versus ticagrelor initiated within 24 hours of symptom onset in patients with high-risk TIA or minor ischemic stroke (NIHSS < 5) (Int J Stroke. 2015). We analyzed the risk for subsequent stroke in patients similar to SOCRATES using the TIAregistry.org, to inform on the generalizability of the trial results.

Methods

The TIAregistry.org was an international, prospective, observational registry of patients with recent (<7 days, 78% being <24 hours of symptom onset) TIA or minor ischemic stroke performed in 61 TIA clinics in 21 countries from Europe, Asia and Latin America (N Engl J Med. 2016, in press).

Results

Among 4,339 patients with ABCD² and NIHSS scores available, 2,428 (56%) satisfied SOCRATES inclusion/exclusion criteria. Among 4,339 patients, 90-day and 365-day stroke risks were 3.9% and 5.2%, respectively. Patients with ABCD² score 6–7 and 4–5 had a KM estimated 365-day stroke risk of 7.8% and 4.9%, respectively and adjusted HRs (95% CI) (as compared to ABCD² 0–3) were 2.00 [1.31–3.07, P < 0.001] and 1.35 [0.92–1.98, P = 0.13]; In patients with large vessel atherosclerosis TOAST subtype, KM estimated stroke risk was 8.6% and adjusted HR (as compared to other TOAST subtypes) was 2.02 [1.49–2.74, P < 0.0001]. Absolute risk of major bleedings at 90 and 365 days was 0.2% and 0.4%, respectively.

Conclusions

SOCRATES inclusion/exclusion criteria applied to a broader TIA and minor stroke population such as in the TIAregistry.org would enable detection of patients at higher risk of recurrent stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

TEMPORAL TRENDS IN THE PREMORBID USE OF PREVENTIVE TREATMENTS IN STROKE AND TIA PATIENTS WITH HISTORY OF VASCULAR DISEASE: THE DIJON STROKE REGISTRY (1985-2010)

C Khoumri ¹, J Durier ¹, B Daubail ¹, B Delpont ¹, GV Osseby ¹, M Hervieu-Bègue ¹, O Rouaud ¹, M Giroud ¹, Y Béjot ¹

Abstract

Background

Although secondary prevention of patients with vascular diseases has improved, a gap between clinical practice and recommendations may exist. We evaluated temporal trends in the use of preventive treatments in ischemic stroke/TIA patients with a history of a least one vascular disease.

Methods

All patients with ischemic stroke/TIA were identified among residents of Dijon, France (151,000 inhabitants), using a population-based registry, between 1985 and 2010. Only patients with a history of vascular disease (coronary artery disease, cerebrovascular ischemic event, and/or peripheral artery disease) were included. We assessed trends in the proportion of patients who were treated by antihypertensive treatments and antithrombotics at the time of their stroke/TIA.

Results

Among the 2128 included patients (mean age 77.3 +/- 11.9, 51% men), 975 (45.8%) were on antithrombotics and 1364 (64.1%) were on antihypertensive treatment. In multivariable analyses, compared with time period 1985–1993, periods 1994–2002 and 2003–2010 were associated with a greater frequency of prior-to-stroke use of antithrombotics (OR = 6.11; 95% CI: 4.74–7.87, p < 0.001, and OR = 6.83; 95% CI: 5.26–8.85, p < 0.001, respectively) but not of antihypertensive drugs. Similar results were found when only considering patients with a history of cerebrovascular ischemic event. Among them, those with an additional vascular disease were more likely to received antihypertensive therapy.

Conclusions

This study suggests that patients with previous vascular disease and presenting with ischemic stroke/TIA were undertreated by recommended preventive therapies. This underuse slightly improved with time for antithrombotics but not for antihypertensive treatments, indicating a potential target to reduce the recurrence of vascular events, especially stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

A RETROSPECTIVE CASE SERIES STUDY ON CLINICAL CHARACTERISTICS AND ANTICOAGULATION THERAPY IN PATIENTS WITH CARDIOGENIC CEREBRAL EMBOLISM

Y Cao ^1,², C Jiang ¹, S You ¹, Y Zhang ¹, J Shi ¹, Z Huang ¹, C Liu ³

Abstract

Background

To investigate factors related to optimal maintenance dose of warfarin, and explore their stroke recurrence rate, hemorrhagic transformation rate and so on in patients with non-valvular atrial fibrillation(AF).

Methods

208 patients with cardiogenic cerebral embolism and 36 outpatients with non-valvular AF who were accepted warfarin were enrolled, 164 non-valvular AF patients were divided into anticoagulation group and antiplatelet group, and the prognosis of patients were compared. Finally, we analyzed the clinical data of 70 warfarin patients.

Results

In 164 cerebral embolism patients with non-valvular AF that proportion for anticoagulation therapy was 20.7%. The incidence rate of extracranial hemorrhage in anticoagulation group was higher than in antiplatelet group (P < 0.05), and there was no significant difference in the incidence rate of intracranial hemorrhage, recurrence rate of cerebral infarction and the mortality rate in one year. Among 70 anticoagulation therapy patients, primary prevention patients were much younger, and lower initial NIHSS, smaller risk of anticoagulation hemorrhage, better long term prognosis (P < 0.05). The initial dose of warfarin in secondary prevention patients was lower, but warfarin withdrawal rate within one year was higher than primary prevention patients (P < 0.05). There was no significant difference in recurrence rate of cerebral infarction and the incidence rate of intracranial or extracranial hemorrhage between INR 1.5–2.0 group and INR 2.1–3.0 group.

Conclusions

In Chinese population, the incidence rate of extracranial hemorrhage in anticoagulation group was higher than in antiplatelet group, there was no significant difference in reducing the incidence of stroke and the risk of hemorrhage between INR 1.5–2.0 group and INR 2.1–3.0 group.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

A QUESTIONNAIRE TO ASSESS THE FEASIBILITY OF SMARTPHONE APPLICATIONS AND WEARABLE DEVICES IN CONSECUTIVE PATIENTS ATTENDING A LONDON TIA CLINIC

L Clayton ¹, A Dados ², R Simister ², S Gill ², A Chandratheva ²

Abstract

Background

Ten major risk factors account for 90% of the population attributable stroke risk. Smartphone applications may be used for education and self-managing risk factors. We aimed to explore use and attitudes towards smartphones and wearable devices in a TIA clinic.

Methods

From September 2015 consecutive patients attending University College Hospitals, London TIA clinic completed a questionnaire, relating to, stroke risk factors and use of smartphones. A likert scale (strongly disagree = 1, strongly agree = 10) evaluated attitudes towards Smartphone applications and wearable devices in stroke education and management.

Results

118 patients completed the questionnaire. Mean age 62.7(±15.8) years, 57(48.3%) male. Twenty (17%) were ≥80years. Only 22(18.6%) measure their own BP despite history of hypertension in 41(34.7%).

Internet access was available for 98(83.1%). Smartphones were used by 78(66.1%), including 7(35.0%) ≥80years. Applications used included internet access in 61(78.2%), calendar function 55(70.5%), social media 39(50.0%) and games in 20(25.6%) games. Only 16(20.5%) used lifestyle applications. Few, 3(3.8%), recorded medical information on their smartphone despite 25(21.2%) presenting without knowing their medications.

Patients reported that they were in favour of accessing stroke information on Smartphones, median response 8(interquartile range (IQR) 4.75), and that they would use an application showing progress; e.g updates on weight, exercise and blood pressure, median 8(IQR 4) and to record medications and results, median 8(IQR 5).

Conclusions

Patients attending hospital TIA services commonly have access to Smartphones and would support using Applications and wearable devices for stroke education and risk factor management. Further studies of actual usage of pilot prevention Smartphone applications are required.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

AN EXTERNAL VALIDATION OF A DIAGNOSTIC TOOL FOR TRANSIENT ISCHAEMIC ATTACK AND MINOR STROKE

A Davey ¹, D Lasserson ², C Levi ³, D Quain ¹, P McElduff ⁴, P Magin ¹

Abstract

Background

Improving diagnosis of transient ischaemic attack and minor stroke (TIAMS) in primary care can reduce the risk of recurrent stroke and improve utilisation of specialist TIAMS clinics. A diagnostic tool for identifying TIAMS was derived in Glasgow from secondary care data (“Dawson tool”). The tool was externally validated using data from an Oxford TIAMS clinic. We aimed to prospectively validate the Dawson tool in a primary care population of unfiltered transient neurological events (TNEs).

Methods

A cohort study of patients from 17 general practices in the Hunter and Manning Valley regions of Australia was conducted. TNEs were ascertained by multiple overlapping methods including searching general practice and hospital databases. Data were extracted from structured interviews of participants and from their medical records. A three-clinician panel adjudicated cases as TIAMS or mimics using these data and (when available) neurovascular imaging. The Dawson tool was assessed by calculating the receiver operating characteristic (ROC) curve. Sensitivity, specificity, positive (PPV) and negative predictive values (NPV) at the recommended cut-point were calculated.

Results

Of 434 adjudicated TNEs there were 230 TIAMS and 204 mimics. The c-statistic for the ROC-curve was 0.80 (95%CI 0.75–0.84). The sensitivity was 95%, specificity 25%, PPV 59% and NPV 82%.

Conclusions

The c-statistic, sensitivity, specificity and NPV are similar to those from Glasgow and Oxford data. The PPV is lower in our study (59% vs 68% in Glasgow). These results prompt further inquiry to find an even more discriminatory tool given the high-stakes nature of TIAMS.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE NORWEGIAN COGNITIVE IMPAIRMENT AFTER STROKE (NOR-COAST) STUDY

H Ellekjær ¹, T Askim ¹, B Indredavik ¹, P Thingstad ¹, T Engstad ², H Næss ³, H Ihle-Hansen ⁴, C Hamre ⁵, M Beyer ⁶, I Saltvedt ¹

Abstract

Background

Post-stroke dementia (PSD) and mild cognitive impairment (MCI) are common sequelae following stroke. Further insight of the mechanisms and modifiable risk factors causing PSD and MCI is needed. The overall aim of this study is to establish a national research platform to improve health outcomes following stroke by increasing the understanding of how to prevent PSD and MCI.

Methods

Nor-COAST is an ongoing descriptive cohort study with partners from the four Norwegian health authorities. Approximately 1000 patients with acute stroke (ischemic or hemorrhagic) admitted to one of the six participating stroke units will be included according to the following criteria; age above 18 years, living in the catchment area of the hospitals and onset within 7 days before hospitalization. Data at baseline, at discharge and at 3 and 18 months include evaluation of cognition, lifestyle, physical activity, cerebral MRI, blood samples, activity monitoring (active PAL), and pharmacological and non-pharmacological secondary prevention.

Results

From May to December 2015, 233 stroke patients have been included. The main reasons for exclusion were onset more than 7 days before admission and lack of consent. Nor-COAST will illuminate important aspects of PSD/MCI; incidence and clinical phenotype, pathogenetic factors including MRI, biomarkers and genetics, impact of physical activity, interaction between secondary prevention and development of PSD/MCI and clinical methods identifying risk patients.

Conclusions

Cognitive impairment after stroke is frequently ignored, and the study will contribute to valuable and useful knowledge for the clinicians and further research like intervention studies.

ClinicalTrials.gov Identifier: NCT02650531

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

SYMPTOMATIC CAROTID NEAR-OCCLUSION: BASELINE RESULTS AND 90-DAYS RECURRENCE FROM A MULTICENTER SPANISH REGISTRY. (STROKE PROJECT OF THE SPANISH CEREBROVASCULAR DISEASES STUDY GROUP)

A Garcia-Pastor ¹, JM Ramírez-Moreno ², F Moniche ³, N González-Nafría ⁴, J Tejada ⁴, JC Portilla-Cuenca ⁵, P Martínez-Sánchez ⁶, B Fuentes ⁶, MÁ Gamero-García ⁷, M Alonso de Leciñana ⁸, D Cánovas-Verge ⁹, Y Aladro ¹⁰, V Parkhutik ¹¹, AM de Arce-Borda ¹², A Pampliega ¹³, Á Ximénez-Carrillo ¹⁴, R Delgado-Mederos ¹⁵, M Bártulos-Iglesia ¹⁶, A Gil-Núñez ¹

Abstract

Background

The risk of recurrent stroke amongst patients with symptomatic carotid near-occlusion (SCNO) is unknown and the management remains controversial. We aimed to describe baseline characteristics and 90-days recurrence of patients with SCNO.

Methods

We conducted a prospective, observational, nation-wide multicenter registry (CAOS study) from January 2010 to December 2015. Patients with angiography-confirmed SCNO were included. Data on baseline characteristics, treatment modalities, and 90-days recurrence (defined as ipsilateral ischemic stroke or TIA) were recorded.

Results

131 patients were included from 16 spanish centers. 113 (86.7%) were male. Mean age: 68.8 (SD: 9.1) years. Ipsilateral ischemic stroke or TIA was the most usual form of presentation (119; 90.8%), while retinal ischemic symptoms occurred in 12 patients (9.2%). 14 patients (10.7%) suffered recurrent TIA. Acute ipsilateral ischemic lesions on neuroimaging were observed in 62.6% of patients and chronic ipsilateral lesions in 35.9%. Agreement between conventional angiography and duplex sonography, CT angiography and MR angiography was 39.6%, 70% and 57.2% respectively. 76 patients (58%) received medical treatment. Revascularization was performed in 55 patients (carotid stenting in 39, endarterectomy in 16), complete revascularization rate was 74.5%. 5 patients (9.1%) suffered a periprocedural stroke/TIA. Global 90-days recurrence rate was 9.2% (95% CI, 4.2–14.2), recurrence rate in medical treatment group was 9.2% (95% CI, 2.6–15.8) and 9.1% (95% CI,1.3–16.9) in the revascularization group, log rank p = 0.985.

Conclusions

90-days recurrence rate of SCNO is 9.2%. Revascularization procedures were associated with a significant rate of periprocedural stroke/TIA and do not seem to reduce the risk of recurrence at 90 days.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

INEQUALITIES IN MEDICATION ADHERENCE TO STATIN TREATMENT AFTER STROKE

EL Glader ¹, M Sjölander ², M Eriksson ³

Abstract

Background

Studies have shown decreasing adherence to secondary preventive treatment after stroke as well as socioeconomic inequalities in stroke care and outcome. The objective of this study was to investigate differences in adherence to statin treatment after stroke based on age, sex, socioeconomic status, and country of birth.

Methods

Patients with ischemic stroke were included from the Swedish stroke register, Riksstroke, in the period 2009–2010. Adherence to statin treatment after stroke was measured as proportion of days covered with 80% as cut-off for adherence. Income, education, and country of birth were obtained from official registers. Factors possibly associated with adherence were controlled for in multivariable logistic regression.

Results

We included 15192 patients, of which 73.9% had an adherence rate ≥80%. The oldest (85 + years) and youngest (18–54 years) patients had the lowest adherence, and a smaller proportion of women were adherent (odds ratio (OR) 0.84; 95% confidence interval (CI) 0.77–0.92). Adherence was less common in patients born in Nordic countries (OR 0.82; 95% CI (0.68–0.97), Europe (OR 0.78; 95% CI 0.65–0.93), and in non-European countries (OR 0.65; 95% CI 0.50–0.84) compared to those born in Sweden. Patients with university education were to a lower extent adherent compared to patients with primary school education (OR 0.81; 95% CI 0.72–0.91). There was no association between adherence and income.

Conclusions

Adherence to statin treatment over two years was suboptimal, and adherence was less common among patients born outside of Sweden and patients with university education.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EARLY CAROTID ENDARTERECTOMY AFTER INTRAVENOUS THROMBOLYSIS IS SAFE

P Ijäs ¹, P Vikatmaa ², L Soinne ¹, M Venermo ²

Abstract

Background

Carotid endarterectomy (CEA) should be performed as early as possible after carotid artery stroke to prevent recurrent strokes. However, the safety of CEA very early (within 48 hours) after intravenous thrombolysis (IVT) is unclear and therefore CEA is often postponed at the cost of stroke recurrence.

Methods

We searched our hospital-based registers containing data on all vascular surgery procedures (HUSVASC) and IVT (Helsinki Stroke Thrombolysis Registry) for patients treated with IVT and subsequent CEA for carotid artery stroke from 2005 to October 2015.

Results

79 patients were treated with IVT and subsequent CEA, performed at median 7 days after IVT (mean 19, 95%CI 9–28, range 0–349 days). 41 patients were operated on within 7 days, 18 within 72 hours, 12 within 48 hours and 3 patients within 6 hours from symptom onset. Stroke recurrences in patients waiting for CEA were 6 (incidence 7.6 %) at median 4.5 days from onset (range 2–9 days), and the number of peri-/postoperative strokes was 4 (5.1 %), occurring within 2–32 days after IVT, all non-fatal. Risk of postoperative stroke was not associated with time between IVT and CEA (HR 1.019, 95%CI 0.955–1.089). Hyperperfusion tended to be more common in patients operated within 48 hours (23.1% vs 7.6%, p = 0.120) but did not lead to serious complications (ICH or seizures).

Conclusions

CEA within 48 hours after IVT appears safe. Risk of hyperperfusion may be higher.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

FAVORABLE IMPACT OF NURSE-LED, TELEPHONE-BASED SECONDARY PREVENTIVE FOLLOW-UP ON THE ASSOCIATION BETWEEN EDUCATIONAL LEVEL AND BLOOD PRESSURE 12 MONTHS AFTER STROKE OR TIA

AL Irewall ¹, T Mooe ¹

Abstract

Background

Low socioeconomic status is a risk factor for cardiovascular disease including stroke also in high-income countries with universal healthcare coverage. Less is known about socioeconomic inequalities within secondary preventive care. We evaluated the occurrence of socioeconomic differences in blood pressure (BP) levels achieved by two different forms of secondary preventive follow-up at 12 months after stroke or TIA.

Methods

We analyzed BP levels of 771 consecutive stroke and TIA patients included in the population-based, randomized, controlled NAILED stroke risk factor trial between Jan 1^st, 2010, and Dec 31^st, 2013. Participants were randomized (1:1) to secondary preventive follow-up within primary healthcare (control) or nurse-led, telephone-based follow-up including titration of pharmacological treatment (intervention). We calculated age-stratified (≤70/>70 years), sex-adjusted, mean differences in BP at 12 months according to level of completed formal education. Participants’ educational level was classified as low (compulsory school/≤10 years) or high (≥upper secondary school). Intervention and control group participants were analyzed separately.

Results

At 12 months, low educated control group participants aged ≤70 years had significantly higher systolic blood pressure (SBP) than high-educated control group participants in the same age group (mean difference 5.7 mmHg, 95% CI 0.8–10.6). Among intervention group participants no difference in BP levels according to educational level was found.

Conclusions

The association between educational level and SBP depends on the organization of secondary preventive follow-up. Nurse-led, telephone-based secondary preventive follow-up seems promising to reduce BP differences related to educational level.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

HEALTHY AGEING THROUGH INTERNET COUNSELLING IN THE ELDERLY (HATICE) - PRELIMINARY RESULTS FROM A RANDOMISED CONTROLLED TRIAL FOR THE PREVENTION OF CARDIOVASCULAR DISEASE AND COGNITIVE IMPAIRMENT

S Jongstra ¹, M Kivipelto ², H Soininen ³, C Brayne ⁴, E Moll van Charante ⁵, Y Meiller ⁶, B van der Groep ⁷, C Beishuizen ¹, F Mangialasche ², M Barbera ³, T Ngandu ⁸, N Coley ⁹, J Guillemont ⁹, S Savy ⁹, WA van Gool ¹, S Andrieu ⁹, E Richard ¹

Abstract

Background

Cardiovascular disease(CVD) and dementia share a number of cardiovascular risk factors. eHealth offers great opportunities for large-scale delivery of prevention programs encouraging self-management. We aim to investigate whether a multi-domain interactive internet intervention to optimise self-management of cardiovascular risk factors can improve the cardiovascular risk profile and reduce the risk of CVD and cognitive decline.

Methods

HATICE is a multi-national, randomised controlled trial with 18-months intervention in 4250 individuals (>=65 years) at increased risk of CVD. The intervention group uses an interactive internet-platform supported by a coach to stimulate a healthy lifestyle. The control group has access to a static platform with general health information. The primary outcome is a composite score of systolic blood pressure, low-density-lipoprotein and body mass index. Main secondary outcomes include effect on individual cardiovascular risk factors, incident CVD, mortality, cognitive functioning and cost-effectiveness.

Results

After two years development, the HATICE platform is ready and easy to use by older adults. European guidelines are integrated and usability has been tested in a pilot. Baseline data of the first 1385 participants with a mean age of 71 years (SD 4.9) show that 53% has a history of CVD, 60% has hypertension with a mean of 145 mmHg (SD 18.6), 70% is overweight and 35% has a lack of physical exercise.

Conclusions

Recruitment is going well and the platform is actively used. A large international internet intervention for the prevention of cardiovascular risk factors for the older adult is feasible.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ASSOCIATION BETWEEN PHOSPHODIESTERASE 4D (PDE4D) GENE POLYMORPHISM AND ISCHEMIC STROKE IN NORTH INDIAN POPULATION: A CASE-CONTROL STUDY

A Kumar ¹, S Misra ², K Prasad ²

Abstract

Background

Stroke remains a leading cause of death and disability worldwide. Ischemic stroke accounts for almost 70% of total stroke and is a complex multi-factorial disease and influenced by combination of vascular, genetic and environmental factors. The aim of present study was to investigate the association of PDE4D (T83C, C87T and C45T) gene polymorphisms with the risk of ischemic stroke (IS) in North Indian population.

Methods

In the present study, 250 patients and 250 age-and sex-matched controls were recruited from Outpatient Department and Neurology ward of All India Institute of Medical Sciences (A.I.I.M.S.), New Delhi, India. DNA (Deoxyribonucleic acid) was isolated using Phenol Chloroform method. Genotyping was performed by using Polymerase chain reaction– Restriction fragment length polymorphism (PCR-RFLP) method.

Results

Hypertension, Diabetes, Dyslipidemia, Low Economic Status and Family Stroke History were found to be independent risk factors. Multivariate conditional logistic regression analysis suggested an independent association between PDE4D (T83C) gene polymorphism and risk of IS under dominant model (OR, 1.59; 95% CI, 1.02 to 2.50; P = 0.04). Subgroup analysis was done according to TOAST criteria and independent association was found with Large Vessel Disease (OR, 2.73; 95% CI, 1.16 to 0.02; P = 0. 02). However, no significant association was found between PDE4D (C87T and C45T) gene polymorphisms and risk of IS.

Conclusions

Present study suggests that SNP 83 of PDE4D gene is an independent risk factor of IS risk whereas SNP 87 and 45 confer no risk of IS in the North Indian population. Further large prospective studies are required to confirm these findings.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EMERGING VALUE OF PLATELET FUNCTION TESTING AT PREDICTING THE RISK OF RECURRENT VASCULAR EVENTS AND OUTCOMES AFTER TIA/ISCHAEMIC STROKE: A SYSTEMATIC REVIEW OF THE LITERATURE

ST Lim ¹, C Coughlan ², S Murphy ¹, V Thijs ³, J Montaner ⁴, I Fernandez-Cadenas ⁵, L Marquardt ⁶, P Kelly ⁷, D McCabe ¹

Abstract

Background

The value of testing for ex-vivo ‘non-responsiveness’, now usually referred to as ‘high on-treatment platelet reactivity’ (HTPR) to predict outcomes in TIA/ischaemic stroke patients on antiplatelet therapy is unclear.

Methods

A systematic review of the literature was performed to collate relevant data on the relationship between ex-vivo HTPR testing and recurrent vascular events or outcomes in ischaemic cerebrovascular disease (CVD) patients on antiplatelet therapy. We focused on data from commonly-available whole blood platelet function analysers and traditional aggregometry. P < 0.05 was considered statistically significant.

Results

One hundred and two articles were reviewed. Twenty studies met criteria for inclusion: PFA-100^® (N = 7); VerifyNow^® (N = 7); Multiplate^® (N = 2); Thrombelastograph Haemostasis Analyser^® (N = 1); and Aggregometry (N = 3). Four studies found a higher risk (P < 0.001) whereas 5 studies found no increase in the risk of recurrent stroke (P = 1.0) between patients with vs. those without HTPR on aspirin. Aspirin-HTPR was associated with more severe strokes at baseline (P = 0.005; N = 5), early deterioration (P = 0.017; N = 3), poorer outcomes (P = 0.047; N = 2), larger infarct size (P < 0.001; N = 1), new DWI lesions (P = 0.04; N = 2) and higher mortality (P = 0.038; N = 1) after ischaemic stroke. There was no relationship between dipyridamole or clopidogrel HTPR status and outcomes in 2 small studies (PFA-100^®).

Conclusions

Emerging data from small studies indicate that HTPR status may predict outcomes on antiplatelet therapy after TIA/ischaemic stroke. Large, adequately-sized, prospective multicentre studies are needed to determine whether assessment of HTPR status on different platelet function testing platforms improves our ability to predict the risk of recurrent vascular events and functional outcomes in CVD.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EVIDENCE-PRACTICE GAP FOR SECONDARY PREVENTION IN STROKE PATIENTS: INSIGHTS FROM THE HIGH CARDIOVASCULAR RISK PATIENTS BRAZLIAN REGISTRY (REACT)

MJ Machline Carrion ¹, O Berwanger ¹, LP Damiani ¹, S Bernardez Pereira ², LA Piva e Mattos ³, J Andrade ⁴, AA de Paola ⁵, FC Colombo ⁶

Abstract

Background

Previous data on stroke outpatients’ care in Brazil are insufficient. Information from broader and representative initiatives is needed.

Methods

A sub analysis focused on stroke patients from a national registry (REACT) conducted in 46 brazilian sites from july 2010 to august 2014, that documented outpatient care in individuals at high cardiovascular risk (defined as the presence of the following factors: coronary artery disease (CAD), cerebrovascular and peripheral vascular diseases, diabetes, or those with at least three of the following: hypertension, smoking, dyslipidemia, age > 70 years, family history of CAD, chronic kidney disease or asymptomatic carotid artery disease) was developed. Basal characteristics, prescriptions rates of pharmacological and non-pharmacological interventions as well as risk factors control were analyzed at baseline, 06 and 12 months.

Results

Overall 719 from 5035 high cardiovascular risk patients (14,28%) had stroke as inclusion criteria, 51.2% men, and with a mean age of 66.9 years (± 10.0). Combined use of ACEi, Antiplatelets and Statins at baseline, 06 months and 01 year was observed in 28.7%, 30.7% and 28.6%/; this prescription was favored by the gender, diagnosis of hypertension and myocardial infarction. Anticoagulation for atrial fibrilation patients in the same time points was observed in 47.8%, 42.2% and 43.4% respectively. Uncontrolled blood pressure (≥140 × 90 mmHg), LDL (≥100 mg/dL) and glycemia (≥110) were observed in 44.3%, 43.1% and 64.1% respectively.

Conclusions

This representative registry identified important gaps in the incorporation of evidence-based therapies and risk factor control, offering a realistic outlook of stroke patients.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

IMPACT OF STROKE EDUCATION OF MIDDLE SCHOOL STUDENTS: A PILOT-STUDY IN PORTUGAL

JP Marto ¹, C Borbinha ¹, R Filipe ², S Calado ^1,³, M Viana-Baptista ^1,³

Abstract

Background

Previous studies suggest that children and teenagers are an interesting target for stroke education, with an impact on prevention and identification of stroke symptoms. Also they can drive familial behavioral changes.

Methods

Objective

To evaluate the impact of stroke education in teenager students on their stroke knowledge and on their parents’.

Methods

In seven Lisbon public schools questionnaires on stroke knowledge (risk factors, stroke symptoms, calling EMS and recognizing a stroke case), were filled by 8^th grade students and their parents. In four of those schools, students attended a stroke lecture, alongside with distribution of educational brochures and magnetic cards, and were encouraged to educate their parents. Students and parents from the other schools were included in a control group. Questionnaires were filled again by all subjects, immediately after the lecture and 3 months later.

Results

From a total of 784 students and 597 parents, 393 (50.1%) and 314 (52.6%) were respectively included in the education group. Mean number of correct answers in the education group and control group, before, immediately after and three months after the intervention were: 41.9% and 40.3%, 98.3% and 50.6% (p < 0.001), 92% and 56% (p < 0.001) in students; 59.3% and 61.3%, 96% and 61.1% (p < 0.001), 93.6% and 61.2% (p < 0.01) in parents, respectively.

Conclusions

Stroke education in schools results in an increase of stroke knowledge and behavior intent in students and their parents. We present a pilot-study in Portugal that may be used as reference for future educational strategies.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

FACTORS AFFECTING BLOOD PRESSURE CONTROL POST-STROKE

J McDaniel ¹, J Conners ¹, V Lee ¹, S Song ¹, S Cutting ¹, L Cherian ¹

Abstract

Background

Approximately 185,000 US patients annually suffer recurrent stroke. Research suggests ∼80% are preventable by addressing modifiable risk factors. Blood pressure (BP) is the most important factor, with a 2 mmHg rise in systolic blood pressure (SBP) correlating with ∼10% increase in risk. Despite extensive focus on BP management following stroke, we suspect patients have difficulty maintaining BP control in the outpatient setting. We speculate a documented relationship with primary care physicians (PCPs) may improve control.

Methods

The 418 study subjects were admitted to Rush University Medical Center (RUMC) with ischemic or hemorrhagic stroke, confirmed by computed tomography (CT) and/or magnetic resonance imaging (MRI) from 1/2012 to 8/2015, and also completed stroke clinic follow-ups. Data included BP on discharge and follow-up, medication type and number, and documented PCPs.

Results

Mean BP at follow-up for all groups was significantly higher than at discharge: 136.34 mmHg vs. 127.81 mmHg (95% CI −10.78 to −6.288, p = 0.00) for SBP and 80.52 mmHg vs. 74.99 mmHg (95% CI −6.93 to −4.13, p = 0.00) for diastolic blood pressure (DBP). However, patients with a documented PCP had significantly lower SBP at follow-up vs. those without: 135.41 mmHg vs. 140.42 mmHg (95% CI −0.05 to 10.07, p = 0.05). As compared to discharge, those with a PCP were on more BP medications at follow up (CI −0.18 to −0.03, p = 0.01) and more beta-blockers (−0.08 to −0.02, p = 0.00).

Conclusions

For all patients, SBP and DBP increased significantly from the time of discharge to follow-up in the stroke clinic, but patients with a documented PCP were able to achieve better control of their BP.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

TRENDS IN STROKE RECURRENCE IN A BIETHNIC COMMUNITY-BASED COHORT

L Morgenstern ¹, B Sanchez ², L Lisabeth ³

Abstract

Background

Stroke incidence and mortality are declining sharply in developing countries. There is less data available about stroke recurrence. Minority populations around the world suffer an increased burden of stroke compared with majority populations. We estimated stroke recurrence trends from 2000–2011, and compared trends in Mexican Americans (minority) with non Hispanic whites (majority) in a community-based study.

Methods

Recurrent stroke was ascertained in the Brain Attack Surveillance in Corpus Christi (BASIC) study, in Texas, USA. The cohort of incident cases were followed to determine 1-year recurrence. Cases were validated by stroke physicians. Cox proportional hazard models assessed adjusted annual recurrence changes and ethnic differences. Models were stratified by ethnicity, and were first age-and sex-adjusted and subsequently adjusted for a priori specified stroke risk factors that also met a significance cut off of p < 0.20 for at least one ethnic group. Trend differences by ethnicity were obtained by including a trend-by-ethnicity interaction term in the model.

Results

The 1-year recurrence rate among Mexican Americans (N = 1,707) was 7.9%, and it was 5.4% among non Hispanic whites (N = 1,355), p = 0.02. One-year recurrence rates were unchanged during 2000–2011 in all models and in both ethnic groups; annual HR = 0.97 (95% CI 0.93–1.01) adjusted for ethnicity, age, sex, hypertension, diabetes, smoking and cholesterol.

Conclusions

Despite previous reports of declining incidence and mortality, stroke recurrence rates are not significantly changing. More aggressive secondary stroke prevention is needed. Mexican Americans have a higher burden of stroke recurrence compared with non Hispanic whites and should receive increased attention for secondary stroke prevention.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

DETERMINANTS OF ADHERENCE TO ORAL ANTICOAGULANTS IN PATIENTS WITH ATRIAL FIBRILLATION AND STROKE

A Polymeris ¹, C Traenka ¹, L Hert ¹, DJ Seiffge ¹, N Peters ¹, GM De Marchis ¹, LH Bonati ¹, PA Lyrer ¹, ST Engelter ¹

Abstract

Background

Non-vitamin K antagonist (VKA) oral anticoagulants (NOACs) are of proven benefit in patients with stroke attributable to atrial fibrillation (AF). However, little is known about adherence to NOACs and its determinants.

Methods

Novel-Oral-Anticoagulants-in-Stroke-Patients (NOACISP) is a prospective monocentric registry aiming at retrieving ‘real-world’ data in patients with stroke associated with AF. This is a nested analysis focused on adherence to treatment. Adherence was assessed using a structured interview including the self-reported number of missed doses and expressed as the percentage of prescribed doses actually taken. Patients reporting at least one missed dose were classified as non-adherent. To establish determinants of adherence we compared demographic variables, medication details, stroke characteristics and occurrence of adverse and outcome events between adherent and non-adherent patients using univariate analyses.

Results

We included 225 patients (52% female, mean age 77.9 ± 9.2 years). Fifty patients had VKAs and 175 NOACs. Mean follow-up was 11.6 (range 3 – 24) months. Mean adherence was 98.8%. Adherent were 178 patients (79%) and non-adherent 47 (21%). Adherence did not differ between VKA- and NOAC-treated patients. Adherence was positively associated with (a) higher total daily pill burden, (b) caregiver administering doses, (c) modified Rankin Scale of ≥3 and (d) previous antithrombotic treatment. Forgetfulness was the most common reason for non-adherence.

Conclusions

In our cohort adherence was remarkably high. Determinants of adherence were -counterintuitively- a high number of daily taken medications and -expectedly- a caregiver involved in daily intake, as well as the previous intake of antithrombotic agents.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ISCHEMIC STROKE RECURRENCE: COHORT STUDY WITH MID- TO LONG-TERM FOLLOW-UP IN PATIENTS WITH ACUTE ISCHEMIC STROKE

D Strambo ¹, G Schwarz ¹, G Comi ¹, L Roveri ¹

Abstract

Background

Ischemic stoke is a leading cause of death and disability worldwide. Stroke recurrence is reported in up to 25% of patients.

Methods

From our database we selected all ischemic stroke patients admitted to the Stroke Unit of San Raffaele Hospital between 01/01/2010 and 30/11/2014 with an available follow-up of at least 6 months.

Results

Our cohort included 1029 patients with a mean follow-up of 25 months. During follow-up 169 patients (16.4%) died and 91 (8.8%) experienced a recurrent stroke (86 ischemic and 5 hemorrhagic). Cumulative rate of stroke recurrence was 5.0% (3.6–6.4%) at 1 year and 18.2% (12.7–23.6%) at 5 years. Index stroke etiology did not affect the rate of stroke recurrence (p. 0.385- log-rank test). At univariate analyses age at index stroke, new onset of hypertension, dyslipidemia and atrial fibrillation during follow-up were associated with stroke recurrence (Crude hazard-ratios and CI95% respectively: 1.028 [CI95% 1.009–1.047], 2.869 [CI95% 1.113–7.394], 2.305 [CI95% 1.138–4.667], 2.113 [CI95% 1.104–4.044]). In multivariable cox regression analysis the onset of atrial fibrillation during follow-up increased the risk of stroke recurrence in patients with cryptogenic index stroke (HR 2.683[CI95% 1.06–6.791]) while anticoagulant therapy reduced the risk of new ischemic events (HR 0.219[CI95% 0.079–0.607]) among patient with index cardioembolic stroke.

Conclusions

New vascular risk factors arising after index stroke should be monitored and considered a key target in secondary prevention. Therapeutic strategies to achieve proper anticoagulation should be implemented to reduce stroke recurrences.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

REGULAR PARTICIPATION IN PRESTROKE LEISURE ACTIVITIES REDUCED RISKS OF DEMENTIA AND IMPROVED COGNITIVE FUNCTIONS AFTER STROKE OR TRANSIENT ISCHEMIC ATTACK: RESULT FROM THE STRIDE STUDY

A Wong ¹, AYL Lau ¹, E Lo ¹, M Tang ¹, Z Wang ¹, W Liu ¹, N Tanner ¹, N Chau ¹, L Law ¹, L Shi ¹, WCW Chu ², J Yang ³, YY Xiong ⁴, BYK Lam ¹, LWC Au ¹, Y Soo ¹, TWH Leung ¹, LKS Wong ¹, LCW Lam ⁵, VCT Mok ¹

Abstract

Background

To examine the effects of recent past leisure activities participation upon cognitive functions and risk of incident dementia after stroke.

Methods

In the Stroke Registry Investigating Cognitive Decline (STRIDE) study, 88 of 1,013 patients with stroke or transient ischemic attack (TIA) having no prestroke dementia were diagnosed to have incident poststroke dementia (PSD) 3–6 months after the index event. Regular participation was defined as participation of ≥30 minutes within 24 hours for ≥3 times a week in intellectual, recreational, social and physical activities over the year before the index event.

Results

Logistic regression analyses showed that regular participation in intellectual (RR 0.36, 95%CI 0.20–0.63) and stretching & toning physical exercise (0.37, 0.21–0.64) was significantly associated with a reduced risk of PSD after controlling for age, education, prestroke cognitive decline, stroke subtype, prior strokes and chronic brain changes including white matter changes, old infarcts and global atrophy. Results were similar in patients with past strokes in unadjusted models. Participation in increased number of activities in general (r = 0.41, p < 0.01) and in intellectual (r = 0.40, p < 0.01), recreational (r = 0.24, p < 0.01), strenuous aerobic (r = 0.23, p < 0.01) and mind-body (r = 0.10, p < 0.01) activities was associated with higher Mini-mental State Examination scores poststroke in models adjusted for prestroke cognitive decline.

Conclusions

Regular participation in intellectual activities and stretching & toning exercise was associated with a significantly reduced short-term risk of PSD in stroke or TIA patients with and without prior strokes. Participation in greater number of recent past leisure activities was associated with better poststroke cognitive performance.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

RISK FACTORS FOR NEWLY-DEVELOPED CEREBRAL INFARCTION AFTER SURGICAL REVASCULARIZATION FOR ADULTS WITH MOYAMOYA DISEASE

JS Ahn ¹, W Park ¹, BD Kwun ¹, K Yang ¹, Y Heo ¹

Abstract

Background

It is important to recognize the incidence and risk factors for ischemic complications after surgical revascularization for moyamoya disease (MMD). However, most studies focus on pediatric MMD or both pediatric and adult MMD. Our study identified the incidence and risk factors of newly-developed cerebral infarction after surgical revascularization for adult MMD.

Methods

Ischemic complications were defined as newly-developed cerebral infarction within 15 days following surgery, as identified by imaging studies. To identify the incidence and these risk factors for adult patients 18 years or older, we retrospectively reviewed our experience with 194 adult MMD patients with 241 surgical revascularizations.

Results

The incidence of symptomatic infarction after surgical revascularization was 5.8% (14 cases) and 30 cases (12.4%) experienced silent infarction. For univariate analysis, initial presentation as infarction, initial presentation as hemorrhage, transient ischemic attacks (TIAs) >3 times/month, involvement of posterior cerebral artery (PCA), combined bypass, and using muscle for revascularization were variables related to newly-developed cerebral infarction. Multivariate analysis revealed that the following factors were independently associated with newly-developed cerebral infarction after surgery: cerebral infarction as initial presentation (OR 1.150; 95% CI 1.038–1.273; p = 0.0073), TIAs > 3times/month (OR 1.188; 95% CI 1.058–1.335; p = 0.0035) and PCA involvement (OR 1.095; 95% CI 1.005–1.194; p = 0.039).

Conclusions

Our findings demonstrate that newly-developed, silent cerebral infarction developed more frequently than symptomatic cerebral infarction in adult patients. Cerebral infarction as initial presentation, frequent TIA before surgery, and PCA involvement were also independent risk factors for newly-developed cerebral infarction after surgical revascularization for adult MMD.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

A YOUNG WOMAN WITH ISCHEMIC STROKE - SHOULD WE PAY MORE ATTENTION TO VARICELLA ZOSTER INFECTION?

C Borbinha ¹, JP Marto ¹, S Calado ^1,², M Viana-Baptista ^1,²

Abstract

Background

Ischemic and hemorrhagic stroke are recognized complications of Varicella-Zoster Virus (VZV) infections, although uncommon and poorly documented.

Methods

N/A

Results

The authors report the case of a 31-year-old woman admitted to a university hospital with acute ischemic stroke of the right posterior cerebral artery and a history of a thoracic rash one month before.The diagnosis of VZV vasculopathy was considered after a stepwise deterioration of the neurological status, with new areas of infarction and hemorrhagic transformation under anticoagulation. Treatment with acyclovir and prednisolone was started. Cerebrospinal fluid analysis and digital subtraction angiography findings supported the diagnosis. The patient suffered no further neurological compromise and was discharged with a modified Rankin scale (mRS) of 4. On the six-month follow-up, she presented only slight disability (mRS 2).

Conclusions

VZV vasculopathy needs to be considered in young adults, in patients with stroke/transient ischemic attack after herpes zoster or varicella and in cases of a stroke of unknown origin. A high index of suspicion and early treatment seem to be important to minimize morbidity and mortality.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CERVICAL ARTERIES DISSECTION: OUR EXPERIENCE OVER THE LAST 10 YEARS

L Crespo-Araico ¹, R Vera Lechuga ¹, A Cruz Culebras ¹, C Matute Lozano ¹, A De Felipe-Mimbrera ¹, P Agüero Rabes ¹, E Viedma-Guiard ¹, C Estévez Fraga ¹, J Masjuan Vallejo ¹

Abstract

Background

Cervical arterial dissections (CAD) can cause 20% of all ischemic strokes in young adults. Reperfusion therapies in acute phase in these patients raise some doubts. We reviewed our experience over the last 10 years.

Methods

Retrospective review of patients with diagnosis of CAD admitted at our comprehensive stroke centre from 2005 to 2014. We collected baseline clinical characteristics, reperfusion therapies, functional outcome at 3 months (modified Rankin Scale) and mortality.

Results

35 cases (23 carotid / 12 vertebral) were recorded. The median age was 47.4 ± 12.5 years and 74.2% were male. In 10 cases (28.5%) the patient had history of trauma before the dissection. The most frequent risk factors were hypertension (31.4%) and smoking (25.7%). The most common clinical presentation was cerebral infarction (30 patients). The median baseline NIHSS score was 3 (1–13). The most commonly used diagnostic method was CT angiography (77.1%), followed by MRI (60%) and digital angiography (40%). 7 (20%) patients were treated with intravenous thrombolysis and 10 (28.5%) patients were treated with endovascular treatment ± intravenous thrombolysis, achieving functional independence (mRS 0–2) at three months in 4 (57.1%) and 6 (60%) cases respectively. Only one patient died (2.8%).

Conclusions

The most common form of presentation of CAD was ischemic stroke. These cases may benefit from reperfusion therapies with a similar prognosis to other patients with non CAD stroke. Largest studies are required to better understand the response to treatments during the acute phase in these patients.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

DOPPLER ULTRASOUND RELIABLY IDENTIFIES SICKLE CELL DISEASE ADULT PATIENTS WITH INTRACRANIAL VASCULOPATHY COMPARED WITH MAGNETIC RESONANCE ANGIOGRAPHY

M Edjlali ¹, MP Gobin-metteil ¹, N Mele ², L Majhadi ³, H Hosseini ³, JL Mas ², C Oppenheim ¹, F Galacteros ⁴, P Bartolucci ⁴, D Calvet ²

Abstract

Background

Sickle cell disease (SCD) is one of the most frequent cause of stroke, in young adults in Africa, where access to magnetic resonance (MR) imaging is limited. The objective of this study was to assess whether Doppler ultrasound is sensitive and specific to identify SCD adult patients with vasculopathy, compared with MR angiography (MRA).

Methods

80 adult SCD patients followed up in an adult sickle cell referral center with past neurological history were screened for intracranial vasculopathy using 3T brain MR imaging with a 3D time-of-flight MRA and Doppler ultrasound performed on the same day.

Intracranial vasculopathy on intracranial carotid artery and proximal middle cerebral artery was defined as follows: ≥50% intracranial stenosis, occlusion, and Moya-Moya collaterals. ≥50% stenosis was defined on Doppler ultrasound as a time-averaged mean of the maximum (TAMMx) velocity ratio ≥3 (ratio of the highest intracranial TAMMx on ipsilateral extracranial internal carotid TAMMx). Ultrasound contrast agent was used when needed.

Results

Among 80 patients (mean age 30.5 +/- 7.9 years) included in the study, 77 had Doppler ultrasound and MRA. 38 patients (50%) had intracranial vasculopathy on MRA, of whom 17 had Moya-Moya. Ultrasound contrast agent was required in 15% of patients. Sensitivity and specificity of Doppler ultrasound to identify patients with intracranial vasculopathy was 87%, and 90% respectively. Positive and negative predictive values were 86% and 87% respectively. Moya-Moya collaterals were identified using Doppler ultrasound in all 17 patients.

Conclusions

Doppler ultrasound may be used to identify SCD adult patients with vasculopathy.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

USEFULNESS OF PLATELET TO LYMPHOCYTE RATIO AND NEUTROPHIL TO LYMPHOCYTE RATIO COMBINATIONS IN PREDICTING THE PRESENCE OF CEREBRAL VENOUS SINUS THROMBOSIS AND IN-HOSPITAL MACE

Y Eylev Akboga ¹, H Bektas ², O Anlar ¹

Abstract

Background

Platelet to lymphocyte ratio (PLR) and neutrophil to lymphocyte ratio (NLR) as recently emerging thrombo-inflammatory indicators were significantly associated with major cerebrovascular adverse events (MACE) and mortality. Therefore, we aimed to assess the effects of combinations of PLR and NLR in predicting the presence of CVST and in-hospital MACE.

Methods

A total of 277 participants comprising 80 patients with evidence of CVST and 197 controls with similar baseline characteristics were included in this study. Patients were classified into 3 groups based on the optimal cut-off values of PLR and NLR calculated with receiver operating characteristic (ROC) curve for in-hospital MACE rates.

Results

PLR (148 ± 61 vs 101 ± 50, p < 0.001) and NLR (3.12 ± 1.4 vs 1.94 ± 1.1, p < 0.001) were significantly higher in the CVST group. Furthermore, patients in the high risk group (a PLR of ≥115.0 and an NLR of ≥2.1) had the highest in-hospital MACE rates including seizure (p = 0.012), papilledema (p = 0.025) and diplopia or blurry vision (p = 0.028). After multivariate logistic regression analysis MPV, PLR (1.052 [1.045 – 1.059], p = 0.001) and NLR (1.442 [1.086 – 1.916], p = 0.012) were found as independent predictors of CVST.

graphic file with name 10.1177_2396987316642909-fig60.jpg

Conclusions

These results suggest that PLR and NLR are easily available and cheap thrombo-inflammatory indicators, so that PLR and NLR could be used in prediction of CVST and in-hospital MACE.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

A RARE CAUSE OF BILATERAL MIDDLE CEREBRAL ARTERY INFARCTS REVEALED BY EARLY DIAGNOSTIC WORKUP

C Guidoux ¹, L Cabrejo ¹, E Meseguer ¹, N Pasi ², P Amarenco ¹

Abstract

Background

We report the case of an 80-year-old hypertensive diabetic woman with hypercholesterolemia who presented in our department with a left-sided hemiparesia of abrupt onset.

Methods

Diffusion MRI showed recent infarcts of both middle cerebral artery territories. Carotid ultrasound revealed a mobile thrombus appended to the right common carotid artery extending towards the carotid bulb (left panel). This was confirmed by a CT angioscan that also revealed a horseshoe plaque of the aortic arch from which originated the mobile thrombus (right panel), extending over 13 centimetres into the right common carotid artery.

graphic file with name 10.1177_2396987316642909-fig61.jpg

Results

Antiplatelet agents were introduced.The intraluminal thrombus had disappeared on control carotid ultrasound performed 12 hours later.

Conclusions

Complete and rapid cardiac workup is mandatory after ischemic stroke. For diagnostic purpose, this workup may need to be performed even earlier to detect proximal and cardiac sources of embolism when lesions are bilateral on MRI. The thrombus has resolved in a few hours, so that late workup would have missed the diagnosis.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

NON-TRAUMATIC INTRACEREBRAL HAEMORRHAGE IN YOUNG ADULTS: ASSOCIATED VASCULAR RISK FACTORS. COMPARATIVE STUDY IN HOSPITAL OF CARTAGENA (SPAIN) FROM 1993 TO 2014

A Guzmán Martín ¹, T Espinosa Oltra ¹, JM Sánchez Villalobos ¹, M Quesada López ¹, A Torres Alcázar ¹, ML Fortuna Alcaraz ¹, MD Ortega Ortega ¹, M López López ¹, T Tortosa Sánchez ¹, V Giménez de Béjar ¹, JJ Soria Torrecillas ¹, JA Pérez Vicente ¹

Abstract

Background

Non-traumatic Intracerebral Haemorrhage (ICH) is the second type of stroke in frequence. Vascular risk factors associated have been studied in detail in patients older than 50, whereas very limited papers about its characteristics in young adults have been published. Among them, a wider and heterogeneous number of etiologies have been depicted, the majority of them modifiable. The best treatment in ICH is its prevention. Hence, a deeper knowledge of its risk factors should be accomplished in order to develop preventive programs specifically directed to this population.

Methods

A retrospective descriptive study of the characteristics of patients with ICH interned in the Department of Neurology of the Hospital of Cartagena (Murcia) between 1993 and 2014 was carried out. A total of 538 patients were included and divided into two groups: aged 18–50 (n = 44, 8.2%) and older than 50 (n = 494, 91.8%). A descriptive and comparative study analyzing vascular risk factors, location and personal and familiar history among both groups was made.

Results

As the literature depicts, high blood pressure was the most prevalent risk factor in both groups, although a more heterogeneous distribution of them was found in young adults. Among our patients, the majority of ICH were lobar, except in old men, in whom haematomas were more frequent in basal ganglia and thalamus.

Conclusions

Developing education and prevention programs is the best method to reduce ICH's incidence rate, being necessary a deeper knowledge of its risk factors, moreover in young patients, in whom the consequences are catastrophic and the studies published are limited.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

QUALITY OF LIFE AFTER CEREBRAL VENOUS THROMBOSIS

S Hiltunen ¹, E Haapaniemi ¹, T Tatlisumak ^1,², J Putaala ¹

Abstract

Background

Cerebral venous thrombosis (CVT) is a rare cause of stroke, affecting mainly working-aged individuals and women. Large majority achieve good long-term functional outcome, but effect of CVT to quality of life remain poorly investigated.

Methods

We included all CVT patients aged >16 years treated in our hospital from January 1987 to August 2014, and invited them to a follow-up visit at least 6 months after diagnosis. Patients gave written consent, and answered to RAND-36 questionnaire which measures eight aspects of health-related quality of life. Results of CVT patients were compared to the Finnish population reference values for persons without chronic illness.

Results

From 197 CVT patients a total of 154 patients were included in our study, after a mean follow-up of 60 months. Mean age was 46 years, and 101 (66%) were women. Functional outcome was good with 98% being independent (mRS 0–2). CVT patients scored below reference values in general health (58.4, 95%CI: 54.6–62.2. vs 72.9, 95%CI: 71.8–76.0), physical functioning (82.0, 95%CI: 77.4–86.6 vs 91.7, 95%CI: 91.0–92.5), and physical role functioning (72.3, 95%CI: 64.1–80.6 vs 87.3, 95%CI: 85.8–88.8). In other categories (pain, fatigue, social and emotional aspects) CVT patients scored below healthy Finns, but no significant statistical difference was found.

Conclusions

Despite good functional recovery, long-term quality of life is affected in CVT patients.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CEREBRAL INFARCTION DUE TO NON-THROMBOTIC PARADOXIAL EMBOLISM IN AN INTRAVENOUS DRUG USER

R Kelly ¹, J Harbison ¹

Abstract

Background

Thromboembolism through Patent Foramen Ovale (PFO) is a recognised cause of stroke in younger people, but other substances may also pass through a PFO.

A case report on a 28 year- old intravenous drug user (injecting Heroin, Cocaine and Zopiclone) presenting with stroke.

Methods

The subject presented to the Emergency Department (ED) with left facial droop, and left hemiplegia starting two days previously. He had previously self discharged from another hospital but represented to ours due to non-resolution of symptoms.

On examination he had left facial weakness and left sided decreased tone and power (4/5). CT and MRI Brain scans showed a small acute right perisylvian infarct with a filling defect in a right M3 MCA branch. The subject was admitted to complete the work-up for stroke mechanism. Cardiac monitoring was normal and it was initially hypothesised that the filling defect was secondary to cocaine related spasm, but echocardiogram with bubble contrast was strongly positive for a PFO with right to left shunt. Further detailed history revealed that the initial event occurred after intravenously injection of ground up Zopiclone tablets

Results

As the subject was unwilling to consider abstinence from intravenous drug use he was not considered a suitable candidate for occlude device insertion because of endocarditis risk. He made a good functional recovery and was discharged with caution as to the risk of future paradoxical stroke.

Conclusions

Younger intravenous drug users presenting with stroke should be specifically asked about injecting practice when PFO is suspected.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CLINICAL CASE OF TOLOSA-HUNT SYNDROME IN YOUNG PATIENT

I Lutsenko ¹, MH Ilyas ¹

Abstract

Background

In this given article the analysis of a very rare and dangerous clinical case of ischemic stroke with severe headache, provoked by cavernous sinus thrombosis in young lady patient was discussed. Imaging findings and early diagnose with treatment is emphasized.

Methods

We present a case of Tolosa-Hunt syndrome with bacterial thrombosis of cavernous sinus lead to ischemic stroke in a young patient. Tolosa-Hunt syndrome is a rare disorder, characterized by severe and unilateral headache with extraocular palsies, involving the third, fourth, fifth and sixth cranial nerves and pain around the side and back of the eye, along with weakness and paralyses (ophthalmoplegia) of certain eye muscles, caused by bacterial thrombosis of cavernous sinus (CST).

Results

The patient experienced left ptosis, midriasis and intensive stabbing headache in the left orbita, and was not able to move because of headache. MRI demonstrated a stasis of venous blood in the left cavernous sinus with perifocal edema and infarction in left temporal lobe. The combination of several chronic inflammatory diseases (hepatitis, pancreatitis, duodenitis, uteritis, adnexitis, gastritis, cholecystitis, mastoiditis, periodontitis) lead to septicemia, latent disseminated intravessel coagulation syndrome, and later to severe complication - bacterial CST. Prescription of wide spectrum antibacterial drugs and corticosteroid antiplatelets lead to dramatic improvement - full regress of ptosis on the very next day and relief of headache during next 15 days.

Conclusions

We recommend to be careful with prescription of anticoagulants because of possible complications as hemorrhagic transformation of infarction. The earliest correct conservative treatment prevents short-term mortality and severe brain complications.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EPYLEPSY RISK PROGNOSIS IN CHILDREN WITH ARTERIAL ISCHEMIC STROKE

O Lvova ¹, M Lukashchuk ², L Shalkevich ³, V Gusev ⁴, A Dron ⁵, A Sulimov ⁵, E Orlova ⁵

Abstract

Background

Seizures are common during the acute periods of pediatric arterial ischemic stroke (PedAIS) but which of them will continue to be the epilepsy exactly unknown.

Methods

Type of study: case-control. We investigated type of seizures and EEG features in acute period in 114 patients without epilepsy (controls) and 22 who had epilepsy (cases) later 12–18 months after PedAIS.

Results

The seizures’ incidence in acute period were 30,9% (n = 42) and antiepileptic therapy was prescribed for majority of patients, but the incidence of epilepsy has been rarely - 16,2% (n = 22). We assessed the prognostic value of seizures and EEG data (table).

Conclusions

The certain type of seizures (generalized and focal with secondary generalization) as well as specific type of changes on EEG (non-epileptic focal, focal epileptiform, spike and spike-wave activity) in the acute period of PedAIS increase the risk of epilepsy more than four times.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CLINICAL CASE OF FABRY DISEASE: DETECTION FOLLOWING THE STROKE

V Gusev ¹, O Lvova ², A Tsoriev ³

Abstract

Background

Fabry disease (FD) may cause the acute ischemic stroke (AIS) in young persons.

Methods

We present the catastrophically delayed of Fabry’s detection in 44 y.o. male with AIS.

Results

In childhood (8 y.o.) he began to complain of acroparesthesia, since 15 y.o. mild angiokeratomas appeared in lips area (image 1).

graphic file with name 10.1177_2396987316642909-fig65.jpg

He was observed in pediatric neurological and reumatological units but never had been examined as FD suspected patient. Since 2002 suffered from typical FD pain crisises twice a month, depression; since 2012 - chronic renal failure II B and symptomatic arterial hypertension II.

Patient was admitted to the stroke unit in May 2015 complained of dysphagia, dysphasia and vomiting during 3 days. MRI showed multiple lacunar infarcts (acute and chronic) and subacute infarct in left subcortical area, microangiopathy (image 2).

graphic file with name 10.1177_2396987316642909-fig66.jpg

According to the diagnostic standard for young patients with AIS dried blood spot was carried out, after positive result the mutation c.612G > C (p.Trp204Cys) in 4 exon GLA gene was identified, FD has been confirmed. Due to renal failure he was transferred to dialysis department where hemorrhagic stroke occurred (image 3) and patient died.

graphic file with name 10.1177_2396987316642909-fig67.jpg

Conclusions

In spite of “Fabry red flags” since childhood to adulthood (acroparesthesia, angiokeratomas, pain crisises, renal failure unknown etiology) patient was never suspected and examined as FD. Only AIS’s protocol for young patient allowed to identify the true diagnose and reason for multi-organ failure. The diagnostic delay for 36 years has been completed dramatically – he did not have enough time to receive his first ERT despite the verified FD.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CHARACTERISATION OF PATIENTS WITH SPONTANEOUS CERVICAL ARTERY DISSECTION

L Mayer ¹, B Dejakum ¹, T Toell ¹, J Willeit ¹, S Kiechl ¹, ER Gizewski ², G Ratzinger ³, M Knoflach ¹

Abstract

Background

Spontaneous cervical artery dissection is the most frequent cause of stroke in patients younger than 50 years. We wanted to characterise risk factors and clinical presentation of affected patients in a large single centre cohort.

Methods

Between January 2001 and December 2012 283 adults with spontaneous cervical artery dissection diagnosed either with MRI or the combination of two other independent imaging modalities were treated at the Department of Neurology at Medical University of Innsbruck. A broad palette of patient characteristics was collected by retrospective chart review.

Results

In total, 141 and 134 patients had vertebral artery (VBA) and internal carotid artery (ICA) dissection and 8 had both. Males were overrepresented in our cohort (168, 59.4%) and on average older than females (P < 0.001). Patients with a VBA dissection were more likely to suffer an ischaemic stroke (P < 0.01) but patients with ICA dissections presented with more severe strokes defined by an NIHSS > 12 (P = 0.004). In 9.9% of patients (n = 28), more than one vessel was affected simultaneously. Patients with multiple dissections had lower rates of vascular risk factors like hypertension (P = 0.02).

Conclusions

This is one of the largest single-centre cohorts of patients with cervical vessel dissection and serves as a basis for the currently ongoing prospective evaluation of long-term patient outcome.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ACUTE ISCHEMIC STROKE CAUSED BY AORTIC DISSECTION: A DIAGNOSTIC CHALLENGE

S Muñiz Castrillo ¹, B Oyanguren Rodeno ¹, M Gonzalez Salaices ¹, E De Antonio Sanz ², M Eimil Ortiz ¹, I Casanova Pena ¹, C Lopez De Silanes De Miguel ¹, MJ Gil Moreno ¹, O Trabajos Garcia ¹

Abstract

Background

Aortic dissection is a rare cause of acute ischemic stroke, but neurological manifestations are frequent among these patients. Although thoracic pain is the most common initial symptom, one third of patients with neurological symptoms at onset are pain-free. The diagnosis in these cases is especially difficult, so the clinical suspicion must be high, as thrombolytic therapy for acute ischemic stroke is contraindicated in aortic dissection.

Methods

We present a case report of acute stroke caused by acute aortic dissection. We describe the semiology and the result of imaging techniques.

Results

We present a case of a 81 year-old woman with hypertension that after complainig of diplopia, suffered fast drowsiness. She did not complain about pain. Her blood pressure was normal, ECG showed sinus rhythm. Peripheral arterial pulses were symmetrical. The first neurological examination suggested a stroke affecting vertebrobasilar territory (impaired consciousness, roving eye movements, flaccid tetraplegia), but a few minutes later it changed: the patient was conscious with left hemiplegia, suggesting a right middle cerebral artery stroke. Craneal CT was normal, but CT angiography showed complete aortic dissection (De Bakey type I, Standford tye A), extending to the right vertebral and internal carotid arteries.

Conclusions

We want to highlight that sympoms of two different vascular territories occurring almost simultaneously must suggest acute aortic dissection in patients with acute stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

DIAGNOSTIC AND THERAPEUTIC WORK-UP FOR CEREBRAL VENOUS THROMBOSIS &NDASH; RESULTS FROM A SURVEY ON GERMAN STROKE UNITS

C Geisbüsch ¹, PA Ringleb ¹, O Busse ², GF Hamann ³, S Nagel ¹

Abstract

Background

Cerebral vein thrombosis (CVT) is a rare disease and systematic studies on diagnosis and management are lacking. Hence, guidelines remain vague. Our aim was to characterize diagnostic and therapeutic strategies on German stroke units (SU).

Methods

We invited clinical leads of all certified SUs in Germany to a standardized anonymous online survey. The questionnaire concentrated on basic characteristics of SUs, diagnostic procedures to detect a cerebral vein thrombosis and therapeutic strategies as well as follow-up visits.

Results

One hundred seven SU leads participated between September and December 2015 (response rate 42,8%). 55% treat 5–10 patients per year and in 77% CVT diagnosis is made by MR-angiography (MRA). 79,1% of SUs determine d-dimers if CVT is suspected and 88,5% induce a screening of thrombophilia after diagnosis. All SUs initiate anticoagulation with heparin, but 69% prefer unfractionated heparin. 44% perform hemicraniectomy and 25% endovascular recanalization procedures in selected cases. 55% determine the point in time to start oral anticoagulation (OAC) on individual basis and only 18% of SUs have experience with new oral anticoagulants (NOACs). 95% of SUs organize a follow-up visit with an MRI, which is performed in 58% within 3 to 6 months after CVT. 14% would continue OAC in patients with failed recanalization after 12 months; 10% were unsure how to proceed; 76% would discontinue OAC.

Conclusions

Our survey reveals certain heterogeneity among German SUs especially on therapeutic strategies for CVT. Future prospective multicenter studies should systematically evaluate therapeutic options to provide better evidence.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

INCIDENCE OF STROKE IN YOUNG ADULTS ADMITTED TO A STROKE UNIT

P Pérez Torre ¹, FJ González-Gómez ¹, A Escobar Villalba ¹, PL Martínez Ulloa ¹, E Monreal Laguillo ¹, A De Felipe-Mimbrera ¹, MC Matute-Lozano ¹, A Cruz Culebras ¹, R Vera Lechuga ¹, J Masjuan Vallejo ¹

Abstract

Background

Recently published studies reveal an increasing stroke incidence in young adults under 56 years of age. Our aim was to study this incidence in our community and the subsequent analysis of stroke subtypes and possible risk factors.

Methods

Prospective registry of patients under 56 years of age admitted to a Stroke Unit (SU) between January 2014 and December 2015. We registered age, sex, classic vascular risk factors, stroke subtypes, reperfusion therapies applied, clinical course and level of psychosocial stress measured by the Perceived Stress Scale (PSS-4).

Results

The proportion of stroke in patients under 56 years old was 11.30% (180 out of 1593). Regarding stroke subtypes, 65.94% were ischemic strokes, 17.81% transient ischemic attacks, 12.81% brain hemorrhages and 3.44% cerebral venous sinus thrombosis. Of the ischemic strokes, 28.31% were cryptogenic, 20.35% atherothrombotic, 17.70% of unusual etiology, 17.69% cardioembolic, and 15.95% lacunar stroke. Of the brain hemorrhages, 57.14% were hypertensive. Smoking (54.28%), hypertension (43.88%), obesity (37.7%) and dyslipidemia (33.3%), were the most frequent vascular risk factors, followed by heart diseases (15.55%), alcohol (15.00%) and diabetes mellitus (13.88%). 61.61% of patients admitted that they were exposed to high levels of psychosocial stress. Reperfusion therapies were performed in 27.42% of the cases of isquemic stroke (10.62% rtPA, 9.73% thrombectomy, 7.07% thrombectomy + rtPA).

Conclusions

The high incidence of stroke in young people under 56 years of age seems to be related to the frequent occurrence of numerous vascular risk factors and high levels of psychosocial stress.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EMERGENT TREATMENT OF ISCHEMIC STROKE SECONDARY TO GIANT DISSECTING ANEURYSM OF THE EXTRA-CRANIAL INTERNAL CAROTID ARTERY IN A YOUNG PATIENT

A Sánchez Gómez ¹, S Rudilosso ¹, S Amaro ¹, N Falgàs ¹, JL Moreno ²

Abstract

Background

We present the case of a 25-year-old man admitted to the emergency service after 4 hours of acute onset of right hemiparesis and aphasia.

Methods

A non-enhanced CT showed incipient signs of acute ischemia in the left Middle Cerebral Artery (MCA) territory. The angio-CT showed a giant dissecting aneurysm of the left extracranial Internal Carotid Artery (ICA) and a left MCA M2 occlusion. The intracranial M2 occlusion was treated with thrombectomy achieving a reperfusion TICI 2b grade. Moreover, a stent was delivered in the dissected portion of ICA.

graphic file with name 10.1177_2396987316642909-fig69.jpg

graphic file with name 10.1177_2396987316642909-fig70.jpg

Results

Despite successful recanalization a follow-up CT scan showed a malignant stroke in the left MCA territory. The patient required decompressive craniectomy and the modified Rankin score at discharge was 5.

Conclusions

Dissecting aneurysms occur in about 12–49% of extracranial carotid dissections, although the clinical presentation as acute brain ischemia and a giant size are extremely rare. In the case of severe acute and critical brain hypoperfusion, emergent stenting of a severe stenosis secondari to a dissecting aneurysm may succesfully restore brain perfusion. However, other factors such as time to reperfusion and collateral circulation are crucial for clinical response to emergent revascularization therapies.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

TRANSCRANIAL DOPPLER FLOW VELOCTIES DYNAMIC IN CHILDREN WITH SICKLE CELL DISEASE: THE INFLUENCE OF HYDROXYUREA

G Silva ¹, S Ademola Adegoke ², MSF Figueiredo ³, R Macedo ¹, J Pellegrini Braga ⁴, D Laranja Gomes Rodrigues ¹

Abstract

Background

The role of transcranial Doppler (TCD) ultrasonography in identifying children with sickle cell anemia (SCA) at risk for stroke is well known and is one of the major advances in the management of the disease Objective: The present study examined whether hydroxyurea (HU) as the main therapy influences the progression of TCD flow velocities.

Methods

The study population included children between the age of 2 and 16 years with SCA who had TCD examinations during the study period, February 2011 to April 2015. TCD results were extracted from the TCD data bank of the neurovascular unit of our Hospital.

Results

From February 2011 to April 2015, a total of 544 TCDs were done on 307 children with SCA. Of the 151 children who had multiple TCDs, 100 who fulfilled our strict inclusion criteria formed the basis of subsequent analyses. A total of 11 patients (21.6%) of the HU-group experienced TCD reversal. This included 9 with reversal from conditional TCD to normal TCD; 1 from abnormal TCD directly to normal TCD and 1 from abnormal TCD to conditional TCD. For those without HU therapy, 7 (14.3%) had reversal from conditional TCD to normal TCD while none reverted directly from abnormal to normal velocities.

Conclusions

This study suggests that hydroxyurea as the main therapy enhanced reduction in TCD flow velocities and seems to be associated with reversal of conditional risk velocities to normal range velocities in children with SCA.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

IMAGING CORRELATE OF HEADACHE IN CEREBRAL VENOUS SINUS THROMBOSIS: ROLE OF CORTICAL VEINS AND VENOUS COLLATERALS

RJ Singh ¹, GB Kulkarni ¹, J Saini ²

Abstract

Background

Cerebral venous sinus thrombosis (CVST) accounts for about 0.5% to 1% of all stroke. Headache constitutes most common symptom but its pathophysiology is still unclear. We sought to investigate imaging correlate of headache in patients with acute CVST.

Methods

Acute CVST patients presenting with headache as dominant symptom without significant parenchymal lesion were included. Side of dural sinus thrombosis (DST), cortical vein thrombosis (CVT) were assessed by conventional and postcontrast magnetic resonance imaging (MRI) and vascular congestion (VC) with susceptibility weighted imaging (SWI).

Results

Among 372 patients (seen over 3 years), 41 patients constituted study cohort. Twenty eight patients had lateralized headache (LH) and 13 nonlateralized headache (NLH) with mean age of 32.25 years, male predominance in former and 27.15 years, female predominance in later group. Common features to both groups were progressive, continuous, moderate to severe intensity headache usually associated with nausea and/or vomiting. Among LH group, DST was lateralized in 20/28 (71.4 %), CVT in 17/28 (60.7 %) and VC in 20/28 (71.4 %). In NLH group DST was lateralized in 10/13 (76.9 %), CVT in 2/13 (15.4 %) and VC in only one patient (7.7 %). Lateralized sinus involvement did not co-localize with headache (p value 0.49) while CVT and VC co-localized well with headache location (p value 0.02 and 0.001 respectively). Interestingly, during follow-up five patients showed no vascular congestion in headache free phase.

Conclusions

This study highlights the role of thrombosed cortical veins and congested venous collaterals as possible underlying mechanism for headache in patients with acute CVST.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

A LONG-TERM FOLLOW-UP OF UNILATERAL INTRACRANIAL ARTERIOPATHY IN 7 PATIENTS WITH CHILDHOOD ARTERIAL ISCHEMIC STROKE

SI Sohn ¹, JH Hong ¹, MS Kang ¹, SW Park ²

Abstract

Background

Unilateral intracranial arteriopathy (UIA) is an important cause of childhood stroke. Children with UIA may suffer from a progressive infarction in the initial worsening stage. However there is very limited information concerning acute management and secondary prevention. The aim of this study was to evaluate the duration of the initial worsening stage and recurrence after stop antiplatelet management.

Methods

We investigated the patients with UIA among 5600 stroke patients of Keimyung stroke database. Inclusion criteria were 1) involvement of unilateral intracranial large artery, 2) repeated vascular imaging at least twice and 3) absence of thrombotic disorders or cardiac disease. They were managed with antiplatelet agents and high dose steroid therapy for 5 days. We also consider immunosuppressive therapy. Antiplatelet agents was discontinued 1 year later in three patients and 2 year later in a patient.

Results

Seven patients had UIA, four of whom became more than 4 years follow up. The mean age was 13.7 (5–20) years with 57.1% women. They have infarction in the basal ganglia or insular cortex. All patients suffered initial worsening stage through 2–7 days. All patients were managed with antiplatelet agents and high dose steroid therapy for 5 days. One patient was received immunosuppressive therapy. Antiplatelet agents were discontinued on a year after onset in 3 patients. There is no recurrence and symptom progression in the 3 patients.

Conclusions

Our experience suggest that discontinuation of antiplatelet agent 1 year later from onset can be safe in patients with childhood UIA.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

LONG-TERM MORTALITY AND RECURRENCE OF STROKE IN YOUNG ADULTS. A POPULATION-BASED STUDY IN ARAGON, SPAIN

H Tejada Meza ¹, J Artal Roy ¹, C Pérez Lázaro ², C Tejero Juste ², M Bestué Cardiel ³, O Alberti Gonzalez ³, L Jarauta Lahoz ⁴, N Hernando Quintana ⁴, Á Giménez Muñoz ⁵, GJ Cruz Velásquez ¹, A Fernández Sanz ¹, M Palacín Larroy ⁶, JR Millán García ⁷, LM Calvo Pérez ⁷, E Muñoz Farjas ⁸, JA Olivan Usieto ⁸, A Latorre Jiménez ¹, J Marta Moreno ¹

Abstract

Background

Aragón is an autonomous community of Spain with 1,325,385 inhabitants in which stroke is the second cause of death. The aim of this study was to ascertain the frequency of risk factors, etiology, long-term prognosis and predictors of unfavourable outcomes of ischemic stroke in young adults.

Methods

All patients aged 18 to 50 years with an ischemic stroke or transient ischemic attack (TIA) who were admitted to any hospital in Aragón (2005–2010) were assessed. Baseline characteristics, subtype, etiology, mortality and recurrence of ischemic stroke in a mean follow-up of 7.4 years were obtained from the electronic health records of the patients. Logistic regression was used to assess the associations between the various factors and risk of recurrent stroke events or death.

Results

In the 431 patients assessed (mean age 42.9 years; 61.7% males), smoking was the most common risk factor for stroke (55%). 35% were lacunar strokes, 35.6% were of undetermined etiology. 23% were TIAs. 10.5% of patients were thrombolyzed. 69.7% had a mRS < 3 at hospital discharge. In the follow-up, mortality was of 11.7% and recurrence 13.6%. Diabetes was the only independent risk factor for recurrence of stroke (p = 0.019). Strokes of rare cause (p = 0.032) and NIHSS < 15 (p = 0.005) were independent predictors of death, while taking antiplatelet agents (APA) was a protective factor (p = 0.01).

Conclusions

Long-term mortality and recurrence of stroke is high in young adults. In our study we found risk factors associated to higher recurrence of stroke events and mortality, being the take of APA a protective factor.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PSYCHOTIC MANIFESTATION IN MULTIPLE CEREBRAL VENOUS SINUS THROMBOSIS AND VASCULITIS ASSOCIATED WITH EXTRAPULMONARY (MEDIASTINAL LYMPH NODES) TUBERCULOSIS

S Tuta ¹, M Manea ², I Coanda ², C Popa ³

Abstract

Background

We present a 37-years old man with multiple cerebral venous sinus thrombosis and diffuse cerebral vasculitis lesions associated with mediastinal lymph nodes tuberculosis.

Methods

Case report. The onset was one year before, in another hospital, with motor partial seizures, but MRI showed a “possible vascular malfomation”. The patient was admitted In our hospital for psychotic behaviour with hallucination. The neurological examination was normal with lack of meningeal signs. After cessation of hallucinations a cognitive impairment was observed with 9/30 points in MOCA test.

Results

A new cerebral MRI revealed possible thrombosis of some major cerebral sinuses but also many multiple demyelinating lesions (infra- and supratentorial) most probable produced by a a small vessel vascultis. A DSA confirmed complete thrombosis of superior sagital, torcular and left lateral venous sinuses and a network of small venous vessels. The biological workup excluded a thrombophilia, antiphospholipid antibody syndrome, autoimmune vasculitis, systemic infections (including Borrelia, HIV or syphilis). A whole body CT scan discovered a posterior mediastinal tumor which after surgical removal and histology examination proved to be a tuberculosis block of lymph nodes. Antituberculosis and anticoagulant therapy was provided. 6 months later a cerebral MRI showed only slight recanalization of occluded venous sinuses but complete disappearance of vasculitis lesions and significant improvement of cognition.

Conclusions

In this young patient a hypercoagulable states and endovascular inflammation associated with complex immune circulation factors produced by tuberculosis are considered responsible for the sinus thrombosis and vasculitis, since the demielinating lesions disappeared in spite of persistent venous stasis.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CHARACTERISTICS OF ISCHEMIC STROKES IN YOUNG WOMEN IN A 10-YEAR PROSPECTIVE SERIES OF 383 PATIENTS

I Zinchenko ¹, V Quenardelle ¹, F Binder ², V Lauer ¹, O Rouyer ¹, N Meyer ², B Geny ³, V Wolff ¹

Abstract

Background

Demographics suggest an anticipated increase of burden of stroke in women due to their higher life expectancy raising the need to recognize and to study sex-specific stroke risk factors and mechanisms in young women.

Methods

We have prospectively included 383 young adults (<45 years) between 2005 and 2015 with an acute ischemic stroke (IS) confirmed by MRI. The patients were investigated by a standardized protocol including biological and toxicological screenings and cardio-vascular check-up.

Results

In this series, 184 patients were females (48%) with mean age of 34.6 ± 6.8 years. Most prevalent risk factors were smoking (45%), oral contraception (45%), migraine (37%), dyslipidemia (35%), hypertension (16%), cannabis use (10%), atrial fibrillation (4%) and diabetes (3%). Eight percent of IS were gravidity or post-partum related. As to the etiologies of IS in women: 25% were cardioembolic, 17% due to intracranial arterial stenosis, 15% due to cervical artery dissection and 5% for each cause due to isolated patent foramen ovale, hematological disease and atherosclerosis. In 27% of cases no etiology was found. The functional outcome at 3 to 6 months was favorable with mRS ≤ 2 in 91% of cases.

Conclusions

Smoking and oral contraception are highly prevalent risk factors for IS especially when they are associated. Pregnancy and post-partum are the periods at risk for women of childbearing age. As to etiology, intracranial arterial stenosis was a second more frequent cause of IS behind cardioembolism, suggesting that this abnormality should me more frequently researched.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

YIELD OF SCREENING TESTS FOR VASCULITIS IN ISCHEMIC STROKE IN YOUNG ADULTS

C Yoon ¹

Abstract

Background

The causes of stroke in young adults are more diverse than in the elderly and require more extensive diagnostic workup including vasculitis panel. However, Little is known about the test’s yield. The aim of this study was to investigate the yield of screening tests for vasculitis in consecutive young patients with ischemic stroke.

Methods

Consecutive patients aged 18 to 45 years with ischemic stroke between January 2011 and September 2015 were included. They all underwent screening tests for vasculitis including rheumatoid factor (RF), antinuclear antibody (ANA), antineutrophil cytoplasmic antibodies (ANCAs), anticardiolipin antibody, lupus anticoagulant, antiphospholipid antibody, anti-DNA antibody, and anti-Ro/SSA and La/SSB antibodies.

Results

Among consecutive 1,560 acute ischemic stroke patients during study period, 103 patients (6.6%) were aged 18–45 years. Vasculitis panel screening results were positive in three patients (2.9%). Two female patients (1.9%) with positive ANA and anti-DNA antibody were finally diagnosed as systemic lupus erythematosus (SLE). They all had clinical symptoms of SLE including malar rash and Raynaud phenomenon. One male patient showed positive anti-Ro/SSA antibody, however, he had no primary symptoms of Sjogren’s syndrome with negative Schirmer's test. Follow up testing resulted in negative finding.

Conclusions

In the absence of systemic symptoms of vasculitis, vasculitis panel screening in young ischemic stroke patients has a low yield. It’s better to consider individual clinical features and cost effectiveness before screening tests for vasculitis in ischemic stroke in young adults.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CLINICAL OUTCOME OF ANTICOAGULANT TREATMENT IN HEAD OR NECK INFECTION ASSOCIATED CEREBRAL VENOUS THROMBOSIS

SM Zuurbier ¹, JM Coutinho ¹, J Stam ¹, P Canhão ², F Barinagarrementeria ³, MG Bousser ⁴, JM Ferro ²

Abstract

Background

Local infections of the head or neck are one of the causes of cerebral venous thrombosis (CVT). Treatment of infectious CVT with heparin is controversial. We examined whether this treatment was associated with intracranial hemorrhagic complications and poor clinical outcome.

Methods

We retrieved data from a prospective cohort study of 624 CVT patients. We compared patients with and without an infection of the head or neck, and anticoagulated versus not anticoagulated. We examined death or dependency, and new intracerebral hemorrhages.

Results

Out of 604 patients, 57 patients had an infection of the head or neck (9.4%). The frequency of therapeutic doses of heparin treatment was similar in both groups (82.5 versus 83.7%). New intracerebral hemorrhages were more common in patients with an infection (12.3 versus 5.3%, p = 0.04) but death or dependency did not differ between patients with and without an infection (15.8 versus 13.7%). In patients with an infection of the head or neck, there was no significant difference in the frequency of new intracerebral hemorrhages and poor outcome between patients who did or did not receive therapeutic doses of heparin.

Conclusions

New intracerebral hemorrhages were more frequent in patients with an infection. The use of therapeutic doses of heparin did not appear to influence the risk of new intracerebral hemorrhages or poor clinical outcome, but the number of patients who did not receive anticoagulation was too small to draw firm conclusions about safety of heparin in adults with CVT and an infection of the head or neck.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PRESENCE OF DIABETES IS ASSOCIATED WITH HIGHER RISK OF EARLY RECURRENCE IN PATIENTS WITH ACUTE STROKE

N Akhtar ¹, S Kamran ¹, A Salam ¹, R Malik ², P Bourke ¹, M Santos ¹, S Joseph ¹, PG Bermejo ¹, D Deleu ¹, A Shuaib ¹

Abstract

Background

Diabetes Mellitus (DM) is an important risk factor for vascular diseases. We report our experience in patients admitted with acute stroke and TIA from the Qatar Stroke Registry (SR).

Methods

Patients presenting with acute ischemic or hemorrhagic stroke and TIAs to Hamad General Hospital (HGH) in Qatar between January 2014 and August 2015 where enrolled in a hospital based SR. Data on ethnicity, clinical presentation, risk factors, hospital course, complications, outcome at discharge and 90 days and recurrent stroke were related to diabetes status.

Results

1,679 patients were enrolled in HGH-SR. Incidence of diabetes was highest in Qataris (68.6%), and non-Qatari Arabs (52.3%), intermediate in South East Asia (45.7%), North Africa (41.3%), Far East Asia (29.6%), and lowest in Caucasians (19%), P = 0.001. Although patients with diabetes were significantly older, had higher rates of HTN, previous strokes and CAD, they had milder strokes (NIHSS 5.7 ± 5.8 versus 6.8 ± 6.7; P = 0.01) and subcortical strokes were more common. Discharge prognosis (mRS 3–6)(DM: 36.5% vs. NDM: 37.6%; P = 0.654) and 90-days outcome (DM: 23.2% vs. NonDM: 24.4%; P = 0.571) were no different between groups. The risk of early stroke recurrence was significantly higher in patients with DM compared to non-DM [28/810(3.5%) versus 6/869 (0.7%); P < 0.001].

Conclusions

There is an alarmingly high incidence of diabtes in patients presenting with stroke in Qatar. However, DM associated stroke is milder, likely due to significantly higher numbers of sub-cortical events. Prognosis at discharge and 90-days was comparable between patients with and without DM, but the risk of early recurrence of stroke was significantly higher.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ANTITHROMBOTIC DRUGS IN SECONDARY PREVENTION AFTER HIGH-RISK TIA OR MINOR ISCHEMIC STROKE: AN OBSERVATIONAL STUDY OF 20,410 PATIENTS IN THE SWEDISH STROKE REGISTER

S Åsberg ¹, B Farahmand ², P Appelros ³, P Hasvold ⁴, S Johansson ⁵, A Terént ¹

Abstract

Background

Secondary prevention with antithrombotic treatment is recommended after transient ischemic attack (TIA) and ischemic stroke (IS). We aimed to compare clinical characteristics and antithrombotic treatment between high-risk TIA (ABCD2 score ≥4) and minor IS (NIHSS score ≤5) populations.

Methods

This observational study included TIA/IS patients discharged alive during 2012–2013. Data regarding TIA/IS, clinical characteristics, and drugs (180 days before and after TIA/stroke) were obtained through record linkages with the Swedish Stroke Register and other national registers.

Results

We identified 20,410 patients with TIA (n = 8675; mean ABCD2 = 4.9) and IS (n = 11,735; mean NIHSS = 1.8). The TIA population had a higher proportion of women (48.9% vs. 44.6%) and hypertension (87.7% vs. 63.4%) than the IS population. Median age (75 years) and other vascular risk factors were similar in both groups; atrial fibrillation (AF) was present in 22%, diabetes in 22%, vascular disease in 16%, previous stroke in 10%, and heart failure in 6% of the patients. Among non-AF patients, antiplatelets were used by 94.7% of the TIA patients (59.7% aspirin, 45.6% clopidogrel, 8.7% dipyridamole) and by 93.5% of the IS patients (58.9% aspirin, 44.2% clopidogrel, 11.1% dipyridamole). Among AF patients, warfarin and novel oral anticoagulants were used by 56.5% and 7.9% of the TIA patients and by 58.6% and 9.6% of the IS patients, respectively.

Conclusions

Besides hypertension and female sex, which were more common among patients with high-risk TIA, there were no major differences in other clinical characteristics or use of antithrombotics in patients after high-risk TIA or minor IS.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CEREBRAL HEMODYNAMICS IN OBESITY

O Ayo-Martín ¹, J García-García ¹, F Hernández-Fernández ¹, T Segura ¹

Abstract

Background

Overweight and obesity are well known risk factors for stroke but little is known about the mechanisms underlying such effect. The objective of this stydy was to evaluate if excess body weight is related to poor cerebral hemodynamics as measured by transcranial Doppler (TCD).

Methods

A cross-sectional prevalence and association study conducted in a group of subjects prospectively and consecutively enrolled, referred from a Nutrition out clinic.

Inclusion criteria were: subjects ≥18 years with body mass index ≥18. Exclusion criteria were cervical or cerebral arteria lesions or another medical conditions which can modify cerebral hemodynamics, like diabetes or previous stroke. Obesity level was determined by waist circumference. TCD studies were performed by the same observer in the right middle cerebral artery (RMCA), to evaluate both, basal (median velocity, Gosling’s pulsatility index) and dynamic (cerebral hemodynamic reserve by carbogen inhalation) parameters.

Results

165 subjects were included with the following basal parameters: men 61%, hypertension 24%, hypercholesterolemia 23%, smoking history 24%. Both, bivariate and multivariate regression showed a linear correlation between waist circunference and hemodynamics in RMCA, with a clear influence of gender: mean velocity (global not significative, men beta −0’26 p < 0’01; women not significative), cerebral hemodynamic reserve (global: beta −0’15 p < 0’01, men: beta −0’29 p < 0’01, women: beta −0’19 p < 0’09). There was no correlation with pulsatility index.

Conclusions

There is a linear and inverse correlation between excess body weight and cerebral hemodynamics in right middle cerebral artery. This relation is independent to other vascular risk factors and is clear influenced by gender.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

MOLECULAR MECHANISM UNDERLYING CEREBRAL HEMODYNAMICS DAMAGE IN OBESITY

O Ayo-Martín ¹, J García-García ¹, F Hernández-Fernández ¹, T Segura ¹

Abstract

Background

In a previous communication we have described a cross-sectional study of prevalence and association showing linear and inverse correlation between excess body weight and cerebral hemodynamics in right middle cerebral artery.

The objective of this study is to evaluate if such relation is mediated by molecules produced in the fatty tissue, which are hemodynamically active in systemic arterial circulation.

Methods

A blood sample was collected in all subjects enrolled in the study previously described, to measure plasma levels of leptin, adiponectin, TNF-α, IL-6, VCAM and CRP. In order to evaluate the roll of such molecules in the relation between waist circumference and cerebral hemodynamic parameters, the plasma levels were included in the multivariate regression models. In case of collinearity, the value of each molecule evaluated would be the residual obtained in a regression model, including waist circumference and the molecule.

Results

There was a high correlation between each molecule and waist circumference with high collinearity values in the regression models. Hence, the molecular values included were the residual. In the multivariate regression models only leptin correlated independently with mean velocity in RMCA (beta 7’24, p < 0’01) and cerebral hemodynamic reserve (beta −0’30, p < 0’01), but in both cases waist circumference remains significantly related with similar values (mean velocity: beta −0’29, cerebral hemodynamic reserve: beta −0’29).

Conclusions

Leptin plays a role in the relation between excess body weight and cerebral hemodynamics. Nevertheless, there must be also another mechanism associated, not identified in this study.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

KNOWLEDGE OF STROKE RISK FACTORS AND STROKE SYMPTOMS IN MEXICAN POPULATION

R Uribe ¹, E Chiquete ², E Villarreal ³, F Barinagarrementeria ⁴

Abstract

Background

Acute stroke is a medical emergency. One of the main challenges in stroke is the early recognition of stroke.Thrombolysis rate in Mexico is lesser than 1%. The purpose of this study was to assess the population knowledge on risk factors and symptoms of stroke.

Methods

This prospective cross-sectional study was performed in an open adult population attending meeting centers of the Mexican city of Queretaro. A standarised-structure questionaire was used. Open questions were used to assess the recognition of tradition risk factors and symptoms of acute stroke. Blood pressure, glucosa, creatinine and colesterol levels were measured.

Results

A total of 1,297 patients were studied (59% women, median age 44 years): Percentage of numbers of symptoms recognised were; 0 (39.6%); 1 (33.8); > 2 (26%). The most frequent recognised risk factors were obesity (52%)%, hypertension (31%) alcohol use (30%), hypercholesterolemia i(26%). Mean systolic and diastolic pressure was 120 (SD 14.7) and 80 (SD 10.9) mmHg respectively. Mean capillary random blood glucosa, colesterol and creatinine was 93 (SD:51.1), 188.3 (SD:187) and 0.82 (SD:0.89) mg/dL respectively. Family history of stroke was declared in 27.2% whereas personal stroke history was found in 5%. The most frequent stroke risk factors recognized was hypertension (39.9%) and hypercholesterolemia (26.1%) Diabetes was recognized just in 18.3%., factors independently associated with recognition of > 2 traditional risk factors are shown Figure 1.

Conclusions

Levels of stroke knowledge among mexican people are low. Majority of people dont recognise stroke symptoms. Educational campaigns could increase the number of patients arrived earlier to hospital

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

REDUCING THE BURDEN OF STROKE USING MOBILE TECHNOLOGY: THE STROKE RISKOMETER APP

R Bhattacharjee ¹, R Krishnamurthi ¹, T Hussein ², M Purohit ³, V Feigin ¹

Abstract

Background

Stroke is the second biggest cause of mortality in the world. However, an estimated 80% of strokes are preventable. The general population is not motivated to control their stroke risk due to a lack of awareness about the risk factors associated with stroke and the unavailability of an easy method of calculating their individual risk.

Methods

The Stroke Riskometer was developed as an easy to use app aimed at addressing these issues. Users can calculate their risk of stroke by answering a series of validated questions. The app provides the user with their risk of stroke, the factors affecting their risk and how to manage them, and their relative risk compared to someone their age and sex with no risk factors. In addition, the app has a research component that allows data collection for the RIBURST study, which aims to determine the prevalence of stroke risk factors on a global level.

Results

To date, the app has had over 25000 downloads and translated versions are currently being tested for release. The RIBURST study has over 1800 consented participants. Data collection commenced in April 2015, and preliminary descriptive analyses of risk factor prevalence collected over the first 12 months of the study will be presented.

Conclusions

The use of the Stroke Riskometer app, combined with its research capability has the potential to reduce the burden of stroke worldwide. The app could also provide a platform for similar products aimed at other non-communicable diseases.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ANGIOGRAPHIC CHARACTERISTICS AND CLINICAL OUTCOMES OF RADIATION-INDUCED CEREBRAL ARTERY STENOSIS COMPARED WITH ATHEROSCLEROTIC LESIONS

Y Cao ^1,², J Xu ¹, J Shi ¹, G Xiao ¹, S You ¹, C Liu ³

Abstract

Background

The exact mechanism by which radiotherapy (RT) induces cerebral artery stenosis remains unclear. We aimed to evaluate the angiographic characteristics of radiation-induced cerebral artery stenosis and the effectiveness of the angioplasty and stenting procedure for this form of stenosis.

Methods

In this retrospective study, 17 patients with cerebral artery stenosis after head and neck radiotherapy (RT group; mean age: 61.53 ± 10.60 years; 15 males, two females) were enrolled, and 35 age- and gender- matched patients without a history of RT were recruited as controls (mean age: 63.97 ± 9.52 years; 31 males, four females). Control patients exhibited atherosclerotic stenosis. The demographic characteristics, risk factors, and angiographic features of the two groups were analyzed. Short-term outcomes following angioplasty were also compared.

Results

The plasma level of fibrinogen was higher in the RT group (p = 0.007). Diabetes mellitus (11.8% vs. 51.4%, p = 0.006) and intracranial artery stenosis were more common in the control group (c2 = 4.028, p = 0.045). The average length of stenosis was significantly longer in the RT group (p = 0.017). In addition, lesions in the anterior circulation and vertebral artery (VA) were longer, and ulcer plaques were more common in the RT group (p = 0.039, p = 0.015, and p < 0.001, respectively).

Conclusions

RT in head and neck affected both the anterior and posterior circulation system. Radiation-induced cerebral artery stenosis was longer and ulcer plaques were more common than atherosclerotic lesions. Furthermore, radiation-induced cerebral artery stenosis may be safely and effectively treated with the angioplasty and stenting procedure in a short-term period.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EFFECTS OF ATORVASTATIN ON THE SERUM LEVELS OF S100B, HMGB1 IN PATIENTS WITH ATHEROSCLEROTIC CEREBRAL INFARCTION

Y Cao ^1,², Y Li ¹, S You ¹, Y Zhang ¹, X Zhang ¹, H Liu ¹, C Liu ³

Abstract

Background

To analyze the clinical efficacy of atorvastatin calcium with different doses and its influence on serum levels of S100B and high-mobility group protein B1 (HMGB1) in atherosclerotic cerebral infarction (ASCI) patients.

Methods

298 patients with atherosclerotic cerebral infarction were enrolled in this study. All patients were randomly assigned to high-dose statin treatment group (atorvastatin 40 mg per day, group A), standard-dose statin treatment group (atorvastatin 20 mg per day, group B), blank group (no statin therapy within 7 days, group C) and control group (group D). Clinical curative effect, blood inflammatory S100B and HMGB1, neurological function defect of the patients (national institutes of health stroke scale, NIHSS) on admission and at 7 day were observed and comparatively analyzed between groups.

Results

The serum levels of S100B in patients with ASCI on admission were significantly higher than normal controls (vs group D: p = 0.006, p < 0.001, p = 0.048). and the levels at 7 day were significantly decreased compared with that on admission in patients from high-dose statin group and standard-dose statin group (p = 0.018, p = 0.057). Conversely, the patients from statin blank group had significantly higher S100B concentrations at 7 day than that on admission (p = 0.034). No significant difference was observed in HMGB1 concentration between cases and normal control (vs group D p > 0.05). NIHSS score differences between admission and that on 7 day in the high-dose statin group were significantly higher than standard-dose statin group and blank group (A vs B, p = 0.01; A vs C, p = 0.015).

Conclusions

Atorvastatin calcium can not only reduce blood lipids levels, but also reduce S100B levels.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE STROKE AND ISCHEMIC HEART DISEASE MORTALITY DISCONNECTION: THE NUMBERS FROM CEARÁ, NORTHEAST BRAZIL

JJF de Carvalho ¹, FO Lima ¹

Abstract

Background

Stroke and ischemic heart disease mortality in Brazil has declining since the 70 s. This has been more pronounced in regions with higher socio-economic status. We investigated the trend of mortality rates from stroke and ischemic heart disease in Ceará, a state with low socio-economic status with 8,530,150 inhabitants in the Northeast of Brazil.

Methods

All death certificates from 2009 until 2013 were evaluated. All ICD-10 codes associated with stroke and ischemic heart disease were analyzed. Only patients 18 years old or older were included.

Results

From January 2009 to December 2013, 220,109 deaths of people ≥18 years were reported (40894, 40818, 44710, 45531 and 48156 deaths, respectively). Subjects who died from stroke (N = 18,624) were 77.3 (±13.0) years old and 50.5% (N = 9,397) males. Subjects who died from ischemic heart disease (N = 18,490) were 72.1 (±14.8) years old and 55.6% (N = 9397) males. A consistent decline in stroke mortality was observed from 2009 to 2013 (9.2%, 8.9%, 8.4%, 8.1% and 7.9%; β = 0.04, p < 0.001) but the coronary heart disease mortality has remained stable over the years studied (8.4%, 8.1%, 8.5%, 8.8% and 8.3%; β = 0.01 p = 0.22).

Conclusions

Stroke remains the deadliest disease in Ceará despite the consistent decline in mortality observed here. Mortality from ischemic heart disease, however, has remained stable during the years investigated. Population based epidemiological studies are necessary to investigate whether stroke incidence has also been declining as well as to clarify the reasons why mortality rates exhibit so different tendency in diseases that share most of the risk factors

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

REVIEWING RISK FACTORS FOR STROKE AMONG INDIVIDUALS WITH INTELLECTUAL DISABILITIES

AF CASEY ¹

Abstract

Background

Stroke remains one of the leading causes of mortality throughout the world. Knowledge of risk factors for stroke as well as possible prevention and rehabilitation strategies are essential. However, little information is available specifically for individuals with intellectual disability despite ever increasing life expectancies. This study reviewed five modifiable risk factors in this population (obesity, diabetes, physical inactivity, depression, diet) with the goal of providing clear intervention strategies moving forward.

Methods

A scoping review design was chosen for this study. A literature search of PubMed and Medline (1995–2015) was carried out to review the presence of modified risk factors in people with various types of intellectual disability. Databases were also searched to reveal any preventative or rehabilitative interventions that have sought to reduce stroke risk among people with intellectual disability

Results

Results from included studies suggest individuals with intellectual disability may be at higher risk for stroke due to high levels of obesity, physical inactivity and poor diet. Little information is available on mental health or diabetes in this population. Only one single-case intervention has targeted secondary stroke reduction risk in individuals with intellectual disability

Conclusions

There are few studies that have discussed stroke risk among individuals with intellectual disability despite the prevalence of certain modifiable risk factors. Researchers need to educate individuals and communities caring for people with intellectual disability on the risks of an unhealthy lifestyle. More interventions are needed to prevent the risk of stroke in this population increasing as life expectancies continue to increase.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PREMORBID TOTAL CHOLESTEROL IS ASSOCIATED WITH LARGE ARTERY AND LACUNAR BUT NOT CARDIOEMBOLIC STROKE SUBTYPES: A POPULATION-BASED CASE CONTROL STUDY

M Crowe ¹, R Wharton ¹, PM Rothwell ²

Abstract

Background

Although hypercholesterolaemia is a well documented risk factor for ischaemic heart disease, studies on the relationship between total cholesterol (TC) and ischaemic stroke are conflicting, possibly due to heterogeneity in association between TC and aetiological ischaemic stroke subtypes.

Methods

We compared premorbid TC measured in primary care in aetiological ischaemic stroke/TIA subtypes (TOAST classification) versus healthy controls (n = 504) in a population-based case:control study (Oxford Vascular Study)

Results

Of all 2204 patients with a first-in-study ischaemic event, premorbid TC was available for analysis on 1652 patients (75%). The median (IQR) time between TC measurement to event was 1.04 (0.4–3.13) years. TC in the event group (5.3+/-1.3 mmol/L) was no greater than the control group (5.5+/-1.1 mmol/L) and did not differ significantly when adjusted for age and sex. However, TC was significantly higher than controls in patients with large artery (5.6+/-1.4/L, OR 1.30, 95%CI 1.12–1.59) and lacunar (5.7+/-1.2 mmol/L OR 1.37, 1.15–1.63) event subtypes, but not significantly different in the cardioembolic subgroup (0.97,0.82–1.16) after adjusting for age, sex, statin use and other risk factors. Similarly, TC was higher in the large artery and lacunar groups when compared directly with the cardioembolic group. Restricting analysis to ischaemic strokes alone resulted in similar findings.

Conclusions

Higher premorbid TC is more common in patients with large artery and lacunar TIA/stroke compared to cardioembolic events.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CHA2DS2-VASC SCORES IN PATIENTS WITH UNDETERMINED STROKE ETIOLOGY AND PRIOR ANTIPLATELET USE

E Ekizoglu ¹, N Yesilot ¹, O Coban ¹, R Tuncay ¹, S Zarko-Bahar ¹

Abstract

Background

The etiology of a substantial number of ischemic strokes (IS) remains undetermined and these patients generally receive single antiplatelet therapy. Although the CHA₂DS₂-VASc score is designed for stroke prediction in atrial fibrillation (AF) patients, it has also been used as a risk factor in the studies investigating paroxysmal AF in cryptogenic stroke (CS).

Methods

We investigated CHA₂DS₂-VASc scores in patients having first ever IS with undetermined etiology while regularly taking antiplatelets and those not taking any antiplatelets, using the prospectively recorded data of the Istanbul Medical School Stroke Registry between 1996 and 2014.

Results

Of the 3586 IS patients, 886 patients with first ever IS had complete data for CHA₂DS₂-VASc score calculation. In 75 (39 women) of them, etiology of stroke remained undetermined despite adequate etiological investigations. CHA₂DS₂-VASc scores were significantly higher in 19 patients having IS while using antiplatelet therapy (mean ± SD: 5.37 ± 1.12) in comparison to 56 patients without antiplatelet therapy (mean ± SD: 4.61 ± 1.27) (p = 0.018). Among the individual items of CHA₂DS₂-VASc, the presence of vascular diseases was more frequent in patients taking regular antiplatelet drugs and they were older than those without antiplatelet therapy (p = 0.025, p = 0.024; respectively).

Conclusions

CHA₂DS₂-VASc score and the history of vascular diseases may be taken into account in stroke patients with undetermined etiology to assess the risk of recurrent stroke in this heterogenous group. It may also be suggested to give CS patients dual antiplatelet or anticoagulant therapy until more detailed cardiac investigations are done.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

SEARCHING FOR NEW RISK FACTORS OF HEMORRHAGIC TRANSFORMATION AFTER ISCHEMIC STROKE

D Filimonov ¹, S Evtushenko ¹, I Evtushenko ¹

Abstract

Background

Previous studies established the basic risks factors of hemorrhagic transformation (HT) of ischemic stroke, such as hypertension, hyperglycemia, massive infarct, high NIHSS scores and others. However, the role of others potential HT risk factors remains unknown.

Methods

During 2010–2015 180 patients aged 35–76 years (women - 72, men - 108) with acute ischemic stroke were enrolled in the study. Patients received antiplatelet and anticoagulation therapy according to international protocols. Multivariate regression analysis was used to evaluate influence of risk factors on the development of HT.

Results

HT was diagnosed in 52 (29%) patients. In 19 (11%) patients HT was revealed during admission, in 13 (7.2%) patients HT developed in 3–7 days, and 20 (11.1%) patient had asymptomatic HT. In most cases HT occurred after cardioembolic stroke. Predictors of HT were hs-CRP >3 mg/L (OR = 1.97; 95% CI 1.12–3.94), macro- and microalbuminuria (OR = 3.16; 95% CI 2.65–5.72), hyperhomocysteinemia >17 mkmol/L (OR = 2.87; 95% CI = 1.82–7.14), total cholesterol <3 mmol/L (OR = 3,07; 95% CI 2.71–5.19), lactate-pyruvate ratio >40 (OR = 1.42; 95% CI = 1.12–2.28), positive D-dimer (OR = 2.56; 95% CI 1.45–4.12). The highest risk of HT was in patients who had combinations of hyperhomocysteinemia with albuminuria, positive D-dimer, high hs-CRP. Patients with symptomatic HT comparable to non-HT had higher fibrinogen levels, TNF-alpha, leukocyte count, and lower antithrombin-III, ADP-platelet aggregation and low-density lipoprotein.

Conclusions

Evaluation and possible therapeutic correction of potential HT risk factors is required not only during ischemic stroke anticoagulation therapy, but also in its primary and secondary prevention.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

RISK FACTORS AND CHARACTERISTICS OF THE ULCERATED CAROTID PLAQUE

L Fisch ¹, D Niry ², A Cheng ¹, R Jäger ², B Martin M ¹

Abstract

Background

Ulcers are considered as one of the high-risk components of the carotid plaque occurring in 14 to 68% of all stenosis. This study aims to determine cardiovascular risk factors and characteristics of symptomatic ulcerated carotid stenosis.

Methods

We retrospectively selected 100 consecutive patients with a carotid stenosis visualized on both CT and MR angiography after a stroke or a TIA. A radiologist and a neurologist assessed all arteries on both imaging independently. We compared three plaque surface types (smooth, irregular and ulcer) in terms of risk factors, plaque length and degree of stenosis.

Results

44, 31 and 25 patients were included in the smooth, irregular and ulcer groups respectively. Males were predominant in the ulcer group (23 vs 19 in the smooth group, p = 0.003). High blood pressure and cholesterol were predominant in the ulcer group compared to the smooth group (80% vs 55%, p = 0.03; 69% vs 34%, p = 0.007; respectively). Others cardiovascular risk factors and the degree of stenosis were equally distributed in groups. Average length of the plaque was 25 mm on CT and 23 mm on MR in the ulcerated group compared to 21 mm and 16 mm in the smooth group, respectively (p = 0.018 and p < 0.001 respectively).

Conclusions

Ulcerated plaques are found in male patients with high blood pressure and hypercholesterolemia. Development of ulcers is correlated with the length of the plaque but not with the degree of stenosis.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PROGRESSIVE COCAINE-INDUCED AND HYPERTENSIVE LEUKOENCEPHALOPATHY IN SERIAL BRAIN-MRIS IN A 42-YEAR OLD MALE

J Fladt ¹, GM De Marchis ¹

Abstract

Background

Cocaine abuse is well known to be associated with symptomatic acute ischemic and hemorrhagic stroke. The association between chronic cocaine abuse, leukoencephalopathy, and asymptomatic lacunar strokes has received less attention.

Methods

Case report from Basel University Hospital Neurology and Stroke Center

Results

A 42 year-old male cocaine abuser suffered from a segmental renal infarction. Work-up revealed a severe chronic arterial hypertension with hypertensive retinopathy with papilledema, and a hypertensive cardiopathy, and a antihypertensive treatment was started. Over the following months, he developed a chronic headache for 6 weeks without neurological deficits. The first brain MRI showed multiple bi-hemispheric focal white matter changes frontoparietal and occipital without gadolinium enhancement. He kept consuming cocaine. Six weeks later, a brain MRI was repeated. It showed three new subacute lacunar lesions on Diffusion Weighted Imaging/apparent diffusion coefficient in the left putamen, the left interne capsule und right pons. The cerebral lesions were not associated with neurological symptoms. A serologic vasculitis screening, as well as a HIV-test was negative. A lumbar puncture did not reveal inflammatory or other causes for the MRI changes. The headache disappeared after work leave, without further treatment. In summary, we diagnosed a leukoencephalopathy due to chronic arterial hypertension and chronic cocaine abuse. While arterial hypertension was well controlled, cocaine consume persisted. The new subacute lacunar lesions observed in the follow-up brain MRI were linked, at least chronologically, to the ongoing cocaine abuse.

Conclusions

This case-report illustrates the association between chronic cocaine abuse, leukoencephalopathy and lacunar stroke as confirmed in subsequent brain MRI.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

IMPACT OF HYPERTENSION IN CEREBROVASCULAR DISEASE IN PARAGUAY. A DESCRIPTIVE STUDY

A Flores ¹, L Seró ¹, C Otto ¹, F Riquelme ¹, R Mernes ¹, S Reyhani ², G Godoy ¹, M Morel ¹, J Cortti ¹

Abstract

Background

Hypertension is one of the most important vascular risk factors associated with cerebro vascular disease. Despite cerebrovascular disease is the second cause of mortality in Paraguay, information about associations of hypertension and others risk factors with stroke in our population is unknown. Our aim was to determine the impact of hypertension and other common risk factors on stroke in our population.

Methods

This is a descriptive, observational, single center study. Data was collected from a prospective registry of patients with stroke admitted to the stroke unit in Paraguay, from April to December 2015.

Results

From 152 patients, 106(69.7%) were ischemic strokes and 46(30.3%) intracerebral hemorrhage(ICH). Patients with ischemic stroke were older and more frequently presented diabetes mellitus , atrial fibrillation, prior antiplatelet treatment, and lower systolic blood pressure at baseline than ICH patients. Hypertension was highly prevalent in both, ischemic(80.2%) and hemorrhagic(82.6%), being hypertensive microangiophathy 69% of the causes of ICH.

Multivariate analysis adjusted for sex, hypertension, diabetes mellitus, prior stroke, and atrial fibrillation showed that lower age(OR0.866, 95%CI 0.793–946) and higher SBP(OR1.098 95%,CI 1.044–1.155) were independently associated with ICH.

Conclusions

In our population, stroke patients are younger and ICH is more frequent than rates observed in prior descriptive series in developed countries. Prevalence of hypertension is remarkably higher than other descriptive studies. These findings could be explained by ethnical and environment differences. Intensive public health programs focused on risk factors control, especially hypertension, are needed for prevent cerebrovascular disease.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ANOMALOUS EQUIVALENT POTENTIAL TEMPERATURE (AEPT): IS THIS ATMOSPHERIC FEATURE PREDICTING DAYS WITH HIGHER RISK FOR ACUTE ISCHEMIC STROKE?

A Folyovich ¹, D Biczó ², N Al-Muhanna ³, KA Béres-Molnár ³, Á Fejős ⁴, Á Pintér ⁵, D Bereczki ⁶, A Fischer ⁴, J Gimesi-Országh ⁷, F Pintér ⁴

Abstract

Background

Acute ischemic stroke (AIS) is related to some risk factors affected by forecastable climatic changes. In previous study we proved three times higher mortality because of acute ischemic stroke (AIS) on days with AEPT.

Methods

We analyzed the number of thrombolysis treatment (TT) of AIS in the central region of Hungary during the winter months of 2009. Because of the narrow therapeutic window, TT allows exact determination of the onset of AIS. Anonymous data were downloaded from the database of the NHIF. Of the meteorological parameters EPT has been chosen for analysis. EPT is generally used for forecasting thunderstorms and suitable for characterizing the air mass inflowing from different regions. EPT values were compared to the climatic (30 years) averages. The human meteorologists were only aware of patients’ age, gender and exact time of TT-s. Attention was paid to the last days of the months, because these periods seem to have more socio-cultural effects on AIS in Hungary than biological factors.

Results

114 patients had TT in the studied period. The number of days with AEPT was 48,5 of total 90. The number of TT-s were equal (57–57) during the normal and anomalous EPT periods. The daily average of TT-s were higher on normal EPT periods (1,37 vs 1,18), but opposite if the last days of months were not calculated (0,91 vs. 0,99).

Conclusions

AEPT’s periods seem to be a risk for AIS, but the influence of socio-cultural effects are more remarkable then the meteorological factors.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

STROKE CHARACTERISTICS IN PRE-DIABETIC, DIABETIC AND NON-DIABETIC PATIENTS

R García Ruiz ¹, J Silva Fernández ², R García Ruiz ³, M Recio Bermejo ¹, P Del Saz Saucedo ¹, Á Mateu Mateu ¹, AM Gonzalez Manero ¹, E Botia Paniagua ¹, J Abellán Alemán ⁴

Abstract

Background

To describe the clinical characteristics of stroke in patients with prediabetes mellitus (pre-DM) and to compare them with DM and non-DM patients.

Methods

Retrospective analysis of a prospective series of acute stroke patients. Demographic and clinical characteristics were compared among the three groups, along with outcome data. Stroke severity was evaluated by modified Rankin scale (mRS) and NIHSS (NIH stroke scale).

Results

138 patients (50 non-DM, 32 pre-DM (23%), and 56 DM). Median age was 74.5 ± 15.35, 73.38 ± 13.20, and 73.84 ± 11.44 years respectively. 44% of non-DM, 53.1% of pre-DM and 58.9% of DM patients were men. The prevalence of other vascular risk factors in non-DM, pre-DM, and DM patients was: hypertension (46, 71, and 89%, **P < 0.05), hypercholesterolemia (42, 65, and 69%, *P < 0.05), smoking habit (14, 15,6 and 7,5%) and atrial fibrillation (6, 15.6, and 16%). Prevalence of ischemic stroke (IS) was 88% in non-DM patients, 84.3% in pre-DM and 94.6% in DM patients (P 0.24). Transient ischemic attack was more common in non-DM patients (36.3% of IS vs 33.3% in pre-DM and 20.7% in DM patients) (P 0.28). There were no differences in stroke severity (4.9 ± 6.2; 4.5 ± 6; and 4.9 ± 5.4 NIHSS median points each group), 3-month mortality (12, 12.5, and 7.1%) 3-month mRS (2.18 ± 2.21; 1.81 ± 2.2; and 1.96 ± 1.92) nor rtPA success rate. P (all groups), *P (non-DM/pre-DM patients), and **P (pre-DM/DM patients).

Conclusions

Frequency of pre-DM is higher than observed in general population (10%). Pre-DM patients occupy an intermediate situation regarding vascular risk factors but has no impact on stroke outcomes in our series.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

AGE-SPECIFIC VASCULAR RISK PROFILES ACCORDING TO STROKE SUBTYPE: A DUTCH PROSPECTIVE MULTICENTER COHORT STUDY

A Hauer ¹, Y Ruigrok ¹, A Algra ^1,², J Kappelle ¹, C Klijn ³

Abstract

Background

Ischemic and hemorrhagic stroke are increasingly recognized as heterogeneous diseases with distinct subtypes and etiologies. Information on variation in distribution of vascular risk factors according to age in stroke subtypes is limited. We investigated the prevalence of vascular risk factors in stroke subtypes in relation to age.

Methods

We studied a prospective multicenter university hospital-based cohort of 4033 patients. For patients with ischemic stroke (IS) caused by large vessel atherosclerosis, small vessel atherosclerosis, or cardioembolism and for patients with spontaneous intracerebral hemorrhage (sICH) or aneurysmal subarachnoid hemorrhage (aSAH), we calculated prevalences of vascular risk factors in four age groups: < 55, 55–65, 65–75 and ≥75 years, and mean differences with 95% confidence intervals in relation to the reference age group.

Results

Patients aged <55 years were significantly more often of non-Caucasian origin (in particular in sICH and aSAH) and most often smoked (in particular aSAH patients). Patients aged <55 years with IS caused by large or small vessel atherosclerosis more often had hypertension, hyperlipidemia and diabetes mellitus than patients with IS of cardiac origin. Overall, the frequency of hypertension, hyperlipidemia, and diabetes mellitus increased with age among all stroke subtypes, whereas smoking decreased with age. Regardless of age, accumulation of potentially modifiable risk factors was most pronounced in patients with IS due to large or small vessel atherosclerosis.

Conclusions

The prevalence of common cardiovascular risk factors shows different age-specific patterns among various stroke subtypes. Recognition of these patterns may guide tailored primary and secondary stroke prevention efforts.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CRYPTOGENIC AND LARGE ARTERY ATHEROSCLEROSIS STROKE SHOW SIMILAR SYSTEMIC INFLAMMATORY BIOMARKER PATTERNS

L Holmegaard ¹, U Andreasson ², H Zetterberg ^2,³, K Blennow ², C Blomstrand ¹, K Jood ¹, C Jern ⁴

Abstract

Background

The cause of ischemic stroke remains unknown in approximately 20% of cases. Inflammation has a pathophysiological role in atherosclerosis, and thus in large artery atherosclerosis (LAA) stroke. Inflammation may play a role also in cryptogenic stroke. We therefore sought to compare inflammatory biomarkers patterns in LAA and cryptogenic stroke.

Methods

We examined participants in the Sahlgrenska Academy Study on Ischemic Stroke (mean age 54 years) with LAA (N = 73) or cryptogenic stroke (N = 162) and their matched controls (N = 235). Blood was drawn once in controls, and in the acute phase and 3 months after index stroke in cases. Plasma levels of 25 cytokines and chemokines were analyzed using the Luminex microbead-based system. Their discriminating properties were analyzed with multivariate orthogonal projections to latent structures discriminant analysis (OPLS-DA).

Results

For most biomarkers, levels and/or proportion of samples with values above the detection limit were higher in cases compared to controls for both subtypes at both time points. OPLS-DA revealed good discrimination between cases and controls with area under the curve (AUC) in receiver operating characteristics graphs of >0.8. RANTES, IL-4, and IFN-γ contributed the most to this separation for both subtypes at both time points. In contrast, OPLS-DA poorly separated the two stroke subtypes (AUC = 0.6 both time points).

Conclusions

Plasma levels of inflammatory biomarkers separated patients with ischemic stroke from controls with the highest discriminatory values for RANTES, IL-4, and IFN-γ, but did not discriminate LAA and cryptogenic stroke. These results support the hypothesis that inflammation plays a role in cryptogenic stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PREVALENCE OF SLEEP APNEA AMONG THE ISCHEMIC STROKE PATIENTS

J Huhtakangas ¹, T Saaresranta ², J Huhtakangas ³

Abstract

Background

The aim was to study the prevalence of obstructive sleep apnea (OSA) among the ischemic stroke patients. To find out if stroke patients with thrombolysis had less frequently or less severe OSA than controls.

Methods

We enrolled 246 compliant ischemic stroke patients to the study. Cardiorespiratory sleep study with ApneaLink (Resmed, Sydney) was done during 48 hours after symptom onset of ischemic stroke.

Results

We obtained sleep recordings of 231 patients. 119 (64% men) patients had thrombolysis and 112 (59%) did not. Mean BMI in both study groups was 27. Groups were equal concerning gender and BMI. Mean age was 65.6 years in the thrombolysis group and 69.4 years in controls (p < 0.035). Mean NIHSS score in the thrombolysis group was higher (7) than that of the controls (4), p < 0.001. Of patients 172 (74.5%) had OSA defined as apnea-hypopnea index (AHI) of ≥5/h. OSA prevalence was 78.2% vs. 70.5% in the thrombolysis and the control group, respectively, and did not differ between the groups. Mean baseline AHI was 18/h in the thrombolysis group and 16/h in the control group. OSA was mild in 45 (59.2%) vs. 31 (40.8%) , moderate in 21 (45.7%) vs. 25 (54.3%), and severe in 27 (54%) vs. 23 (46%) in the thrombolysis and the control groups, respectively. No significant differences were observed in sleep apnea severity between the groups.

Conclusions

In this study 75% of ischemic stroke patients had OSA. No significant differences were observed in sleep apnea prevalence or severity between the groups.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

MIDNOR TIA - A PROSPECTIVE COHORT STUDY OF 578 PATIENTS WITH TRANSIENT ISCHEMIC ATTACK IN CENTRAL NORWAY, PRELIMINARY RESULTS

F Ildstad ¹, B Indredavik ¹, E Hanne ¹, F Hild ²

Abstract

Background

Transient ischemic attack (TIA) is a predictor of stroke. The primary aim of this study was to investigate stroke risk after TIA in short (1 week) and long term (3 months, 1 year). Secondary aims were to assess the ability of ABCD2 score to predict stroke risk, identify risk factors in TIA patients and estimate the incidence of other vascular events after TIA.

Methods

A prospective, multicenter cohort study conducted from October 2012 until June 2015 at 8 hospitals in Central Norway. Patients with probable or possible TIA admitted to one of the participating hospitals were included and screened for risk factors by clinical examination, imaging, blood samples and questionnaires. Vascular events during 1-year follow-up were achieved from medical quality registers and administrative health registers. Kaplan-Meier analysis, log-rank test and c-statistics were used in the final analyses.

Results

578 patients (mean age 70,6 years) were included, 413 (71,6%) with a probable and 164 (28,4%) with a possible TIA. The number of patients suffering an ischemic stroke after 1 week, 3 months and 1 year were 5 (0,9%), 19 (3,3%) and 31 (5,4%), respectively. Mean ABCD2 scores were 4,6 for those who suffered an ischemic stroke and 3,9 for those free from stroke during follow-up.

Conclusions

Baseline data of our study are comparable with data from similar studies, while preliminary results showed a fairly low incidence of ischemic stroke during the first year. Endpoint data are now being thoroughly analysed, and the final results will be presented at the conference.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ADEQUACY OF RISK FACTOR CONTROL TEN YEARS AFTER STROKE: LUND STROKE REGISTER

AC Jönsson ¹, B Norrving ¹, A Lindgren ¹

Abstract

Background

The aim was to examine the control of major risk factors in survivors ten years after stroke.

Methods

A one-year population of 416 first-ever stroke patients in Lund Stroke Register, were registered 2001–2002. Ten years after stroke, all 145 (35%) survivors, median age 78.1 range 28–97 years at follow-up, were examined regarding four main risk factors; hypertension, diabetes, smoking and atrial fibrillation.

Results

Ten years after stroke, 118 (81%) of the 145 patients had been diagnosed with hypertension, but 58 (49%) of them had not reached the target blood pressure (BP) ≤139/89. Among 27 (19%) participants without hypertension diagnosis, 12 (44%) had a BP above target. Diabetes was diagnosed in 33 (23%) of 141 patients (4 HbA1c missing), 18 (54.5%) of these had not reached the target HbA1c <52 mmol/mol. Among the 112 (77%) with no diabetes diagnosis, 19 (18%) had HbA1c 42–55 mmol/mol indicating need for further investigation. Current smokers were only 14 (9.5%), 65 (45%) had never smoked, 52 (36%) had ceased smoking before stroke and 14 (9.5%) after stroke. Among 126 participants with CI, 37 (29%) had atrial fibrillation, and 5 of these were not treated with warfarin.

Conclusions

About half of the patients with hypertension diagnosis ten years after stroke had not reached the target blood pressure and about a fourth had unsatisfactory blood glucose levels. This indicates a need for careful long-term follow-up of stroke survivors.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

SYSTEMIC LUPUS ERYTHEMATOSUS AS A RISK-FACTOR OF AN ACUTE ISCHEMIC STROKE

N Khizanishvili ¹, N Kvirkvelia ², M Beridze ³, T Kherkheulidze ³

Abstract

Background

Systemic lupus erythematosus (SLE) is an autoimmune disease with possible cause of inflammation. The aim was to reveal correlation between: 1) change of concentration of anti-nuclear antibodies (ANA) and degree of inflammation and 2) risk of development of acute ischemic stroke.

Methods

Totally 52 SLE patients with acute ischemic stroke (AIS) investigated: 34 females and 18 males. Examinations performed: Neurological as well as rheumatologic examination, Brain contrast MRI (1.5 tesla), and laboratory tests: fool blood count (FBC) and ANA in serum.

Results

NIHSS score was 5–30, brain contrast MRI showed multiple small size lesion in cortical and subcortical areas. Leukocytosis was detected in all patients. There was a positive result for ANA in serum. The results of leukocytosis and ANA were in correlation with a degree of inflammation and NIHSS scale. Statistical analysis performed by SPSS 11.0.

Conclusions

The level of leukocytosis and increase of ANA are in correlation with increased risk for development of an acute stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

HEMORHEOLOGICAL ALTERATIONS IN CAROTID ARTERY STENOSIS

C Lovig ¹, K Tótsimon ², A Nagy ³, B Sándor ², K Bíró ², Á Csathó ³, K Tóth ², Z Márton ², P Kenyeres ², L Szapáry ¹, P Csécsei ¹, E Lovadi ¹

Abstract

Background

Carotid artery stenosis (CAS) is not only an important risk factor of cerebrovascular events but it can also indicate generalized atherosclerosis. Hemorheological parameters are altered in CAS and in chronic cerebrovascular disorders as well, but it is controversial if hemorheological parameters could be markers of stenosis or atherosclerosis.

Methods

107 patients were investigated, 40% of them had stroke or TIA in case history and 48% had CAS. Routine lab parameters were determined and hemorheological variables were measured: hematocrit, plasma viscosity, whole blood viscosity, red blood cell aggregation, and deformability.

Results

In the stenotic group whole blood viscosity and red blood cell aggregation were deteriorated (p < 0.05). Whole blood and plasma viscosity were higher and red blood cell deformability was lower in the symptomatic group (p < 0.05). Plasma viscosity and red blood cell deformability were altered in the evolving atherosclerosis group and the CAS groups compared to patients having no signs of stenosis (p < 0.05), but there was no difference among the CAS groups.

Conclusions

Although hemorheological parameters are impaired both in CAS and chronic cerebrovascular disorders, the severity of stenosis cannot be detected based on hemorheological parameters. Our investigation suggests that alteration of hemorheological parameters could indicate carotid atherosclerosis.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE POSSIBLE ROLE OF THROMBOPHILIC SINGLE NUCLEOTIDE POLYMORPHISMS AS A RISK FACTOR FOR ACUTE ISCHEMIC STROKE IN TODDLERS

O Lvova ¹, D Baranov ², V Gusev ³

Abstract

Background

Inherited thrombophilia is described as a risk factor for acute ischemic stroke (AIS) in children. But single nucleotide polymorphisms (SNPs) are not investigated thoroughly especially in early life period.

Methods

Type of study: case-control. Inclusion criteria: 35 children with AIS’s debut under the age 3 y.o. confirmed by brain CT(MRI) scan (1st group); 71 full-term neonates without thrombotic episodes during first three years of life (2nd group); slavic origin; informed consent form. We identified 10 SNPs of thrombophilia and folic acid cycle’s enzymes in blood samples by polymerase chain reaction.

Results

All children had the significant number of thrombophilic SNPs in homozygous or heterozygous state 5,2+/-1 (1st group) versus 4,8+/-1 (2nd group) (p = 0,9). We found FGB:G-455A 29vs19 (OR = 1,7, 95% CI 0,8–4,0; p = 0,14); F2: G20210A 2vs4 (OR = 1,0, 95% CI 0,2–6,1; p = 0,65); F5: G1691A 1vs7 (OR = 0,3, 95% CI 0,03–2,4; p = 0,96); the ITGA2: C807T 30vs41 (OR = 4,7, 95% CI 1,5–12,9; p = 0,003); ITGB3: T1565C 13vs30 (OR = 0,8, 95% CI 0,3–1,9; p = 0,76); PAI-1:-675(5G4G) polymorphism 29vs52 (OR = 1,8, 95% CI 0,6–5,0; p = 0,2). We identified SNPs of folic acid enzymes: MTHFR:C677T 17vs37 (p = 0,71); MTHFR:A1298C 20vs17 (OR = 4,2, 95% CI 1,8–10,2; p < 0,001); MTR:A2756G 14vs14 (OR = 2,7, 95% CI 1,1–6,8; p = 0,03); MTRR:A66G 25vs29 (OR = 3,6, 95% CI 1,5–8,8; p = 0,003).

Conclusions

The number of thrombophilic SNPs and incident of the most severe (F2: G20210A, F5: G1691A, MTHFR:C677T) did not differ significantly in this age. The carrier state of ITGA2: C807T, MTHFR:A1298C, MTR:A2756G, MTRR:A66G increased the chance of AIS in toddlers twice and more. Stroke in toddlers remains multifactorial disease but thrombophilia can play the role of the “the last straw”

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THROMBOPHILIC GENES’ COMBINATIONS AS THE RISK FACTORS FOR PAEDIATRIC TRANSIENT ISCHEMIC ATTACK

O Lvova ¹, V Gusev ², E Orlova ³, M Lukashuk ⁴

Abstract

Background

The exact role of prothrombotic single nucleotide polymorphisms (SNPs) and their combinations in children with transient ischemic attacks (TIA) is not established clearly

Methods

Case-control study: 52 patients were compared with 117 controls. 12 single nucleotide polymorphisms (SNPs) in blood coagulation and folic acid cycle’s enzymes genes were identified. Inclusion criteria: TIA’s debut under 18 y.o.; slavic origin; no changes on brain CT (MRI) and spinal tap.

Results

The quantity analyses showed that only 3 and more folic acid enzymes’ SNPs differed in TIA patients (20 vs 19, p < 0,05). The incident of F2: G20210A, F5: G1691A, MTHFR:C677T didn’t differ in those groups (OR < 1, p > 0,05).

We compared more than 25 SNPs’ combinations (table).

Conclusions

The number of thrombophilic SNPs and incident of the most severe (F2: G20210A, F5: G1691A, MTHFR: C677T) don’t play the important role in TIA’s patients in childhood. The carriers of 3 SNPs’ in folic acid cycle’s enzymes genes as well as persons who carry FGB:-455G>A, PAI-1:-675 5G > 4G and “sticky platelet” SNPs consider to be the candidates for paediatric TIA with high probability.

Gene’s combination	TIA, n = 52	Control, n = 117	OR	CI, 95%	Fisher
FGB:-455G > A + PAI-1:-675 5G > 4G	16	27	1,57	0,74-3,32	0,155
FGB:-455G > A + ITGB3:1565T > C	5	15	0,76	0,25-2,25	0,78
FGB:-455G > A + ITGA2:807C > T	14	12	3,40	1,42-8,18	0,005
FGB:-455G > A + ITGA2:807C > T + PAI-1:-675 5G > 4G	12	5	7,07	2,29-21,87	0,0003
FGB:-455G > A + ITGB3:1565T > C + PAI-1:-675 5G > 4G	5	11	1,07	0,34-3,33	0,553
FGB:-455G > A + ITGA2:807C > T + ITGB3:1565T > C + PAI-1:-675 5G > 4G	5	3	4,22	0,94-18,97	0,053
FGB:-455G > A + ITGA2:807C > T + ITGB3:1565T > C + PAI-1:-6755G > 4G + MTHFR:677С > Т	4	2	5,00	0,85-29,26	0,066
FGB:-455G > A + ITGA2:807C > T + ITGB3:1565T > C + PAI-1:-675 5G > 4G + MTR2756 А > G	2	4	1,18	0,20-6,88	0,582
FGB:-455G > A + ITGA2:807C > T + ITGB3:1565T > C + PAI-1:-675 5G > 4G + MTHFR:677С > Т + MTHFR:1298А > С	3	3	2,43	0,46-12,88	0,252
FGB:-455G > A + ITGA2:807C > T + ITGB3:1565T > C + PAI-1:-675 5G > 4G + MTHFR:677С > Т + MTHFR:1298А > С + MTR2756А > G + MTRR:66 А > G	1	1	2,37	0,14-40,88	0,51

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Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

INFECTIVE ENDOCARDITIS AND STROKE: EXPERIENCE OF A MULTIDISCIPLINARY APPROACH

O Maisterra ¹, M Quintana ¹, N Fernández Hidalgo ², P Tornos ³, MN Pizzi ⁴, T González Alujas ³, M Galiñanes ⁵, B Almirante ², J Álvarez Sabín ¹

Abstract

Background

We aimed to study stroke frequency and characteristics in patients with infective endocarditis (IE) from 2000 until December 2015 and analyze whether protocolized neurologists' evaluation influence their outcome.

Methods

We analized clinical data, treatment and prognosis of 146 patients with IE and stroke comparing the period between 2000 and 2012 with the incorporation of a stroke neurologist in the EI hospital committee (from 2013 until December 2015).

Results

Between 2000 and 2012, 18.4% patients with IE suffered a stroke. From 2013 to December 2015, 18.1% did. In both groups median age was similar (64 vs 63), most were male patients (75.2% vs 70.7; p = 0.577) and the most frequent causal agent was S. aureus (32,4% vs22%; p = 0.214). Incidence of ischemic stroke (57.7% vs 82.9%; p = 0.004) was higher than cerebral haemorrhage (26.9% vs 29.3%; p = 0.776). The majority were native valve IE, although from 2013, number of affected prosthetic valves has increased (21% vs 48.8%; p = 0.001). In both periods, nearly same number of patients required cardiac surgery (42.9% vs 53.7%;p = 0.239) and were with anticoagulants (30.9% vs 42.1%; p = 0.208). There was less mortality (48.6% vs 20.5%;p = 0.002) in the second group, even though number of patients with mRS ≥ 3 remained similar (35.1% vs 36.8%;p = 0.850).

Conclusions

Neurologist participation in the multidisciplinar IE group has resulted in less mortality in patients with IE and stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EARLOBE CREASE AS MARKER OF CAROTID WALL CHANGES

L Martínez-Rodríguez ¹, C García-Cabo ¹, L Benavente ¹, P Martínez-Camblor ², N Riesco ¹, A García-Rua ¹, A Pérez ¹, P Suárez-Santos ¹, S Calleja ¹

Abstract

Background

Earlobe crease (ELC) is a diagonal wrinkle in the lobule portion of the pinna. Several studies have confirmed that ELC is associated with vascular disease. Although in ischemic stroke patients (ISP) ELC has been correlated to an increased carotid intima-media thickness (IMT), the phisiophatological connection in ISP is not well known yet. The aim of this study was to examine the association between ELC and carotid wall changes.

Methods

ISP who were admitted in a Comprehensive Stroke Center during four months were included in an observational study. Carotid ultrasonography (CUS) was performed in all of them. ELC presence, TOAST classification of stroke, IMT and number of carotid plaques were collected. The relationship between IMT and ELC was measure by means of average-to-average, and the relationship between carotid plaques and ELC by means of a contingency table.

Results

Eighty five patients were included, 75,3% of them had ELC. Internal carotid artery IMT was significantly increased (p = 0,019 for right ECL and 0,014 for left ECL) and more atherosclerotic plaques were found in those patients with ECL (p = 0.096 for right ECL and 0,1 for left ECL). The incidence of ECL was higher (90.9%) in patients with atherothrombotic stroke, according to TOAST. However, other etiologies weren´t related to the presence of ECL. These associations were stronger in patients with bilateral ECL (p = 0,036 and 0.096).

Conclusions

ELC has been previously demonstrated as a marker of stroke. This study showed that ELC could also be associated with the severity of cerebrovascular disease and atherosclerosis and therefore with atherosclerotic stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

FEATURE OF STROKE IN ENVIRONMENTALLY HARSH TO ARAL SEA

R Matmurodov ¹, I Kilichev ¹

Abstract

Background

Cerebral stroke is the leading cause of disability dependent, which entails a huge economic cost and imposes social obligations to society and the family members of the patient. In Uzbekistan annually more than 40 thousand people for the first time ill stroke.

Methods

To solve this problem we have analyzed the case histories of 253 patients with brain stroke, the case of inpatient treatment in the Khorezm branch hospital of the republik of Uzbekistan. Of these, 148 were men (58.5%) women - 105 (41.5%). The average age of patients was 57,3 ± 2,3 years (men-56,7 ± 1,6 and women-58,2 ± 2,1)

Results

The highest number of patients were aged between 60 and 74 years (43.4%) and 45 to 59 years (40%) patients of working age (20 to 59 years old) accounted for 52.6% y men often cerebral strokes observed between the ages of 45 and 59 years (43.5%), and of working age (59 years) accounted for 55.9% y the majority of patients were women aged 60 to 74 years (46.8%) and prevailed the number of patients older than 60 - years of age - 52.6%. The main cause of cerebral stroke are hypertension - 58%, and the rest were atherosclerosis of cerebral vessels - 15.2%, in combination with atherosclerosis, hypertension - 15.8%, rheumatism, cerebral vascular aneurysms, diabetes and so on. - 11.0%.

Conclusions

Stroke in the Aral Sea region are characterized by a predominance of patients of working age and the main causes of all forms of cerebral stroke is hypertension.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EFFECT OF CIGARETTE SMOKING ON HEMATOMA EXPANSION AND 3-MONTH OUTCOME PATIENTS WITH INTRACEREBRAL HEMORRHAGE

AL Georgiadis ¹, S Majidi ², S Sivakumar ³, MS Miran ⁴, T Steiner ⁵, AI Qureshi On behalf of the, VISTA-ICH collaboration ⁴

Abstract

Background

Experimental data suggest that nicotine exposure may lead to reduced hematoma formation and therefore provide a protective effect in patients with intracerebral hemorrhage (ICH).

Methods

We performed a retrospective analysis of data on patients with ICH recruited in multi-center clinical trials using the Virtual International Stroke Trials Archive. We analyzed demographics, risk factors, imaging, and clinical outcome data. Hematoma expansion was defined as increase in volume by 6 mL or 33% on the 24-hour computed tomography (CT) scan compared with the baseline CT scan. Outcome was assessed by modified Rankin Score (mRS) at 3 months.

Results

Among 985 subjects, 118 (12%) were smokers. Smokers were younger at the time of enrollment (mean age 59.3 (±11.02) years vs. 66.9 (±13.22) years, p < 0.0001) and more likely to be men (81% vs. 61%, p < 0.0001). Initial hematoma volumes were similar between the two groups (mean of 20.44 mL for smokers, vs. 23.16 mL for non-smokers, p = 0.22). At 24 hours, CT showed higher rates of hematoma expansion among cigarette smokers (55% vs. 39%, p = 0.028). This difference persisted after adjusting for age and gender [odds ratio (OR) 2.04, 95% confidence interval (CI) 1.1–3.79]. No difference was found in the proportion of subjects with favorable outcome (mRS = <2) at 90 days (39% of smokers vs. 34% of non-smokers, p = 0.32).

Conclusions

Cigarette smoking was associated with higher rates of hematoma expansion at 24 hours in patients with ICH. Further studies into the effect of chronic nicotine exposure on cerebral arterial integrity may provide new insights into the mechanism of hematoma expansion.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

NUTRITIONAL STATUS AND N-3 FATTY ACIDS IN VERY ELDERLY JAPANESE STROKE PATIENTS AGED 75 OR OLDER

T Mori ¹, Y Tanno ¹, S Kasakura ¹, K Yoshioka ¹

Abstract

Background

Very elderly Japanese stroke patients (veJSP) aged 75 or older may have good nutritional status (NS) and high blood levels of n-3 fatty acids: eicosapentaenoic acid (EPA) and/or docosahexaenoic acid (DHA), and high EPA/ arachidonic acid (AA) ratio, because they have a long life. The aim of our study was to investigate NS and blood levels of EPA, DHA and EPA/AA ratio in veJSP.

Methods

Included were veJSP 1) who were admitted between 2014 and 2015, and 2) whose blood levels of albumin (Alb), EPA, DHA and AA were measured at arrival. Patients’ features and blood levels of EPA, DHA, AA, albumin (Alb), triglyceride (TG), high-density lipoprotein cholesterol (HDL-c).

Results

One hundred sixty patients (pts) were anakyzed. Median (m) age was 80 years, EPA (m) was 59.1 mg/ml, an average (a) DHA; 139.4 mg/ml, AA (a); 178.5 mg/ml, EPA/AA ratio (m); 0.35, Alb (a); 3.8 g/ml, LDL-c(a); 119.7 mg/dl, TG (a); 102.0 mg/dl, HDL-c (a); 59.3 mg/dl. They didn’t have dyslipidemia. Among them, 33 pts (20.6%) had Alb of less than 3.5 g/ml (N poor) and 127 pts (79.4%) had Alb of 3.5 g/ml or more (N good). In N poor and good groups, median EPA was 45.6 and 68.6(p < 0.0001), EPA/AA ratio was 0.29 and 0.37(p < 0.005), DHA was 116 and 141.4 (p < 0.05), HDL was 42.1 and 61.7 (p < 0.0001), respectively.

Conclusions

About 80% of veJSP had good NS at onset, but their EPA and EPA/AA ratio were not high. Other 20% of veJSP with poor NS had much lower EPA and EPA/AA ratio.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

D-DIMER AS A PREDICTOR OF EARLY NEUROLOGICAL DETERIORATION IN CRYPTOGENIC STROKE WITH ACTIVE CANCER

KW Nam ¹, K Chi Kyung ¹, K Tae Jung ¹, A Sang Joon ¹, J Han-Gil ¹, K Sang-Bae ¹, Y Byung-Woo ¹

Abstract

Background

The occurrences of stroke in cancer patients are complicated with conventional vascular risk factors and cancer-specific mechanisms. However, cryptogenic stroke patients with cancer not having conventional stroke mechanisms were considered more related to cancer-specific hypercoagulation. In this study, we evaluated the possibility of D-dimer as a predictor of early neurological deterioration (END) in cryptogenic stroke patients with active cancer.

Methods

We recruited 109 cryptogenic stroke patients with active cancer within 72 hours from symptom onset. We defined END as an increase of ≥1 point in motor NIHSS or ≥2 in total NIHSS within 72 hours from admission. After adjusting possible confounding factors in multivariate analysis, we calculated the odds ratios (ORs) and confidence intervals (CIs) of D-dimer to predict END.

graphic file with name 10.1177_2396987316642909-img19.jpg

Results

Among 109 patients, END events were detected in 34 (31%) within 72 hours from admission. Higher proportion of systemic metastasis (P = 0.01), multiple vascular territory lesions in MRI (P = 0.01), higher initial NIHSS score (P < 0.01) and D-dimer levels (P < 0.01) were significantly associated with END. In multivariate analysis, D-dimer (adjusted OR, 1.11; 95% CI, 1.04–1.17, P < 0.01) predicted END after adjusting possible confounding factors. In addition, initial NIHSS score (adjusted OR, 1.08; 95% CI, 1.01–1.15, P = 0.03) was also associated with END independently from D-dimer.

graphic file with name 10.1177_2396987316642909-img20.jpg

Conclusions:

graphic file with name 10.1177_2396987316642909-img21.jpg

D-dimer may predict END events in cryptogenic stroke patients with active cancer.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

APOLIPIPROTEIN B48 IS A NOVEL MARKER FOR LARGE ARTERY ATHEROSCLEROTIC ISCHEMIC STROKE: A CASE-CONTROL PILOT STUDY

MS Oh ¹, KH Yu ¹, JH Lee ², JM Park ³, HJ Bae ⁴, KS Hong ⁵, J Koo ⁶, OY Bang ⁷, JH Rha ⁸, BW Yoon ⁹, HS Nam ¹⁰, MU Jang ¹¹, BC Lee ¹

Abstract

Background

Postprandial hypertriglyceridemia is recognized as a risk factor for ischemic stroke and postprandial triglyceride-rich lipoproteins(TRLs) may contribute to the development of atherosclerosis. Reportedly, serum apolipoprotein B48(apoB48), as a good marker for TRLs derived from intestine, was associated with the presence of carotid plaque. However, it remains uncertain whether the apoB48 level is associated with large artery atherosclerotic ischemic stroke. Our aim was to test the association between apoB48 level and large artery atherosclerotic ischemic stroke(LAA).

Methods

We enrolled 56 patients (age, 65.8 ± 11.3; men, 71.4%) with ischemic stroke presenting within 48 h after symptom onset: 28 with LAA and 28 with small vessel occlusive ischemic stroke (SVO) matched on age (±5 years), sex, and the presence of diabetes mellitus. The fasting and post-prandial plasma apoB48 levels were compared between patients with LAA and patients with SVO. The plasma fasting and post-prandial apoB48 were measured by ELISA.

Results

Patients with LAA had significantly higher fasting apoB48 levels than those with SVO (6.4 ± 2.4 vs 5.4 ± 1.7 μg/ml, p = 0.010). After adjusting by major confounders, such as age, sex, diabetes mellitus, hypertension, smoking, body mass index, and fasting plasma lipids, conditional logistic regression analysis showed fasting apoB48 level was independently associated with LAA (OR, 1.07; 95% CI, 1.01–1.14; p = 0.023).

Conclusions

Compared with SVO, elevated levels of fasting apoB48 are associated with LAA. This result suggests the fasting apoB48 level might be an independent marker of atherosclerotic ischemic stroke. Further study should be needed to confirm the finding of out pilot study in large number of cases

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

NCCT IN PREDICTING SHORT TERM STROKE RISK AFTER TIA

E Ozaydin Goksu ¹, F Tuter Yilmaz ², A Unal ³, K Karaali ⁴

Abstract

Background

The aim of the present study was to evaluate the role of non-contrast computed tomography (NCCT) in patients presenting to emergency department (ED) with symptoms suggestive of transient ischemic attack (TIA) and minor stroke and its association with diffusion-weighted imaging (DWI) and stroke within 7 days.

Methods

Data were retrospectively collected from patients who had TIA. Demographic properties of the patients, past medical history, presenting neurological symptoms, ABCD2 score of each patient, time interval between DWI and NCCT, stroke occurrence within a week of ED presentation were collected.

Results

The 7-day risk for stroke was 6.3%. All early strokes, 2 occurred in patients with positive DWI and 1 occurred in patients with positive NCCT and only three patients had ABCD2 score of ≥4. Acute ischemic lesions were demonstrated by DWI in 39 (41%) patients. Patients with positive DWI were more likely to have ABCD2 ≥ 4 (odds ratio [OR] = 2.5; 95 % CI, 1.0% to 6.1%, p = 0.04). NCCT scan was abnormal in 54 (56.8%) patients. Patients with positive NCCT were more likely to have HT (odds ratio [OR] = 2.6;95 % CI, 1.2% to5.9%, p = 0.02) and previous stroke (OR = 6.3; 95 % CI, 1.9% to 20.4%, p < 0.001).

Conclusions

We could not detect an association between the NCCT result and subsequent risk of stroke within 7 days of TIA.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CHRONIC INFECTIONS, INFECTIOUS BURDEN AND THE RISK OF STROKE

F Palm ¹, P Pussinen ², A Aigner ³, H Becher ³, F Buggle ¹, C Grond-Ginsbach ⁴, A Safer ⁵, C Urbanek ¹, A Grau ¹

Abstract

Background

There is evidence that infectious diseases contribute to the risk of stroke. We tested the hypothesis that the aggregate burden of chronic infections to which an individual has been exposed during lifetime, increases the risk of ischemic stroke.

Methods

Within a population-based stroke registry, we performed a case–control study with 470 incident cases of ischemic stroke patients aged 18 to 80 years and 809 age- and sex-matched stroke-free controls, randomly selected from the population (study period October 2007 to April 2012). Serum levels of IgA against Aggregatibacter actinomycetemcomitans (Aa), Porphyromonas gingivalis (Pg), Chlamydia pneumoniae (Cp) and Mycoplasma pneumoniae (Mp) and IgG antibodies against Aa, Pg, Cp, Mp and Helicobacter pylori (Hp) were assessed. Aggregate burden of chronic infections was calculated as the cumulative number of IgA-positivity, IgG-positivity and aggregated IgG/IgA-positivity with conditional logistic regression adjusted for common known risk factors and socioeconomic status.

Results

Mp-IgG (OR 0.67; 95% CI 0.5–0.9) and Aa-IgA (1.45; 1.03–2.05) were independently associated with stroke risk. In subgroup analysis Aa-IgA (1.74; 1.08–2.8) and cumulative IgA-seropositivity (2.12; 1.18–3.81) were associated with ischemic stroke due to large vessel disease (LVD) but not with cardioembolic stroke or small vessel disease.

Conclusions

In our study, infectious burden as measured with cumulative IgA-seropositivity independently increased ischemic stroke risk only in patients with LVD pointing towards atherosclerosis linking chronic infections and stroke risk.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE ROLE OF NON-SPECIFIC CONNECTIVE TISSUE DYSPLASIA IN DEVELOPMENT OF THE CEREBROVASCULAR ACCIDENT

G Rakhmatullaeva ¹, K Khalimova ²

Abstract

Background

define the role of unspecific connective tissue dysplasia in development of the cerebrovascular accident.

Methods

analysis of results of the clinical and neurological examination, for 30 patients with cerebrovascular abnormalities

Results

there were 30 patients with migraine under the care with various abnormalities of the brain and 20 migraine patients without abnormalities, at the age of 17–45 years (mean age 22.3 ± 2.5 years). In the first group, there were the signs of undifferentiated connective tissue dysplasia (UCTD): increased skin extensibility and hyperelasticity, in addition to vascular abnormalities. There were the easy skin vulnerability, which slowly healed, leaving keloid scars, even after minimal trauma, and increased mobility and laxity of the joints noted. During the study there was a chronic arthralgia noted without signs of the joints inflammation in 13.7% of patients. Scoliosis, kyphosis, and flat feet were noted. The patients under care showed structural tissue failure of internal organs manifested in the form of: hernias in 7.8% of cases, descent of internal genitals in 9,7%, and marked premature rupture of membranes, preterm birth and post-partum haemorrhage in 21.3% of the cases. There was a frequent sign of dissection of extra- or intracranial segments of the vertebral arteries, which has been confirmed in 7 female patients diagnosed with basilar migraine. The cerebrovascular accidents have subsequently developed in 3 cases.

Conclusions

Unspecific connective tissue dysplasia serves as a risk factor for development of the VA dissection, which leads to the cerebrovascular accident. There with, the dissection of the VA is often diagnosed in women

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

MOLECULAR - GENETIC FEATURES OF GENE VEGF (VASCULAR ENDOTHELIAL GROWTH FACTOR - C634G VEGFA), AT CEPHALGIC SYNDROME WITH ANOMALIES OF CEREBRAL VESSELS

G Rakhmatullaeva ¹, K Khalimova ², S Khudayarova ²

Abstract

Background

To identify the molecular genetic polymorphism of gene VEGF in patients who have cephalgia with and without of the anomalies of cerebral vessels

Methods

to analyze of the results of molecular genetic polymorphism C634G of gene VEGF

Results

It has been performed the molecular genetic examination of 178 (100%) patients who have cephalgic syndrome with and without anomalies of cerebral vessels, also 172 healthy people of Uzbek nationality.

In the result of investigation were identified two alleles of the gene VEGF: C, and G. Thus, C allele occurred more frequently in the control group, 86.9% and 75.3% in the primary, the G allele was significantly more common in the main group.

Genotype C / C was observed most frequently (57.9%) in the main group , than the genotypes C / G (34,8%) and G / G (7,3%). Also genotype C / C (76.2%) was revealed frequently more than C / G (21.5%), and G / G (2,3%) in the control group. Comparison of the two groups showed that the mutation homozygous genotype G / G was observed more frequently patients in the main group than patients in the control group (χ2 = 4.7; P = 0.03; OR = 3.3; 95% CI 1.05- 10.36). Also Heterozygous types C / G was observed in patients, which consisted 34.8% and OR = 1.2

Conclusions

Mutation G / G increases the risk of deformation of the vessels in 3.3 times, and heterozygous types C / G in 1.2 times

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

DETECTION OF UNDERDIAGNOSIS IMPAIRED GLUCOSE IN A FAST REFERRAL CONSULTING OF PATIENTS WITH CARDIOVASCULAR RISK

S Reverté-Villarroya ¹, P Esteve-Belloch ¹, M Garcés-Redondo ¹, G Martin-Ozaeta ¹, J Zaragoza-Brunet ¹, S Escalante-Arroyo ¹, C Matamoros-Obiol ¹, R Benet-Martí ¹, E Inglada-García ¹, E Forcadell-Ferreres ¹, S Gálvez-Vicente ¹, JJ Baiges-Octavio ¹

Abstract

Background

Risk of stroke soon after a transient ischemic attack (TIA) is high. Prediabetes is an independent risk factor for future stroke. Urgent care and a good control of cardiovascular risk factors (CRF) can reduce this risk. In January 2014, we set up a fast referral consulting (FRC) for management of patients with acute TIA and minor stroke, prioritizing urgent care, comprehensive study and CRF controls. We aimed to evaluate underdiagnosis population with prediabetes CRF attended the FRC.

Methods

Participants were patients with a minor stroke or TIA and without a history of type 2 diabetes mellitus (DM).

Results

52 patients were evaluated with age of 62 ± 12 years old. 62,3% are men. 58,5% presented TIA and 41,5% lacunar stroke, modified Rankin scale was ≤0–2. CRF were (hypertension 71,7%, dislipemy 49,1%, cardiophaty 28,3%, prior stroke 22,6%, smoker 26,4%, alcoholism 20,8% and renal insufficiency 3,8%. 47,1% patients showed impaired glucose, 35,8% prediabetes alert (100–125 mg/dl), 9,4% diabetes (≥126 mg/dl) and 1,9% (≥200 mg/dl) at least two basal blood glucose values (WHO criteria). A significant positive relationship between prediabetes alert and overweight (IMC = 25–29.99) has been observed (p = 0.007).

Conclusions

We have detected that impaired glucose is underdiagnosed in our rural population. DM is an important fact that can be relation to an increase of stroke risk in the future. We propose to try to diagnose this illness before including the determination of HbA1c in the screening blood test. There is also a significant relationship between prediabetes alert and overweight, so we apply health behaviors to control CRF.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

INCREASED RISK OF STROKE IN PATIENTS WITH EPILEPSY: ANALYSIS OF THE TASMANIAN EPILEPSY REGISTER

LM Sanders ^1,², M Tan ¹, MJ Cook ^1,², WJ D'Souza ^1,²

Abstract

Background

Recent data indicate that there is an increased risk of stroke in patients with epilepsy. However, understanding this association requires further investigation.This study aimed to evaluate associations between seizures and stroke using the Tasmanian Epilepsy Register (TER).

Methods

TER is a unique dataset compiled from a longitudinal, community-based cohort of patients with treated epilepsy. Cases were ascertained from the Australian National Prescription Database between July 2001 and June 2002. Stroke and seizure occurrence were reported by both patients and witnesses. Seizure classification was determined by an epileptologist, using standardised validated criteria. Proportion denominators were censored for missing data.

Results

Data were available for 997 registry participants (male: 50.4%, mean age: 44.9+/-19.7). Stroke was reported by 13.7% of participants (95%CI 11.4–16.4%; witness agreement κ = 0.66). A pre-stroke diagnosis of epilepsy was reported in 39/90 (43.3%;33.6–53.6%) participants with lifetime stroke. Median age of first seizure in those with pre-stroke epilepsy was 21 (IQR 12–44) with median age of stroke lower than the national average (51;44–59). Idiopathic Generalised Epilepsy (IGE) was diagnosed in 8/39 (20.5%;10.8–35.3%). There was no difference in stroke incidence or age of stroke for participants with IGE compared with non-IGE. Incidence of diabetes was higher in pre-stroke epilepsy participants (15.4%;7.2–29.7%) than those without stroke (5.1%;3.6–7.2%;p < 0.001) but similar to those with post-stroke seizures (14.0%;7.0–26.2).

Conclusions

Stroke occurred at younger age and higher frequency than expected in this cohort. These results suggest that epilepsy is associated with an increased risk of early lifetime stroke and may represent a modifiable risk factor.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

VASCULAR PROGNOSIS OF FOCAL AND MIXED TRANSIENT NEUROLOGICAL ATTACKS

M Santos ¹, P Canhão ²

Abstract

Background

Transient Neurological Attacks (TNA) are sudden neurological events completely resolving within 24 hours, and may be classified as focal, mixed or non-focal. The prognosis of focal TNA is well known, but it remains controversial if patients with mixed TNA have a worse outcome. We aimed to assess the prognosis of focal and mixed TNA in the first year after a TNA.

Methods

Observational study in a TIA clinic cohort, including consecutive patients with focal or mixed TNA for seven years. Primary outcome was a composite of vascular events (TIA, stroke, myocardial infarction and vascular death), and secondary outcomes were each of them separately. Patient’s baseline characteristics, symptoms distribution and TNA subtype were recorded. Outcomes in the first year of follow-up were assessed. Variables were compared between patients with focal and mixed TNA using Pearson Chi-Square Tests. Event-free rates were compared between focal and mixed TNA using Kaplan Meier survival curves.

Results

510 patients were included: 358 (70.2%) focal and 152 (29.2%) mixed TNA. Mean follow-up time was 681 days (SD = 575 days), and median 561 days. One year vascular event rate was 16.0% in mixed TNA patients, and 14.2% in focal TNA patients (p = 0.381). Primary and secondary outcomes did not significantly differ between groups.

Conclusions

Non-focal symptoms accompanying focal symptoms were frequent, afflicting one third of patients. Patients with focal and mixed TNA had similar prognosis during the first year after the TNA. These results did not confirm those from other studies suggesting that mixed TNA may have worse prognosis.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

OCCURENCE OF OBSTRUCTIVE SLEEP APNEA SYNDROME IN PATIENTS WITH TRANSIENT ISCHEMIC ATTACK

M Schipper ¹, K Jellema ¹, R Rijsman ^1,²

Abstract

Background

Obstructive sleep apnea syndrome (OSAS) is a sleep breathing disorder with episodes of upper airway obstructions. Patients with cardiovascular diseases such as myocardial infarction and stroke show a high prevalence of OSAS. Several studies focus on stroke and not on TIA, suggesting it could be a symptom after stroke. We analyzed the occurrence of OSAS in high-risk patients with TIA.

Methods

There were 555 patients suspected for TIA by the general practitioner who were referred to our TIA daycare clinic. They were diagnosed with TIA or another diagnosis. They were screened for OSAS using three screening factors: snoring (yes/no), Body Mass Index (BMI) ≥30 and Epworth Sleepiness Score (ESS) > 10. When 2 out of 3 were positive, patients were high-risk for OSAS and received a polysomnography. An apnea/ hypopnea index (AHI) of 5–15 is defined as mild OSAS, AHI 15–30 as moderate OSAS and AHI > 30 as severe OSAS.

Results

77 high-risk patients received a polysomnography. 25 patients had a diagnosis of TIA, 18 of cerebral ischemia and 34 had other diagnoses. 20 of the 25 (80%) TIA patients had OSAS, compared to 16 of the 34 (47%) patients without a vascular diagnosis (p = 0,010). When excluding patients with cardiovascular history, there were 15 of the 20 patients with OSAS, compared to 14 out of 30 patients (p = 0.047).

Conclusions

There is a significant higher occurrence of OSAS in TIA patients compared to patients without a vascular diagnosis, even after excluding patients with a history of cardiovascular events.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

VASCULAR EVENTS ARE COMMON IN ASIAN PATIENTS WITH EXTRACRANIAL CAROTID STENOSIS MANAGED MEDICALLY- SIX YEAR FOLLOW-UP STUDY

V Sharma ¹, RW Liu ¹, RW Liu ¹, B Chandra ¹

Abstract

Background

Extra-cranial carotid artery disease occurs less commonly in Asians. Symptomatic carotid stenosis correlates significantly with subsequent cerebral ischemic events. We aimed at evaluating the natural history of symptomatic carotid steno-occlusive disease in our cohort of ischemic stroke patients.

Methods

In this retrospective study, patients with symptomatic >50% carotid artery stenosis during previous 3-months, admitted during the year 2009 were included. Demographic characteristics and vascular risk factors were recorded. We present the event rates for stroke/transient ischemic attack (TIA), myocardial infarction (MI) or death during 6-year follow up.

Results

Of the total of 822 patients admitted for stroke/TIA, 87 (10.6%) were found to have symptomatic carotid stenosis; median age 76 years (range 41–93), 59 (67.8%) male and 68 (78.2%) Chinese. Hypertension was the commonest risk factor in 64 (73.6%) patients. Carotid endarterectomy was performed in 18 (20.7%) patients while 69 (79.3%) were managed with best medical therapy. Mean time to any vascular event was 26.8 months in the best medical management group, which included Stroke/TIA in 6 (8.7%) and MI in 14 cases (20.3%). 27 cases (39.1%) died during follow-up. No cerebrovascular events were reported in patients in the surgically treated patients. However, 3/18 (16.7%) developed MI and 3/18 (16.7) died during the 6 years follow up.

Conclusions

Symptomatic steno-occlusive disease of cervical carotid artery carries a high risk of subsequent vascular events and mortality despite best medical therapy. Perhaps, better methods of risk stratification and an aggressive approach towards revascularisation in eligible cases are warranted.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CHANGE IN LONG TERM EXERCISE PARTICIPATION POST STROKE: THE NORTH EAST MELBOURNE STROKE INCIDENCE STUDY (NEMESIS)

D Simpson ¹, M Callisaya ^1,², C English ^3,⁴, AG Thrift ², S Gall ¹

Abstract

Background

Following stroke exercise is recommended to reduce cardiovascular risk and improve function and psychological wellbeing, but little is known about how exercise participation changes in the long term.

Methods

We used data from a population-based stroke incidence study with 10-year follow-up. Questionnaires about exercise (defined as activity ≥20 minutes duration causing sweating or ‘huffing and puffing’) were collected at 5 (2001–04) and 10 (2006–09) years post stroke. We classified people as exercising or not at 5 and 10 years, and then created change categories between 5 and 10 years. Multinomial regression was used to determine how pre-stroke exercise participation, exercise advice and participant characteristics (age, sex, stroke severity, stroke type, social class and disability at 5 years) were associated with change in exercise participation.

Results

There were 276 (85%) people with complete data at 5 and 10 years post stroke (mean age 69 [SD 14] years, 47% female). One hundred and one (37%) participants identified as exercising prior to stroke. Forty-two participants (15%) reported exercising at both 5 and 10 years post-stroke, while 27 (10%) reported commencing exercise between 5 and 10-years. Continuous exercise participation between 5 and 10 years was associated with younger age, less disability at 5 years, pre-stroke exercise engagement and recall of health professional advice to exercise.

Conclusions

Few people regularly exercise following stroke with even fewer commencing regular exercise. Exercise before stroke and recalling exercise advice was associated with long term exercise participation.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

STROKE RISK IN NORTHERN RURAL HUNGARY: A COHORT STUDY

A Szucs ¹, G Szabó ², C Óvary ³, T Szentes ⁴

Abstract

Background

Because stroke and stroke-mortality are highly prevalent in Hungary; shortening life expectations and healthy years of life, we aimed to analyse the factors associated to a previous stroke in a rural cohort of northern Hungary.

Methods

18 general practitioners caring for a population of 88222 in Nógrád county, Hungary used an odd-ball selection-method choosing 50 persons from their praxis. The individuals were asked to answer questions of our structured interview on demographics, life style, socio/medical features, stroke risk-factors and past medical history/medication. They underwent screening measurements for body mass index, blood pressure, blood sugar, triglyceride, cholesterol and filled a Beck depression scale. We used a logistic regression model to assess factors associated to a preceding stroke occurring in the past.

Results

886 individuals (617 females; mean age 52.7 15–92 years) were involved. Age, hypertension, diabetes, atrial fibrillation, alcohol abuse, depression, the lack of physical activity,>70 working hours/week, and living far from a family doctor; associated with a stroke in past medical history. 40% were unemployed, 50% had less than 12 years’ basic education, the income of 40% was just sufficient for survival. The ratio of the gipsy population based on own admission, was importantly below official demographic estimation.

Conclusions

Our study has shown an association of the known stroke factors as well as over-tiring; with a preceding stroke. Under-education, poverty, high rate of alcohol consumption and smoking characterize this handicapped region. The under- representation of self-admitted gipsy population in our sample needs further evaluation.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EFFICACY OF DIPEPTIDYL PEPTIDASE-4 INHIBITORS ON CAROTID ATHEROSCLEROSIS PLAQUE COMPONENTS IN TYPE2 DIABETIC PATIENTS

M Takasaki ¹, T Hyo ², T Kinoshita ¹, K Yamagami ¹, T Hongo ¹, T Hashiba ¹, E Miyahara ¹, Y Keiichi ¹, Y Fujimoto ¹

Abstract

Background

Dipeptidyl peptidase-4 inhibitors(DPP-4i) are oral incretin-based glucose lowering agents, and have great efficacy for type2 diabetes mellitus (t2DM) patients. DPP-4i also have been suggested about effect on cardiovascular risk reduction. On the other hand, there are few reports about the relationship between DPP-4i and internal carotid artery stenosis (ICS). We assessed the hypothesis that DPP-4i have protective properties about carotid plaque component.

Methods

From October 2012 to July 2015, 46 t2DM patients(median age:69 y.o.) with atheroscrelotic ICS were followed and underwent carotid black-blood (BB) MRI to diagnose plaque components. We evaluated the relative signal intensity(rSI) which is quantified as the ratio between the signal intensities of plaque and adjacent musle using T1-weighted images of BB-MRI. We defined the changes of rSI as follows; ‘elevated-rSI’ means the change elevated above 0.3, ‘diminished-rSI’ means the change diminished under 0.3. Other characteristics; age, symptom, hypertension, dyslipidemia, and insulin usage were also evaluated.

Results

19 patients could be followed for 1 year. In 6 patients with DPP-4i, one (17%) showed the ‘diminished-rSI’ change, and none of them showed the ‘elevated-rSI’ change. In 13 patients without DPP-4i, none showed the ‘diminished-rSI’ change, and two(15%) showed the ‘elevated-rSI’ change.There was no significant difference about the changes of between patients with and without DPP-4i. All other characteristics showed no significant differences similarly.

Conclusions

Treatment with DPP-4i showed no significant efficacy on ICS for 1 year. We need to accumulate more cases and keep following up for more years, in order to evaluate the long-term efficacy.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PLATELET REACTIVITY AND CLINICAL FACTORS FOR CARDIOVASCULAR EVENTS IN STROKE PATIENTS TREATED WITH CLOPIDOGREL: A SUBANALYSIS OF THE COGNAC STUDY

T tanaka ¹, H yamagami ¹, M ihara ¹, S miyata ², T miyata ¹, H yamamoto ³, K toyoda ¹, K nagatsuka ¹

Abstract

Background

In COGNAC (Contribution of Genetic Analysis to the efficacy of Clopidogrel) study, we identified that CYP2C19 polymorphisms significantly contribute to platelet aggregation in stroke patients treated with clopidogrel, but these genetic variants did not affect the recurrence of cardiovascular events (CVEs). Previous studies showed that non-genetic factors such as higher body mass index (BMI) were the independent predictors of high on-treatment platelet reactivity (HTPR) to clopidogrel (‘clopidogrel resistance’). However, little is known whether and how the HTPR affects the clinical outcomes through the above predictors.

Methods

A multicenter, prospective cohort study of stroke patients receiving clopidogrel for the secondary prevention of CVEs enrolled 501 patients between September 2010 and March 2012 in 14 hospitals in Japan. Platelet reactivity was assessed by ADP-induced platelet aggregation and vasodilator-stimulated phosphoprotein (VASP) index. HTPR was defined as VASP greater than 50%. We followed all patients for 2 years to evaluate the association of clinical factors with CVEs.

Results

Of 501 patients, 278 (55.6%) patients showed HTPR (VASP index: 63.6 ± 8.4%) and 28 (5.6%) patients had recurrent CVEs during the follow-up. In addition to younger age and high triglycerides, higher BMI were significantly related to HTPR (p < 0.05). Nevertheless, lower BMI was the only independent predictor of CVEs (HR per unit: 0.86, 95%CI 0.75–0.99, p = 0.035).

Conclusions

Although higher BMI was related to HTPR (clopidogrel resistance), lower but not higher BMI was paradoxically associated with higher recurrence of CVEs.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

POSSIBLE AND PROBABLE FAMILIAL HYPERCHOLESTEROLAEMIA IN 802 CONSECUTIVE PATIENTS WITH ISCHEMIC STROKE OR HIGH-RISK TIA IN THE STROKE-CARD COHORT

T Toell ¹, L Mayer ¹, K Willeit ¹, S Krebs ², J Ferrari ², M Knoflach ¹, W Lang ², S Kiechl ¹, J Willeit ¹

Abstract

Background

Identification of patients with familial hypercholesterolemia (FH) among vascular risk subjects is important given the availability of new highly efficient lipid-lowering drugs. The proportion of FH among patients with stroke is poorly defined while a recent study reported proportions for FH as high as 1.6% (probable/definite) and 17.8% (possible) in patients with acute coronary syndromes.

Methods

The prevalence of FH was estimated in 802 unselected patients with stroke or high-risk TIA included in the ongoing prospective “Stroke-Card Study” (NCT02156778). Based on LDL-cholesterol levels and personal and familial history of premature CVD the validated Dutch Lipid Clinic Network algorithm (DLCNA: probable/definite ≥6 points; possible 3–5 points) was applied. Cholesterol levels were measured within 24 hours after stroke onset. In 241 (30.0%) patients on statin therapy, untreated LDL cholesterol levels were estimated based on validated correction factors considering type and dosage of the statin used.

Results

According to the DLCNA, 8 (1.0%) had probable/definite and 79 (9.9%) possible FH with a joint prevalence of 10.8% (95%CI, 8.7–12.9). There was no difference between men and women. Among 156 patients with premature stroke (age <55 in men, <60 in women), 4 (2.6%) had probable/definite and 20 (12.8%) had possible FH according to the DLCNA with a joint prevalence of 15.4% (95%CI, 9.7–21.1). Only one patient was pre-diagnosed with FH.

Conclusions

A putative diagnosis of FH, based on easily applicable algorithms, is common among patients with ischemic stroke and high-risk TIA and assessment of clinical FH status should be part of routine patient care.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PREDICTORS OF SUBSEQUENT ISCHEMIC STROKE EVENTS IN PATIENTS WITH TRANSIENT ISCHEMIC ATTACK ATTRIBUTABLE TO INTRACRANIAL ARTERIAL OCCLUSIVE LESION

T Uehara ¹, T Ohara ¹, K Nagatsuka ², K Minematsu ¹, K Toyoda ¹

Abstract

Background

The purpose of this study was to determine the predictors of subsequent ischemic stroke events in patients with transient ischemic attack (TIA) attributable to intracranial arterial occlusive lesion.

Methods

Subjects of this study were 82 patients (55 men, 69.3 ± 12.1 years) with TIA probably attributable to intracranial arterial occlusive lesion who admitted to our stroke care unit within 48 hours of TIA onset between April 2008 and November 2015. The primary endpoint was ischemic stroke within 90 days of TIA onset.

Results

Twelve patients (14.6%) had ischemic stroke within 90 days of TIA onset. Patients with ischemic stroke had DWI lesions more frequently (58% vs 26%, p = 0.039) and tended to have history of ischemic stroke (50% vs 26%, p = 0.088) compared to those without. Serum levels of alkaline phosphatase (ALP) on admission were significantly higher in patients with ischemic stroke than those without (283.7 ± 67.8 vs 220.1 ± 63.9 U/L, p = 0.009). Cox proportional hazard multivariate analysis revealed that DWI positivity (HR: 8.53, 95%CI: 2.16–40.55, p = 0.002), history of ischemic stroke (HR: 4.06, 95%CI: 1.08–16.02, p = 0.038), and high serum levels of ALP (HR: 1.15, 95%CI: 1.05–1.26, p = 0.002, for every 10U/L) were significant independent predictors of ischemic stroke within 90 days after TIA onset.

Conclusions

Some recent studies from Asia showed the associations between serum levels of ALP and stroke. Our results suggested that serum levels of ALP could be a predictive marker for ischemic stroke events in patients with TIA attributable to intracranial arterial occlusive lesion.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

LONG-TERM RISK AND PREDICTORS OF RECURRENT ISCHEMIC STROKE

G Tekgol Uzuner ¹, D Darici ¹, N Uzuner ¹

Abstract

Background

Previous studies have shown that the advanced age, diabetes mellitus, previous myocardial infarction, smoking, and atrial fibrillation are predictors of stroke recurrence. We investigated the predictors of recurrent stroke in Eskisehir (Middle Anatolia in Turkey) during 5 years follow-up time beginning at 2008.

Methods

We scanned the ischemic stroke patients in our stroke registry data bank. The eligible patients were followed for recurrent stroke.

Results

This study included 230 patients. Sixty-nine (30%) patients had a recurrent stroke during the follow-up period. The mean stroke recurrence time was 506 days (9–1919 days). Significant predictors of stroke recurrence were coronary artery disease (89.9%, p < 0.001) and smoking (53.6%, p < 0.05). The age, gender, atrial fibrillation, hypertension, congestive heart disease, diabetes mellitus, hyperlipidemia were not significantly associated with stroke recurrence.

Conclusions

Smoking is an important health problem in our country. According to our study, patients seem not to be able to give up smoking even after the first-ever stroke. Despite the appropriate treatments patients with coronary heart disease have a higher rate of recurrence risk for ischemic stroke in our study. However, a clear relation between coronary heart disease and ischemic stroke has been known.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

IMAGING BIOMARKERS OF ATHEROSCLEROSIS ARE NOT ASSOCIATED WITH VWF:AG LEVELS OR ADAMTS13 ACTIVITY. THE PLAQUE AT RISK STUDY (PARISK)

A van Dijk ¹, M Sonneveld ², A de Rotte ³, F Schreuder ⁴, M Truijman ⁵, M van Liem ⁶, T Zadi ⁷, P Koudstaal ⁸, F Leebeek ², R Saxena ⁹, A van der Steen ¹⁰, M Daemen ¹¹, R van Oostenbrugge ¹², W Mess ¹³, J Kappelle ¹⁴, P Nederkoorn ⁶, J Hendrikse ³, E Kooi ¹⁵, M de Maat ², A van der Lugt ⁷

Abstract

Background

High VWF levels and low ADAMTS13 activity are associated with an increased risk of ischemic stroke, but the precise mechanism is unclear. We hypothesize that atherosclerosis plays a role. Therefore, we assessed the association between novel imaging biomarkers of the atherosclerotic plaque and VWF levels and ADAMTS13 activity.

Methods

Patients were derived from the PARISK-study (Plaque-At-RISK; clinicaltrials.gov NCT01208025). We measured VWF:Ag levels and ADAMTS13 activity in 180 patients with a recent TIA, including amaurosis fugax, or minor stroke and a mild-to-moderate symptomatic carotid artery stenosis. Imaging biomarkers of atherosclerosis were determined in the symptomatic carotid artery by MDCTA (n = 158; degree of stenosis, plaque ulceration, calcification volume) and MRI (n = 169; maximum vessel wall area, lipid and intraplaque hemorrhage volume). We used linear regression models to investigate the association between imaging and blood biomarkers. Adjustments were made for age, gender and cardiovascular risk factors. In the analyses with VWF:Ag, we also adjusted for blood group.

Results

Age and blood group non-O were associated with VWF:Ag levels (β = 0.01 IU/ml, p = 0.001 and β = 0.22 IU/ml, p < 0.001, respectively). Age and interval event–blood withdrawal were inversely associated with ADAMTS13 activity (β = −0.60%, p = 0.002 and β = −0.13%, p = 0.008). None of the imaging biomarkers were associated with either VWF:Ag levels or ADAMTS13 activity.

Conclusions

Imaging biomarkers of atherosclerosis are not related to VWF:Ag levels or ADAMTS13 activity in patients with a recent TIA or ischemic stroke and a symptomatic mild-to-moderate carotid artery stenosis. Atherosclerosis doesn’t seem to explain the association between the blood biomarkers and ischemic events.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

INCIDENCE, RISK FACTORS AND COMPLICATIONS OF OROPHARYNGEAL DYSPHAGIA ONE YEAR AFTER STROKE

D Muriana ¹, E Palomeras ¹, L Rofes ², D Álvarez-Berdugo ³, N Vilardell ³, V Casado ¹, ML Sebastian ¹, E Serrano ¹, AM Ciurana ¹, A Pradas ¹, E Vilardell ¹, MP Fossas ¹, P Clavé ³

Abstract

Background

Oropharyngeal dysphagia (OD) is an underdiagnosed condition following stroke. To evaluate the incidence, risk factors and early, mid- and long-term complications of post-stroke OD.

Methods

Prospective study of 403 stroke patients (SP) consecutively admitted to our hospital over 28 months. OD was assessed with the volume-viscosity swallow test within 24 hours of admission and patients were clinically monitored over one year. We collected demographic data, functional status and Spanish Stroke Registry (RENISEN) data. We performed a multivariate logistic regression analysis to identify risk factors associated with post-stroke OD and the effect of OD on outcome variables.

Results

OD was present in 45.1% of SP (safety impairment, 39.24%; efficacy impairment, 38.48%). OD was independently associated with advanced age: OR 1.1 (1.0–1.1), previous stroke: OR 2.4 (0.9–5.8), higher severity according the National Institute of Health Stroke Scale: OR 3.5 (1.6–7.9) and stroke volume: OR 1.0 (1.0–1.1). OD was significantly associated with higher risk of respiratory infections: 11.8% OD vs 1.4% non-OD, OR 4.9 (2.3–10.5); longer hospital stay: 8.2 mean days OD vs 6.1 mean days non-OD, beta = 0.81; higher rates of institutionalization: 56% OD vs 16.2% non-OD, OR 4.1 (2.0–8.5) and higher mortality at 3 months: 11.2% OD vs 0.5% non-OD, OR 17.7 (5.5–57.4) and at 1-year: 31.1% vs 3.2%; OR 5.8 (1.3–27.0), respectively.

Conclusions

Incidence of post-stroke OD is very high. It is associated with stroke severity and strongly and independently affects early, midterm (3 months) and 1-year clinical outcome particularly mortality. We recommend systematic screening of OD among all patients admitted with stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE ASSOCIATION BETWEEN GLOMERULAR FILTRATION RATE ESTIMATED ON ADMISSION AND ACUTE STROKE OUTCOMES: THE SHIGA STROKE REGISTRY

A Widhi Nugroho ^1,², H Arima ^3,⁴, N Takashima ⁵, Y Kita ^5,⁶, K Miura ^3,⁵, K Nozaki ^1,³

Abstract

Background

Although low estimated glomerular filtration rate (eGFR) has been found as an independent risk factor for poor stroke outcome, few studies ever reported the association in a large scale population-based study with wide range of eGFR categories, particularly in Japan.

Methods

Analyses were performed in 2,835 subjects aged 18 years old or older that were registered in the Shiga Stroke Registry in 2011, admitted within 7 days from onset with complete information on serum creatinine on admission and modified Rankin Scale (mRS). GFR was estimated using the Japanese Society of Nephrology (JSN) equation. Outcomes were defined as in-hospital death (mRS 6) and death/disability (mRS 2–6) at discharge.

Results

Through multivariate logistic regression analyses across levels of GFR, compared with the reference group of eGFR 60–89 mL/min/1.73 m², those with eGFR < 45 mL/min/1.73 m² exhibited strong significant associations with in-hospital death (OR, 95%CI 1.83, 1.26–2.66 [p = 0.004]) and death/disability at discharge (OR, 95%CI 1.57, 1.11–2.22 [p = 0.04]). Further analyses with wider range of eGFR categories confirmed a J-shaped association with in-hospital death (OR, 95%CI 1.83, 1.26–2.66; 1.28, 0.86–1.90; 1.00 [reference] and 1.03, 0.66–1.62 for eGFR <45, 45–59, 60–89, and >90 mL/min/1.73 m², respectively, and OR, 95%CI 2.01, 1.18–3.43; 1.41, 0.81–2.43; 1.10, 0.67–1.81; 1.00 [reference] and 1.78, 0.73–4.32 for eGFR <45, 45–59, 60–89, 90–119, and >120 mL/min/1.73 m², respectively).

Conclusions

GFR <45 mL/min/1.73 m² estimated on admission is a strong independent risk factor for in-hospital death and death/disability at discharge in acute stroke patients. The identification of a J-shaped association with acute stroke outcome necessitates further investigation.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

RADIATION INDUCED VASCULOPATHY AS A RISK FACTOR FOR RECURRENT ISCHAEMIC STROKE

A Wijewardane ¹, A Blight ¹

Abstract

Background

A 51 year old gentleman presented with left hemiparesis and dysarthria. Magnetic Resonance Imaging(MRI) brain revealed a right thalamic infarct and high signal throughout white matter bilaterally consistent with small vessel disease in the absence of smoking, hypercholesterolaemia, hypertension and diabetes. R test showed no evidence of atrial fibrillation.

Past medical history included a pineal dysgerminoma diagnosed 27 years ago for which he received chemotherapy followed by craniospinal irradiation and high dose steroids with curative response.

Methods

Clinical improvement seen with rehabilitation but presented 6 months later with a new left hemiparesis. The only identifiable conventional risk factor for stroke at this point was hypertension. MRI revealed an infarct in the right external capsule.

Results

He represented two months later with new right hemiparesis and an infarct in the left internal capsule on MRI. Intracranial angiogram showed major arteries of normal caliber and no stenoses or irregularities to suggest vasculopathy. We believe this patient's main risk factor is his previous history of radiotherapy leading to small vessel vasculopathy.

Conclusions

It has been described that radiation vasculopathy is primarily an accelerated form of atherosclerosis, others have described it as a distinct disease entity shaped by the initial radiation insult to the vasa vasorum. The relative risk of transient ischaemic attack or ischaemic stroke has been shown to at least doubled by head and neck radiotherapy.

Radiation induced vasculopathy should be considered as a mechanism for stroke with history of cranial irradiation particularly in the absence of detectable conventional stroke mechanism.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ARCTIGENIN, A POTENT INGREDIENT OF ARCTIUM LAPPA L, MEDIATED CYCLIC NUCLEOTIDE AND NITRIC OXIDE SYNTHASE IN A PI3K/Akt MECHANISM AND SUBARACHNOID HEMORRHAGE INDUCED CEREBRAL APOPTOSIS

CZ Chang ¹, W Shu-Chuan ², L Chih-lung ³, K Aij-Lie ⁴

Abstract

Background

Subarachnoid hemorrhage (SAH) induced cerebral apoptosis is believed to determine neurological deficits in patients with a ruptured aneurysm. Owing lack of effective therapeutic armamentarium, it is of interest to examine Arctigenin (ARC), a potent antioxidant, on cyclic guanosine monophosphate (cGMP) and protein kinase B (PI3D/Akt) signaling in an experimental SAH study.

Methods

A rodent SAH model was employed. 75/150/300uM/kg/day ARC was administered orally in the SA animals. Basilar arterys(BAs) were collected to examine cGMP (ELISA). Cerebral cortex was harvested for PI3D/Akt, B-cell lymphoma 2(Bcl-2) (western blot), and caspases (rt-PCR) examination. Neuronal Nuclei(NeuN), 5-bromo-2'-deoxyuridine(BrdU), inducible nitric oxide synthase(iNOS) monoclonal antibody were used for cellular analysis.

Results

ARC significantly improved neuro-behavior in the SAH rats, when compared with the SAH group. cGMP, Bcl-2, phospho-PI3D and phospho-Akt levels were decreased in SAH animals, compared with the healthy controls, but increased in the 300uM/kg/day ARC treatment SAH groups. Cleaved caspase-3 and caspase-9a in the SAH groups were induced, and treatment with ARC induced cGMP, phospho-PI3D and Akt to the control levels. The administration of perifosine, an Akt inhibitor, reduced the bio-expression of cGMP, phospho-PI3D and Akt, and also reduced Bcl-2 and increased cleaved caspase-9a and -3 level in 300uM/kg ARC treatment + SAH groups (p < 0.01).

Conclusions

These results demonstrate ARC exerts dual effects on cyclic nucleotide and iNOs through an Akt signaling in SAH-induced apoptosis. Through activating PI3D/Akt signaling and inactivating apoptosis-related caspases, ARC shows promise to be an effective strategy for the treatment of this disease entity.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE EFFECTIVENSS OF ACUPUNCTURE ON CEREBRAL VASOSPASM AFTER ANEURYSMAL SUBARACHNOID HEMORRHAGE: A DOUBLE-BLIND, RANDOMIZED CONTROLLED TRIAL

SY Cho ¹, DH Lee ¹, JM Park ¹, CN Ko ¹, SU Park ¹

Abstract

Background

Several serious complications including cerebral vasospasm frequently arise after successful surgery in subarachnoid hemorrhage patients. The purpose of this study is to assess the effectiveness of acupuncture on cerebral vasospasm after SAH.

Methods

Thirty-two patients with SAH who had undergone aneurysm clipping or coil embolization within 96 hours of onset were enrolled. Participants received acupuncture or sham acupuncture for 2 weeks. The incidence of delayed ischemic neurologic deficit (DIND), angiographic vasospasm, TCD vasospasm and vasospasm-related cerebral infarction were evaluated. After 2 weeks or at discharge, mortality and rate of subjects who recovered as mRS ≤ 2 were also examined. Serum nitric oxide (NO) and endothelin-1 (ET-1) concentration before and after intervention were measured.

Results

The incidence of angiographic vasospasm and vasospasm-related cerebral infarction in the treatment group was lower than the control group. The percentage of subjects who recovered as mRS ≤ 2 at 2nd follow up (4 weeks or discharge) was higher in the treatment group. For both serum NO and ET-1 level, there was a significant difference during 2 weeks only in non-vasospasm group, not in vasospasm group. After 2 weeks’ intervention, there was a significant increase in the level of NO in the treatment group.

Conclusions

Acupuncture had a tendency to improve the incidence of DIND, angiographic vasospasm, vasospasm-related cerebral infarction and functional recovery. Also, NO would be a potential mechanism of acupuncture on preventing cerebral vasospasm.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

UK AND IRELAND SAH DATABASE: CAN CONSISTENT DATA BE COLLECTED OVER TIME?

L Dulhanty ¹, J Galea ², H Patel ¹

Abstract

Background

Measurement of outcome following subarachnoid haemorrhage (SAH) is essential in ensuring that patients receive high quality care, and to initiate future research hypotheses. This requires commitment from individuals and institutions to ensure consistent data collection. In 2011, initially with a collaborative of 5 centres we started to collect process and outcome data for all patients presenting with SAH (UK and Ireland SAH database). The aim of this study is to demonstrate whether data collection could be sustained over time.

Methods

We reviewed data submitted over a 4 year period, this included; demographics, disease severity, time to treatment, previous medical history, treatment modality, complications, length of stay, discharge destination and outcome. Data were analysed descriptively, number of patients submitted monthly were analysed from Sept 2011 to September 2015. Data were reviewed for completion; missing fields and category of missing data were tabulated. We describe the acquisition, accumulation and completion of data to illustrate collection over time.

Results

4634 patient data were submitted from 14 centres over a 4 year period. 6 provided complete data, 4 submitted no data for ≤6 months and 4 submitted data irregularly. Fisher grade was the most common missing data point (19.5%) with lower rates for; WFNS grade (1.2%), Re-bleed (0.05%), CSF diversion (1.53%), Vasospasm (0.05%), GOS (4%) and Discharge destination (3%)

Conclusions

The development and maintenance of a SAH database in the UK and Ireland is feasible. Key to sustaining this process is dedicated personnel responsible for data entry and complete and consistent data submission.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

SHOULD WE TREAT ELDERLY (>75 YEARS) POOR GRADE ANEURYSMAL SUBARACHNOID HAEMORRHAGE (aSAH) PATIENTS?

H Patel ¹

Abstract

Background

With increasing life-expectancy and incidence of aSAH in the elderly, more treatment decisions are required for this cohort. Although age and presentation in poor grade (World Federation of Neurological Surgeons Grade 4 &5) are independent predictors of poor outcome little data exists on outcomes in elderly poor grade aSAH patients.

The aim of this study was to compare the outcome(s) (Mortality, Glasgow Outcome Scale (GOS) at discharge, discharge home) in poor grade elderly patients that were treated (aneurysm secured) or not.

Methods

Poor grade elderly patients were identified from the UK and Ireland SAH database. Outcome (mortality, favourable outcome, proportion of patients discharged home) was compared for patients treated versus those that were not (Chi-square test).

Results

Fifty-Four patients with a median age (IQR) of 79(5) years were identified. 42 (77%) had their aneurysm secured in a median IQR 2(3) days. More patients in the treated group presented as a grade 4 SAH (41% vs 68% p = 0.09). There was a significant difference in mortality (24% CI (13–40) vs 92% CI (65–99) p < 0.001) and favourable outcome (27% CI (15–43) vs 0 CI (0–24) p < 0.044). The mean length of stay for treated patients was 31 days + 8, and no significant difference in the proportion of patients discharged home was observed (12% CI (6–27) vs 0 CI (0–24) p < 0.192)

Conclusions

Elderly patients can achieve functional independence. The low frequency of positive outcomes means that treatment decisions require case by case consideration.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

OUTCOME IN PATIENTS PRESENTING WITH THUNDERCLAP HEADACHE AND HAVE A NORMAL INITIAL CT HEAD SCAN

S Elyas ¹, C Ali ², R Langley ³, P Mitchlemore ³, A Rose ³, G Darch ³, R O'Brien ³

Abstract

Background

Thunderclap headache(TH) is a common presentation to emergency rooms. SAH is an important cause of TH. The majority of patients with an initial normal CT head go on to have further investigations such as lumbar puncture(LP) and CTA/MRA to rule out SAH. This puts extra pressure on resources.The outcome of those patients and the benefits of further investigations are not entirely clear.

Methods

Retrospective identification of patients who presented to our hospital with thunderclap headache and had a normal CT head scan(February 2010-February 2011).The results of LP, further imaging and the outcome of those patients were examined at 1 year.

Results

124 patients were admitted over 1 year period with thunderclap headache and had an initial CT head scan that was reported as normal. Mean age 44 ± 16 years, 76 females(61%). All patients went on to have LP, >50% of patients had abnormal CSF results, 6 patients had >1000 RBC in CSF and 3 patients had positive xanthochromia. 42 patients(including the 3 patients with positive xanthochromia) had further imaging(CTA and MRA),one patient had a 4 mm anterior communicating artery aneurysm and one had a dural AVM. 15 of these patients were re-admitted to the hospital and 5 of them represented with TH. No death was reported at 1 year follow up.

Conclusions

TH is a common presentation and is relatively non-specific. An initial negative CT head scan could potentially rule out significant SAH. In the absence of features suggesting CNS infection, investigations with CTA/MRA might help reduce the need for regular LPs in patients presenting with TH.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

11C-PIB PET IN CORTICAL SUBARACHNOID HEMORRHAGE

MM Gomez-Schneider ¹, M Hawkes ¹, SF Ameriso ¹

Abstract

Background

Cerebral amyloid angiopathy (CAA) is a leading cause of microbleeds, intracerebral hemorrhage (ICH) and cortical subarachnoid hemorrhage (cSAH), especially in the elderly. The latter is a less well characterized presentation of the disease. CAA is associated with the deposit of β-amyloid in extracellular plaques and vessel walls. The 11C-Pittsburgh compound B (PIB) is a PET ligand that binds cerebral β-amyloid with high sensitivity and specificity. We describe the use of PIB-PET in the non-invasive diagnosis of CAA in patients with cSAH.

Methods

Records from patients with cSAH in MRI and PIB-PET obtained between June 2009 and May 2015 were retrospectively analyzed. Demographic, clinical and imaging data were assessed.

Results

Six patients (3 women) aged 66 to 77 years old were included. All met Boston Criteria for probable CAA. One patient had had a prior ICH. Paresthesia (4/6) and focal weakness (4/6) were the most prevalent symptoms. On MRI 5 patients had microbleeds on gradient Echo sequence and 3 showed restrictions in DWI in the cortex next to cSAH. Digital subtraction angiography performed in 4 patients was unremarkable. Cognitive assessment revealed minimal cognitive impairment with subcortical pattern in 3 patients. PIB-PET showed cortical β-amyloid deposits in all patients. During an average follow up of 28 months (3–60) 3 patients had recurrence of bleeding, 2 cSAH and one ICH.

Conclusions

PIB-PET is useful to support the diagnosis of CAA in patients with cSAH. This noninvasive method may, in the future, replace brain biopsy as the gold standard for the diagnosis.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

MIGRAINE AND ANATOMICAL VARIATIONS IN THE CIRCLE OF WILLIS IN PATIENTS WITH ISCHEMIC STROKE

A Hamming ¹, M van Walderveen ², I Mulder ¹, I Van der Schaaf ³, LJ Kapelle ⁴, B Velthuis ³, M Ferrari ¹, M Visser ⁵, W Schonewille ⁶, A Algra ^7,⁸, M Wermer ¹

Abstract

Background

Whether anatomical variants in the circle of Willis (CoW) are more common in patients with migraine is a matter of discussion. Since migraine is a risk factor for stroke and CoW-variations have been suggested to play a role in this association, a possible difference in CoW-variations between migraine patients and non-migraine patients might be more pronounced in a stroke population. We compared the presence of CoW-variants in stroke patients with and without migraine.

Methods

We recruited participants from the Dutch-Acute-Stroke-Study (DUST). All participants underwent CT-angiography on admission. Migraine history was assessed with a migraine screener followed by an extensive interview based on the ICHD-II-criteria. CoW was assessed for incompleteness (any segment <1 mm), for anterior cerebral artery (A1) asymmetry and for posterior communicating artery (Pcom) dominance. Odds ratios (OR) were calculated with logistic regression.

Results

Forty-two (88%) of 48 included patients with migraine had an incomplete CoW versus 504 (85%) of the 593 participants without migraine (OR:1.24;95% CI: 0.51–2.99). There were no differences between the two groups in variations for the anterior or posterior CoW separately nor for presence of A1 asymmetry (OR:0.65;95% CI 0.31–1.37) or Pcom dominance (OR:0.56;95% CI 0.27–1.19). In addition, there were no differences in CoW-variations between migraine patients with or without aura.

Conclusions

In stroke patients anatomical variations in the circle of Willis are equally common in patients with and without a history of migraine. This finding does not support the theory that CoW variations play a role in migraine pathophysiology or in the relationship between migraine and stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

RISK FACTORS FOR INTRACRANIAL ANEURYSM RUPTURE: MULTICENTER CASE-CONTROL STUDY IN OVER 2300 INDIVIDUALS

I Hostettler ¹, V Alg ¹, N Shahi ¹, F Jichi ², S Bonner ³, D Walsh ⁴, D Bulters ⁵, N Kitchen ⁶, M Brown ¹, H Houlden ⁷, J Grieve ⁶, D Werring ¹

Abstract

Background

Background and Purpose

Despite recent improvements in the diagnosis and treatment of aneurysmal subarachnoid haemorrhage (aSAH), clinical outcome and quality of life remains poor. Identifying risk factors for intracranial aneurysm (IA) rupture is critical for successful prevention strategies.

Methods

We included clinical data from patients recruited at 22 UK hospital sites between 2011–2014, using standardized case report forms. We investigated risk factors associated with IA rupture status using multivariable logistic regression analysis.

Results

2334 patients were included (mean age 54.22 years; 1729 with ruptured IA causing aSAH, and 605 patients with unruptured IA). In multivariable adjusted analyses, the following variables were independently associated with an increased risk of ruptured IA status: recreational drug use (mainly cocaine: OR 1.85; 95% CI 1.03–3.34, p 0.004); and posterior versus anterior circulation location (2.65 OR; 2.02–3.48 95% CI, p < 0.001). The following variables were associated with non-ruptured IA status, suggesting a protective effect: antihypertensive medication (0.67 OR; 0.52–0.86 95% CI, p 0.002), hypercholesterolemia (0.68 OR; 0.52–0.89 95% CI, p 0.005); antiplatelet medication (0.25 OR; 0.18–0.34 95% CI, p < 0.0001); and larger aneurysm size (per mm increase) (0.92 OR; 0.90–0.94 95% CI, p < 0.001).

Conclusions

Recreational drug use and posterior aneurysm location are risk factors for IA rupture. Antihypertensive medication, antiplatelet medication, hypercholesterolemia and aneurysm size might protect against IA rupture. The apparently large protective effect of antiplatelet treatment may justify randomized trials in patients with unruptured IAs.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

OCCIPITAL ARTERY-POSTERIOR INFERIOR CEREBELLAR ARTERY BYPASS SURGERY FOR TREATING VA DISSECTING ANEURYSM INVOLVING THE PICA ORIGIN

S Joo ¹, MS Park ¹

Abstract

Background

To report experience of vertebral artery (VA) dissecting aneurysm involving the posterior inferior cerebellar artery (PICA) origin that were treated with occipital artery (OA)-posterior inferior cerebellar artery bypass.

Methods

Over 10 years, 17 cases of OA-PICA bypass was done. 8 cases of vertebral artery (VA) dissecting aneurysm involving the posterior inferior cerebellar artery (PICA) origin were treated with OA-PICA bypass. The clinical data, characteristics of aneurysms, and results of treatment were analyzed.

Results

OA-PICA bypass was performed before trapping of the aneurysms in all patients. Of the 8 aneurysms, 7 were totally obliterated with surgery, 1 was treated with additional endovascular coiling, and 1 was obliterated by endovascular coiling before bypass. Postoperative angiography revealed that the patency of the grafts was good in all 8 patients. In 1 patient who were treated with additional endovascular coiling, low cranial nerve palsy developed after endovascular coiling, but there was no complication after bypass surgery in all patients.

Conclusions

OA-PICA bypass with obliteration of the aneurysm may be effective therapeutic method for treating VA dissecting aneurysm involving the PICA origin, because it can preserve the perforators and distal blood flow from the PICA.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CEREBRAL HEMODYNAMIC DISTURBANCE IN DURAL ARTERIOVENOUS FISTULA WITH RETROGRADE LEPTOMENINGEAL VENOUS DRAINAGE: A PROSPECTIVE STUDY USING 123I-IODOAMPHETAMINE SINGLE PHOTON EMISSION COMPUTED TOMOGRAPHY

K Kanemaru ¹, K Hashimoto ¹, H Yoshioka ¹, H Kazama ¹, H Kinouchi ¹

Abstract

Background

The cerebral hemodynamic disturbance caused by retrograde leptomeningeal venous drainage (RLVD) of dural arteriovenous fistula (dAVF) is related to neurological morbidity and unfavorable outcome. However, it has not been elucidated well. The aim of this study was to assess the relationship between the cerebral venous congestive encephalopathy and the cerebral hemodynamics examined by 123I-iodoamphetamine (IMP) SPECT, and the predictive value of it of venous congestion encephalopathy.

Methods

Based on pre- and post-treatment HIA on T2WI associated with venous congestion encephalopathy, the patients were divided into three groups: normal, edema, and infarction group. The regional cerebral blood flow (rCBF) analyzed by 123I-IMP SPECT were compared among the groups.

Results

There were 11, 6, and 3 cases in the normal, edema, and infarction group. No cases in normal group, but all cases in the edema and infarction groups developed neurological symptoms. The rCBF in the edema group was significantly lower than that in the normal group, and higher than that in the infarction group. The cerebral vascular reactivity (CVR) of the infarction group was significantly lower than the other two groups. After treatment, the neurological signs disappeared in the edema group, but only partial improvement was seen in the infarction group. The rCBF significantly increased in the normal and edema groups, but not in the infarction group.

Conclusions

Quantitative rCBF measurement is useful for evaluating hemodynamic disturbance in dAVF. The reduction of rCBF was strongly correlated with the severity of venous congestive encephalopathy, and loss of CVR is a reliable indicator of irreversible venous infarction.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

SURGICAL TREATMENT OF CEREBRAL ARTERIOVENOUS MALFORMATION: 10-YEAR EXPERIENCE OF A SINGLE INSTITUTE

JE Kim ¹, WS Cho ¹, TK Kim ¹, JS Bang ¹, YJ Son ¹, CW Oh ¹

Abstract

Background

The treatment of cerebral arteriovenous malformation (AVM) is very challenging and consists of microsurgery, radiosurgery, and embolization. With advent and advancement of radiosurgery and onyx-based embolization, the role of microsurgery, the classical treatment, should be re-established.

Methods

The author has a series of cerebral AVM that has been treated with microsurgery. Between 2003 and 2013, a total 85 cases were operated in a single institute. Male-to-female ratio was 50 to 30, and mean age was 37 years. Ruptured AVM was 62%. Eighty three percent of this cases were classified as Spetzler-Martin grade 1 or 2. For size, 70% was less than 3 cm in diameter. Non-eloquent location was 68%, and superficial drainage was 82%.

Results

Surgical outcome was favorable with change of preoperative mRS 1.23 to postoperative 1.08, and of preoperative KPS 87 to postoperative 90. Severe complication was in 3 cases (3.5%). The good prognosticator was superficial location. With this results, the author will present interesting and representative cases showing innovative technique such as FLOW 800®, and advantages of microsurgery over other treatment modalities.

Conclusions

In conclusion, microsurgical resection of cerebral AVM is a feasible and effective treatment for small sized non-eloquent, superficial AVM, and AVM with hematoma owing to less complication rate, auto-dissection by hematoma, and reducing ICP. Safer and easier surgery can be performed with innovative technique such as FLOW 800®. Microsurgery should also be preferential for the treatment of cerebral AVM with combined lesions.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ANEURYSMS WITH THE THIRD CRANIAL NERVE PALSY: LONG-TERM RESULTS OF INTENTIONAL SPARING OF DAUGHTER SAC FROM COIL PACKING

HJ Kwon ¹, HS Koh ¹, H Jung ¹

Abstract

Background

Aneurysms which cause oculomotor nerve [cranial nerve (CN) III] palsy, are frequently found with a daughter sac of the aneurysm dome. We assumed that CN III might be compressed by the daughter sac and it would be more helpful not to fill the daughter sac with coils than vice versa during endosaccular embolization for recovering from CN III palsy, because it may give a greater chance for the daughter sac to shrink by itself later. We reviewed the long-term follow up results of our experiences of such cases.

Methods

Among 17 aneurysms accompanied by CN III palsy, 13 (12 unruptured, 1 ruptured) showed a daughter sac. We tried to fill the main dome completely and spare the daughter sac from coil filling to increase the possibility of decompression. We evaluated the initial and long-term effectiveness of this concept using medical records and follow-up images.

Results

After initial embolization, all of CN III palsy caused by unruptured aneurysms (12/12) resolved completely after various periods (3–90 days) of time. No adverse effects were noted during and after the procedures except for one case of harmless coil stretching during coil filling using double microcatheter technique. Mean follow-up period is 45.2 months (3–96, median 65). Coil compaction was found in one aneurysm at 6 months and re-embolization was done.

Conclusions

During the coil embolization of the cerebral aneurysm causing CN III palsy, sparing the daughter sac from coil packing while tightly packing the main dome can be helpful in increasing the effectiveness of decompression.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

M-FICOLIN LEVELS ARE ASSOCIATED TO VASOSPASM AND CEREBRAL ISCHEMIA AFTER SPONTANEOUS SUBARACHNOID HEMORRHAGE

L Llull ¹, S Thiel ², S Amaro ³, Á Cervera ⁴, X Urra ³, A Planas ⁵, Á Chamorro ³

Abstract

Background

Spontaneous subarachnoid hemorrhage (SAH) is a highly disabling neurological disease. A possible pathogenic role of complement system activation has been proposed. We examined the association between the circulating levels of M-ficolin (a complement associated protein) and vasospasm or cerebral ischemia after SAH.

Methods: M-Ficolin plasmatic levels were measured in 45 SAH patients at 24 hours after bleeding onset and at 90 days. Hunt and Hess (HH) grade, modified Fisher scale (mFS) and the rupture of an aneurysm as the cause of bleeding were assessed at admission. Neurological complications were monitored daily during hospital stay. Angiographic vasospasm was evaluated using transcranial Doppler or angio-CT and considered symptomatic when new focal deficits were associated. New cerebral ischemia was defined as new ischemic lesions in the follow-up neuroimaging.

Results

High M-Ficolin levels (ng/ml) at 24 h were associated to poor HH grade at admission [mean 1158 (SD 360) vs 1654 (871), p = 0.004]. M-Ficolin levels were higher in patients developing angiographic vasospasm [1119 (374) vs 1514 (755), p = 0.025] and new cerebral ischemia [1067 (325) vs 1610 (766), p = 0.003]. Higher M-Ficolin levels remained associated to new ischemic lesions (OR per 100 ng/ml of increase: 1.34, 95%CI 1.04–1.73, p = 0.026) in multivariate models adjusted for HH score, leucocyte count and aneurysmal rupture

Conclusions

M-Ficolin might be used as a marker of clinical severity and to predict the occurrence of brain ischemia after SAH. The potential neuroprotective role of the therapeutic modulation of this protein deserves further study.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

INCIDENCE OF UNRUPTURED INTRACRANIAL ANEURYSMS IN FEMALE PATIENTS WITH ISCHAEMIC HEART DISEASE

B Muinjonov ¹, E Giyazitdinova ², G Rakhimbayeva ²

Abstract

Background

Concurrence of coronary atherosclerotic lesions and intracranial aneurysms has been pointed out in several postmortem and clinical studies. However, the relative risk for intracranial aneurysms in patients with ischaemic heart disease remains uncertain. The aim of this study is to elucidate clinically whether ischaemic heart disease is a risk factor for intracranial aneurysms.

Methods

Between October 2013 and May 2015, 84 patients with ischaemic heart disease with angiographically established coronary artery stenoses who had no history of stroke (ischaemic heart disease group; men:women = 58:26, mean (SD) age = 61.1 (9.6) years) and 200 age matched subjects with minor neurological disorders who had no history of ischaemic heart disease (control group; men-:women = 117:83, mean (SD) age = 62.0 (9.2) years) were screened with magnetic resonance angiography (MRA) for the presence of unruptured intracranial aneurysms. For all MRA positive patients, selective angiography was then undertaken.

Results

In the ischaemic heart disease group, the frequency of unruptured intracranial aneurysms established angiographically was 3.4% for men and 15.4% for women, compared with 2.6% and 3.6% respectively in the control group. Multiple logistic regression analyses disclosed that ischaemic heart disease was a significant and independent predictor for intracranial aneurysms in women.

Conclusions

These results suggest that in women ischaemic heart disease is a risk factor for intracranial aneurysms. Coexistence of intracranial aneurysms should be suspected in women

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

TACHYPACING INDUCED CARDIAC FLOW ARREST: A NOVEL SURGICAL STRATEGY FOR DEFLATING CEREBRAL ANEURYSMS IN CLIPPING SURGERY

Y Niiya ¹, M kawabori ¹, M Iwasaki ¹, S Mabuchi ¹, K Houkin ²

Abstract

Background

Transient deflation of the cerebral aneurysm is helpful to facilitate the clipping surgery, especially when the size of the aneurysm is large. Temporary occlusion of the parent artery is an effective method to reduce the pressure of the aneurysm. However, it may not be feasible in some case. Transient cardiac arrest (TCA) induced by adenosine triphosphate (ATP) is another method for such cases. We usually use a bolus dose of ATP to provoke a short period of cardiac arrest, but its precise duration of arrest is unpredictable. Tachypacing can control the cardiac output at will. We present the efficiency of tachypacing induced cardiac flow arrest in the clipping process.

Methods

320 consecutive patients with cerebral aneurysms (ruptured: 147, unruptured: 173) were surgically treated between 2007 and 2015. Of these, 2 patients underwent microsurgery with tachypacing. Pacing electrode was placed after general anesthesia induction. During microsurgery, the pacing rate was elevated to decrease the cardiac output when aneurysm deflation was needed.

Results

In one case, we observed about 40 seconds of flow arrest and noted remarkable softening of the aneurysm, and the aneurysm was successfully obliterated. In another case, tachypacing was used for the management of premature rupture of the aneurysm. Complications associated with tachypacing were not observed in any of these patients.

Conclusions

Tachypacing facilitated safe and quick dissection of the aneurysm and clip application. This method is useful when temporary occlusion of the parent artery is difficult. Tachypacing is basically a better method than ATP-induced TCA in terms of time controllability.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CONTRIBUTION OF ENDOTHELIAL-TO-MESENCHYMAL TRANSITION IN HUMAN CEREBRAL CAVERNOUS MALFORMATIONS

S Takada ^1,², M Hojo ^1,³, K Tanigaki ², S Miyamoto ¹

Abstract

Background

The analysis of gene-targeted mouse mutants has demonstrated that endothelial-to-mesenchymal transition (EndMT) is crucial in the onset and progression of cerebral cavernous malformations (CMs). However, the role of EndMT in the development of human cerebral CMs remains unclear. The aim of this study was to elucidate the contribution of EndMT to the pathogenesis of human cerebral CMs.

Methods

Eight human intracranial CMs (five cerebral CMs and three orbital CMs) were immunohistochemically investigated.

Results

CD31 (an endothelial marker), α-smooth muscle actin (α-SMA, a mesenchymal marker) and CD44 (a mesenchymal stem cell marker) were expressed in endothelial layers of vascular sinusoids in all cases. These findings suggest that endothelial cells had undergone EndMT in human intracranial CMs. In all cases, Notch1 and Notch3 were expressed in endothelial layers, whereas its effecter Hey2 was scarcely detected. These results are consistent with previous findings in gene-targeted mouse mutants and cultured cells, and suggest that the impairment of Notch signaling is involved in the formation of human intracranial CMs. In all cases, both ephrin-B2 and EphB4 were detected in endothelial layers, suggesting that endothelial cells of vascular sinusoids are immature or malformed cells and have both arterial and venous characteristics in human intracranial CMs.

Conclusions

EndMT plays a critical role in the pathogenesis of human intracranial CMs. In addition, the impairment of Notch signaling is involved in the formation of human intracranial CMs. They are composed of immature or malformed endothelial cells with both arterial and venous characteristics.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

SCEPTER BALLOON CATHETER FOR TREATMENT OF CEREBRAL VASOSPASMS IN PATIENTS WITH SUBARACHNOIDAL HEMORRHAGE

I Tsogkas ¹, D Behme ¹, K Schregel ¹, V Malinova ², M Knauth ¹, MN Psychogios ¹

Abstract

Background

Delayed cerebral ischemia is one of the leading causes of death and disability in patients with subarachnoidal hemorrhage (SAH). Balloon angioplasty is a therapeutic option for vasospasms affecting proximal intracranial arteries. We report our experience using the Scepter balloon catheter for the treatment of cerebral vasospasms due to SAH.

Methods

We reviewed patients from our hospital from 2014 to 2016. Seventeen cases (mean age 43, 9 women) with SAH-related cerebral vasospasms, that were endovascularly treated with the Scepter balloon catheter, were identified. All patients suffered from vasospasms refractory to medical treatment. Patients were screened with transcranial doppler sonography and multimodal computed tomography (CT) including CT angiography and CT perfusion.

Results

Use of the Scepter balloon catheter for the treatment of cerebral vasospasms was feasible. Due to the improved trackability of the Scepter balloon catheter and the softness of the balloon we were able to successfully reach and treat the affected proximal intracranial vessels in all cases. The A1 segment of the anterior cerebral artery was treated in 4 cases. No complications and no vasospasm recurrence of the treated arteries requiring endovascular retreatment were observed.

Conclusions

Balloon angioplasty has been successfully used to treat SAH patients suffering from cerebral vasospasms refractory to medical treatment. Use of the Scepter balloon catheter shows improved feasibility and trackability and isn’t associated with major complications.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

IMPROVING THE QUALITY OF MEDICAL DISCHARGE SUMMARIES FROM AN ACUTE STROKE UNIT: AN AUDIT PROJECT

D Addala ¹, V Nelatur ¹

Abstract

Background

Written discharge summaries handover key information from hospitals to community care. Maintaining high quality discharge summaries is essential to facilitate secondary prevention, therapy and long term treatment of stroke patients.

Methods

Our aims were to improve the information included in electronic discharge letters (EDLs) from a busy stroke unit at the Royal Berkshire Hospital, Reading. Using NICE and local guidelines we derived a stroke specific discharge template including 15 essential information ‘fields’ (Figure-1). 48 EDLs over 2 × 2 month cycles were retrospectively audited before and after intervention.

Our standards were:

>85% of EDLs should contain adequate information overall

>85% compliance with each individual ‘field’

Results

Our baseline measurement showed <10% of EDLs included adequate information overall with only 3/15 essential fields meeting the 85% compliance.

Our key interventions included an educational session for junior doctors, making an electronic copy of the ideal EDL template available on ward computers, and displaying posters in targeted locations.

Our final cycle showed 80% of discharge letters included adequate information and 13/15 fields met >85% compliance. The rate of driving advice improved from 70% to 96% and recording of blood pressure, lipid targets and NIHSS dramatically improved (Figure- 1).

graphic file with name 10.1177_2396987316642909-fig71.jpg

Conclusions

Our project has shown that a novel stroke specific discharge template can improve the quality of communication between secondary and primary care, improving patient safety and enhancing long term care of stroke patients.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

IMPROVEMENT IN ACUTE STROKE OUTCOMES AFTER ADAPTING A NOVEL TRIAGING SYSTEM FOR PATIENT DISPOSITION - THE DHOW3 STUDY

N AKHTAR ¹, P Bourke ¹, S Kamran ¹, S Joseph ¹, M Santos ¹, A Salam ¹, D Deleu ¹, A Shuaib ¹

Abstract

Background

A delay in admission of acute stroke patients from the emergency department (ED increases the risk of complications, increased the length of stay in hospital and mortality. We wish to evaluate if better triaging of high-risk stroke patients from the ED will reduce complications and lead to better outcome.

Methods

Based on the data available from our stroke registry, we designed a score to evaluate the risk of complications [DHOW3- dysphagia, hemiplegia, observation, wet {incontinent}, weight (obesity}, wait {time spent in ED} see figure 1). We implemented the use of DHOW3 score in the ED, piloted it for validity and inter-rater variability. The DHOW3 score was used to expedite transfer of patients at the highest risk for development of complications.

graphic file with name 10.1177_2396987316642909-fig72.jpg

Results

A total of 473 patients were evaluated, mean score 5.06 ± 2.06, mean NIHSS score 5.0 ± 5.3 and mean ED duration 15.17 ± 14.1 hours. Complications were noted in 2.3% of patients. Complications were associated with more severe DHOW3 score (≥5 in 90.9% vs 9.1%, p < 0.001), and longer duration of stay in ED (81.8% ≤4 hours ED stay vs 18.2% for >4 hours, p = 0.37) Patients with complications had a higher mean score of 7.7 ± 2.0 (vs 5.0 ± 1.7, p < 0.001), more severe stroke (mean NIHSS 14.09 ± 7.0 vs 4.73 ± 5.0, p < 0.001).

Conclusions

Adapting a novel system of patient disposition may lead to reduce complications, and reduced length of stay in ED, especially in patients with severe stroke. This will create more space for other high risk patients in a significantly busy ED.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CASE-CONTROL STUDY OF IMPACT OF TELEMEDICINE CONSULTATIONS ON THE OUTCOME OF PATIENTS WITH INTRACEREBRAL HEMORRHAGE

A Alasheev ¹, A Belkin ¹, F Badaev ¹, E Chadova ²

Abstract

Background

During the initial application of telemedicine for stroke, the use of neurocritical care robotic teleconsulting (NCCT) was explored in patients with intracerebral haemorrhage (ICH). We aimed to analyze the impact of NCCT on the outcome of patients with ICH compared with no NCCT.

Methods

Medical records of adult patients with ICH admitted between December 2009 and December 2013 in four randomly selected primary stroke units of the Sverdlovsk region were analyzed retrospectively. In a blinded manner, cases using NCCT were matched with control case of patients with no NCCT. Pairs were matched by hospital, year of admission, gender and age.

Results

Sixty-one matched pairs were selected from 428 medical records. In the group with NCCT 43 (70%) patients died versus 50 (82%) in the group with no NCCT. Odds ratio for death was 0.46 (95% confidence interval, CI 0.14 to 1.30), p = 0.108. In multivariate analysis, the effect of the use of NCCT on mortality was not significant, p = 0.746. There were significantly more patients requiring mechanical ventilation in the NCCT group (28% versus 11%, p = 0.021). The estimated power of the study was 35.2%.

Conclusions

The use of NCCT in patients with intracerebral hemorrhage did not adversely affect mortality in this small sample. NCCT was used in more severe patients. Further research is necessary to assess the safety and efficacy of NCCT in this patient group.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE COST OF STROKE ASSOCIATED PNEUMONIA IN A UK DISTRICT GENERAL HOSPITAL

A Ali ¹, J Howe ², J Redgrave ², A Majid ², S Pownall ³, R Bainbridge ², E Richards ², K Chris ², A Abdelhafiz ⁴

Abstract

Background

Stroke associated pneumonia (SAP) occurs in approximately 25% of stroke patients, imparting greater morbidity and mortality than patients free of pneumonia. Such complications probably have significant health resource implications. Our objective was to investigate the direct acute care costs associated with SAP.

Methods

Clinical and sociodemographic data were prospectively collected from 213 consecutive patients with confirmed stroke (196 ichasemic), admitted to a UK district general hospital, November 2011 to October 2012. Patients classified as developing SAP if they fulfilled criteria for probable or definite infection according to the Centres for Disease Control and Prevention (CDC) guideline, within the first 7 days of stroke. Resource use was calculated using a ‘bottom up’ approach. Univariate and multivariate stepwise regressions were performed to identify predictors of direct costs.

Results

Twenty eight patients (13.1%) developed SAP. Mean costs across all patients (year 2012) were £7,035 (standard deviation [SD] £6,767), but were significantly higher among patients with SAP than without (£14,371 [9,484] vs £6,103 [5,735], p = < 0.001). SAP independently predicted costs, resulting in an adjusted incremental effect of an additional £5,817 (95% CI 4,945 – 6,689; p = 0.001).

	All patients (n = 213)	No SAP (n = 185)	SAP (n = 28)	P
Median NIHSS (IQR)	5(11)	5(9)	17.5(13)	<0.001
Independent on discharge (MRS 0-2) %	43.4	48.4	4.2	<0.001
Mean total acute care costs (SD) £	7035(6767)	6103(5735)	14371(9484)	<0.001

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Conclusions

Development of SAP may independently increase direct costs of acute stroke by 80%. This is the first such study within a UK setting and highlights the importance of further research to reduce the burden of SAP.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

USE OF MODELLING TO PLAN REGIONAL RE-CONFIGURATION OF HYPER-ACUTE STROKE SERVICES

K Pearn ¹, M Allen ¹, M Pitt ¹, K Stein ¹, M James ²

Abstract

Background

Recent reorganisations of stroke services in England have focussed on centralising acute care into fewer, larger hyperacute stroke units (HASUs) admitting 600–1500 patients/year. Such reorganisation in urban settings requires minimal compromise in ambulance transport times, but challenges are much greater in dispersed, mixed urban and rural environments.

Methods

We modelled the clinical impact of reconfiguration of hyperacute stroke services in South West England (population 4.5 million, 201 people/km²) presently served by 14 acute hospitals, and with over 7,500 acute stroke admissions/year. We developed a model that identified solutions with between 2–14 HASUs, meeting a number of criteria. These included 1) minimise average and maximum ambulance travel time, 2) maximise anticipated net clinical benefit (based on onset-to-thrombolysis times), 3) maximise number of patients who live and are treated within the region, and 4) maximise proportion of patients attending hospitals with 600–1500 admissions/year.

Results

High level results are shown in the table.

graphic file with name 10.1177_2396987316642909-fig73.jpg

Conclusions

Geographical modelling of HASU services produced a range of configurations for each indicative number of HASUs. Selection of a particular configuration is dependent on other factors, principally workforce availability and co-location with other critical services such as interventional cardiology and neuroradiology. Our experience was that modelling contributes significantly to the planning of services but must never be performed in isolation from knowledge of the other factors that may influence selection from a range of ‘near-equivalent’ configurations.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

FACTORS DRIVING THROMBOLYSIS USE AND SPEED. A RETROSPECTIVE DATA ANALYSIS AND MODELLING STUDY OF SEVEN ACUTE HOSPITALS

M Allen ¹, K Pearn ¹, M Pitt ¹, T Monks ², K Stein ¹, M James ¹

Abstract

Background

There remains significant variation between hospitals in the UK in both thrombolysis rates for ischaemic stroke and door-to-needle times.

Methods

We performed an analysis of thrombolysis pathway data from seven regional hospitals whose overall thrombolysis rates for ischaemic stroke ranged from 7.0% to 15.9%, and used these data as the basis for a computer simulation model to investigate factors that affect use and speed of thrombolysis. Each of the seven hospitals had different pathways for delivering thrombolysis.

Results

Three factors were pivotal in governing thrombolysis rate: (1) the proportion of patients where stroke onset time was determined (range 44%-73%), (2) pathway speed (median arrival to scan ranged from 11–56 minutes for those arriving within 4 hours of onset, median scan to thrombolysis ranged from 21–44 minutes) and (3) predisposition to thrombolyse: thrombolysis rate ranged between 32%-65% for ischaemic stroke patients scanned with 30 minutes left to thrombolyse. Most variation in speed was observed in the arrival to scan stage. Those hospitals with paramedics taking patients to CT scanner had significantly faster arrival to scan times (median 11–15 minutes) than those hospitals where there is a handover to ED staff prior to scanning (median 30–56 minutes).

Conclusions

Three key factors governing thrombolysis rates and speed have been identified. Service improvement should be targeted to the factor(s) which are most limiting thrombolysis rate or speed. Simulation allows prediction of future performance if specific factors are targeted.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CENTRALISING STROKE SERVICES IN A MIXED URBAN AND RURAL ENVIRONMENT: WINNERS AND LOSERS?

M Allen ¹, K Pearn ¹, M Pitt ¹, T Monks ², K Stein ¹, M James ³

Abstract

Background

Recent reorganisations of stroke services in England have focussed on centralising hyperacute care (first 72 hours) into fewer hospitals, creating Hyperacute Stroke Units (HASUs). Such reorganisation has shown the potential to reduce mortality and offer improved 24/7 access to imaging and specialist staff.

Methods

In investigating the impact of reconfiguration in a large mixed urban and rural region in South West of England (population 4.7 million, 201 people/km²), we created a geographic model starting with the current 14 acute stroke centres. The model predicted ambulance travel times in a reconfigured system of 2–13 centralised HASUs. Clinical benefit was estimated based on modelled onset-to-treatment times, using either current door-to-treatment times or an assumed 45 min for any future HASUs.

Results

With eight centres, average onset-to-thrombolysis time could be reduced by 8 minutes and maximum onset-to-thrombolysis time could be reduced by 20 minutes. The clinical benefit (number of additional patients with no significant disability per 100 eligible patients thrombolysed) increased from 10.2 using 14 units with current door-to-needle times to 10.6 when reconfigured into 8 units delivering 45 minutes door-to-needle times.

With 8 HASUs 77% of patients would be expected to experience faster onset-to-thrombolysis time, with the remaining 23% of patients experiencing slower onset-to- thrombolysis time.

Conclusions

Centralisation of stroke services in a mixed rural and urban setting could lead to overall clinical benefit gain, but a significant minority of patients would experience slower onset-to-treatment times. The slower thrombolysis may be offset by the additional benefits of care in a larger specialist centre.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

‘RING-FENCING’ BEDS FOR STROKE PATIENTS IN ACUTE AND COMMUNITY SETTINGS. IS IT FEASIBLE TO RESERVE STROKE BEDS FOR STROKE PATIENTS?

K Pean ¹, M Allen ¹, M Pitt ¹, T Monks ², K Stein ¹, M James ³

Abstract

Background

English stroke care standards stipulate that all stroke patients should be admitted to a specialist stroke ward within 4 hours of admission and 90% or more of their stay should be in a specialist stroke unit. One means of achieving this is to ‘ring-fence’ stroke beds exclusively for stroke patients.

Methods

We have analysed and modelled an acute and community stroke system to test the feasibility of reserving a pool of acute and community beds. The acute hospital admits 721 patients per year with acute stroke, and the two linked rehabilitation hospitals 383 patients per year (combined).

Results

In the model of the acute hospital in order to have a free bed available 90% of the time 10 beds would be required, with 7 beds being occupied on average. In the two rehabilitation hospitals in order to have a free bed available 90% of the time 19 and 21 beds would be required, with 14 and 16 beds being occupied on average. In order to have a free bed available 90% of the time the acute stroke unit would need to run at no more than an average 70% occupancy and the rehabilitation hospitals ∼75% occupancy.

Conclusions

Though protection of stroke beds for stroke patients is regarded as desirable from the clinicians’ and patients’ perspective, it demands running at unfeasibly low levels of bed occupancy in order to accommodate significant variation in demand.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

WHICH WAY SHOULD THE AMBULANCE TURN? IS TIME TO HOSPITAL ARRIVAL OR TIME TO TREATMENT MOST IMPORTANT?

K Pearn ¹, M Allen ¹, M Pitt ¹, K Stein ¹, M James ²

Abstract

Background

For acute ischaemic stroke, call-to-needle time is critical to the efficacy of thrombolysis. Efficacy reduces rapidly over the first few hours after stroke onset. Ambulance crews respond to this urgency by conveying patients to the closest hospital providing hyperacute stroke care. However, this disregards the fact that there remains significant variation between hospitals in door-to-needle times.

Methods

We performed analysis and modelling of the combined effect of ambulance call-to-door times and hospital door-to-needle times. The setting we modelled was a system in South West of England with a population of 4.5 million, with 14 acute hospitals admitting emergency stroke patients and ∼7,500 acute admissions per year.

Results

If call-to-needle time, rather than just call-to-door time, is taken into account, then the decision on which hospital to take a patient to would be different for 1,831 patients per year. For those patients affected, the average difference is approximately 8 minutes. 306 patients per year could have time to treatment improved by 15 minutes or more by being taken further to a hospital with shorter door-to-needle times. Our analysis allows the production of maps that could be used by ambulance services in the UK to select hospitals for emergency stroke treatment according to potential clinical benefit rather than simply distance.

Conclusions

Such geographical analysis involving the whole hyperacute stroke pathway, from call to treatment, could have a significant impact on the overall clinical benefit from time-critical treatment for hyperacute stroke through the improved selection and use of hospitals delivering the quickest treatments to the greatest number.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

RECEIVING ALL COMPONENTS OF A STROKE CARE BUNDLE IMPROVES POST-DISCHARGE SURVIVAL AND QUALITY OF LIFE OUTCOMES

NE Andrew ¹, CS Anderson ², NA Lannin ³, S Middleton ⁴, CR Levi ⁵, HM Dewey ¹, B Grabsch ⁶, S Faux ⁷, K Hill ⁸, R Grimley ⁹, GA Donnan ⁶, D Cadilhac ¹

Abstract

Background

Further research on how evidence based organised stroke care can improve patient outcomes is needed. We examined the association between receiving an evidence based care-bundle and post-discharge outcomes in an Australian cohort of patients discharged to the community from acute care.

Methods

2010–2013 data, from patients with stroke or transient ischaemic attack discharged to the community from hospitals participating in the Australian Stroke Clinical Registry (AuSCR: N = 38), were assessed. Adherence to a care-bundle containing: admission to a stroke unit; receiving antihypertensive medication at discharge; and provision of a discharge care plan, was calculated. Regression and survival analyses, adjusted for patient and clinical factors and clustering, were used to assess differences in Quality of Life (QoL) at 90–180 days (EQ-5D Visual analogue scale 0–100, death = 0) and survival within 180 days.

Results

7673 episodes of care (median age 72 years, 45% female, 56% ischaemic stroke) were assessed: 29% received all care-bundle components; 40% received two; 26% received one and 6% received none. Compared to patients who did not receive any components, those who received two (Hazard Ratio: 0.5, 95%CI: 0.4, 0.8) and those who received all three (Hazard Ratio: 0.4, 95%CI: 0.3, 0.6) had a significantly reduced risk of death within 180 days. Better QoL at 90–180 days was also found (two components, co-efficient: 5.7, 95% CI: 0.8, 10.6 or three components, co-efficient: 7.7, 95%CI: 2.7, 12.7).

Conclusions

Our findings highlight the importance of receiving all components of a care-bundle, containing care on stroke units and discharge processes, to maximise outcomes.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

INTEGRATING AN ACUTE STROKE TELEMEDICINE SERVICE INTO USUAL PRACTICE: AN INTERNATIONAL COMPARISON OF SPECIALIST PROVIDERS’ PERCEPTIONS OF IMPLEMENTATION

K Bagot ^1,^2,³, D Cadilhac ^1,³, C Bladin ^1,³, M Vu ¹, G Donnan ¹, H Dewey ⁴, H Emsley ⁵, P Davies ⁶, E Day ⁷, G Ford ⁸, C Price ^9,¹⁰, C May ¹¹, CL Watkins ^12,¹³, E Lightbody ^2,¹⁴

Abstract

Background

Stroke telemedicine can reduce inequities in healthcare by increasing rural access to stroke specialists for thrombolysis decisions, thereby improving patient outcomes. Successful implementation requires specialists adapting to providing consultations remotely: a disruptive innovation. How specialists’ experiences vary internationally is unknown. We aimed to compare perceptions of United Kingdom (UK) and Australian specialists providing acute stroke telemedicine consultations remotely.

Methods

Semi-structured interviews were conducted (recorded and transcribed) with remote specialists purposively sampled pre- and post-implementation of these new telestroke networks: Australia’s Victorian Stroke Telemedicine Program (n = 6; 2010–13) and UK’s Cumbria and Lancashire telestroke network (n = 5; 2010–2012).

Using NVivo, two coders independently undertook deductive analysis using the Normalisation Process Theory framework designed for assessing integration of interventions into usual practice. Inter-rater reliability: 74–100% agreement, weighted average k = 0.67.

Results

Preliminary results (n = 3 Australia, n = 3 UK) revealed cross-cultural similarities and differences. UK and Australian specialists described old and new consulting practices, expectations and associated benefits of the telemedicine system working. Australians spoke more about telemedicine’s influence on their usual role. UK specialists discussed system governance and policy/procedures more than the Australian respondents. UK specialists focussed on tasks being workable, right skills/training and sufficient resources. In both countries, not knowing the rural Emergency Department and Radiology colleagues’ assessment and diagnostic skills was an issue. Full results will be presented.

Conclusions

Despite concerns raised, the specialists were engaged with and accepting of telemedicine as an alternate method of providing consultative care for acute stroke. The cross-cultural variation identified may reflect different models of care requiring further exploration.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

STROKE HOSPITALIZATIONS IN HUNGARY: WEEKEND LOWS - WEEKDAY HIGHS. INITIAL RESULTS FROM THE NEUROHUN-2004 - 2017 PROJECT

D Bereczki ¹, A Ajtay ¹, F Oberfrank ², D Sisak ¹, A Folyovich ³, I Szőcs ¹, I Sipos ¹, I Vastagh ¹

Abstract

Background

Stroke morbidity and mortality in Europe is highest in former Eastern-block countries including Hungary, a country with 10 million inhabitants and a single-payer health insurance system. Preliminary analyses suggested that hospital admissions for stroke are much less during weekends than on weekdays. We set forth to compare weekday and weekend hospitalizations for stroke and TIA in a nationwide database covering a 10-year period.

Methods

In the framework of the Hungarian Brain Research Program we created the anonymized NEUROHUN database from medical reports submitted for reimbursement purposes to the National Healthcare Fund from all hospital and outpatient neurological services throughout the country for 2004 – 2013. ICD-10 codes for ischemic stroke (I63 and I64), intracerebral hemorrhage (I61 and I62), subarachnoid hemorrhage (I60) and transient ischemic attack (G45) were used for patient selection from the database for the current analysis. The proportion of weekend-day to working day admissions was calculated in each group.

Results

Between January 1, 2004 – April 30, 2010, 570,932 patients were hospitalized with ischemic stroke, 48,337 with intracerebral hemorrhage, 13,080 with subarachnoid hemorrhage and 261,883 with TIA. Weekend-day to weekday rate for hospital admission was 0.93 for subarachnoid hemorrhage, 0.54 for intracerebral hemorrhage, 0.36 for ischemic stroke and 0.23 for TIA.

Conclusions

The numbers suggest that although the real incidence of ischemic stroke and TIA might be somewhat lower on weekend days than on weekdays, in many cases of weekend strokes and TIA-s hospitalization is delayed until the next working day. Public health education programs should improve this situation.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

WHAT IS IMPORTANT TO KNOW IF YOU WANT TO RUN A STROKE UNIT? RESULTS OF A DELPHI SURVEY AMONG SENIOR STROKE EXPERTS AND MASTER STUDENTS

M Brainin ¹, A Dachenhausen ¹, M Keindl ¹, Y Teuschl ¹, B Firlinger ¹

Abstract

Background

As a supporting action for the setup of a stroke unit in low/middle income countries a list of learning objectives for stroke physicians was developed.

Methods

A two-round Delphi process was performed among nine international senior stroke experts. In the first round 54 prespecified learning objectives (LO) which included three categories: acute management ‘(31LO), early rehabilitation ‘(16LO), and, quality management’ (7LO) were rated as either ‚essential‘, ‚less essential‘, or ‚rarely essential‘. In the second round new items considered important could be added and items with low importance were eliminated. The results were then compared to the rankings performed by the ESO Master Students of Stroke Medicine.

Results

In the category ‚acute managment’ the most preferred LO were: recognize acute stroke, diffentiate ischemic from hemorrhagic stroke, identify patients for thrombolysis, and assess vital functions. Indications for secondary prevention, recognize disturbances of speech and language, and management of a multidisciplinary stroke unit, were higly weighted LOs for early rehabilitation and to train paramedics and to avoid pre- and intrahospital time delays were preferred in the quality management category. Students were largely in agreement with these rankings but also preferred some technical items, such as LO for echocardiography and coagulation disorders. In contrast, the senior stroke experts gave more importance to identifiying prehospital delays.

Conclusions

Rankings chosen by senior stroke experts and by Master students were largely compatibel and seem useful for training of stroke physicians in low/middle income countries.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

MOVING BEYOND THE "WEEKEND EFFECT" TO DESCRIBE 24/7 VARIATION IN THE QUALITY OF ACUTE STROKE CARE

B Bray ¹, G Cloud ², M James ³, H Hemingway ⁴, L Paley ⁵, K Stewart ⁶, P Tyrrell ⁷, CDA Wolfe ⁸, A Rudd ⁹

Abstract

Background

Studies in many health systems have found evidence of a "weekend effect" (poorer quality of care on weekends) in stroke care. In the first study of its kind, we aimed to describe 24/7 variation in quality across the entire week, and not just between weekends and weekdays.

Methods

Nationwide registry based prospective cohort study. Data were from the Sentinel Stroke National Audit Programme of 74307 patients admitted with acute stroke in England and Wales. Temporal variation in thirteen measures of acute care quality was visualised using heatmaps and modelled with multilevel multivariable regression models

Results

Measures of quality differed in both the magnitude and pattern of 24/7 variation, affecting patients across the whole week and not just those admitted at weekends. Four patterns of variation were identified: a diurnal pattern (e.g. dysphagia screening), a day of the week pattern (e.g. occupational therapy assessment), an off hours pattern with worse quality both overnight and at the weekend (e.g. door to needle time) and a flow pattern where quality changed sequentially across weekdays (e.g. stroke unit admission). There was no significant difference in adjusted 30 day survival between weekends and weekdays (aOR 1.03, 0.95–1.13) but patients admitted overnight had lower odds of survival (aOR 0.90, 0.82–0.99).

Conclusions

The "weekend effect" is a simplification of more complex patterns of temporal variation in stroke care quality that extend across the whole week. Recognising these patterns may be an important new tool for quality improvement in stroke care.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

MOVING FROM QUALITY TO VALUE: BUILDING HEALTH ECONOMICS INTO A NATIONAL STROKE QUALITY REGISTER

B Bray ¹, X Xu ², E Vestesson ³, A Desikan ⁴, D Wonderling ², CDA Wolfe ⁴, A Rudd ⁵

Abstract

Background

Understanding the costs of healthcare is a fundamental component of healthcare quality, recognised in the Institute for Health Improvement's "Triple Aim". We aimed to use health economic modelling to enable the national quality register of England and Wales (SSNAP) to routinely report on the costs of stroke to health and social care services

Methods

An individual patient sampling model was built to simulate the stroke care pathway and derive estimates of direct health and social costs attributable to acute stroke in England. Data on patient demographics, acute stroke care and rehabilitation practice were extracted from SSNAP. Data on post stroke survival, disability and quality of life were extracted from the South London Stroke Register, a population based register with long term longitudinal follow up.

Results

The model is being validated and results will be available in January 2016. The model produces cost estimates of 1 and 5 year health and social care costs based on individual patient characteristics (age, stroke type, sex, admission NIH stroke severity score). Costs will be estimated for all patients included in SSNAP (80000/year). This will enable SSNAP to publish data every 3 months on the quality, outcomes and cost of stroke care for all admitting hospitals in England

Conclusions

SSNAP will be one the first national quality registers in the world to integrate reporting of health and social care costs alongside other data on healthcare quality. This will allow new uses of SSNAP data for quality improvement in stroke care.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

INTEGRATED COMMISSIONING IN LONDON. FEASIBILITY OF A NEUROREHABILITATION STEP DOWN UNIT TARGETING PATIENTS FROM ACUTE STROKE UNITS READY OR 'NEAR READY' FOR EARLY SUPPORTED DISCHARGE

G Christofi ¹, A Chandratheva ¹, C Walters ², E Bretherton ², V yeardley ², D Lally ², R Brealey ², H warwick ², B tahtis ², S Meechin ², V Stevenson ¹, S daniels ¹, C Melody ¹, S browning ¹, S edwards ¹, R macarimban-ingelsant ¹, V basan ¹, R simister ¹

Abstract

Background

Hyperacute stroke units (HASU) within metropolitan areas serve multiple boroughs which can restrict patient flow. We developed an acute neurorehabilitation model to improve patient flow from HASU to the community. We aimed to see if regular neuro-navigator in-reaching to HASU and spoke acute stroke units (ASU), 7 days/week from multiple boroughs to our unit, prior to ESD could improve flow through the stroke pathway.

Methods

We developed a 7-bedded (winter pressures project) neurorehabilitation step-down unit at St Pancras Hospital, London (January 26th-May 27th 2015). We accepted patients from HASU and ASU assessed by a neuro-navigator, providing early rapid, paperless assessment. Referred patients were deemed ESD ready or ‘nearly ready’ and accepted regardless of borough. Cost analysis was performed.

Results

We admitted 82 patients from 12 London boroughs: Islington 21 (26%), Camden 17 (21%), Haringey 15 (19%), Enfield 12 (15%); others: 17 (20%). 66 (80%) were stroke; 16 (20%) were non-stroke and ineligible for ESD. 64 (79%) were admitted within one day of referral; 30% were admitted Friday-Sunday, releasing acute weekend beds. Average length of stay (LOS) was 8 days. Cost analysis comparison with the standard pathway demonstrated a £2300/patient saving. In-reaching into one ASU reduced average LOS by 3 days and expedited transfer for further neurorehabilitation by 11 days.

Conclusions

Admitting patients from multiple boroughs improves bed occupancy, enhances partnership, supports flow of patients from HASU and potentially offers an additional spoke to the pathway particularly for non-stroke patients ineligible for ESD or repatriation to local stroke units.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

DIRECT ADMISSIONS TO A LONDON ACUTE STROKE UNIT - WHO IS MISSING OUT ON HYPER ACUTE STROKE UNIT (HASU) CARE?

L Choy ¹

Abstract

Background

Since 2010, all suspected stroke patients in London should be taken to one of the 8 HASUs instead of the nearest hospital. Patients are then repatriated back to their local Stroke Unit (SU) 48–72 hours later.

The FAST test has been advertised to the general public and non-specialists to increase the awareness of the signs of stroke.

This audit reviewed the records of stroke patients who were directly admitted to a local SU.

Methods

All 244 patients admitted with a primary diagnosis of stroke between 1 April 2014 and 31 March 2015 were included.

Results

218 were repatriated from a HASU.

Of the other 26 patients:

-3 were transferred from another medical ward

-23 were admitted via the Emergency Department and GP referrals

Of the 23 direct admissions, 18 were FAST negative. Common presentations were dysphasia only (9), posterior circulation symptoms (2), visual field deficit (1), other including reduced GCS or seizures (6). Only 1 was transferred to a HASU. None of the 5 FAST positive patients were transferred: 3 due to lack of beds, 1 as >1 week since stroke onset, 1 was too unstable.

Conclusions

There remains a proportion of patients who are are missing out on hyperacute care, in particular those who are FAST negative. Increased awareness regarding the symptoms of stroke especially around dysphasia and those of posterior circulation strokes are needed. Patients are also not being transferred to a HASU due to lack of beds. This is multifactorial and includes delays within the local SU and community services.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

TIA REFERRALS TO A UK DISTRICT GENERAL HOSPITAL: 2011-2015

L Choy ¹

Abstract

Background

The National Clinical Guidelines for Stroke recommend that all patients with a suspected TIA are investigated at a specialist clinic within 24 hours for high risk patients and one week for low risk patients.

This audit looked at the number of referrals, delays and final diagnoses in a TIA clinic.

Methods

Data collected from the clinic from April 2011 to March 2015 were included.

Results

The number of referrals has increased from 340 in 2011–12, 359 in 2012–13, 440 in 2013–14 and 424 in 2014–15. The proportion of high risk referrals has remained constant at 27%, 30%, 26% and 29% respectively. The percentage of patients with a final diagnosis of TIA also has remained constant at 41%, 48%, 43% and 42% respectively with more mimic diagnoses in the low risk group.

There has been improvement in the proportion of referrals seen within target times with better performance for low risk referrals (from 83%, to 82% to 87% to 88%) compared to the high risk referrals (74% to 70% to 78% to 77%). Most delays were due to referrers and patients rather than lack of clinic availability.

Conclusions

The proportion of patients with a final diagnosis of TIA has remained constant over the last 4 years with mimic rates consistent with published data.

There have been improvements in how quickly patients are being assessed, however, performance figures are still not achieving the national target of 90%. TIA symptoms and the importance of prompt referral need to be reinforced to patients and healthcare professionals.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

STROKE DISPATCHMENT IN AN ITALIAN REGION: TREND 2008-2014 IN UMBRIA

F Corea ¹, N Murgia ², V Caso ³, A Gamboni ⁴, C Colosimo ⁵, M Zampolini ⁶, S Ricci ⁷

Abstract

Background

According to the declaration of Helsinborg, update 2006, all patients with acute stroke, who are potentially eligible for acute specific treatment, should be transferred to hospitals where there is the technical capacity and expertise to administer such treatment. Purpose of the present survey was to monitor the dispatchment of stroke patients in an Italian county Umbria between 2008 and 2014.

Methods

the database from the Progetto Nazionale Esiti (PNE) recorded by the central national agency for disease control (Centro Controllo Malattie) was analyzed. The annual volume of admissions for ischemic stroke ICD-9-CM: 433.x1, 434.x1, 436 codes were available for each hospital. A Wilcoxon signed-rank test was performed on matched year samples. A chi squared test was performed dichotomizing to admission in hospital with or without stroke unit.

Results

We observed a non significant trend in the study period to the dispatchment of patients to stroke centers. (nearly 90% in 2014). Above more than 20 authorized hospitals/clinics in 2008, only 15 of them are admitting strokes in 2014. In 2014, 1602 patients were admitted in hospitals with stroke units. The remaining 236 cases were dispatched by the ETS to other hospitals. The trend in hospitalization demonstrated a non significant increase also in admission volume with 8 out of 15 hospitals still below 100 stroke per year. Only 1,8–2.5% of patients were admitted outside the county.

Conclusions

The majority of stroke patients are admitted to appropriate hospitals. A 10% of cases are treated outside the stroke network mostly because of major geographical barriers.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

IS HELICOPTER TRANSFER STILL EFFICIENT ONCE TELESTROKE HAS BEEN IMPLANTED? AIR TRANSPORT EXPERIENCE FOR STROKE PATIENTS AND TELESTROKE IN ARAGON

GJ Cruz Velásquez ¹, A Fernandez Sanz ¹, H Tejada Meza ¹, J Artal Roy ¹, MJ Borruel ², M Samperiz ³, R Marron Tundidor ⁴, G Martinez Borobio ⁵, M Bestue Cardiel ⁶, J Marta Moreno ¹

Abstract

Background

Aragon has 47,719.2 km2 and 1,325,385 inhabitants, and its low population density (27.77 inhabitants/km2) makes it one of the least populated regions anywhere in Europe. Thrombolysis (TBL) and endovascular therapy (ET) is difficult to deal with when patients are coming from rural areas.

Methods

Data was gathered concerning consecutive helicopter transports and telestroke assistance from January 2010 to December 2014. We have analyzed the following data: time onset of symptoms to hospital arrival (TOSH), distances, diagnosis, TBL/ET and flight costs.

Results

69 patients were transferred to a tertiary stroke center. 26% of them received TBL and 1.4% ET. The remaining 83.6% were deemed to be unnecessary transfers (20% hemorrhagic stroke, 9% transient ischemic attack, 66% ischemic stroke without TBL/ET criteria, 5% other diagnosis).

The average distance traveled by helicopter was 106.09 km (CI 75.6–179). The average TOSH was 143.9 minutes (CI 75–270), most patients (82%) arrived within 180 minutes. TBL rate in Aragon increased from 4.4% (2010) to 8.3% (2014). 30% of all TBL were performed in peripheral hospitals. 62% of unnecessary transfers were avoided by telestroke, TBL was administered in 38% of all telestroke support. The transport by helicopter decreased 80% in 2014 compared to 2010. The cost-per-flight-hour was 5,297.25 €.

Conclusions

Air transport improved access of patients from rural areas but telehealth is a great complement. Once implanted telestroke, both the number of transfers as well as their costs decreased. Telestroke has led to a suitable selection of patients, enables a timely transfer for ET and rtPA administration.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE IMPACT OF ENHANCED WEEKEND THERAPY SERVICE PROVISION IN A LONDON HYPERACUTE STROKE UNIT

J Eng ¹, R Simister ², M Melnychuk ³

Abstract

Background

In the UK inpatient stroke therapy services have historically been provided Monday to Friday. Although it is assumed that the creation of a 7 day therapy week will improve patient care and reduce length of stay (LOS) little is known about the impact of this change on patient flow. This study aimed to determine the impact of having enhanced therapy provision on a HASU on LOS, discharge activity and therapy activity and workload.

Methods

We recorded data on therapist activity during the baseline period when only emergency therapy cover was provided at weekends, and during a four month extended seven day therapy provision trial period. Data obtained from the period of intervention was compared with data from comparable months from the previous year to determine impact on LOS and discharge activity.

Results

A comparative analysis revealed no significant differences in LOS (4.7 d in 2014 vs 5.0 d in 2015) or number of discharges on Saturday (1.9 d in 2014 vs 1.9 d in 2015) and Sunday (1.5 d in 2014 vs 1.6 d in 2015) with enhanced weekend therapy provision. However a difference was identified in other weekend therapist activity with therapists spending only 10% of time on rehabilitation activities during the baseline phase and over 40% during the intervention.

Conclusions

There was no significant impact with the introduction of full weekend therapy on length of stay or discharge activity compared to similar months. We found that enhanced weekend therapy provision allowed therapists to provide more rehabilitation during the interventional period which may improve long term health recovery.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

STROKE ALERTS - A LOW-TECHNOLOGY INTERVENTION ASSOCIATED WITH HIGH REPERFUSION THERAPY RATES. OBSERVATIONS FROM THE SWEDISH STROKE REGISTER

M Eriksson ^1,², EL Glader ², B Norrving ³, B Stegmayr ², K Asplund ²

Abstract

Background

In a between-hospital analysis including all hospitals in Sweden, we have analyzed if more frequent use of ambulances and stroke alerts are associated with increased reperfusion (thrombolysis and thrombectomy) rates. We also describe factors associated with high and low use of ambulances and stroke alerts.

Methods

This study included 49 907 stroke patients from the Swedish Stroke Register (Riksstroke) 2011–2012. We used multiple logistic regression to analyze independent predictors of stroke alert and ambulance service.

Results

The national stroke alert frequency was 22% (hospital range: 0.5% to 46%), and 73% of patients used ambulance service (hospital range: 60% to 94%). The reperfusion therapy rate was 12% in ischemic stroke patients ≤80 years (hospital range: 2.6% to 23%). There was a strong correlation between hospital reperfusion rates and stroke alerts (r = 0.75, p < 0.001), but not with use of ambulances (r = −0.02, p = 0.84).

The probability of stroke alert was higher in patients who were living in institution, were drowsy on hospital admission, had hemorrhagic stroke or AF. Age ≥ 75 years, living alone, primary school education, non-European origin, previous stroke, diabetes, smoking, and dependency in ADL, were associated with a lower probability.

Use of ambulance was associated with higher age, living alone, primary school education, non-European origin, previous stroke, AF, dependency in ADL, living in institution, being drowsy or unconscious, and hemorrhagic stroke.

Conclusions

Pre-hospital stroke management varies between hospitals and patient groups. Increasing the use of stroke alerts seems as a key component in increasing the reperfusion therapy rate.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

DOOR-TO-NEEDLE TIME IN STROKE TREATMENT: IS THERE A JULY EFFECT?

MA Hawkes ¹, F Carpani ¹, M Fernandez-Suarez ¹, MM Gomez-Schneider ¹, SF Ameriso ¹

Abstract

Background

Intravenous thrombolytic therapy (IVT) improves outcomes in acute ischemic stroke, but its benefit is time dependent. Door-to-needle time (DTNT) is an important variable to evaluate the activity of the stroke team. The “July effect” refers to a worsening of outcomes in teaching hospitals with arrival of new inexperienced house staff. As residents actively participate in acute stroke management at our institution, our aim was to evaluate the impact of the July effect in the DTNT.

Methods

Retrospective analysis of FLENI Stroke Database between June 2003 and June 2015. Data from patients with acute ischemic stroke treated with IV-rtPA were included. DTNT was stratified in 4 trimesters (June-August, September-November, December-February, March-May). As in Argentina the academic year begins in June, DTNTs of the first trimester (June-August) were compared with the last one (March-May). Percentage of thrombolysis in <60 minutes, thrombolysis of stroke mimics and post thrombolysis intracranial hemorrhages (ICH) were also assessed.

Results

Ninety-one patients received IVT between June 2003 and May 2015. There were 27 patients in the first trimesters and 23 patients in the last trimesters. DTNT was similar between first and fourth trimester (62,7 vs 62,3 min p = 0.844).

We did not find differences in other variables such as symptomatic hemorrhages, thrombolysis of stroke mimics and number of thrombolysis in <60 minutes between first and fourth trimesters.

Conclusions

In our institution we did not find a July effect in the DTNT for IVT. The staggered supervision and continuing medical education of residents may be, at least in part responsible for these findings.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EMBEDDING PARAMEDICS IN HYPERACUTE STROKE UNIT CARE

H Haran ¹, A Bhalla ¹, J Birns ¹

Abstract

Background

The best outcomes for acute stroke treatment occur through rapid recognition and transfer of patients to hospitals with a hyperacute stroke unit (HASU). Pre-hospital ambulance paramedics are crucial to this process as first responders but they have limited feedback on subsequent patient care and progress to improve their learning.

Methods

Over a 3 month period, 30 paramedics were invited to spend a ‘work-shift’ at a HASU where they individually received a standardised introductory educational briefing and subsequently participated in clinical activities with multidisciplinary HASU staff. On completion of their ‘shift’, they completed a standardised semi-structured questionnaire about their learning and experience of technical and non-technical skills. All text was thematically analysed and themes were developed by iteratively recoding and regrouping the data.

Results

100% of paramedics reported that a ‘work-shift’ at a HASU was useful to their learning and training with ‘real-world’ transferability. 93% stated that they benefited from directly observing a clinician performing patient assessments and 73% commented that they gained a better understanding of care pathways and treatment. These 2 themes encompassed 48% of 160 free-text responses with the other responses being grouped into 4 further themes (improved ‘handover’; improved patient communication; increased awareness of subtle signs of stroke; localisation of intracranial pathology).

Conclusions

Paramedics reported that clinical attachment to a HASU improved their clinical and non-clinical skills in managing stroke and considered it to be useful and effective. This emphasises the importance of a collaborative approach to improving stroke patient care and outcomes across healthcare boundaries.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

WHAT HAPPENS TO ACUTE STROKE INPATIENTS' FLUID BALANCE, RENAL STATUS AND DEHYDRATION IN THE FIRST TWO WEEKS: HOW CAN THEY BE MARKEDLY IMPROVED?

S Hart ¹, L Burton ¹, R craig ¹

Abstract

Background

The precise pattern of acute stroke patients daily fluid balance, dehydration and renal function in a modern acute stroke unit were unknown until our presentation (UKSF 2014, shortlisted for prize). Biochemical markers of hydration, renal dysfunction and impending Acute Kidney Injury (AKI) were significantly increased every day in the first week, remaining increased at 2 weeks (P < 0.02). In 2015 we introduced numerous new interventional measures to correct this.

Methods

The following were prospectively re-audited for new acute stroke patients (n = 60) in 2015 vs 2014 (n = 60): total fluid input/output, net fluid input, plasma urea:creatinine ratio (U:Cr), urea:baseline urea (U:Ba) and e GFR. Many were analysed on an almost daily basis for the first two weeks.

Results

In 2014, markers of hydration and renal dysfunction, mean (U:Cr) and (U:Ba) were significantly increased on every consequetive day in the first 2 weeks [p < 0.02]. Average net fluid balance was often negative, despite repeated daily evidence of dehydration with markers suggesting impending AKI.

In 2015, new additional measures were introduced. There were statistically significant improvements in Net Fluid Balance every day during the first week [p < 0.05] with dramatic, statistically significant improvements of all biochemical markers of dehydration including (U:Cr), (U:Ba) and AKI [p < 0.05].

Conclusions

In 2014, adequate hydration, known to be important for stroke recivery and wellbeing, was not achieved. There was recurrent daily evidence of impending AKI. In 2015 new measures effectively corrected this, dramatically improving biochemical markers of dehydration and AKI. We will list and explain all the new interventions that achieved this marked and significant improvement.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CENTRALIZATION OF ACUTE STROKE TREATMENT IS ASSOCIATED WITH IMPROVED QUALITY OF CARE AND LOWER MORTALITY

S Hastrup ¹, SP Johnsen ², P von Weitzel-Mudersbach ¹, CZ Simonsen ¹, N Hjort ¹, AT Møller ¹, T Harbo ¹, MS Poulsen ¹, N Ruiz de Morales Ayudarte ¹, D Damgaard ¹, G Andersen ¹

Abstract

Background

In May 2012 a comprehensive reorganization of stroke service was implemented in Central Region Denmark (CRD) with 1,282,750 inhabitants. Admission of patients with symptoms of acute stroke/TIA was centralized from five to two hospitals providing specialized stroke unit care including thrombolysis (IV tPA). The objective of this study was to determine the quality and safety of the reorganization.

Methods

We obtained data on all stroke patients admitted to hospital in CRD in the period 01-05-2011 to 30-04-2015 from the Danish Stroke Registry (DSR). The DSR is a mandatory nationwide, population-based clinical registry, which holds data on patient characteristics and care. The study population was divided into 4 subgroups based on time of admission: Before - during - after - after + 1year. Quality of care was assessed using evidence-based process performance measures (n = 16).

Results

9611 stroke events were included. When comparing the process performance measures, we found risk ratios (RR) ranging from 0.81–1.54 when comparing the “after” with the “before” period. The largest improvements were observed for the proportion of patients receiving IV tPA (RR = 1.23, 95%CI: 1.07–1.41), patients with door-to-needle time ≤1 hour (RR = 1.35, 95%CI: 1.22–1.48) and the proportion of patients with carotid endarterectomy within 14 days (RR = 1.54, 95%CI: 0.99–2.40). All-or-none for the process performance measures were significantly improved (RR = 1.22 95%CI: 1.16–1.29).The mortality within 30 days of admission was reduced significantly after the reorganization (“Before” 10.37% (95%CI 9.15–11.69); “after” 8.20% (95%CI 7.13–9.38); RR = 0.79 (95%CI: 0.66–0.95)).

Conclusions

Centralization of acute stroke services was associated with an improved quality of stroke care and a reduced mortality.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

REFERRAL OF ACUTE STROKE PATIENTS FOR THROMBECTOMY IN THE POST MR CLEAN ERA; A LOGISTICAL CHALLENGE

W Hinsenveld ¹, M Wermer ², J Boiten ³, W Schonewille ¹

Abstract

Background

To evaluate the logistic process of patients presenting with an acute ischemic stroke to an intervention centre in the post MR CLEAN era.

Methods

From January 2015 through December 2015, all patients who were transferred for possible intra-arterial thrombectomy (IAT) were registered in 5 intervention centres in The Netherlands. Data were collected on the time intervals between time to presentation at the ER of the referring centre, and the diagnostic and therapeutic interventions, both in the referring and the intervention centres. These data were compared to the data collected of patients presenting directly at an intervention centre. Functional outcomes at 90 days were compared between both groups using the modified Rankin score (mRS).

Results

Data were collected on 190 patients. 149 patients were transferred to an intervention centre of which 49% was treated with thrombectomy. 41 patients were treated with IAT after direct referral. Preliminary analysis showed a time of symptom onset to groin puncture of 169 minutes in direct referrals versus 256 minutes in transferred patients. There was a better functional outcome at 90 days follow up for direct referrals (42% vs 32%).

Conclusions

Delays in symptom to groin time are considerable in transferred patients as compared to direct referrals. Improving logistics, especially in the timeframe between CT scan and arrival in the intervention centre, can potentially lead to better functional outcome.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

DEVELOPING AN ANNUAL REPORT ON STROKE CARE WRITTEN WITH AND DESIGNED FOR PATIENTS

M Kavanagh ¹, A Rudd ², M James ³, G Cloud ⁴, B Bray ², A Hoffman ¹, E Vestesson ¹, L Paley ¹, A Waite ¹, V McCurran ¹, P Tyrrell ⁵; On behalf of the SSNAP Collaboration⁶

Abstract

Background

The Sentinel Stroke National Audit Programme (SSNAP), the national stroke care register in England and Wales, routinely produces a suite of bespoke reports for targeted audiences, including clinicians, managers and policy-makers. To complement clinically-focused reports, a stroke care report written with and for patients is produced annually.

Methods

Meetings were held with patient groups to ascertain key questions on stroke care from a patient’s perspective. SSNAP data relating to 80,754 patients with acute stroke admitted between April 2014 and March 2015 were analysed. Graphs, maps, patient pictures and quotes were used to ensure findings were easily understandable and prioritised the patient voice.

Results

4 key questions were identified by patients, “What has happened to me?”, “What can be done about it?”, “Will I get better and what are the timescales?” and “What happens next?” These were addressed using SSNAP data in the Annual Report ‘Is stroke care improving?’ published on 2 December 2015. The report had over 20,000 downloads in the first week and over 52,000 as of 12 January 2016.

graphic file with name 10.1177_2396987316642909-fig74.jpg

Conclusions

Following patient consultation and feedback clinically-focused national data were used to produce a patient-centred report to answer some of the most pertinent issues in stroke care. Quality improvement registers can use such methods to ensure their data are relevant and useful for stroke survivors, as well as clinicians.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EXPERIENCE OF THE TWO-LEVEL SYSTEM OF PRIMARY AND COMPREHENSIVE STROKE UNITS IN THE RUSSIAN URBAN SETTING: LITTLE IMPROVEMENT IN SAINT-PETERSBURG

TV Kharitonova ¹, ER Kashaeva ², DV Kandiba ³, IA Voznyuk ⁴

Abstract

Background

WHO recommends reaching 15% stroke mortality and 75% functional independence among survivors by 2016, which is expected to result from the practical implementation of measures with proven efficacy, including organization of stroke units and use of acute reperfusion strategies.

Methods

Under the national stroke program, two-level model of primary and comprehensive stroke units was launched in Saint-Petersburg in 2011–2014. We aimed to analyze the results of their 5-year practice.

Results

Number of the treated stroke patients increased steadily from 8574 in 2011 to 20394 in 2015. Rate of admission before 4.5 hours from stroke onset remains low, though increased from 10–11% in previous years to 13% in 2015 (p < 0.001). Use of IV rtPA is permanently rare (0.7–1.8%). 3-month outcomes of stroke thrombolysis are comparable with international global statistics based on SITS registry: in 2014, mortality was 17% and functional independence (modified Rankin Scale score 0–2) was 38% (final data for 2015 will be available in March 2016). The use of acute endovascular interventions demonstrates positive trend (45 procedures, or 0.3%, in 2014 vs. 122, or 0.7%, in 2015, p < 0.001). Stroke mortality remains high, with a small decrease from 21.3% in 2014 to 20.4% in 2015 (p = 0.036). Rivermead score exceeds 8 in only 45% of survivors.

Conclusions

We conclude that despite high priority of stroke for the emergency medical services, and launch of stroke units with multidisciplinary teams, improvement of stroke care is weaker than expected. Further research and additional strategy may be needed to facilitate the achievement of WHO goals by low-income countries.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

WEEKEND VERSUS WEEKDAY HOSPITAL DISCHARGE: EXPERIENCE FROM THE AUSTRALIAN STROKE CLINICAL REGISTRY

D Cadilhac ¹, M Kilkenny ¹, N Lannin ², C Levi ³, S Faux ⁴, H Dewey ⁵, R Grimley ⁶, K Hill ⁷, B Grabsch ⁸, N Andrew ¹, C Anderson ⁹, G Donnan ⁸, S Middleton ¹⁰

Abstract

Background

Literature on the ‘weekend’ effect on stroke care has variable conclusions. Our aim was to compare quality of care and outcomes for patients (with stroke/TIA) discharged on weekdays compared with those discharged on weekends.

Methods

Data from the Australian Stroke Clinical Registry (AuSCR) between January 2010 and December 2013 (n = 40 hospitals) were analysed. Differences in processes of care by timing of discharge were described. Multilevel regression and survival analyses (up to 180 days post event) were undertaken.

Results

Among 14,693 eligible registrants, 1,270 (8.7%) were discharged on weekends (54% male; median age 74 years). Compared to those discharged on weekdays, patients discharged on weekends were more likely to have had a TIA (weekend 31% vs 19%; p < 0.001), could walk on admission (51% vs 41%; p < 0.001) and less often received stroke unit care (68% vs 79%; p < 0.001). Patients discharged on weekends were discharged to home more often (65% vs 50%; p = 0.001), but were less often prescribed antihypertensive medication at discharge (63% vs 70%; p < 0.001) or received a care plan if discharged to the community (42% vs 48%; p = 0.001). After accounting for patient characteristics and clustering by hospital, patients discharged on weekends had a one day shorter length-of-stay (coefficient −1.41, 95% CI: −1.8 to −1.03) and were more likely to die within 180 days (HR: 1.30, 95%CI: 1.07 to 1.60) than those discharged on weekdays.

Conclusions

Patients with stroke or TIA discharged on weekends were more likely to receive sub-optimal discharge care and have a worse outcome. Understanding the factors related to poor outcomes is important.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE TRANSREGIONAL NETWORK FOR STROKE INTERVENTION WITH TELEMEDICINE (TRANSIT-STROKE) FOR SUSTAINABLE IMPROVEMENT OF STROKE CARE IN NORTH-WESTERN BAVARIA

P Kraft ¹, S Wiedmann ², S Hillmann ², R Schneider ³, B Griewing ⁴, J Mühler ⁵, C Kleinschnitz ¹, J Volkmann ¹, PU Heuschmann ²

Abstract

Background

Despite an increasing number of stroke units (SU) in Germany, the availability of acute SU care is still limited in rural areas. Telestroke networks are increasingly implemented to improve acute stroke care (ASC) in those regions.

Methods

The recently established Transregional Network for Stroke Intervention with Telemedicine (TRANSIT-Stroke) aims to optimize ASC in north-western Bavaria, a rural region of about 1.4 mio inhabitants with approximately 6000 strokes per year. TRANSIT-Stroke comprises the majority of ASC providers in this region (hospitals without department of Neurology (level 1; n = 5), with regional SU (level 2; n = 2) or supra-regional SU (level 3; n = 4)). Supra-regional SU provide telemedical consultations for level 1 and 2 hospitals by a rotating scheme. The impact of the implementation of TRANSIT-Stroke on the quality of ASC, functional outcome and patient satisfaction will be measured in a follow-up three months after discharge of patients.

Results

In the first year of TRANSIT-Stroke (10/2014 to 9/2015) we carried out 692 acute teleconsultations. 82% of teleconsultations were provided for level 1, 18% for level 2 hospitals. Stroke mimics have been assumed in 26% of teleconsultations. In level 1 hospitals, approximately 10% of patients with suspected ischemic stroke received thrombolysis. 1472 patients were enrolled in the follow-up study in the participating hospitals.

Conclusions

TRANSIT-Stroke provides the unique opportunity to improve ASC for a whole region and allows the generation of important data about quality of ASC across all hospital levels. These figures are essential for assessment and further improvement of ASC of the local source population.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE EUROPEAN STROKE ORGANISATION (ESO) STROKE UNIT AND CENTRE NETWORK FOR THE ESO CERTIFICATION OF STROKE UNITS AND STROKE CENTRES

P Lyrer ¹, U Waje-Andreassen ², M Kaste ³, H Rodgers ⁴, HK Christensen ⁵, J Arenillas ⁶, A Zini ⁷, I Staikov ⁸, T Moulin ⁹, O Skoda ¹⁰

Abstract

Background

The ESO SU Committee is setting up a novel web based network of stroke units and centres. It will be designed to allow online certification according to the ESO recommendations (1). The aim is to warrant high quality of care and to certify institutions in Europe.

Methods

The certification will be based on an online platform where the applicants select if they want to be certified as “Stroke Unit” (SU) or “Stroke Centre” (SC). By submitting all the required information and closing the application form the information will be stored in a database, and approved by two ESO experts and one supervisor. They will advise the ESO to give the label of “ESO certified stroke unit” or “ESO certified Stroke Centre”.

Results

Once the SU or SC is certified the members will have full access to the network information and are regular members of the online platform. The items that will be evaluated are: competence of the personnel to run an interdisciplinary 24/7 stroke service, the infrastructure of the service, quality indicators such as number/amount of i.v. thrombolysis and i.a. interventions (SC), documentation of pathways (Standard Operating Procedures), and scientific contributions.

Conclusions

The displayed poster provides comprehensive information of the process and the way to proceed to a successful certification. Further information will be available at the congress booth of the ESO-office.

ADDIN EN.REFLIST

1. Ringelstein EB, Chamorro A, Kaste M, Langhorne P, Leys D, Lyrer P, et al. European Stroke Organisationrecommendations to establish a stroke unit and stroke center. Stroke 2013;44(3):828-40.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

FEASIBILITY OF NON-VASCULAR NEUROLOGICAL DISEASES MANAGEMENT IN STROKE UNITS

MC Matute-Lozano ¹, A De Felipe-Mimbrera ¹, R Vera Lechuga ¹, A Cruz Culebras ¹, S Sainz De La Maza ¹, A Alonso Canovas ¹, R Alvarez Velasco ¹, J Masjuan Vallejo ¹

Abstract

Background

Stroke units (SU) are specialized units (level 2 care) for the care of patients with acute stroke. They have demonstrated improved outcomes in comparison with neurology wards or intensive care units (ICU-level 3 care). This level 2 care could also benefit patients with non-vascular neurological diseases (NVND) deemed unsuitable or as an alternative to an ICU.

Methods

We prospectively collected data of all patients admitted in our SU with NVND from January 2007 to December 2013, including clinical variables, admission diagnosis, median stay, complications and mortality.

Results

3937 patients were admitted to our SU, 135 (3.4%) had NVND. 55.5% were male, with a median age of 61.6 years (SD 18.8, range 15–94). The most frequent diagnosis were epileptic disorders (pon la N, sin % 71.1%), followed by encephalopathies (10), Guillain-Barre syndrome (6), encephalitis (5), HaNDL syndrome (5), myasthenia gravis crisis (4), migraine with aura (3), myelitis (2), meningitis (1), glossopharyngeal neuralgia (1), multiple sclerosis relapse (1) and neuroleptic malignant syndrome (1). Median stay was 1.3 days (range 0.25–5), with 73.3% admitted from the emergency department, 14.1% Neurology ward, 7.4% ICU and 5.1% from other medical wards. We had 20 respiratory complications (50% pneumonia, 50% respiratory failure), 3 adverse drug reactions, one rhabdomyolysis, and one cardiac arrest. Twelve patients (8.9%) subsequently required ICU care and 7 (5.1%) died.

Conclusions

Stroke Units can be a valuable resource in NVND as an alternative to ICU, providing similar surveillance as those with stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

POOR LEVELS OF SWALLOW SCREENING ASSOCIATED WITH INCREASED RATES OF PNEUMONIA

J McCormack ¹, P McElwaine ², C Brennan ³, H Coetzee ⁴, P Cotter ⁵, R Doyle ⁶, A Hickey ⁷, F Horgan ⁸, P Kelly ⁹, C Loughnane ¹⁰, C Macey ¹¹, P Marsden ³, D McCabe ¹², R Mulcahy ¹³, I Noone ¹⁴, E Shelley ³, T Stapleton ¹⁵, D Williams ¹⁶, J Harbison ²

Abstract

Background

Dysphagia affects up to 72% of patients following stroke and is associated with increased risk of aspiration and pneumonia. Swallow screening by trained nurses may help identify dysphagia early and prevent pneumonia.

Methods

We compared swallow screening rates and outcomes in the Irish National Stroke Audit 2015 with SSNAP UK stroke register 2014, an audit performed in a neighbouring and comparable healthcare system and population.

Results

85% (23/27) of Irish hospitals admitting acute stroke reported availability of swallow screening within 24-hours however only 52% (11/21) of stroke units reported the availability of nurses trained in swallow screening compared to 96% in the UK. 6% of Irish cases had an urgent swallow screen compared to 56% in the UK (p < 0.0001. Chi Sq) and 29% had a swallow screen within 24 hours compared to 81% in the UK (p < 0.0001).

The rate of post stroke pneumonia was significantly higher in Ireland (144/874 (16.4%) vs 5702/66798 (8.5%). p < 0.0001.) In contrast, there was no significant difference in rate of urinary tract infection. 54/874 (6.2%) vs 3311/66798 (5.0%) p = 0.1 suggesting the difference in pneumonia rate was not due to ascertainment bias. 82% (106/144) of Irish subjects developing pneumonia had no swallow screening performed within 24 hours of admission.

Conclusions

Despite similar health care systems the rate of post-stroke pneumonia in Ireland is nearly double that of the UK this is likely to be related to the relative lack of swallow screening in Ireland.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

IRISH NATIONAL STROKE AUDIT 2015 - THE IMPACT OF ORGANISATION OF SERVICES IN A CHALLENGING ENVIRONMENT

P McElwaine ¹, J McCormack ², C Brennan ³, H Coetzee ⁴, P Cotter ⁵, R Doyle ⁶, A Hickey ⁷, F Horgan ⁸, P Kelly ⁹, C Loughnane ¹⁰, C Macey ¹¹, P Marsden ¹², D McCabe ¹³, R Mulcahy ¹⁴, I Noone ¹⁵, E Shelley ¹², T Stapleton ¹⁶, D Williams ¹⁷, J Harbison ¹

Abstract

Background

In 2008 Ireland published its first national audit of stroke services, showing large in service provision and access. In 2015 a second national audit was undertaken. In the interim a national stroke programme emerged to develop services but the country also suffered a severe economic recession with a 23% reduction in health funding 2008–2014.

Methods

We assessed 27 acute hospitals through a survey of service organisation and a clinical review of 874 cases.

Results

In the 2015 audit 27 hospitals admitted acute stroke patients compared with 37 hospitals in 2008. 21 sites (78%) provided stroke unit care, compared with 1 unit (3%) in 2008 (p < 0.001, Chi Square). Only 29% of patients were admitted directly to a stroke unit and 54% spent some time in a unit during their admission.

24/7 access to CT was available in all hospitals (78%, 2008 p < 0.05). Specialist physicians and nurses in 23 sites (85%) increased from 14% in 2008 (p < 0.001). 11% of nonhaemorrhagic strokes were thrombolysed compared with 1% in 2008 (p < 0.001).

Average length of stay reduced from 30 days to 22 days, with a reduction in newly institutionalised patients to residential care down from 15% to 8% (p < 0.001). Inpatient mortality rate dropped from 19% to 14% (p < 0.01).

A deficit in the availability of rehabilitative therapists exists, with deficits of 61%, 50% and 31% for OT, physiotherapy and SLT respectively when compared to British Association of Stroke Physician guidelines.

Conclusions

Reorganisation of services and recruitment and training of specialist staff improved service provision and outcomes for stroke patients in Ireland.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

AN EVALUATION OF STROKE KNOWLEDGE AMONGST HOSPITAL STAFF

L Mellon ¹, H Hasan ¹, D Williams ¹, S Lee ¹, A Hickey ¹

Abstract

Background

Up to 10% of stroke incidence occurs in hospital in-patients, with significant delays to treatment occurring in this population. It has been suggested up to 15% of in-hospital stroke (IHS) are denied thrombolysis due to delays in recognition of symptoms. This study sought to examine knowledge of stroke symptoms, and treatment pathways for stroke amongst general hospital staff.

Methods

A survey was conducted among hospital ward staff members using the Stroke Awareness Questionnaire, which was adapted for use among hospital staff to assess their knowledge of stroke symptoms, acute treatments, and hospital protocols for treatment of stroke.

Results

Ninety-six staff members were interviewed, 81% of whom were clinical staff (medical, nursing, allied health professionals). Overall, stroke knowledge was excellent, with 92% able to name ≥3 stroke symptoms. However, only 49% of staff were aware of thrombolysis treatment, and only 48% could identify the time window for thrombolysis administration, with staff from stroke-related specialties likely to name thrombolysis as an acute treatment for stroke (71%; odds ratio = 3.36, 95% confidence interval 1.17–9.61). Only 52% of staff on general wards were aware of an in-hospital stroke protocol.

Conclusions

Hospital staff had adequate knowledge of stroke signs and symptoms; however, low awareness of thrombolysis therapy and its correct treatment time window was identified amongst staff working in non-stroke related disciplines. Targeted educational programmes among hospital staff regarding stroke are required to optimize acute stroke care

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

24/7 HYPERACUTE STROKE CARE IN LONDON: RELATIONSHIP BETWEEN THE TIME OF ADMISSION TO THE HOSPITAL, HEALTH OUTCOMES AND THE QUALITY OF CARE RECEIVED

M Melnychuk ¹, S Morris ¹, A Baim-Lance ¹, G Black ¹, M Brown ², J Eng ³, N Fulop ¹, A Ramsay ¹, R Simister ³

Abstract

Background

Research suggests that patients receive poorer care if treated outside conventional working hours. However this has not been consistently observed for patients with stroke as specialist stroke units aim to meet standards of 24/7 care. We examined whether time of admission to eight Hyperacute Stroke Units (HASUs) in London was associated with health outcomes and processes of care.

Methods

Regression analysis using data from 7,094 patients admitted to 8 London HASUs in the 2014 Sentinel Stroke National Audit Programme. Time of admission to hospital was measured in 30 min intervals. Health outcomes were: Modified Rankin Scale (mRS) > =3 at discharge and inpatient mortality. Care processes were: brain scan <1 h of admission; admission to stroke bed <4 h; swallow screen <4 h; assessment by a Stroke Consultant and other therapists <12 h and <24 h; treatment with intravenous thrombolysis. We controlled for HASU, age, sex, stroke type, comorbidities, and admission method.

Results

Adjusted probabilities of mRS > =3 at discharge and inpatient mortality varied by time of admission during the night but not the day. This pattern was similar for the care processes, except the probability of being seen by a Stroke Consultant <12 h: patients admitted during the night were more likely to see a Consultant <12 h compared to those admitted during the evening (p < 0.01), which might be attributed to the timing of Consultant ward rounds.

Conclusions

Among patients admitted to London HASUs there were some differences in care processes depending on time of admission to the hospital, but not in terms of outcomes.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

REGIONAL VARIATION IN ORGANISATION OF ACUTE STROKE CARE: ANALYSES FROM THE HEADPOST TRIAL NETWORK

P Munoz Venturelli ¹, P Lavados ², V Olavarría ², H Arima ³, L Billot ⁴, M Hackett ¹, J Lim ¹, S Middleton ⁵, O Pontes-Neto ⁶, B Peng ⁷, L Cui ⁷, L Song ⁸, G Mead ⁹, T Robinson ¹⁰, CL Watkins ¹¹, RT Lin ¹², TH Lee ¹³, J Pandian ¹⁴, A Da Silva ¹⁵, C Anderson ¹

Abstract

Background

Few studies have assessed regional variation in the organisation of Stroke services, particularly with reference to discrepancies between low- to middle-income countries (LMIC) and high-income countries (HIC).

Aim: To compare different aspects of stroke care organization within LMIC and HIC hospitals in the HeadPoST study.

Methods

HeadPoST is an ongoing international multicenter crossover cluster randomized trial of up versus down head positioning in acute stroke patients since 2014. As part of the start-up phase, all hospitals are required to complete a stroke care organization questionnaire.

Results

There were 92 hospitals from 9 countries who completed the questionnaire. Hospitals were evenly located in LMIC and HIC regions. LMIC hospitals have more beds than in HIC (mean 1440 vs 706 respectively, P < 0.001), but the reverse applies for dedicated multidisciplinary stroke teams (82% vs 95% respectively, P = 0.043) and having special pathway, ward or service organization for stroke care (80% vs 95%, P = 0.033). More commonly in HIC hospitals is the emergency department notified of a stroke patient by the ambulance before arrival (91% vs 71%, P = 0.018). Over 90% in both groups have onsite specialists physicians responsible for stroke patients, offer iv-thrombolysis and have guidelines for acute stroke treatment. Of note, 41% of stroke patients in HIC hospitals arrive <4 hours of symptoms onset, compared to 13% in LMIC (P < 0.001).

Conclusions

Organized pathways for acute stroke care are more common in HIC hospitals, with associated earlier patient presentation. Future multilevel analyses aims to determine the influence of organizational factors on patient’s outcomes.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

BACKGROUND OF APPLICANTS AND IMPACT ON THE PROFESSIONAL CAREER

O Nerg ¹, JC Fernández-Ferro ², LH Abdelnour ³, A Abdul-Rahim ⁴, M Barboza ⁵, J Calleja ⁶, ME Collantes ⁷, S De Blauwe ⁸, A Fromm ⁹, M Garro ¹⁰, A Hansen ¹¹, H Hashim ¹², Y Imam ¹³, N Logallo ⁹, N Soultanian ¹⁴, DM Stanca ¹⁵, P Ylikotila ¹⁶, WD Heiss ¹⁷, M Brainin ¹⁸

Abstract

Background

The European Master in Stroke Medicine (EMSM) is a postgraduate programme which covers all areas of cerebrovascular diseases and is provided by a faculty of leading European experts. The program is organized by the ESO and endorsed by the WSO. Currently on its fifth intake, the programme aims to establish evidence-based knowledge standards of stroke diagnosis and therapy. The course was designed for physicians from around the world to gain knowledge and scientific skills in stroke medicine and to promote networking opportunities. We investigated the

Background of the programme’s participants and its impact on their careers.

Methods

After a literature search an online questionnaire-based survey was designed. All present and past participants were invited to participate. The questionnaire was divided into four sections; demographics,

Background, personal impact and progression beyond the programme. Past graduates were asked to answer all sections, while current participants answered the first two.

Results

Total of 76 students from 22 different countries were contacted with a response rate of 51% (n = 39). The majority (72%) worked in the field of neurology. 70% had formed a network of collaboration during the course. Students reported learning useful clinical skills, receiving tools for educating patients and colleagues about stroke and that the course had enhanced their career opportunities. 69% of the responding participants would recommend this course to a colleague.

Conclusions

Participants of the EMSM programme reported a number of benefits to their clinical practice and career opportunities. The multinational student network offers a platform for future collaboration in the field of stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

LOOKING FORWARD: USING A RISK FEEDING CARE BUNDLE TO SUPPORT PATIENTS WITH DYSPHAGIA POST STROKE

S Nightingale ¹, A Lang ², P Sommerville ³, J Birns ³

Abstract

Background

The FORWARD bundle (Feeding via the Oral Route With Acknowledged Risk of Deterioration) was developed to support multidisciplinary management of acute stroke patients with an unsafe swallow, for whom tube feeding was inappropriate or declined. FORWARD facilitated patient identification, decision-making, implementation of oral feeding and further management.

Methods

Stroke unit in patients with dysphagia, who were eating and drinking with acknowledged risk of aspiration, were noted for six months before and after introduction of FORWARD. Data was collected on each patient including rationale for risk feeding, documentation of capacity/best interests, discussion with patient and/or next of kin, as well as treatment/escalation plans and clinical outcome.

Results

Data from 7 patients before and 10 patients after FORWARD implementation were evaluated. The majority of cases were palliative/end of life care. Documentation of mental capacity increased from 57% pre-FORWARD to 100% post-FORWARD. Where capacity was lacking, documentation of best interests’ discussion increased from 66% to 100% and discussion with next of kin from 33% to 100%. There was also evidence of documented treatment planning for anticipated likely clinical events (eg whether a patient was appropriate for escalation or anti biotics for chest infection) for 100% of patients.

Conclusions

The FORWARD care bundle supports multi disciplinary management of stroke patients with dysphagia for whom tube feeding is contra indicated/declined. It guides appropriate selection of patients. It prompts staff to ensure timely decision making and optimal care, with appropriate liaison with family and documentation, in line with best practice.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

IMPROVING PATIENT CARE UTILISING A STANDARDISED APPROACH TO WARD ROUNDS IN AN HYPER-ACUTE STROKE-UNIT (HASU)

M Ramjee ¹, M Taylor ¹, S Alam ¹, P Guyler ¹, D Sinha ¹, L Coward ¹

Abstract

Background

Patients on a Hyper-Acute Stroke-Unit (HASU) often have complex clinical requirements. It is critical that a high quality patient care is provided in a timely and reliable manner. However considerable variability exists in how ward rounds are performed especially when dealing with assessment of key issues such as investigations, resuscitations-status, VTE-prophylaxis, nutrition, hydration and medications. Improving the quality of ward rounds through a structured approach provide consistency in patient assessments and communication within teams and with patients and families. This subsequently leads to improved patient safety, patient experience, shared learning and efficient use of resources.

Methods

A group was established to review the ward round process and a check-list of essential elements of stroke and general care was compiled into a structured pro-forma. Team engagement and empowerment ensured completion of the pro-forma while one team member was allocated to checking completion of all required entries. A staff satisfaction survey was carried out to assess the intervention outcome.

Results

There was an improvement in the overall quality of ward-rounds. It was noted that documentation regarding diagnosis, investigations, treatment, escalation plan and resuscitation-status were vastly improved. There was also an improvement in timely prescription of medications and fluids along with communication between teams. The only reported downside was an increase in the duration of ward rounds.

graphic file with name 10.1177_2396987316642909-fig75.jpg

Conclusions

We recommend taking a standardised approach during ward rounds. Our intervention has yielded positive results and improved staff satisfaction. Furthermore it has yielded better documentation and improved medical decision making process in a timely manner.

Table.

Incidence of seizures and EEG data in acute period of PedAIS

Data	Cases	Controls	OR	CI	χ²	Fisher
Generalized seizures	10	18	4,44	1,67-11,83	9,926	0,004
Focal seizures	2	9	1,17	0,23-5,81	0,035	0,693
Focal seizures with secondary generalization	5	1	33,24	3,66-302,00	20,877	0,0004
Generalized epileptiform activity	0	2	–	–	0,392	1,000
Focal epileptiform activity	5	8	3,90	1,14-13,32	5,264	0,037
Spike and spike-wave activity	8	18	3,05	1,12-8,32	5,048	0,037
High-amplitude slow paroxysmal activity	3	12	1,34	0,35-5,20	0,182	0,710
Normal
Background activity	2	18	0,53	0,12-2,49	0,660	0,529
Non-epileptic focal changes	6	12	3,19	1,05-9,70	4,504	0,045
Slow activity	10	47	1,19	0,48-2,98	0,135	0,814

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Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

FACTORS INFLUENCING PROVISION OF 24/7 CARE IN LONDON HYPERACUTE STROKE UNITS

A Ramsay ¹, A Baim-Lance ¹, G Black ¹, J Eng ², N Fulop ¹, M Brown ³, S Morris ¹, M Melnychuk ¹, R Simister ²

Abstract

Background

Eight ‘hyperacute’ stroke units (HASUs) provide acute stroke care in London, offering assessment by specialist stroke teams, brain imaging, and thrombolysis (if appropriate) 24 hours a day, 7 days a week (24/7). Research suggests the London system is significantly more likely to provide evidence-based care than stroke services in other urban areas of the English NHS. However, little is known about how 24/7 provision is achieved in HASUs.

Methods

We aimed to analyse organisation and provision of 24/7 care in London HASUs, and identify influential factors.

We conducted a thematic analysis of 77 interviews with London HASU staff (stroke physicians, nurses, allied health professionals, administrators, and managers), 31 interviews with stroke patients and carers, and 41 non-participant observations of organisation and provision of care in HASUs at different times of day and week.

Results

London HASUs provide care 24/7, but achieve this within the context of the ‘conventional workday’ common in hospitals, where staffing and clinical activities are concentrated Monday-Friday during daytime hours. Several adaptations are required beyond conventional workday hours, including: role flexibility (e.g., staff taking on other disciplines’ tasks); and amending rotas to extend the conventional workday Adaptations, while necessary, can be disadvantageous, e.g. using less experienced staff who admit ‘false positives’ more frequently. Effective adaptation depends on collaboration both within the HASU team and beyond (e.g. through building alliances with associated specialties across the hospital).

Conclusions

24/7 HASU care requires accommodation of the ‘conventional workday’ and associated out of hours pressures. Successful adaptations rely upon active management and system-wide collaboration.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

NUMBER OF DOCTORS ON STUDY DELEGATION LOG CORRELATED WITH INCREASED RECRUITMENT RATES: DATA FROM THE ON-GOING TRANEXAMIC ACID FOR HYPERACUTE PRIMARY INTRACEREBRAL HAEMORRHAGE (TICH-2) TRIAL

N Sprigg ¹, K Robson ¹, J Appleton ¹, P Bath ¹

Abstract

Background

Recruitment in acute trials is difficult; many fail to reach target. A limiting factor is availability of staff trained in the trial and Good Clinical Practice. In drug trials, doctors are often needed to take consent and/or prescribe drugs.

Methods

The number of TICH-2 trained professionals is recorded on each centres delegation log. Monthly recruitment rates were calculated and compared, for each centre, with the number of doctors, using Spearman rank-order correlation, to see if a relationship could be seen.

Results

As of 24^th November 2015, 1260 participants had been enrolled into TICH-2, from 93 centres. The number of doctors ranged between 1 and 29, with median [IQR] 5 [3, 7]. Recruitment rates ranged from 0.03 to 3.6 patients a month, with median 0.35 [0.17, 0.6]. A correlation of 0.596 was found and a graph produced to visualise this relationship. Hyper-acute Stroke Research Centres (HSRC) were found to have more doctors on their delegation logs (median 11 [7, 13] vs. 4 [3, 6]) and higher than average recruitment rates (median 1.31 [0.84, 1.53] vs. 0.29 [0.16, 0.55]). Of the ten centres with the most doctors, six of them were a HSRC.

graphic file with name 10.1177_2396987316642909-fig76.jpg

Conclusions

A moderate-strong correlation was seen between the recruitment rate and number of doctors on the delegation log. HSRC’s have a greater number of doctors and a higher than average recruitment rate.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ARAGON STROKE CARE PROGRAM (PLAN DE ATENCIÓN ICTUS EN ARAGÓN, SPAIN). STRATEGY AND OUTCOMES IN THE 2008-2014 PERIOD

H Tejada Meza ¹, J Marta Moreno ¹, M Bestué Cardiel ², Á Giménez Muñoz ³, M Palacín Larroy ⁴, PAIA Plan de Atención al Ictus en Aragón ⁵

Abstract

Background

In 2008, Aragon had stroke mortality, morbidity and disability rates higher than the Spanish average. The need to develop a Stroke Care Program (PAIA) was established.

Methods

We present the dynamics of the PAIA planning, implementation, evaluation and improvement developed between 2008–2014, and the 5-year results.

Results

The PAIA has improved key structure, process and outcome indicators (audits 2008–2010–2012): stroke rate in 2013: 2.07 (2008: 2.36); 78% of stroke cases seen in areas/units in 2014 (2008: 30%); fibrinolysis rate in 2014: 8.3% (2010: 4.4%); fibrinolysis in secondary hospitals (30% of total); fibrinolysis by Telestroke: 9%; stroke mortality decline: 38%; years of potential life lost (YPLL) in 2013: 67.7 (2008: 144); nursing training, neurosonology, networking, protocols and best practices shared between health sectors.

Conclusions

This integrated process management coupled with multidisciplinary teams and established protocols and evaluations deployed across the whole territory have proved to be powerful tools to ensure health care quality and equity. The PAIA, for its dynamic and sustained improvement of clinical involvement, is a good example of clinical governance and networking.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

DOCTOR'S FOLLOW-UP AFTER STROKE IN THE SOUTH OF SWEDEN: AN OBSERVATIONAL STUDY FROM THE SWEDISH STROKE REGISTER (RIKSSTROKE)

T Ullberg ¹, E Zia ¹, J Petersson ¹, B Norrving ²

Abstract

Background

Most stroke guidelines recommend doctor’s follow-up after stroke, but follow-up is often based on individual needs rather than following a structured program. This study aimed to analyse what proportions that were followed up within 90, 120, 180 and 365 days after hospital discharge following stroke, and the influence of patient characteristics on the probability of 90-day follow-up.

Methods

Data on patients living in Skåne hospitalized with acute ischemic or haemorrhagic stroke from January 1, 2008-December 31, 2010, were obtained from Riksstroke and merged with data on all doctor’s visits during the year following stroke. The probability of follow-up was calculated using a Kaplan-Meier function. Cox-regression was used to analyse how patient characteristics influenced the probability of 90-day follow-up, with separate analyses for all patients and those discharged to home.

Results

The number of registered patients were 8164. The cumulative probability of a doctor’s follow up within 90 days was 76.3%, 83.6% within 120 days, 88.7% within 180 days and 93.1% within 365 days.

Using Cox-regression, factors influencing 90-day follow-up in all patients were: female sex Hazard Ratio (HR) = 1.066 (95%CI:1.014–1.12), age: HR65–74 = 0.928 (95%CI = 0.863–0.999), HR75–84 = 0.943 (95%CI:0.880–1.011), HR85+:0.836(95%CI:0.774–0.904), baseline dependency in activities of daily living (ADL): HR = 0.902(95%CI = 0.819–0.994), prior stroke HR = 0,902(95%CI:0.764–0.872) and comatose at baseline HR = 0.506(95%CI:0.407–0.629).

In patients discharged home, factors influencing follow-up were: age: HR65–74:0.92(95%CI:0.848–0.999), HR75–84:0.901(95%CI:0.831–0.976), HR85+ = 0.765(95%CI:0.695–0.843), baseline ADL dependency HR = 1.249(95%CI:1.046–1.492), diabetes HR = 1.119(95%CI:1.037–1.209) and prior stroke HR = 0.920(95%CI = 0.847–0.999).

Conclusions

One out of four patients was not followed up within 3 months after hospital discharge. High age was the overall most important negative factor for receiving stroke follow-up.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

AN INDIVIDUALIZED COACHING PROGRAM FOR PATIENTS WITH ACUTE ISCHEMIC STROKE: FEASIBILITY STUDY

D Standaert ¹, N Libbrecht ¹, V Maqueda ¹, I Vansteenkiste ¹, P Maere ¹, S De Blauwe ², G Vanhooren ², L Yperzeele ³, P Vanacker ⁴

Abstract

Background

An individualized stroke care program was developed to match patients’ education with their needs regarding stroke knowledge, secondary prevention and rehabilitation. Our purpose was to assess feasibility of in-hospital and post-discharge, personalized stroke coaching.

Methods

Acute ischemic stroke patients enrolled in the ASTRAL-B stroke registry (Sint-Lucashospital, Belgium) with: (a) hospitalization between 12/2014–12/2015, (b) discharge back home, and (c) without cognitive decline, were selected. The stroke coach contacted patients twice during hospitalization (2 × 20 min) and post-discharge via phone calls using standardized WSO Post-Stroke Checklist. Risk factor management, review of medications and clinical evolution were discussed. Participants were contacted at 2 weeks, followed by repeat calls if necessary and at ambulatory consultations at 1, 3, 6 and 12 months.

Results

Of all 255 patients, 152 (59.7%) received individualized education during hospitalization by the stroke coach. Median age of our population was 74 years, with median NIHSS of 5. The majority of patients had at least two cardiovascular riskfactors. Patients were not coached because of palliative care/decease (10%), unfavorable life expectancy (2%), dementia (8.5%) and lack of time due to short hospitalization (22%). A quarter of all stroke patients were contacted after discharge at least once by phone call, 12% were contacted at least twice.

Conclusions

We demonstrated the feasibility of an individualized coaching program executed by a well-trained stroke nurse. The possibility of integrating mobile health applications in our stroke coaching program will be addressed. Hence, a two-arm pilot study will start recruiting in Spring 2016 (Sint-Lucas & Sint-Jan hospital Bruges).

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE OPTIMIZATION OF THE ACUTE STROKE MANAGEMENT: A PROJECT IN NORTHERN ITALY

S Vidale ¹, M Arnaboldi ¹, G Bezzi ², G Bono ³, G Grampa ⁴, M Guidotti ⁵, P Perrone ⁶, D Zarcone ⁷, A Zoli ⁸, E Agostoni ⁹

Abstract

Background

Thrombolysis is an effective treatment in ischemic stroke, but the principal limitation in its application is the time. In our large geographical area with more than 3 millions of inhabitants, we conducted a project to improve the management of stroke patients, reducing the avoidable time.

Methods

All consecutive patients admitted to 11 Hospitals in Northern Italy for stroke were enrolled during a 6 months period. Corrective factors were previously introduced: public stroke awareness campaigns and application of a stroke code. Demographical data, time of single steps of stroke pathway and treatment procedures were registered for each patients. Statistical analysis was conducted using t-test and chi-square test for univariate and logistic regression for multivariate analysis.

Results

1688 patients were recruited (Median age: 76 years). A stroke code during transport was applied in 19.3% of subjects, while we registered an application of this code in 26.7% of patients at triage. The median of total, pre-hospital and in-hospital times were 190 minutes, 97 minutes and 67 minutes, respectively. The use of EMS and the application of stroke codes reduced significantly all times (p < 0.01). 13% of patients was treated with thrombolysis. At multivariate analysis, thrombolytic treatment was more applied in patients transported with EMS and with a stroke code at triage (p < 0.001).

Conclusions

The optimization of the stroke pathway contributed to increase the number of thrombolytic treatments. Our projections allowed to calculate an increasing of recanalization procedures up to 200% if the all corrective factors should be applied for each patients.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PULSE WAVE VELOCITY, BLOOD PRESSURE VARIABILITY AND CEREBROVASCULAR REACTIVITY IN 29 MILD STROKE PATIENTS

G Blair ¹, Y Shi ¹, M Thrippleton ¹, I Hamilton ¹, P Andrews ¹, F Doubal ¹, I Marshall ¹, J Wardlaw ¹

Abstract

Background

Lacunar stroke is due to cerebral small vessel disease (SVD). The pathophysiology of SVD remains poorly understood but functional changes in both systemic and cerebral circulations likely play important roles. To test this we measured blood pressure variability (BPV), pulse wave velocity (PWV) and cerebrovascular reactivity (CVR) in mild stroke patients.

Methods

29 mild stroke patients were recruited and underwent CVR MRI scan, PWV measurement, and had seven blood pressure measurements. Stroke subtype was classified as lacunar or cortical clinically and on imaging. Systolic BPV was calculated as standard deviation, coefficient of variation, average real variability and successive variation.

Results

18 patients had lacunar stroke, 11 had cortical stroke (median age 67 and 68 respectively). Complete PWV data were obtained in 28/29, BPV in 26/29 patients and CVR data are fully processed in 15 patients so far. PWV was higher in lacunar patients (8.7 vs 8.4 m/s). All four measures of BPV were higher in lacunar patients despite their having lower mean blood pressures. Lacunar patients had lower CVR in 5/7 subcortical regions of interest. None of these differences reached statistical significance in this small sample available to date.

Conclusions

Our data suggest that patients with lacunar stroke have higher PWV, indicating increased blood vessel stiffness, more variable blood pressure and poorer CVR. A larger sample will determine if these changes in vascular function are characteristic in SVD and lacunar stroke, which this ongoing study is powered to detect.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

FREQUENCY AND PREDICTORS OF DYSPHAGIA IN PATIENTS WITH RECENT SMALL SUBCORTICAL INFARCTION

S Fandler ¹, T Gattringer ¹, K Doppelhofer ¹, S Eppinger ¹, K Niederkorn ¹, C Enzinger ², F Fazekas ¹

Abstract

Background

While dysphagia is a common symptom in stroke, detailed data on the occurrence of swallowing dysfunction in patients with recent small subcortical infarcts (RSSI) is lacking. In this study, we therefore aimed at assessing the frequency of and risk factors for dysphagia in RSSI patients.

Methods

We identified all inpatients with MRI-confirmed RSSI between January 2008 and February 2013 at our primary and tertiary care university hospital. Demographic and clinical data were extracted from our stroke database. The presence and severity of dysphagia were determined according to the Gugging Swallowing Screen.

Results

We identified 337 patients with RSSI (mean age: 67.7 ± 11.9 years, 65% male). Most RSSI were located in the basal ganglia (n = 108), followed by the pons (n = 91), thalamus (n = 75), and centrum semiovale (n = 63). Dysphagia was diagnosed in 88 patients (25.2%). The probability of dysphagia was associated with stroke severity (NIHSS 5–9: OR 2.44, CI 1.33–4.46, p = 0.004; NIHSS ≥ 10: OR 20.38, CI 4.46–93.15, p < 0.001) and dysphagia more often occurred in brainstem RSSI compared to the other anatomic locations (OR 1.71, CI 1.01–2.90, p = 0.048). Patients <50 years had a lower risk for swallowing dysfunction (OR 0.11, CI 0.01–0.81, p = 0.03).

Conclusions

Dysphagia has to be expected in about a quarter of patients with RSSI, with higher NIHSS scores and brainstem location as main risk factors. These findings indicate that swallowing dysfunction needs to be carefully explored also in patients with RSSI and especially those at higher risk to avoid related complications.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CORTICAL MICROINFARCTS (CMI) ON MRI IN PATIENTS WITH VASCULAR COGNITIVE IMPAIRMENT (VCI)

D Ferro ¹, L Exalto ¹, S Van Veluw ², D Koek ³, GJ Biessels ¹

Abstract

Background

Brain autopsy studies identify CMI’s as a common vascular pathology associated with cognitive decline and dementia. CMI’s can now be detected in vivo on high-resolution MRI. We address their frequency and associated clinical features in patients with VCI.

Methods

186 memory-clinic patients with VCI underwent a standardized work-up including 3 Tesla MRI and cognitive assessment. Control group consisted of 60 age-matched healthy individuals. CMI’s were rated according to established criteria.

Results

CMI’s were more common in VCI-patients (20.3%) than controls (11.7%, p < .05). VCI-patients with CMI’s were more likely to have a history of stroke compared to patients without CMI’s (Table 1). Moreover their burden of white matter hyperintensities and lacunar infarcts was increased (Table 2) and their working memory performance was worse (Table 3).

Conclusions

CMI’s on MRI appear to be relatively common in patients with VCI. They co-occur with other imaging markers of small vessel disease, but may carry complementary information on causes and consequences of VCI.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

INDIVIDUAL PREDICTION OF 3-YEAR CLINICAL COURSE IN CADASIL

E Jouvent ¹, E Duchesnay ², F Hadj-Selem ², F De Guio ³, JF Mangin ², D Hervé ⁴, M Duering ⁵, S Ropele ⁶, R Schmidt ⁶, M Dichgans ⁵, H Chabriat ⁷

Abstract

Background

Several factors are associated with disease severity in CADASIL, a model of subcortical ischemic vascular dementia, but actual predictors of disease evolution at the individual level are undetermined. Our aim was to build the simplest algorithms predicting further disease evolution in CADASIL patients and validated for unseen cases.

Methods

Innovative methodology including processes from machine learning was used to build, validate and compare on independent samples, models based on the smallest number of variables all measured at baseline and predicting further clinical changes. This work was based on a 3-year longitudinal study of 236 genetically confirmed patients. Models were built and validated to predict changes of global cognitive status (mini-mental state evaluation (MMSE) and Mattis dementia rating scale (MDRS)), processing speed (Trail making test version B (TMTB)) and disability (modified Rankins scale (mRS)) at 3 years.

Results

Best and simplest models relied only on the baseline values of the score to predict, of brain volume and of volume of lacunes for MMSE, MDRS, TMTB and mRS (figure 1).

graphic file with name 10.1177_2396987316642909-fig77.jpg

Conclusions

Best predictive models were based only on the baseline values of the considered score, of brain volume and of volume of lacunes, while all other variables, including age and gender and cardiovascular risk factors were of no help to predict further disease evolution. Our results provide new insights both for patient care and research in CADASIL, but also more generally for determining the vascular component in most prevalent forms of cerebral small vessel diseases.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

TRANSCRANIAL DOPPLER ULTRASOUND FOR DETECTION OF PRECLINICAL CEREBRAL WHITE MATTER HYPERINTENSITY IN SUBJECTS WITH VASCULAR RISK FACTORS

D Kang ¹

Abstract

Background

We explored the clinical utility of pulsatility index (PI) of the middle cerebral artery (MCA) as derived by the transcranial Doppler ultrasound for detecting subclinical white matter hyperintensity (WMH) in subjects with vascular risk factors.

Methods

Among 480 potentially eligible subjects (i.e. age 64–85, non-demented, stroke-free subjects with HT and/or diabetes mellitus [DM]), 331 (69%) had temporal window with MCA PI obtained. WMH volume on 3.0 Tesla MRI was quantified automatically by BrainNow Co. Subjects were divided into four age strata (age 65–69, 70–74, 75–79 and 80+ group) and classified into having low WMH (i.e. WMH volume <1 standard deviation (SD) of that stratum) and high WMH (i.e. WMH volume ≥1 SD of that stratum). The cutoff WMH volume for the four strata were 7.17, 9.37, 11.2 and 14.9 mL, respectively. We investigated the MCA PI's ability to differentiate between low and high WMH using independent sample t-test.

Results

MCA PI failed to differentiate between low and high WMH in all four age strata. We however observed that female gender, DM and hyperlipidemia were associated with high WMH in the age 75–79 stratum (χ²= 5.711, p = 0.017; χ²= 4.762, p = 0.029; t = 4.228, p < 0.001, respectively) while serum vitamin B12 level was associated with high WMH in the age 80+ stratum (t = −2.669, p = 0.014).

Conclusions

Among subjects with vascular risk factors, MCA PI cannot differentiate between low and high subclinical WMH. Risk factors profiles associated with high WMH may vary according to age strata among the elderlies.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

HIGH-SENSITIVITY CARDIAC TROPONIN T LEVELS AND RISK OF CEREBRAL MICROBLEEDS IN ACUTE ISCHEMIC STROKE PATIENTS WITH ATRIAL FIBRILLATION AND/OR RHEUMATIC HEART DISEASE

J Liu ¹, D Wang ¹

Abstract

Background

Elevated high-sensitivity cardiac troponin T (hs-cTnT) levels may be associated with cardiovascular and cerebrovascular diseases, but few prospective data are available for subclinical small-vessel disease. The purpose of this study was to examine associations between serum hs-cTnT levels and risk of cerebral microbleeds (CMBs) in acute ischemic stroke patients with atrial fibrillation and/or rheumatic heart disease.

Methods

This prospective study involved consecutively recruited acute ischemic stroke patients with atrial fibrillation and/or rheumatic heart disease treated at a large tertiary care hospital in southwestern China. Clinico-demographic data were collected and analyzed by logistic regression to identify predictors of CMB occurrence and location.

Results

Of 66 patients (27 males; mean age, 68.7 years), 39 (59.1%) had CMBs. Median hs-cTnT levels did not differ between patients with or without CMBs (P = 0.49).In multivariable analysis, patients with hs-cTnT levels ≥17.78 ng/L were at significantly higher risk of any type of CMB(OR 8.03,95%CI 1.09 to 59.18; P = 0.04) and of nonlobar CMBs(OR7.90,95%CI 1.21 to 51.70; P = 0.03) than those with hs-cTnT levels <17.78 ng/L.

Conclusions

High hs-cTnT levels may be independent predictors of the occurrence of CMBs, particularly of nonlobar CMBs. This finding justifies further research into how hs-cTnT levels may contribute to CMBs and potentially other subclinical small-vessel diseases.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CLINICAL PECULIARITIES OF CEREBRAL VASCULITIS LEAD TO STROKES IN YOUNG PATIENTS OF KYRGYZSTAN

I Lutsenko ¹, T Musabekova ²

Abstract

Background

This paper presents a series of cases of cerebral vasculitis (CV) which in young patients manifested with ischemic strokes.

Methods

All patients passed standard neurological observation, assessment on NIHSS, Glasgow coma scale, general and specific laboratory investigations (immunoglobulines blood tests, antineutrophil cytoplasmic antibodies (ACA), CRP-examination, etc). Patients were followed-up for 6 years.

Results

Patients with the following pathologies were present: primary angiitis of the central nervous system (5), small vessel vasculitis with ACA (3), vasculitis in non-specific aortoarteritis (Takayasu disease) (9), subacute autoimmune vasculitis on the

Background of AIDS (2), syphilitic vasculitis of cerebral vessels (14), cerebral vasculitis in systemic lupus erythematosus (3). An onset with acute cerebral ischemia in 15 patients regressed within 1 week, but in 9 patients had caused irreversible brain infarction and severe neurological deficit. 11 patients experienced intense headaches, 4 epileptic seizures, 4 dysfunctions of the cranial nerves. Stroke course was depending on it’s etiology: autoimmune subtypes were characterized by gradual start and quick regression, but vasculitis based on infections left severe neurological deficit. Changes in cerebral tomograms and angiograms of patients in our observation were present as foci of ischemia, edema, multiple segmental contractions and expansions of blood vessels, vascular occlusion and lengthening of the time of blood flow on extracranial arteries in doppler ultrasound.

Conclusions

Ischemic stroke in young patients requires careful diagnostic search through the study of immunoglobulins, specific infections of the nervous system, as well as a thorough analysis of neuroimaging data in dynamics in order to diagnose clinical polymorphic cerebral vasculitis.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

SAMPLE SIZE ESTIMATES FOR RANDOMISED CONTROLLED TRIALS IN THE PREVENTION OF ADVERSE OUTCOMES AFTER LACUNAR STROKE

S Makin ¹, FN Doubal ², F Chappell ³, K Shuler ³, M Dennis ², J Wardlaw ³

Abstract

Background

Lacunar stroke may require different treatments to other ischaemic stroke subtypes, and randomised controlled trials (RCTs) for lacunar stroke are needed. The use of composite outcomes could increase efficiency by reducing sample size.

Methods

We prospectively recruited patients with lacunar ischaemic stroke. At one year post stroke we assessed recurrent stroke, TIA, ischaemic heart disease (IHD), and modified Rankin Score (mRS) in all; a subset had cognitive testing with Addenbrookes Cognitive Examination (ACE-R). We estimated sample sizes for hypothetical RCTs using individual and combined outcomes at power 80%, alpha 5% required to detect a relative 10% risk reduction in each outcome measure.

Results

We recruited 118 patients, (88 after cognitive testing was introduced), all followed up at one year post-stroke (69/88, 78%, with cognitive testing): 7% had recurrent stroke, 2% had TIA, 10% had new IHD, 38% had mRS ≥ 2, 22% had ACE-R ≤82, 1% had died. An RCT using a single outcome e.g. of recurrent stroke, or TIA, or IHD would require >20,000 patients or of mRS ≥ 2 would require >5117. However, a composite outcome of ‘any recurrent stroke, TIA, new IHD, ACE-R ≤82, dementia or mRS ≥ 2' (without double counting) totalled 65%, and would require only 1700 patients.

Conclusions

Composite outcomes including vascular events, dependency and cognition are patient-relevant and would increase efficiency and feasibility of RCTs in lacunar stroke. However composite endpoints may make clinical interpretation more difficult and cognitive testing is limited by the 20% untestable patients.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

IN PATIENTS WITH NON-DISABLING STROKE LOWER RENAL FUNCTION IS RELATED TO AGE AND LARGE VESSEL DISEASE, NOT SMALL VESSEL DISEASE, NOR BLOOD BRAIN BARRIER LEAKAGE

S Makin ¹, F Doubal ², K Shuler ³, J Staals ⁴, F Chappell ³, MC Valdés Hernández ³, A Heye ³, M Dennis ², J Wardlaw ³

Abstract

Background

Introduction

Renal impairment is associated with cerebral small vessel disease (SVD), but data are conflicting on whether this reflects co-association with vascular risk factors or a common microvascular impairment.

We hypothesized that in patients with a non-disabling stroke lower renal function would be associated with lacunar stroke, MRI features of SVD, and blood brain barrier (BBB) leakage.

Methods

We recruited patients with a non-disabling lacunar or cortical ischaemic stroke, assessed vascular risk factors, measured estimated glomerular filtration rate (eGFR; Cockcroft Gault formula), albuminuria (albumin/creatinine ratio >3.5 for women and >2.5 for men), and BBB leakage using dynamic contrast enhanced (DCE) MRI. We scored individual SVD features (lacunes, microbleeds, enlarged perivascular spaces (EPVS)), WMH) blind to renal function. Patients with severe renal impairment were excluded.

Results

We recruited 264 patients, aged 35–97 (median 67) years, 118 with lacunar and 146 with cortical stroke. 201 patients had DCE MRI scan, 193 had urine tested for albuminuria, 172 had both. Reduced eGFR was associated with cortical stroke, ischaemic heart disease, peripheral vascular disease, AF, smoking, and microbleeds, lacunes, WMH and EPVS. Albuminuria was associated with older age, diabetes, and AF. On analysis adjusted for age and vascular risk factors neither SVD features nor BBB leakage were associated with reduced eGFR or albuminuria.

Conclusions

Most renal impairment in these mild stroke patients reflected a co-association with large vessel disease. We found no association between renal function and BBB leakage or SVD features.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PATIENTS WITH MINOR STROKE WHO HAVE CUT-DOWN ON SALT DURING ADULT LIFE HAVE REDUCED RISK OF LACUNAR STROKE AND SMALL VESSEL DISEASE

S Makin ¹, F Doubal ², J Staals ³, M Dennis ², J Wardlaw ⁴

Abstract

Background

High salt intake increases stroke risk and all-cause mortality. Adding salt to food is associated with greater white matter hyperintensity (WMH) volume. We hypothesised that lifetime salt intake may be associated with other features of small vessel disease (SVD).

Methods

We recruited patients with a lacunar or cortical non-disabling ischaemic stroke, performed brain MRI, and recorded a simple dietary salt history including whether the patient had cut-down their dietary salt intake since age 20. We scored individual SVD features (lacunes, microbleeds, perivascular spaces (PVS), WMH) and calculated the total SVD burden score, blind to salt history. We used logistic regression to calculate odds ratio (OR) and 95% confidence interval (CI) of lacunar stroke subtype and SVD features in patients who had cut-down salt intake against those who had not.

Results

We recruited 250 patients, 112 lacunar and 138 cortical stroke; 104 patients had cut-down dietary salt since age 20. Patients who had cut-down were less likely to have lacunar stroke, a lacune, a microbleed, severe WMH, and lower total SVD scores. After adjusting for age, sex, hypertension, smoking and vascular disease, cutting down on salt was associated with reduced risk of lacunar subtype (OR 0.52, 95%CI 0.30–0.90), and total SVD score ≥2 (OR 0.70, 95%CI 0.53–0.91)

Conclusions

In patients with minor stroke, those who had cut-down salt intake since age 20 were less likely to have a lacunar stroke, or SVD features. These results should be assessed in larger, prospective studies and in non-stroke individuals.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

A NOVEL IMAGING MARKER FOR SMALL VESSEL DISEASE AND VASCULAR COGNITIVE IMPAIRMENT BASED ON WHITE MATTER TRACT SKELETONIZATION AND DIFFUSION HISTOGRAMS

E Baykara ¹, B Gesierich ¹, R Adam ¹, AM Tuladhar ², JM Biesbroek ³, S Ropele ⁴, E Jouvent ⁵, H Chabriat ⁵, B Ertl-Wagner ⁶, M Ewers ¹, R Schmidt ⁴, FE de Leeuw ², GJ Biessels ³, M Dichgans ¹, M Duering ¹

Abstract

Background

Cerebral small vessel disease (SVD) is a major contributor to vascular cognitive impairment (VCI) and dementia. Current imaging disease markers have methodological limitations (e.g. time-consuming and prone to observer bias) and show only weak associations with cognitive deficits in SVD.

Methods

The aim of the current study was to develop a robust, fully-automated and easy-to-implement marker for SVD that reflects disease burden and is strongly associated with processing speed performance, the major cognitive deficit in SVD. For this purpose, we combined skeletonized mean diffusivity (MD) data and histogram analysis in the new marker “peak width of skeletonized MD” (PSMD).

We studied PSMD and conventional SVD markers (brain atrophy, lacune and white matter hyperintensity volumes) first in patients with hereditary SVD (n = 113). Subsequently, we validated our findings in independent samples of both inherited (n = 57) and sporadic forms of SVD (n = 549) and assessed the specificity for SVD by testing healthy controls (n = 241) and patients with Alzheimer pathology (n = 153).

Results

PSMD was strongly and independently associated with processing speed across all samples with SVD (p-values 2.8 × 10⁻³ to 1.8 × 10⁻¹⁰). Importantly, PSMD consistently explained most of the variance in processing speed (adjusted R² up to 46%) as compared with conventional markers. PSMD was linked to SVD but not to Alzheimer pathology.

Conclusions

PSMD consistently outperformed conventional disease markers. Its calculation is fully-automated and observer-independent. Thus, this novel marker can readily be used to quantify vascular pathology in large samples and can therefore be of great value in research studies and for clinical use.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

NEUROFILAMENT LIGHT CHAIN AS A SERUM MARKER FOR CEREBRAL SMALL VESSEL DISEASE

M Duering ¹, S Tiedt ¹, E Baykara ¹, P Lyrer ², S Engelter ², B Gesierich ¹, M Achmüller ¹, R Adam ¹, M Dichgans ¹, J Kuhle ², N Peters ²

Abstract

Background

Disease markers for cerebral small vessel disease (SVD) rely mostly on MR imaging. Currently, no blood-based marker is established. Serum levels of Neurofilament Light Chain (NfL) have been described to correlate with neuroaxonal injury in other diseases. The goal of this study was to evaluate serum NfL as a blood marker for SVD.

Methods

The cross-sectional study comprised 51 patients with CADASIL, a genetically defined SVD. MR imaging at 3 Tesla was used to evaluate white matter hyperintensity volume, lacune volume, brain volume and mean diffusivity form diffusion tensor imaging. Clinical characterization included neuropsychological testing and assessment of disability (modified Rankin scale, mRS) and dependence (Barthel index). Serum NfL was measured by electrochemiluminescence immunoassay. We used (multiple) linear regression and (stepwise, ordinal) logistic regression to investigate associations between serum NfL levels and imaging markers, processing speed, mRS, and Barthel index.

Results

All SVD imaging markers showed a significant correlation with serum NfL levels. The strongest correlation was found with mean diffusivity (R²= 0.527, p = 1.01e-09). Serum NfL levels were associated with processing speed performance (R²= 0.291, p = 2.62e-05), but not independently when including imaging markers in the model. There were significant and independent associations between serum NfL levels and disability (mRS: p = 2.17e-06) and dependence (Barthel index: p = 0.00148).

Conclusions

In conclusion, serum NfL levels were strongly related to imaging markers and clinical symptoms of SVD. For disability and dependence there was an added value of serum NfL levels beyond imaging markers.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

COMPARISON OF IN PERSON VERSUS REMOTE ASSESSMENT OF COGNITION AFTER STROKE

CA McHutchison ¹, V Cvoro ¹, K Shuler ¹, S Makin ¹, M Dennis ¹, JM Wardlaw ¹

Abstract

Background

Cognitive changes are common following stroke, from mild impairment to dementia, and can have a significant impact on quality of life. Cognition is usually assessed in person but this may be difficult in large studies after stroke. We aimed to determine the validity of remote versus in person assessment of several domains of cognition in patients living in the community after a mild stroke.

Methods

Participants in the Mild Stroke Study were followed up 3–4 years post mild ischaemic stroke. Cognitive performance was measured by trained researchers in person using the Addenbrooke’s Cognitive Examination–Revised (ACE-R) and the Montreal Cognitive Assessment (MoCA). Self-reported cognition was collected by post using the Memory and Thinking domain (M + T) of the Stroke Impact Scale (SIS).

Results

In 146 participants aged 38–94 years (M = 68.64, SD = 10.96), the SIS Memory domain score significantly predicted performance on the ACE-R and MoCA (F (1,144) = 6.624, p = 0.011 and F (1,147) = 4.078, p = 0.045 respectively). In addition, the SIS M + T domain score significantly predicted performance on the Memory (F (1,145) = 6.92, p = 0.001), Fluency (F (1,145) = 5.393, p = 0.022) and Language (F (1,144) = 4.01, p = 0.047) sub-scales of the ACE-R. The Attention, Orientation and Visuospatial sub-scales of the ACE-R were not significantly predicted by the SIS M + T domain score.

Conclusions

Self-reports of cognition such as the SIS show high agreement with in person cognitive tests and can be used to assess overall cognitive functioning in mild stroke patients, but may be more reliable for some cognitive domains than others.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

BURDEN OF WHITE MATTER HYPERINTENSITIES IN ASIA: THE ASIAN WHITE MATTER HYPERINTENSITIES (AWARE) STUDY

VCT Mok ¹, BYK Lam ¹, JY Lee ², YH Yang ³, S Kim ⁴, S Marasigan ⁵, E Ampil ⁵, JC Dominguez ⁶, H Wang ⁷, PA Ong ⁸, Y Dikot ⁹, V Senanarong ¹⁰, C Chen ¹¹

Abstract

Background

To date, only few studies evaluated the prevalence of confluent white matter hyperintensites (cWMH) among Asians. It is of interest to study the risk factors of cWMH and variations in the prevalence of cWMH across Asian countries. However, no previous study has attempted to address this issue.

Methods

Subjects [total = 4,255; stroke/transient ischemic attack (TIA) = 1,927; cognitive disorders = 2,328] were recruited into the study across 8 Asian cities (Bangkok, Bandung, Beijing, Hong Kong, Kaohsiung, Manila, Seoul, Singapore). cWMH was defined as a score ≥2 (max. 3) on FLAIR/CT images using either the modified Fazekas’ scale, or age-related white matter changes scale.

Results

The prevalence of cWMH in the total population, stroke/TIA group and the cognitive disorder group were 1777 (42.1%), 862 (42.1%) and 913 (39.9%) respectively. Logistic regression showed hypertension (OR = 2.0; 95% CI = 1.7 to 2.4) consistently predictive of cWMH, in the overall population, stroke/TIA and cognitive disorder group, after adjustment for age, gender and education. Furthermore, the severity of WMH was associated with poorer performances on MMSE, F(4, 3749) = 384.3, p < 0.001. With Hong Kong being the reference group, participants from Thailand, Singapore and Indonesia showed a higher risk of cWMH while those from the Philippines and Korea showed less risk.

Conclusions

This is the first large-scale hospital/clinic-based study investigating cWMH in Asia. The burden of WMH in Asia is high and of major importance given the expanding aging population. Targeting reversible risk factors of cWMH (i.e. hypertension) could potentially reduce the risk of stroke and dementia, especially in groups at high risk.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

A THRESHOLD OF WHITE MATTER HYPERINTENSITIES VOLUME DOUBLING THE RISK OF COGNITIVE DECLINE IN PATIENTS WITH STROKE OR TRANSIENT ISCHEMIC ATTACK

V Mok ¹, S Lin ², B Lam ², W Chu ³, A Lau ², E Lo ², WY Liu ², A Wong ²

Abstract

Background

The threshold of white matter hyperintensities (WMH) burden that predicts cognitive decline remains unknown.

Methods

245 stroke or transient ischemic attack (TIA) patients were followed over a mean period of 37.4 months. The Montreal Cognitive Assessment (MoCA) was administered at baseline (mean 5.1 months [SD = 1.1] post event) and follow-up (42.5 [1.4] months). Change in MoCA score was calculated as follow up minus baseline and patients were classified as having no change/improved or declined on the MoCA scores. WMH burden was expressed using 1) visual rating by Age-Related White Matter Changes Scale Global score; 2) raw WMH volume measured on MRI; 3) highest quartile of raw WMH volume; 4) WMH volume corrected for intracranial volume (ICV) to account for differences in head size; and 5) highest quartile of ICV-corrected WMH volume. WMH volume was quantified by BrainNow. The association between WMH burden and decline in MoCA was tested using multivariate binomial regression models corrected for age, sex, education and baseline MoCA scores.

Results

Highest quartile of raw WMH volume (13 ml) was most strongly associated with MoCA decline (Odds 2.3, 95% Confidence Interval 1.2–4.4), followed by ARWMC Global score (1.2, 1.003–1.4). Raw WMH volume, ICV-corrected WMH volume or its highest quartile, were not significantly associated with MoCA decline.

Conclusions

13 ml of WMH doubled the risk of cognitive decline over 3 years in patients with stroke or TIA. This volume may represent a threshold for cognitive decline in these patients. Visual rating using ARWMC scale predicted decline but to a lesser extent.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

1 H-MR SPECTROSCOPY METABOLITE LEVELS CORRELATE WITH EXECUTIVE FUNCTION IN VASCULAR COGNITIVE IMPAIRMENT

B Muinjonov ¹, E Giyazitdinova ²

Abstract

Background

White matter hyperintensities (WMHs) are associated with vascular cognitive impairment (VCI) but fail to correlate with neuropsychological measures. As proton MR spectroscopy (1 H-MRS) can identify ischaemic tissue, we hypothesised that MRS detectable brain metabolites would be superior to WMHs in predicting performance on neuropsychological tests.

Methods

60 patients with suspected VCI underwent clinical, neuropsychological, MRI and CSF studies. They were diagnosed as having subcortical ischaemic vascular disease (SIVD), multiple infarcts, mixed dementia and leukoaraiosis. We measured brain metabolites in a white matter region above the lateral ventricles with 1 H-MRS and WMH volume in this region and throughout the brain.

Results

We found a significant correlation between both total creatine (Cr) and N-acetylaspartyl compounds (NAA) and standardised neuropsychological test scores. Cr levels in white matter correlated significantly with executive function (p = 0.001), attention (p = 0.03) and overall T score (p = 0.007). When lesion volume was added as a covariate, NAA also showed a significant correlation with executive function (p = 0.003) and overall T score (p = 0.015). Furthermore, while metabolite levels also correlated with total white matter lesion volume, adjusting the Cr levels for lesion volume did not diminish the strength of the association between Cr levels and neuropsychological scores. The lowest metabolite levels and neuropsychological scores were found in the SIVD group. Finally, lesion volume alone did not correlate significantly with any neuropsychological test score.

Conclusions

These results suggest that estimates of neurometabolite levels provide additional and useful information concerning cognitive function in VCI not obtainable by measurements of lesion load.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

RETINAL SMALL VESSEL DISEASE AND THE DIABETIC BRAIN

T Phan ¹, C Moran ², T Robyn ³, A Hughes ⁴, M Costan ⁵, B Leigh ⁵, R Beare ², N Witt ⁴, A Venn ⁵, G Muench ⁶, B Amaratunge ⁷, V Srikanth ¹

Abstract

Background

It is uncertain whether small vessel disease underlies the relationship between Type 2 Diabetes Mellitus (T2DM) and brain atrophy. We aimed to study whether retinal vascular architecture, as a proxy for cerebral small vessel disease, may modify or mediate the associations of T2DM with brain atrophy.

Methods

Cross-sectional study using Magnetic Resonance Imaging (MRI) scans and retinal photographs in 451 people with and without T2DM. We measured brain volumes, geometric measures of retinal vascular architecture, clinical retinopathy, and MRI cerebrovascular lesions. Linear or logistic regression was used to study relationships between T2DM, brain MRI and retinal measures.

Results

There were 270 people with (mean age 67.3 years; Hb_A1c 7.1 %) and 181 without T2DM (mean age 72.9 years). T2DM was associated with lower gray matter volume (ml) (β = −3.60, p = 0.008). In univariable regression, T2DM was associated with greater arteriolar diameter (β = 0.48, p = 0.03) and optimality ratio (β = 0.01, p = 0.04), but these associations were attenuated by adjustments for age and sex. Only optimality ratio was associated with lower gray matter volume (ml) (β = −22.5, p = 0.026). The inclusion of retinal measures in regression models did not attenuate the association of T2DM with gray matter volume.

Conclusions

In this sample, the association of T2DM with lower gray matter volume was independent of retinal vascular architecture and clinical retinopathy. Retinal vascular measures or retinopathy may not be sufficiently sensitive to confirm a microvascular basis for T2DM-related brain atrophy. Longitudinal study is required to confirm the lack of relationships.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

MACHINE LEARNING APPROACH TO DISCOVERING THEMES IN LITERATURE ON LACUNAR STROKE

T Phan ¹

Abstract

Background

Fisher’s landmark studies on lacunar stroke has been popularised as intrinsic small vessel disease. In this study, an unsupervised machine learning method, probabilitistic topic modeling (PTM), is used to discover if the ‘hidden’ themes from the scientific work by Fisher on lacunar stroke is homogenous with regards to human description of lacunar stroke.

Methods

Articles were searched from Pubmed, Medline, Scopus. The inclusion criteria were: 1) papers authored by CM Fisher; 2) the term “lacunar” is mentioned at least once in the document. The portable document format (pdf) of these articles were transformed into text files and processed to create a document term matrix. These topics were fitted to Dirichlet (multivariate probability) distribution for theme discovery. The theme includes the terms with the highest frequency within that theme.

Results

There were 16 articles and 3063 words yielding matrix of 16 by 3063. Frequent words were: artery [frequency 569], lesion [frequency 397], right [frequency374], left [frequency 326], lacune [frequency 285]. Figure 1 is a word cloud depicting frequent occurring words by the size of the words. The top 5 themes were: 1) sensory and motor stroke; 2) pontine stroke; 3) histopathology of vessel lumen (contains plaque [frequency 47] and atherosclerosis [frequency 83]); 4) cerebellar stroke; 5) histopathology of vessel wall.

graphic file with name 10.1177_2396987316642909-fig78.jpg

Conclusions

This analysis show that the Fisher’s works on lacunar stroke were not as homogenous as depicted. Theme discovery from PTM provides an unbiased method to re-evaluate works by key contributor to the literature on lacunar stroke or other scientific works.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

BRAIN VASCULAR LESIONS, GAIT AND BALANCE

D Pinter ¹, S Ritchie ², F Doubal ³, T Gattringer ¹, Z Morris ⁴, M Bastin ⁴, M del, MC Valdés Hernández ⁵, N Royle ⁵, J Corley ⁶, S Munoz Maniega ⁵, A Pattie ⁶, DA Dickie ⁵, AJ Gow ⁷, J Staals ⁸, JM Starr ⁶, IJ Deary ⁶, C Enzinger ⁹, F Fazekas ¹, J Wardlaw ¹⁰

Abstract

Background

Gait and balance impairment is highly prevalent in older people. Therefore, we aimed to assess whether and how single or combined small vessel disease (SVD) features predict gait and balance function independently of other variables, such as demographics and risk factors.

Methods

680 community-dwelling healthy subjects from the Lothian Birth Cohort 1936 who underwent comprehensive risk factor assessment, gait and balance assessment as well as brain MRI, were examined. Gait speed, chair-stand and standing balance of the Short Physical Performance Battery were assessed as main outcomes. SVD features were assessed on structural brain MRI and a total SVD score was derived according to the severity of morphologic damage.

Results

Subjects were 71–74 years old and 53% of the sample were male. Most had a SVD score of 0–1 (80.8%). A regression model, including demographic variables, risk factors and MRI visible SVD features revealed that age and sex, hypertension and diabetes significantly predicted gait speed. In addition, the total SVD score significantly predicted gait. Similar associations were observed if white matter hyperintensity (WMH) score or volume were included in the regression model.

Conclusions

Our study confirms a negative impact of SVD-related morphologic brain changes on gait speed in addition to age, sex and vascular risk factors in a large cohort of community-dwelling older individuals. This effect was best captured by a total SVD score, although in our cohort this was mainly accounted for by WMH. This relatively simple score may thus inform patient counseling and preventive strategies.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CEREBRAL MICROVASCULAR INJURY AND INCIDENT LATE-LIFE DEPRESSIVE SYMPTOMS IN THE FRAMINGHAM HEART STUDY

A Shoamanesh ¹, J Himali ², A Beiser ³, S Preis ², C DeCarli ⁴, C Kase ⁵, S Seshadri ⁵, J Romero ⁵

Abstract

Background

Disruption of cerebral circuits secondary to cerebrovascular lesions may drive the occurrence/progression of late-life depressive symptoms(DS). We aimed to assess the relationship between cerebral microvascular lesions and incident late-life DS in a community-dwelling population.

Methods

We evaluated stroke, dementia and depression-free Framingham Offspring Cohort participants who underwent brain MRI allowing for cerebral microbleed(CMB) detection and assessment for DS with the Center for Epidemiological Studies Depression Scale(CES-D). MRI markers of interest were covert brain infarcts(CBIs), extensive white matter hyperintensity volume(eWMHV), and CMB presence and topography. Presence of incident DS was defined as developing a CES-D score beyond 15 and/or new antidepressant medication use during follow up.

Results

In 977 participants (mean age: 64), 160 (16%) developed incident DS during a mean follow-up of 6 ± 0.6 years. Participants with incident DS had greater proportions of current smoking (14% vs. 8%,p < 0.01), diabetes (15% vs. 9%,p = 0.03), and prevalent cardiovascular disease(CVD; 15% vs. 8%,p < 0.01), and lower antithrombotic medication use (20% vs. 34%,p < 0.001). Multivariable logistic regression analyses adjusting for vascular risk factors (age, sex, diabetes mellitus, hypertension, current smoking, CVD, statin use and antithrombotic use) suggested higher odds of incident DS among persons with eWMHV (OR 1.5, 95% CI 1–2.3), CBIs (1.6, 0.9–2.6) and lobar CMBs (2.0, 1.0–4.1). There was no notable association with the other CMB topographic patterns.

Conclusions

Our results suggest that vascular risk factors and microvascular cerebral insults are associated with late-life DS in community-dwelling persons, and that antithrombotic therapy may mitigate the risk of developing late-life DS. Further research is required to explore/validate these findings.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

DISRUPTION OF RICH CLUB ORGANISATION IN CEREBRAL SMALL VESSEL DISEASE

A Tuladhar ¹, A Lawrence ², D Norris ³, T Barrick ⁴, H Markus ², FE de Leeuw ¹

Abstract

Background

Cerebral small vessel disease (SVD) is an important cause of vascular cognitive impairment. Recent studies have demonstrated that structural connectivity of brain networks in SVD is disrupted. However, little is known about the extent and location of the reduced connectivity in SVD. Here we investigate the rich club organisation - a set of highly connected and interconnected regions - and investigate the role of rich club disruption in SVD.

Methods

Diffusion tensor imaging (DTI) and cognitive assessment were performed in a discovery sample of SVD patients (n = 115) and healthy control subjects (n = 40). Results were replicated in an independent dataset (49 SVD with confluent WMH cases and 108 SVD controls) with SVD patients having a similar SVD phenotype to that of the discovery cases. Rich club organisation was examined in structural networks derived from DTI followed by deterministic tractography.

Results

Structural networks in SVD patients were less dense with lower network strength and efficiency. Reduced connectivity was found in SVD, which was preferentially located in the connectivity between the rich club nodes rather than in the feeder and peripheral connections, a finding confirmed in both datasets. In discovery dataset, lower rich club connectivity was associated with lower scores on psychomotor speed (β = 0.29, p < 0.001) and executive functions (β = 0.20, p = 0.009).

Conclusions

These results suggest that SVD is characterized by abnormal connectivity between rich club hubs in SVD and provide evidence that abnormal rich club organisation might, at least in part, contribute to the development of cognitive impairment in SVD.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CEREBRAL MICROBLEEDS IN PATIENTS WITH MILD COGNITIVE IMPAIRMENT AND SMALL VESSEL DISEASE: THE VASCULAR MILD COGNITIVE IMPAIRMENT (VMCI)-TUSCANY STUDY

R Valenti ¹, A Poggesi ¹, E Salvadori ¹, A Del Bene ¹, A Ginestroni ², G Pracucci ¹, L Ciolli ¹, S Marini ¹, S Nannucci ¹, M Pasi ¹, F Pescini ³, M Mascalchi ², S Diciotti ⁴, G Orlandi ⁵, M Cosottini ⁶, A Chiti ⁵, U Bonuccelli ⁵, D Inzitari ¹, P Leonardo ¹

Abstract

Background

Cerebral microbleeds (CMBs) are one of the neuroimaging expressions of small vessel disease (SVD). In a cohort of SVD patients with MCI we investigated: 1) the reliability of the Microbleed Anatomical Rating Scale (MARS); 2) the burden and location of CMBs and their association with cognitive performances, independent of other clinical and neuroimaging features.

Methods

Patients underwent a clinical, neuropsychological, and MRI assessment. On T2*-weighted gradient-echo (GRE) sequences, presence, number, and location of CMBs were assessed using MARS by 3 raters; inter-rater agreement was evaluated. Cognitive performances in four specific domains were evaluated.

Results

Out of the 152 patients (57.2% males; mean age ± SD: 75.5 ± 6.7 years), forty-one (27%) had at least one CMB. Inter-rater agreement for number and location of CMBs ranged from good to very good [multi-rater Fleiss kappa (95%CI): 0.70–0.95]. Correlation analysis showed that attention/executive and fluency domains were significantly associated with total number of CMBs and with those in deep and lobar regions. Lacunar infarcts were associated with CMBs presence; hypertension and low physical activity were associated with deep and lobar CMBs, respectively, migraine with infratentorial and the use of calcium channel blockers with both deep and infratentorial CMBs.

Conclusions

In a cohort of SVD patients with MCI, MARS proved to be a reliable instrument to assess CMBs. Nearly one third of patients had at least one CMB; total CMBs burden was associated with some potentially modifiable risk factors, lacunar infarcts and with attention/executive functions and fluency domains deficits.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

BIOLOGICAL SIGNIFICANCE OF TOTAL SMALL VESSEL DISEASE MRI BURDEN IN CEREBRAL AMYLOID ANGIOPATHY

R Valenti ¹, A Charidimou ², G Boulouis ², YD Reijmer ², SR Martinez ², L Xiong ², P Fotiadis ², S Davidsdottir ³, MJ Jessel ², A Ayres ², G Riley ², L Pantoni ¹, EM Gurol ², SM Greenberg ², A Viswanathan ²

Abstract

Background

Cerebral amyloid angiopathy (CAA) is a major cause of lobar intracerebral hemorrhage and cognitive impairment in the elderly. Different neuroimaging markers of CAA are related to distinct biological or clinical aspects of the disease. We investigated the biological significance of a composite score designed to capture the total brain MRI burden in CAA, by evaluating its correlation with white matter connectivity, and overall disability measures.

Methods

We applied the total MRI small vessel disease (SVD) score in a prospective cohort of 96 patients with probable/possible CAA. The score, ranging from 0 to 6, considered 4 MRI features: lobar microbleeds, focal or disseminated cortical superficial siderosis, moderate-to severe enlarged perivascular spaces in the centrum semiovale, and moderate-severe white matter hyperintensities (WMH). We explored the association of the score with white matter connectivity in adjusted ordinal and linear regression analyses.

Results

The median MRI SVD score was 4.00 (IQR: 3.00–5.00). Higher total MRI SVD score was associated with global network efficiency (coefficient [95% CI]: −0.004 [−0.008 to −0.002]), in addition to brain atrophy (OR [95%CI]: 1.57 [1.16–2.12]) and posterior predominance of WMH (OR [95% CI]: 1.65 [1.11–2.46]). The score was related with lower memory performance (coefficient [95% CI]: −0.14 [−0.28 to −0.01]) and depressive symptoms (coefficient [95% CI]:1.17 [0.30–2.04]).

Conclusions

The total MRI SVD score reflects the global network efficiency, and might be helpful to capture the cumulative effects of microangiopathy burden in patients affected by sporadic CAA. Larger studies are needed to validate our findings.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE INFLUENCE OF CARDIOVASCULAR RISK MANAGEMENT ON WHITE MATTER HYPERINTENSITY PROGRESSION IN HYPERTENSIVE OLDER PEOPLE IN THE PreDIVA TRIAL

JW van Dalen ¹, M Caan ², A Nederveen ², E Moll van Charante ³, WA van Gool ¹, E Richard ⁴

Abstract

Background

White matter hyperintensities (WMH) on magnetic resonance imaging (MRI) in asymptomatic older people are associated with age, hypertension, cardiovascular risk factors, and risk of future cognitive decline and dementia. Whether treatment of cardiovascular risk factors can impede WMH progression is unknown. The prevention of dementia by intensive vascular care (preDIVA) trial evaluated the efficacy of six-year nurse-led intensive vascular care on the prevention of dementia. In an MRI sub-study, we evaluated the intervention effect on WMH progression.

Methods

195 participants between 72 and 82 years old with a baseline systolic blood pressure >140 mmHg underwent 3T MRI after 3 years of intervention. 135 (70%) completed MRI follow-up 3 years later. WMH volume was measured using automatic segmentation. The effects of the intervention and blood pressure lowering during the study on WMH volume change were evaluated using linear regression, adjusted for initial WMH volume and brain volume change.

Results

Median baseline WMH volume was 6.3 ml (IQR = 3.5–10.9) in the intervention (n = 64) vs. 5.7 ml (IQR = 3.3–11.1) in the control group (n = 62). Progression of WMH volume was similar in both groups (1.9 vs. 2.1 ml respectively, beta = −0.01, p = 0.97). WMH progression was significantly associated with mean arterial pressure (MAP) at baseline (0.04 ml/mmHg, p < 0.001) and change in MAP during the study (0.02 ml/mmHg, p = 0.04).

Conclusions

In 72–82 year old persons with hypertension, intensive vascular care did not influence WMH progression. WMH progression was inversely associated with blood pressure reduction. This suggests successful management of hypertension can slow WMH progression in community-dwelling elderly.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE ASSOCIATION BETWEEN VISIT-TO-VISIT BLOOD PRESSURE VARIABILITY AND COGNITIVE IMPAIRMENT IN OLDER PEOPLE

T van Middelaar ¹, JW van Dalen ², WA van Gool ², EP Moll van Charante ³, E Richard ^1,²

Abstract

Background

Blood pressure variability (BPV) is independently associated with small and large artery cerebrovascular disease. Whether it is associated with cognitive impairment in older people is unclear. Our aim was to investigate whether visit-to-visit BPV is associated with cognitive impairment and cognitive function.

Methods

We studied the population of community-dwelling elderly of the ‘Prevention of Dementia by Intensive Vascular Care’ trial as a single cohort. At baseline, two, and four years, blood pressure (BP) was measured. BPV was defined as the coefficient of variation (CV; standard deviation [SD] divided by mean) of systolic BP. We only included participants who attended all three visits. For this analysis we defined cognitive impairment as a score <24 on the mini-mental state examination (MMSE) and/or a diagnosis of dementia, during 4–8 years of follow-up.

Results

In 2212 participants (mean baseline age: 74 years, SD = 2.4) mean systolic BP over the first three visits was 150 mmHg with a SD of 13, yielding a CV of 0.08. After 4–8 years of follow-up, 98 developed dementia and another 31 had a MMSE <24. Unadjusted, the odds ratio of CV and cognitive impairment was 1.0 (95% confidence interval [95% CI] 0.7–1.4). Adjusted for absolute BP change, sex, age and education, the odds ratio was 0.8 (95% CI 0.5–1.2). Exclusion of participants with a baseline MMSE <26 (n = 132) did not alter results, nor did median MMSE differ between tertiles of CV (median 29, p = 0.35).

Conclusions

In this study, visit-to-visit BPV was not associated with cognitive impairment.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

MAGNETIC RESONANCE SPECTROSCOPY IN HEALTHY SUBJECTS WITH INCIDENTAL BRAIN WHITE MATTER LESIONS

R Vibo ¹, T Tomberg ², P Kampus ³, E Salum ³, M Ennok ⁴, J Kõrv ¹

Abstract

Background

Cerebral white matter lesions (WML) are associated with cognitive decline and increased risk of future stroke, particularly lacunar type. The importance of WMLs in healthy subjects remains unknown. The aim of this cohort study is complex profiling of healthy subjects aged ≤64 years with incidental WMLs.

Methods

Subjects without clinical neurological signs, no history of neurological disease and normal cognition aged ≤64 years were included. For radiological investigations a 3.0 Tesla whole body scanner is used. WML on T2-weighted MR images are scored according to the Fazekas scale. Proton MR single voxel spectroscopy was performed from left frontal white matter.

Results

We studied 77 subjects (56 with WMLs and 21 with normal MRI) aged 19–62 (mean age 46.6 ± 10.5) years, 86% were female. Forty-two patients (55%) had Fazekas score of 0 or 1, 25 subjects (32%) had Fazekas score 2 and 11 subjects (13%) had score ≥3. Thirty-nine subjects had 1 to 10 WMLs and 17 subjects had >10 WMLs. The multinominal logistic regression analysis showed statistically significant association of the number of WMLs and composite of glutamate-related metabolites from MRS (p = 0.0002, adjusted for age). There was no associations with ohter measured metabolites.

Conclusions

We found that glutamate-related metabolites measured from frontal white matter of healthy subjects are significantly associated with the amount of WMLs. This finding could indicate that these subjects are prone to white matter damage, but the improtance of this finding should be determined in further analysis.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

WHITE MATTER MRI CORRELATES OF VASCULAR COGNITIVE IMPAIRMENT: A COMPARISON BETWEEN MOCA AND MMSE

G Zamboni ¹, L Griffanti ¹, S Mazzucco ¹, M Jenkinson ¹, S pendlebury ¹, P Rothwell ¹

Abstract

Background

Among scales used to screen for cognitive impairment, the Montreal Cognitive assessment scale (MoCA) captures more impairment after TIA or non-disabling stroke than the Mini-Mental State Examination (MMSE). We hypothesised that the MoCA would therefore be associated with greater white-matter (WM) damage on MRI, measured as white-matter hyperintensity (WMH) and fractional anisotropy (FA), relative to the MMSE.

Methods

In 397 consecutive TIA/minor-stroke patients from the Oxford Vascular Study who underwent MRI, MMSE and MoCA, we correlated cognitive scores with WMH and FA and performed group comparisons on patients divided according accepted cut-offs of MMSE <27 and MoCA <26 to indicate impairment.

Results

MMSE and MoCA scores were significantly correlated with WMH volumes (MMSE r₃₉₄ = −0.292, MoCA r₃₉₄ = −0.333, p < 0.001) and average FA (MMSE r₃₃₀ = 0.349, MoCA r₃₃₀ = 0.405, p < 0.001), but only the MoCA still correlated with WMH volumes (r₃₉₃ = −0.115, p = 0.022) and average FA (r₃₂₉ = 0.177, p = 0.001) when controlling for the effect of age and MMSE. Voxel-wise analyses showed that lower cognitive scores on both scales correlated with higher probability of WMH in the frontal anterior WM and reduced FA in all WM tracts. Among patients who had normal MMSE scores (≥27), those who had abnormal MoCA (<26) showed significantly higher WMH volumes (t = 3.1, p = 0.002), lower average FA (t = −4.0, p < 0.001), and widespread lower voxel-wise FA in almost all WM tracts relative to those who had normal MoCA (≥26).

Conclusions

The MoCA is significantly associated with WM damage over and above the effect of MMSE, and detects more microstructural white matter damage than the MMSE.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

TYPE OF INFARCT AND OUTCOME IN MALIGNANT MCA STROKES

S Kamran ¹, N Akhtar ¹, A Salam ¹, J Inshasi ², A Alboudi ², A Shuaib ¹

Abstract

Background

Impact of stroke type on outcome in hemicraniectomy for malignant MCA strokes has not been reported.

Methods

A retrospective analysis of Hemicraniectomy database pooled from three countries [Pakistan, Qatar and UAE] was carried out for infarct type and volume. Outcome was measured using mRS at 3-months.

Results

Total of 203 patients, 137 had surgery and 66 treated conservatively.

Conclusions

MCA with additional infarcts [ACA, PCA] led to poor functional outcome and increased mortality with or without surgery.

Table 1.

Type of Infarctⁿ⁼²⁰³	Maximum Infarct Volume cm3	mRS 3-month	30-day Mortality
2/3^rd MCA without BG	242.1 (215.7–288.2)	3 (2–4)	0
2/3rd MCA with BG	269.7 (217.1–316.8)	3 (3–4)	3 (6.8)
Complete MCA without BG	319.5 (255.5–374.6)	4 (3–6)	5 (27.8)
Complete MCA with BG	379.0 (300.7–450.1)	4 (3–5)	4 (7.1)
2/3^rd MCA without BG/Add. infarct	258.9 (235.5–439.9)	5 (3–5.5)	1 (20.0)
2/3rd MCA with BG/Add. Infarct	357.9 (273.8–436.6)	5 (4–6)	14 (45.2)
Complete MCA without BG/Add.Infarct	333.1 (311.2–341.6)	5 (4–5.75)	2 (25.0)
Complete MCA with BG/Add. infarct	451.4 (375.1–559.2)	5 (4–6)	13 (43.3)
P-value	<0.001	<0.001	<0.001

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Results expressed as Median (Inter-Quartile Range), and number (percentage). BG-Basal Ganglia, Add. Infarct- Additional infarcts anterior and/ or posterior cerebral artery.

Table 2.

Prognosis at 3-month	Total	MCA with Add. Infarct	MCA without Add. Infarct
Good (mRS 0–4)	124 (61.1)	25 (33.8)	99 (76.7)	<0.001
Poor (mRS 5–6)	79 (38.9)	49 (66.2)	30 (23.3)
30-Day Mortality	42(20.7)	30 (40.5)	12 (9.3)	<0.001

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Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PRE-THROMBOLYSIS NEUTROPHIL / LYMPHOCYTE RATIO IS NOT AN INDEPENDENT PREDICTOR OF PROGNOSIS IN ISCHEMIC STROKE PATIENTS

J Araújo ¹, M Taveira ², JN Alves ¹, J Pinho ¹, C Ferreira ¹

Abstract

Background

Recent studies suggest that a higher pre-thrombolysis neutrophil/lymphocyte ratio (NLR) in ischemic stroke patients is robustly associated with worse prognosis. Our goal was to determine if NLR in ischemic stroke patients treated with thrombolysis is an independent predictor of 3-month prognosis.

Methods

Selection of all consecutive ischemic stroke patients treated with intravenous thrombolysis from our Stroke Unit prospective registry between February/2007 and August/2015, in which pre-thrombolysis complete blood count and 3-month prognosis were available. Favourable prognosis was defined as modified Rankin Scale 0–2. We performed descriptive, univariate and multivariate statistical analysis and Spearman correlation.

Results

We included 477 patients, median age 73 years, 54.7% of female sex. In univariate analysis, favourable prognosis was associated with a lower NLR (p = 0.042), younger age (p < 0.001), lower admission blood glucose (p < 0.001), lower admission NIHSS (p < 0.001), lower NIHSS 24 h after thrombolysis (p < 0.001), lower ASPECTS/pcASPECTS (p < 0.001), lower frequency of infection <48 h and >48 h after admission (p < 0.001 and p < 0.001) and lower frequency of symptomatic intracranial hemorrhage (p < 0.001). NLR was higher in the group of patients with early infection (p = 0.008). In multivariate analysis NLR was not an independent predictor of favourable prognosis (OR = 1.03, 95%CI = 0.92–1.14, p = 0.646), mortality (OR = 1.11, 95%CI = 0.97–1.26, p = 0.120) or 7-day symptomatic intracranial hemorrhage (OR = 1.09, 95%CI = 0.95–1.26, p = 0.215) when adjusted for variables flagged in the univariate analysis, including early infection.

Conclusions

NLR is not an independent predictor of outcome, specifically when adjusted for variables such as occurrence of early infection. The major limitation of the previous studies demonstrating this association was the absence of adjustment for infection.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

DEPRESSION TRAJECTORIES AND THE RISK OF MORTALITY 10 YEARS AFTER STROKE; THE SOUTH LONDON STROKE REGISTER

S Ayis ¹, A Rudd ², L Ayerbe ³, S Crichton ⁴, CDA Wolfe ⁴

Abstract

Background

In a recent study we have established heterogeneous patterns for the development of symptoms of depression (trajectories) after stroke. Here we examined the risk of 10 years mortality among these.

Methods

Data from the South London Stroke Register (1998–2013) were used. Patients were assessed on socio-demographics, stroke severity, and medical history at stroke onset, and were followed up at 3 months after stroke, then annually. The Hospital Anxiety and Depression scale (HADs) was used to screen for depression at each follow up. A Latent Class Growth Analysis (LCGA) method was used to derive trajectories of depression symptoms over 5 years after stroke. The Cox regression model was used to estimate the hazard ratio (HR) of 10 years mortality among patients in the trajectories derived

Results

Of 761 patients who survived at least 5 years after stroke four trajectories of depression were identified (Group I- IV), comprising 15.51% who had no symptoms and remained so over time; 49.54% had mild symptoms, predicted mean HADS score, 3.89 (se = 0.30); 28.65% had moderate symptoms, a tendency to get worse over time, predicted mean score 7.36 (se = 0.35) and 6.31% of patients had severe symptoms, predicted mean score, 15.74 (se = 1.06). The age adjusted HRs (95% CI) of 10 years mortality for groups II-IV, respectively were: 1.32(1.02–1.71), 1.50(1.14–1.98), and 1.49(1.00–2.22), significantly higher than group I (reference), at the 5% significance level.

Conclusions

The risk of 10 years mortality is remarkably higher in patients with increased depression symptoms over 5 years after stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

IMPACT OF WHITE MATTER HYPERINTENSITY ON THE LONG-TERM OUTCOME IN STROKE PATIENTS WITH LARGE ARTERY ATHEROSCLEROSIS

M Baik ¹, SH Jeong ¹, KH Kim ¹, YD Kim ¹, DB Song ¹, JH Heo ¹, HC Kim ², HS Nam ¹

Abstract

Background

Presences of white matter hyperintensity (WMH) are related with poor long-term outcomes. The highest mortality rates are observed in patients with large atherosclerosis (LAA) or cardioembolism, and the lowest with lacunar strokes. However long-term outcome is unknown in patients with LAA and WMH. We investigated the differential impact of WMH on the long-term outcome in patients with LAA.

Methods

From May 1999 until June 2007, consecutive patients with acute ischemic stroke were enrolled. They were followed for a median of 7.7 years (IQR, 5.5–9.9). Long-term mortality and causes of death were identified using death certificates or telephone interviews. Degree of WMH was assessed by Fazekas grade using FLAIR image. Severe WMH was defined as Fazekas grade ≥2.

Results

Among 2913 patients, the stroke subtype was LAA in 753 patients (25.8%). After excluding without FLAIR images, 556 patients were analyzed. Mean age was 65.6 ± 10.3 years old and 66.9% were men. Severe WMHs were found in 284 patients (51.1%). During follow-up, 208 patients (37.4%) died. The Kaplan-Meier survival analysis showed that old age, diabetes, initial NIHSS score, and severe WMH were associated with long-term mortality. The Cox regression analysis showed that severe WMH was independent predictor for long-term mortality. LAA patients with severe WMH showed 1.52-fold (95% CI, 1.14–2.04) higher mortality compared to those without.

Conclusions

Degree of WMH might be one of surrogate marker for long-term outcome in patients with LAA. Burdens in both small and large artery might impact on long-term prognosis in ischemic stroke patients.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CLINICAL DETERMINANTS OF ISCHAEMIC STROKE OUTCOME IN AN HIV ENDEMIC POPULATION

L Benjamin ¹, H Mzinganjira ², I Peterson ³, N Nagelkerke ³, M Connor ⁴, T Solomon ¹, T Allain ²

Abstract

Background

We sought to determine the clinical determinants of being alive or dead by 180-days after an acute ischaemic stroke in an HIV endemic country.

Methods

During 2011, all adult patients with confirmed ischemic stroke presenting to Queen Elizabeth Central Hospital, Blantyre Malawi were prospectively included in this study. Demographic data, vascular risk factor profile, severity of stroke were evaluated. Each case had a comprehensive investigation to determine the aetiology. Outcome (dead or alive) was determined at 180-days. Uni- and multivariate cox regression analysis was performed to determine independent predictors of death after a stroke.

Results

171 ischaemic stroke patients were included between February 2011– April 2012. The median age of survivors and those who died were 56 years (IQR:39,67) and 62 years (IQR:40,79) respectively. HIV prevalence was higher in those who died (41%) compared with survivors (36%) by 180-days. The estimated 180-day survival was 0.619 (standard error = 0.040). In the univariate analysis, death was associated with increasing severity of stroke [Hazard ratio HR 1.31 Confidence Interval CI: 0.78,2.21] whist being HIV positive was trending towards an association with death HR 1.31 (CI 0.78,2.21). The multivariate analysis showed an independent association of increasing severity [HR 1.11 (1.08,1.14) and HIV positivity [HR 2.04 (1.05,3.97)] with death. HIV treatment, immunosuppression and established vascular risk factors were not statistically significant predictors of death by 180-days.

Conclusions

HIV is associated with death following a stroke. This risk may be independent of immunosuppression. A better mechanistic understanding might point the way to an appropriate intervention.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ALTERED VULNERABILITY OF STRUCTURAL NETWORKS TO SIMULATED STROKE IN MILD COGNITIVE IMPAIRMENT

R Berlot ¹, M O'Sullivan ²

Abstract

Background

Neurodegeneration preferentially targets network hubs, which leads to redistribution of processing. This might be reflected in altered vulnerability of the brain connectome to stroke. To test this, we simulated the effect of stroke within the “rich club”, a group of highly interconnected hubs. We assessed if the vulnerability to rich-club lesions is altered in patients with mild cognitive impairment (MCI), the prodromal stage of Alzheimer’s disease.

Methods

20 patients with MCI and 25 matched controls underwent diffusion-weighted MRI. Whole-brain tractograms were used to construct network graphs. Lesions of rich-club nodes were simulated by removing a node and its connections from the graph. The proportional change in global efficiency due to lesion was calculated. Differences in vulnerability were related to patterns of node atrophy.

Results

Simulated stroke affecting either precuneus led to the largest decreases in global efficiency for controls. In contrast, the MCI group exhibited increased vulnerability to lesions of the right putamen but less vulnerability to precuneal damage. Difference in vulnerability was not related to atrophy of the precuneus.

Conclusions

Networks of patients with MCI exhibit an altered pattern of vulnerability to simulated stroke. Connections essential for efficient network structure “shift” away from the precuneus, which is affected early in Alzheimer’s disease, while other structures such as the putamen become critical to network efficiency. Undetected Alzheimer pathology is likely to be present in many patients with stroke. Structural connectome alterations in response to early neurodegeneration represent a potential mechanism for synergy between neurodegeneration and vascular lesions in post-stroke cognitive impairment.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

DELAYS IN THE EMERGENCY DEPARTMENT FOR STROKE PATIENTS, MEDICAL COMPLICATIONS AND PREDICTORS OF OUTCOMES: THE MCGILL EXPERIENCE

C Legault ¹, BY Chen ¹, L Vieira ², B Lo ³, L Wadup ², R Côté ²

Abstract

Background

The Canadian Stroke Best Practice recommends admission of patients to a stroke unit within three hours. We aimed at assessing delays in our emergency department (ED) and correlating these with medical complications and clinical outcomes.

Methods

This is a retrospective review of patients (n = 353) admitted with ischemic strokes (January 2011-March 2014). We assessed the length of stay in ED, medical complications in ED and the stroke unit, functional status (modified Rankin Scale) at discharge and survival. Standardised β coefficients described the slope of linear regressions for continuous outcomes.

Results

The median delay in ED was 13.8 hours. The mean duration of hospital stay was 20 days. The rate of medical complications in the ED was 14% (most common being delirium, pneumonia and urinary tract infection), compared to the stroke unit with a rate of 46.7% (most common being pneumonia, urinary tract infection and delirium). Worse functional outcome was correlated with increasing age (standardised β coefficient = 0.2, p < 0.01), diagnosis of pneumonia (standardised β coefficient = 0.2, p = 0.001) and presence of brain oedema in the stroke unit (standardised β coefficient = 0.2, p < 0.01). Increased risk of death was correlated with pneumonia in ED (odds ratio, OR = 25.5, 95% confidence interval, 95%CI = 3–190, p < 0.01), brain oedema (OR = 649.2, 95%CI = 19–2184, p < 0.01) and sepsis in the stroke unit (OR = 26.8, 95%CI = 2.1–339, p < 0.01).

Conclusions

We found a significant delay in the admission of our patients from the ED to the stroke unit, which is not in keeping with the present guidelines. Several medical complications were correlated with worse outcomes. Future analyses will correlate ED delays with clinical outcomes.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE CHARACTERISTICS OF IN-HOSPITAL STROKE - IMPLICATION OF FAST EVALUATION AND MANAGEMENT

JY Wang ¹, HJ Ho ², MC Tseng ³, YW Chen ¹

Abstract

Background

Stroke needs immediate identification and proficient evaluation whenever it is suspected. In-hospital stroke (IHS), 4–17% of all acute stroke, is often delayed in management as compared with the community-onset counterpart. We aimed to investigate the characteristics of IHS.

Methods

We performed an analysis of IHS in a stroke registry in the Landseed Hospital, a regional teaching hospital in Taiwan, from July 2010 to December 2014. Patients’ characteristics, stroke types, primary-care departments, presenting symptoms, quality measurements for intravenous thrombolysis were recorded through chart review.

Results

Totally 43 IHS (1.5%) are identified in the stroke registry. Education of medical personnel and and a rapid response team has been implemented since 2011. The majority of IHS patients were located in the cardiology ward (23.3%), followed by intensive care unit (16.3%) and chest medicine (16.3%). Facial droop, arm drift, speech disturbance and time (FAST) in Cincinnati Prehospital Stroke Scale help identify IHS in 23 patients (53.4%), and conscious disturbance (37%) was a common symptom accompanying family or caregivers noticed and thus became alert. Two (4.6%) presented seizure as chameleons of stroke. Four patients (10.5%) received intravenous thrombolysis, more than 4.8% in the community-onset stroke.

Conclusions

IHS in the study hospital is less common than that reported in West. Cardiovascular instability may attribute to the calamity. Most patients can be identified by FAST and conscious disturbance screen. Implementation of a rapid response team and education of the medical personnel and family may help identify thrombolytic candidates to improve stroke care.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EXTERNAL VALIDATION OF THE ASTRAL AND DRAGON SCORES FOR PREDICTION OF FUNCTIONAL OUTCOME IN STROKE

C Cooray ¹, M Mazya ¹, M Bottai ², L Dorado ³, O Skoda ⁴, D Toni ⁵, GA Ford ⁶, N Wahlgren ¹, N Ahmed ¹

Abstract

Background

ASTRAL and DRAGON are two recently developed scores for predicting functional outcome after acute stroke. We aimed to perform external validation of these scores to assess their predictive performance in the large multicentre-SITS-International Stroke Thrombolysis Register (SITS-ISTR).

Methods

We calculated the ASTRAL and DRAGON score in 36131 and 33716 patients respectively registered in SITS-ISTR 2003–2013. The proportion of patients with 3-month modified-Rankin-Scale (mRS) 3–6 was observed for each score point and compared to the predicted proportion according to the risk-scores.

Results

Predictive performance of the ASTRAL (AUC = 0.790, 95% CI 0.786–0.795) and the DRAGON score was acceptable (AUC = 0.774, 95% CI 0.769–0.779). All ASTRAL parameters except range of visual fields, and all DRAGON parameters were significantly associated with functional outcome in multivariate analysis.

Conclusions

ASTRAL and DRAGON scores show an acceptable predictive performance. ASTRAL does not require imaging-data and may have an advantage for use in pre-hospital triage of patients with predicted bad outcome despite thrombolysis to centres with endovascular interventional capabilities. DRAGON may have a role for selecting patients for multimodal imaging upon hospital arrival, as it uses predictive information from initial plain computed-tomography.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ROLE OF SDF-1α ON NEUROLOGICAL, FUNCTIONAL AND COGNITIVE RECOVERY AT THREE MONTHS AFTER ISCHEMIC STROKE: A PILOT DTI STUDY

R Dacosta-Aguayo ¹, W Zinke ², T Auer ³, T Sobrino ⁴, N Lamonja ¹, M Graña Romay ⁵, E López-Cancio ⁶, M Gomis ⁷, N Pérez de la Ossa ⁷, M Millán ⁷, N Bargalló ⁸, M Via Garcia ¹, I Clemente ¹, P Toran ⁹, M Alzamora ⁹, G Pera ⁹, A Davalos ⁶, M Mataró ¹

Abstract

Background

Post-stroke brain remodelling involves several different mechanisms including neurogenesis, angiogenesis and brain plasticity. However, biomarkers for predicting stroke (IS) severity and outcome are lacking. Our aim is to investigate how serum levels from different remodelling biomarkers are related with clinical and cognitive outcomes.

Methods

Study of twelve consecutive (IS) and twelve age-matched healthy controls. DWI-3T data were acquired at 3T three months after (IS). We performed: 1) Whole-brain group analysis using Tract Based Spatial Statistics (TBSS) to investigate the effect of 5 biomarkers serum levels (VEGF, EPO, BDNF, G-CSF, SDF-1α) measured by ELISA on Fractional Anisotropy (FA); 2) Analysis of partial correlations between significant FA values from 1) and cognitive, neurological (NIHSS) and functional outcome (Rankin scale-mRS).

Results

Significant interaction effect on FA was found between groups and SDF-1α levels in the left Genus of the Corpus Callosum (Figure 1) as well as in the right Corticospinal Tract (p = 0.01, FWE-corrected). In IS patients, FA values showed negative correlations with NIHSS (r = −0.671; p = 0.034), mRS (r = −0.733; p = 0.016) and infarct volume (r = −0.626; p = 0.05); while positive correlations were found for Semantic Fluency (r = 0.631; p = 0.05). In controls, FA values showed negative correlations with Grooved Pegboard (r = −0.739; p = 0.015).

Conclusions

In our pilot study, chemokine SDF-1α was associated with changes in specific white matter tracts, which resulted in better cognitive and functional outcomes after IS. However, these findings deserve future research.

graphic file with name 10.1177_2396987316642909-fig79.jpg

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PREDICTORS OF HEALTH-RELATED QUALITY OF LIFE AFTER INTRACEREBRAL HAEMORRHAGE: POOLED ANALYSIS FROM THE INTERACT STUDIES

C Delcourt ¹, D Zheng ¹, X Chen ¹, M Hackett ¹, H Arima ¹, E Heeley ¹, R Al-Shahi Salman ², Y Huang ³, T Robinson ⁴, P Lavados ⁵, R Lindley ¹, C Stapf ⁶, J Chalmers ⁷, C Anderson ¹, S Sato ¹

Abstract

Background

Limited data exist on health-related quality of life (HRQoL) after intracerebral haemorrhage (ICH). We aimed to determine associations with HRQoL among participants from the Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage Trials (INTERACT).

Methods

INTERACT1 (pilot) and INTERACT2 (main) randomized controlled trials of early intensive blood pressure (BP) lowering in patients with imaging-confirmed ICH (<6 hrs of onset) and elevated systolic BP (SBP, 150–220 mmHg). We used multivariable analyses to determine associations with poor HRQoL determined by the European Quality of Life Scale (EQ-5D) at 90 days.

Results

Of 2756 patients, poor HRQoL (lower mean EQ-5D utility score) was associated with older age (OR 1.35 (95%CI 1.25–1.45)), randomization outside of China (OR 1.21 (95%CI 1.03–1.35)), pre-ICH antithrombotic use(OR 1.61 (95%CI 1.21–2.15)), higher baseline SBP(OR 1.03 (95%CI 1.01–1.06)), higher baseline National Institutes of Health Stroke Scale (NIHSS) score(OR 3.06 (95%CI 2.52–3.71)), larger and deep ICH(OR 1.59 (95%CI 1.44–1.75) and OR 1.32 (95%CI 1.04–1.67)), intraventricular ICH extension(OR 1.56 (95%CI 1.30–1.87)), and dependence on proxy-responders(OR 1.92 (95%CI 1.61–2.28)). Higher NIHSS score, larger ICH, and proxy-responders were common predictors of low scores in all 5 dimensions of EQ-5D. Randomization outside of China was associated with low score in self-care, usual activity, and anxiety/depression dimensions.

Conclusions

Poor HRQoL after ICH was related to age, clinical severity, ICH characteristics including presence of intraventricular extension, proxy-responders, and non-Chinese patients.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EARLY CEREBRAL BLOOD FLOW RESPONSE TO HEAD-OF-BED MANIPULATION IS RELATED TO OUTCOME IN ACUTE ISCHEMIC STROKE: A TRANSCRANIAL OPTICAL MONITORING STUDY

R Delgado-Mederos ¹, C Gregori-Pla ², P Zirak ², I Blanco ², P Camps-Renom ¹, L Prats-Sánchez ¹, A Martínez-Domeño ¹, J Marti-Fabregas ¹, T Durduran ²

Abstract

Background

Cerebral blood flow (CBF) regulation during head-of-bed (HOB) manipulation is variably altered in acute ischemic stroke (AIS) patients. We explored whether CBF response to HOB angle changes is related to stroke outcome by using diffuse correlation spectroscopy (DCS), an optical technique that allows noninvasive bedside CBF monitoring.

Methods

We prospectively included patients with a large anterior circulation AIS at <48 h. Bilateral frontal CBF measurement was performed with continuous DCS during HOB changes between 0° and 30°. We categorized measurements as early (<12 h) or late (>12 h). NIHSS scores were recorded at baseline and 48 h. Rankin Scale (RS) was used to assess 3-month functional outcome (unfavourable when >2).

Results

We studied 18 patients (age 80 ± 12 y, 61% were men). Median NIHSS was 19. On average, frontal CBF decreased in the ipsilesional (−3.2 ± 12.8%,) and contralesional hemisphere (−7.3 ± 17.4%) with 0° to 30° HOB elevation. A paradoxical response (CBF increase or no change) was observed in 7 (39%) patients. CBF change was not correlated to NIHSS. At early stages (<12 h, n = 10), a lower decrease or paradoxical increase of CBF with HOB elevation in the ipsilesional hemisphere was associated with worse outcome (RS 0–2: −11.9 ± 3.2% Vs. RS > 2: 4.5 ± 11.8%, p = 0.017) but not contralaterally. Later CBF response to HOB changes was not related to clinical outcome. Interestingly, all paradoxical responders had a poor outcome.

Conclusions

Early low or paradoxical CBF response to HOB manipulation is associated with a worse outcome in patients with AIS. Bedside optical monitoring may help individualize optimal patients positioning in the setting of acute stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

SURVIVAL AND RECURRENCE STUDY ON A COHORT OF 2000 STROKE PATIENTS HOSPITALISED IN THE BESANCON STROKE UNIT

B Bouamra ¹, L Vaconnet ¹, V Côte ¹, L Delmotte ¹, V Dufour ¹, K Chakroun ¹, T Moulin ²

Abstract

Background

A retrospective study was performed on a cohort of stroke patients hospitalised in the Besancon stroke unit from January 2007 to June 2012 and followed by the Emergency Neurology Network of Franche-Comte. Main objective: calculating the rates of survival and recurrence at 2 years. Secondary objectives: calculating the Rankin score for each patient, finding causes of death and reasons for rehospitalisation.

Methods

All patients alive at hospital discharge during the study period were included, totalling 2034 patients (12 refused to take part). Several sources of information were used to research patient outcome: electronic records; correspondence with the patient, their registered general practitioner, their town council; telephone calls.

Results

The mean participation time (time between origin date and date of last news) was 4 years (max. 8 years). The rate of patients lost to follow-up at 2 years from hospitalisation was 1%. A survival curve was created with the collected data. The probability of survival beyond 2 years of stroke patients alive at hospital discharge was 87.3%. The response rate on recurrence and cardiac events was 90%. A total of 198 recurrent strokes were logged. Among the 574 registered deaths, 68% were from an identified cause of death. Following the initial stroke, 2386 rehospitalisations were identified.

Conclusions

The follow-up of the Besancon stroke unit cohort enabled an improved definition of patient outcome after a stroke and a clarification of the most frequent and severest complications, thereby allowing better prevention and the set-up of adapted preventive actions.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CLINICAL FRAILTY IS AN INDEPENDENT PROGNOSTIC FACTOR FOR HIGHER 28-DAY MORTALITY AND LONGER HOSPITAL ADMISSION AFTER ISCHAEMIC STROKE

N Evans ¹, J Wall ², S Wallis ², R Romero-Ortuno ^2,³, E Warburton ¹

Abstract

Background

Clinical frailty is characterised by loss of physiological reserves and increased mortality across numerous medical conditions, though its role in stroke is poorly understood. We demonstrate frailty is an independent prognostic factor for 28-day mortality and length of stay (LOS) for the first time.

Methods

Individuals aged 75 years and over admitted with ischaemic stroke to Addenbrooke’s Hospital were retrospectively dichotomised into two cohorts using the premorbid Clinical Frailty Scale (CFS): ‘non-frail’ (CFS 1–4) and ‘frail’ (CFS 5–8). Continuous data was analysed using Mann-Whitney U-tests and categorical data using Z-tests of two proportions. Multivariate analysis included variables significant on bivariate analysis.

Results

214 individuals were included: 119 frail and 95 non-frail. Frail individuals had higher 28-day mortality (17.6% versus 4.2%, p < 0.01) and longer median LOS: 15.9 (IQR 15.2) versus 9.6 (IQR 15.2) days, p < 0.01. The frail cohort was older (median age 87 versus 83 years, p < 0.01), with a higher proportion of women (63% versus 47.4%, p = 0.02), and lower thrombolysis rate (11.8% versus 25.3%, p = 0.01). NIHSS, prevalence of hypertension, diabetes, ischaemic heart disease, atrial fibrillation did not differ between cohorts (all p > 0.05).

After multivariate analysis (adjusted for frailty, age, sex, thrombolysis) only frailty remained independently associated with LOS (p = 0.02). Frailty (p = 0.01), age (p = 0.03), female sex (p = 0.04) were each independently associated with 28-day mortality.

Conclusions

Clinical frailty is an important novel independent prognostic factor for longer LOS and higher 28-day mortality following ischaemic stroke, independent of conventional cardiovascular risk factors. We advocate routine frailty assessment to improve prognostication and clinical management.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

VISUOSPATIAL INATTENTION PREDICTS FUNCTIONAL OUTCOME 7 YEARS AFTER ISCHEMIC STROKE

J Gerafi ^1,^2,³, H Samuelsson ^1,³, JI Viken ¹, C Blomstrand ¹, C Jern ⁴, K Jood ¹

Abstract

⁴Institute of Biomedicine, Department of Medical and Clinical Genetics- Sahlgrenska Academy- University of Gothenburg, Gothenburg, Sweden

Background

Visuospatial inattention (VSI) and language impairment (LI) are often present early after stroke. Associations between these early symptoms and an unfavorable functional outcome have been reported mainly within one year post-stroke. Knowledge about these associations in the long-term perspective is limited. The purpose of this study was to investigate if a screening test of attention and language as indicators of cortical symptoms early after stroke could predict long-term functional outcome.

Methods

A consecutive cohort of 375 ischemic stroke patients aged 18 to 69 years was assessed early post-stroke for the occurrence of VSI with the Star Cancellation Test and of LI with the language item in the Scandinavian Stroke Scale (SSS). Other neurological deficits and vascular risk factors were also assessed. Seven years after index stroke functional outcome was assessed by the modified Rankin Scale (mRS) in 235 survivors without recurrent stroke, 13 % were lost to follow-up.

Results

Relationships between baseline predictors and functional outcome at 7 years were analyzed with bivariate correlations and a multiple categorical regression (CATREG) with optimal scaling. The regression model significantly explained variance in mRS (R2 = 0.409, p < .001) and identified VSI and overall neurological deficit (the SSS score without the language item) as the significant independent predictors (p < .001).

Conclusions

These results emphasize the importance of identifying early symptoms of visuospatial inattention after stroke for the prediction of long-term functional outcome.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ACUTE RENAL DYSFUNCTION IS ASSOCIATED WITH MORTALITY AND DISABILITY AFTER ISCHAEMIC STROKE AND TIA - A POPULATION STUDY

D Hayden ¹, C McCarthy ², L Akijian ¹, E Callaly ¹, D Ni Chroinin ¹, G Horgan ¹, L Kyne ¹, J Duggan ¹, E Dolan ³, K O'Rourke ¹, D Williams ⁴, S Murphy ¹, Y O'Meara ⁵, PJ Kelly ¹

Abstract

Background

Renal impairment is a major cause of morbidity and has been reported to be associated with greater mortality and disability after stroke. Earlier studies have been performed in selected hospital samples, and may be limited by selection bias. Prospective population-based studies are required to address this issue.

Methods

The North Dublin Population Stroke Study is a population-based, prospective cohort study of stroke and TIA. Renal function was measured using the CKD EPI equation. Acute renal dysfunction (ARD) was defined as eGFR <60 ml/min/1.73 m².

For this analysis inclusion criteria were: (1) new ischaemic stroke or TIA (2) Creatinine level available. Exclusion criteria: (1) intracerebral/subarachnoid hemorrhage, (2) Undetermined pathological type (3) Unavailable renal data.

Cox-regression analysis was performed for predictors of fatality, and logistic regression for predictors of poor functional outcome (mRS 3–5).

Results

547 patients (stroke 76.4%, TIA 23.6%) met pre-specified eligibilty criteria.

On multivariate analysis, eGFR < 45 ml/min/1.73 m² (HR 2.53, p = 0.01), NIHSS (HR 1.12 per one-point increase, p < 0.0001) and hypertension (HR 2.35, p = 0.04) independently predicted 28-day mortality, while statins were protective (HR 0.25, p = 0.001). 2-year survival declined with increasing severity of renal dysfunction (p = 0.0002, log-rank). However after adjusting for confounders, no association was observed between renal dysfunction and late mortality.

ARD (OR 2.2, p = 0.04), age (OR 1.06, p < 0.0001), greater pre-stroke mRS (OR 2.0, P = 0.002) and NIHSS (OR 1.18, p < 0.0001) independently predicted poor functional outcome (mRS 3–5).

Conclusions

In our population-based cohort, ARD independently predicted early fatality and late disability after ischaemic stroke/TIA. Further studies investigating the mechanism of this association are needed.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

LONG-TERM OUTCOME AFTER CAROTID ENDARTERECTOMY IN PATIENTS WITH ISCHEMIC HEART DISEASE

SH Heo ¹, H Nam ¹, DI Chang ¹

Abstract

Background

The long-term outcome after carotid endarterectomy (CEA) is determined by many confounding factors. Ischemic heart disease (IHD) is linked to atherosclerotic stroke, and it is a very important cause of death during the perioperative and follow-up periods after CEA. We aimed to investigate mortality and long-term major adverse cardiovascular events (MACEs) in IHD patients compared with non-IHD patients.

Methods

We consecutively enrolled 229 patients who underwent CEA procedures from 2000 to 2011. Among these patients, 45 patients had known or probable IHD defined by history or medical record of myocardial infarction, stable/unstable angina, previous coronary revascularization such as percutaneous coronary intervention or coronary artery bypass graft, or positive stress test. Long-term outcome was identified by using death certificates from the Korean National Statistical Office and telephone interviews by June 2013. We investigated predictors of early (≤30 days) and long-term mortality and MACEs (stroke, MI, death).

Results

Mean follow-up period was 49 months. Cox proportional analysis adjusted for potent predictors revealed symptomatic stenosis (HR 1.72, 95% CI 1.02–2.88, p = 0.042) and presence of IHD (HR 1.93, 95% CI, 1.09–3.42, p = 0.025) as significant predictors of long-term MACEs. Kaplan-Meier analysis showed a significantly lower rate of survival (p = 0.030) and MACE-free survival (p = 0.003) in the IHD group.

Conclusions

In this study, a poor long-term outcome was observed in patients with IHD and symptomatic stenosis but not in patients with conventional high-risk factors for surgery. Therefore, evaluation and treatment of IHD are strongly recommended before and after CEA.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

INCREASED RISK OF LONG-TERM PROGRESSION OF SUBCORTICAL WHITE MATTER HYPERINTENSITIES IN ISCHEMIC STROKE DUE TO SMALL ARTERY OCCLUSION

L Holmegaard ¹, C Jensen ², P Redfors ¹, C Blomstrand ¹, C Jern ³, K Jood ¹

Abstract

Background

White matter hyperintensities (WMH) are common in ischemic stroke patients. We sought to investigate whether ischemic stroke due to small artery occlusion (SAO) and/or WMH at index stroke are predictors of WMH progression in long-term follow-up.

Methods

We examined patients from the Sahlgrenska Academy Study on Ischemic Stroke (mean age 54 years). MRI of the brain was performed within six months (N = 320) and seven years (N = 188) after index stroke. WMH at baseline was graded according to the Fazekas scale. The Rotterdam progression scale was used to assess progression. Stroke subtype was classified according to TOAST.

Results

The SAO subtype had highest WMH load at baseline, however this association was not significant after adjustment for vascular risk factors. In contrast, SAO predicted more extensive subcortical WMH progression defined as progression in ≥3 regions; odds ratio 2.46 (95% CI: 1.02 to 5.89) in SAO compared to the other subtypes after adjustment for vascular risk factors. A high load of WMH at baseline (Fazekas grade ≥2) predicted both subcortical and periventricular WMH progression; odds ratios of 5.02 (95% CI: 2.00 to 13.2) and 2.58 (95% CI: 1.01 to 6.52) after adjustment.

Conclusions

Patients with an index stroke of the SAO subtype and patients with more extensive WMH already at index stroke are at an increased risk of long-term progression of WMH. This suggests that a higher activity in the pathological processes related to small vessel disease at baseline continues over time and may be an important predictor of long-term prognosis.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

HIGH-SENSITIVITY C-REACTIVE PROTEIN IN ACUTE STROKE PATIENTS AND VASCULAR RISK IN THE FIRST YEAR: COHORT STUDY AND SYSTEMATIC REVIEW

JB Hong ¹, M Endres ^2,^3,^4,⁵, B Siegerink ¹, T Liman ^1,²

Abstract

Background

We sought to determine the association between admission levels of high sensitivity C-reactive protein (hs-CRP) and long-term vascular risk in acute stroke patients, through a prospective cohort study and a systematic review of the literature.

Methods

First-ever stroke patients were recruited from our stroke unit and followed up for 1 year. Blood samples taken within 7 days of stroke onset were used to measure hs-CRP, which we categorized into quartiles. Recurrent strokes, myocardial infarcts and death due to any cause comprised the combined vascular endpoint (CVE). Cox regression analyses were performed to obtain hazard ratios (HR) and corresponding confidence intervals. For the systematic review, PubMed and EMBASE databases were searched for prospective cohort studies that included stroke patients, had a follow-up time of at least 1 year, and investigated the relationship between hs-CRP levels and vascular risk.

Results

488 acute stroke patients were included in our 1 year follow up study, during which 46 CVEs occurred. Adjusted HRs were 2.71 (95%CI: 1.13–6.54) for the CVE, 1.42 (95%CI: 0.38–5.29) for recurrent stroke, and 4.03 (95%CI: 1.12–14.55) for mortality. A systematic search of the literature identified 20 heterogeneous studies. Six of the 20 studies had measured hs-CRP within a day of stroke onset, and had a pooled adjusted HR of 3.54 (95%CI: 2.61–4.82) for CVE.

Conclusions

In our acute stroke cohort, high hs-CRP levels at admission were associated with increased 1-year mortality and CVE risk, but not with recurrent stroke risk. Comparable HRs for CVE were found in published studies, as well as methodological heterogeneity.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

STROKE PATIENTS WITH INTRACRANIAL ATHEROSCLEROTIC DISEASE, CONCURRENT SYSTEMIC ATHEROSCLEROSIS AND 4-YEAR PROGNOSIS

T Hoshino ¹, L Sissani ¹, J Labreuche ¹, G Ducrocq ², P Lavallée ¹, E Meseguer ¹, C Guidoux ¹, L Cabrejo ¹, C Hobeanu ¹, F Gongora-Rivera ¹, PJ Touboul ¹, PG Steg ², P Amarenco ¹

Abstract

Background

Little is known on intracranial atherosclerotic stenosis (ICAS) and concurrent coronary and carotid artery diseases. We attempted to describe the systemic atherosclerosis burden and 4-year event risk among patients with ischemic stroke according to the presence of ICAS.

Methods

The AMISTAD study was designed to evaluate the prevalence of systemic atherosclerotic disease, i.e., coronary, carotid and femoral arteries, and thoracic and abdominal aorta, in patients with brain infarction. In AMISTAD, 289 consecutive patients with acute ischemic stroke underwent MR angiography to examine the presence of ICAS (≥50% stenosis). Carotid ultrasound was performed to detect atherosclerotic plaque in extracranial carotid arteries, and patients with no known history of coronary heart disease underwent coronary angiography. After a 4-year follow-up, we estimated the risk of major adverse cardiovascular event (MACE, vascular death, nonfatal cardiac event, nonfatal stroke, or major peripheral arterial event).

Results

The prevalence of ICAS was 30.8%, of which 16.6% were symptomatic and 14.2% asymptomatic. Patients with ICAS more frequently had extracranial carotid artery (78.2% vs. 66.2%, P = 0.04) and coronary artery diseases (76.9% vs. 56.4%, P = 0.004) than those without ICAS. The 4-year MACE risk was 13.6% in patients with no ICAS, 29.2% with asymptomatic ICAS, and 12.2% with symptomatic ICAS, respectively. Using patients with no ICAS as reference, adjusted hazard ratio of MACE was 1.57 (95% CI 0.84–2.95, P = 0.16) in patients with ICAS.

Conclusions

Patients with ICAS frequently had concurrent extracranial carotid and coronary artery atherosclerotic diseases and had a high 4-year MACE risk.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

MID-REGIONAL PRO-ADRENOMEDULLIN (MR-proADM) IS AN INDEPENDENT PREDICTOR OF POST STROKE MORTALITY

C Huber ¹, J Schneider ¹, B Mueller ², M Christ-Crain ³, M Katan ¹

Abstract

Background

Adrenomedullin – an immune modulating and vasoactive peptide- is associated with stroke outcome. However, little is known about the incremental prognostic role of mid-regional pro-adrenomedullin (MR-proADM) in the acute stroke setting. We hypothesize that MR-proADM improves risk-stratification beyond established vascular risk-factors.

Methods

MR-proADM-levels were measured in 362 consecutively enrolled acute ischemic stroke patients. Patients were followed for 90 days and functional outcome and mortality was determined by structured telephone-interviews. Cox proportional hazard and logistic regression models were fitted to estimate hazard and odds ratios for the association of MR-proADM with functional outcome and mortality. The discriminatory value of MR-proADM was evaluated, by calculating the area under the receiver operating characteristic curve (AUC). The incremental value for risk-stratification was assessed by the net reclassification improvement (NRI) and integrated discrimination improvement (IDI).

Results

After adjustment for traditional risk-factors MR-proADM levels remained independently associated with mortality (HR 6.65, 95%CI 3.63–12.16, p < 0.001) but not with functional outcome (OR 0.80, 95%CI 0.33–1.95, p = 0.64). Adding MR-proADM levels to the multivariate model improved the discriminatory accuracy of the model for mortality significantly (from AUC 0.90 to AUC 0.92, p-value < 0.001). The continuous NRI of 0.721 (95%CI 0.302–1.145) and IDI of 0.060 (95%CI 0.006–0.151) suggests clinical meaningful improvement in risk classification, for the endpoint mortality.

Conclusions

MR-proADM is a novel prognostic blood biomarker in the acute stroke setting, improving risk prediction for mortality beyond established risk factors, probably due to its pleotropic effects on the cerebral vasculature and immune response. Further validation studies are needed to confirm these results.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

IMPLICATION OF WHITE MATTER HYPERINTENSITY ON THE LONG-TERM MORTALITY IN PATIENTS WITH CRYPTOGENIC STROKE

SH Jeong ¹, JS Yoo ¹, HS Nam ¹, JH Heo ¹

Abstract

Background

Etiology of a quarter of ischemic strokes is unknown despite extensive evaluations. The white matter hyperintensity (WMH) is prevalent in ischemic stroke including cryptogenic stroke(CS) patients and risk of death is increased when the patients have WMH. In this regard, we sought the implication of WMH in the long-term mortality in patients with CS.

Methods

During a 10-year period (July 1997–June 2007), the consecutive CS patients were enrolled and followed up until December 2013. Long-term mortality and causes of death were identified using death certificates from the Korean National Statistical Office, chart reviews, or regular interview for stroke cohort. A Fazekas’ score ≥2 in the periventricular white matter or the deep white matter area was regarded as high-grade WMH.

Results

696 (21.2%) patients were CS after systematic etiology evaluations. After excluding 153 patients without FLAIR image, 553 patients were enrolled and followed-up for a median of 8.4 years (IQR, 6.6–10.8). High-grade WMHs were found in 221 (40.0%) patients. The Kaplan-Meier survival analysis showed that more CS patients with high-grade WMHs died during long-term follow-up compared to those without (HR 2.53, 95% CI, 1.86–3.43). The Cox regression analysis revealed that age, diabetes, initial stroke severity, and high-grade WMH were independent predictors for long-term mortality. The CS patients with high-grade WMH had a 1.52-fold (95% CI 1.08–2.15) higher death rate compared to those without.

Conclusions

In this study, we demonstrated that the high-grade WMH were independently associated with the long-term mortality in CS patients.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

NON-INFECTIOUNS COMPLICATIONS OF ACUTE STROKE AND THEIR IMPACT ON HOSPITAL MORTALITY IN URBAN POLISH STROKE UNIT: CHANGES FROM 1995 TO 2013

M Karliński ¹, J Bembenek ¹, A Baranowska ¹, I Kurkowska-Jastrzebska ¹, A Członkowska ¹

Abstract

Background

Our aim was to investigate changes in the occurrence of non-infectious complications of acute stroke and their impact on hospital mortality over the last two decades in a single urban stroke centre.

Methods

It is a retrospective registry-based analysis of consecutive acute stroke patients from a highly urbanized area (Warsaw, Poland) admitted to a single stroke centre between 1995 and 2013. A total of 4770 patients were divided to four time periods: 1995–1999 (n = 637), 2000–2004 (n = 1501), 2005–2009 (n = 1575) and 2010–2013 (n = 1057). Odds ratios for hospital death were adjusted for pre-existing disability, stroke type, age and baseline neurological deficit.

Results

Over time there was a significant decrease in the occurrence of myocardial infarction (2.1%, 1.7%, 1.0% and 0.6%, respectively) and exacerbated congestive heart failure (4.4%, 5.5%, 3.1%, 1.7%). The proportions of patients experiencing pulmonary embolism (1.3%, 1.3%, 1.3%, 1.5%), recurrent stroke (1.3%, 1.5%, 2.0%, 1.9%) and seizures (0.3%, 0.4%, 0.3%, 0.7%) remained stable. The occurrence of gastrointestinal bleeding was fluctuating with an increasing tendency (0.0%, 1.1%, 2.0%, 1.2%). All investigated complications, apart from seizures, increased odds for hospital death. However, there were individual exceptions for gastrointestinal bleeding (years 2000–04) or myocardial infarction, heart failure and recurrent stroke (years 2010–13).

Conclusions

All non-infectious complications of acute stroke but seizures increase odds for hospital death. The occurrence of myocardial infarction and exacerbation of congestive heart failure decreased over the years, whilst the negative effect of cardiac conditions and recurrent stroke has been recently attenuated. It may reflect positive changes in Polish urban stroke care.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

SEVERE WHITE MATTER HYPERINTENSITY IS ASSOCIATED WITH LONG-TERM MORTALITY IN ISCHEMIC STROKE PATIENTS WITH ATRIAL FIBRILLATION

KH Kim ¹, HS Nam ¹, JH Heo ¹

Abstract

Background

Atrial fibrillation is the most common cause of cardioembolic stroke and is associated with poor prognosis in survivors after ischemic stroke. White matter hyperintensity (WMH) is frequently found in elderly and it is associated with an increased mortality in patients with stroke. We hypothesized that burdens of WMH may impact on long-term mortality in ischemic stroke patients with atrial fibrillation.

Methods

Consecutive ischemic stroke patients were enrolled and followed up until December 2013. During admission systematic evaluation was underwent to uncover stroke etiologies. The WMH was determined using FLAIR MRI and assessed according to Fazekas’ score. A Fazekas’ score ≥2 was regarded as severe WMH.

Results

538 (19.7%) patients had more than one potential cardiac sources of embolism. Atrial fibrillation was present in 342 (63.8%) patients. After excluding 96 patients without FLAIR image, 246 patients were enrolled and followed-up for a median of 6.6 years (IQR, 1.8–8.4). The Cox regression analysis revealed that old age and initial NIHSS score were independent predictors of long-term mortality.

We performed a sensitivity analysis for the atrial fibrillation patients younger than 70. Sensitivity analysis using the Cox regression analysis revealed that severe WMH were associated with long-term mortality along with older age and initial NIHSS score. The existence of severe WMH showed twice higher mortality rate compared to those without (HR 1.92, 95% CI, 1.06 – 3.50).

Conclusions

We demonstrated that the WMH were independently associated with the long-term mortality in younger patients with atrial fibrillation.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

NEUTROPHIL-TO-LYMPHOCYTE RATIO PREDICTS SHORT-TERM FUNCTIONAL OUTCOME IN ACUTE ISCHEMIC STROKE WITH DIABETES MELLITUS

MK Kim ¹, K Su Kyoung ², H Yoon Seok ¹, Y Bong Goo ¹

Abstract

Background

As indicators of systemic inflammatory response, neutrophil-to-lymphocyte ratio (NLR) have been proposed to predict clinical outcome in cardiovascular disease. We assessed significance of NLR as predictor of outcome in patients with acute ischemic stroke with diabetes mellitus (DM).

Methods

The study included 129 patients (63.2% men, mean age 66.29 ± 12.8 years) within 3 days after onset of acute ischemic stroke with DM. We measured NLR in all patients. Outcomes were measured as 3-month modified Rankin Scale (mRS) score. Good functional outcome was defined as mRS of 0–2 points, whereas poor outcome was defined as mRS of >2 points. Multivariate logistic regression was used to assess association among clinical, inframmatory and serological parameters including NLR and mRS scores.

Results

The frequency of atrial fibrillation, heart failure, hypertension, and coronary artery disease, NIHSS score at admission, and level of ESR, Pro-BNP and NLR were each significantly higher in poor outcome group (p < 0.05). The cut-off values of NLR and NIHSS score at admission for prediction of poor outcome were 1.955 (sensitivity 0.875, specificity 0.527) and 5.5 (sensitivity 0.813, specificity 0.978), respectively. In age-adjusted analysis, NLR were significantly correlated with 3-month mRS score (partial r = 0.359, p < 0.001). Multivariate logistic regression analysis demonstrated that age (OR, 1.095; 95% CI, 1.017–1.180, p < 0.001), NIHSS score (OR, 1.611 95% CI, 1.288–2.015, p < 0.001), NLR (OR, 1.316; 95% CI, 1.026–1.688, p < 0.001) were independently associated with poor functional outcome.

Conclusions

The NLR is useful marker for short-term functional outcome in acute ischemic stroke with DM. NLR may have role in risk stratification for predicting poor outcome.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

HIGHER BODY TEMPERATURES ARE ASSOCIATED WITH INCREASED RECANALIZATION RATES AFTER INTRA-ARTERIAL TREATMENT FOR ACUTE ISCHEMIC STROKE

S Kuipers ¹, M Geurts ¹, DWJ Dippel ², HB Van der Worp ¹; MR CLEAN investigators²

Abstract

Background

Fever is associated with poor outcome after acute ischemic stroke (AIS) but in vitro studies suggest that higher body temperatures improve clot lysis. The relation between body temperature and recanalization after intra-arterial treatment (IAT) for AIS is unknown. We assessed 1) the relation between body temperature on admission and during the first day after stroke and recanalization in patients with IAT for AIS; and 2) the relation between body temperature during the first week and poor outcome in these patients.

Methods

We retrospectively identified all available body temperatures during the first week in 214 patients treated with IAT after AIS, enrolled in the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN). The relation per 1.0°Celsius increase in mean and peak body temperatures and recanalization at 24 hours (modified TICI 2b/3) or poor outcome (modified Rankin Scale ≥3) was tested by Poisson regression analyses.

Results

There was no relation between body temperature on admission and recanalization, but higher mean and peak body temperatures on day one were independently related to a higher recanalization rate (adjusted relative risks 1.40 [1.09–1.79] and 1.28 [1.07–1.53], respectively). Increased body temperatures on day four, six and seven were independently associated with poor outcome.

Conclusions

Higher body temperatures on the first day after IAT for AIS are associated with better recanalization, but higher body temperatures at later points in time are associated with poor outcome. These findings may have consequences for the timing of measures to reduce body temperature in clinical trials.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ELEVATED LIPOPROTEIN (A) LEVELS PREDICT CARDIOVASCULAR EVENTS AFTER FIRST ISCHEMIC STROKE

KS Lange ¹, AH Nave ¹, TG Liman ¹, U Grittner ², M Endres ¹, M Ebinger ¹

Abstract

Background

The association of elevated Lipoprotein (a) [Lp(a)] serum levels and incidence of cardiovascular disease is well-established. However, evidence on levels of Lp(a) and residual cardiovascular risk in stroke survivors is lacking. We aimed to elucidate the risk for recurrent cardiovascular events in ischemic stroke patients with elevated Lp(a).

Methods

Patients with first ever acute ischemic stroke who participated in the prospective Berlin “Cream & Sugar” study between January 2009 and August 2014 with available 1 year follow up data and stored blood samples were eligible for inclusion. Lp(a) levels were determined using an isoform-insensitive nephelometry assay. We assessed the risk for the composite cardiovascular disease (CVD) endpoint of ischemic stroke, transient ischemic attack, myocardial infarction, coronary revascularization and cardiovascular death with elevated Lp(a) defined as >30 mg/dL using Cox regression analyses.

Results

Out of 524 study participants, 250 patients with available blood samples had 1 year follow up and were included into the analysis. Twenty-six patients (10.4%) experienced a CVD event during the follow up period. The risk of having a CVD event was significantly higher in patients with elevated Lp(a) levels after adjustment for potential confounders (HR 2.60, 95% CI 1.19–5.67, p = 0.016).

Conclusions

Elevated Lp(a) is an independent risk factor for cardiovascular event recurrence in ischemic stroke survivors. Lp(a) might therefore be an important target for secondary prevention.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

HYPERCOAGULABILITY AND MORTALITY AFTER STROKE IN PATIENTS WITH ACTIVE CANCER

MJ Lee ¹, S Kwon ¹, GM Kim ¹, CS Chung ¹, KH Lee ¹, OY Bang ¹

Abstract

Background

Hypercoagulability is common in stroke patients with cancer. We hypothesized that cancer-related coagulopathy determines survival after stroke in patients with active cancer.

Methods

We prospectively coded 271 patients with acute ischemic stroke and active cancer. Conventional stroke mechanisms (CSMs) were determined using cardiologic and vascular studies. Hypercoagulability was assessed using plasma D-dimer levels before treatment in all patients and 7 ± 3 days after treatment in patients without CSMs. Data on time from onset to death or last follow-up were collected. Factors associated with survival were tested in univariate and multivariate Cox proportional hazard models in patients.

Results

Among the 271 included patients, 185 deaths were identified, and 86 patients were censored at a median 263 (interquartile range [IQR] 62–1700) days. In 195 patients without CSMs, higher baseline D-dimer level was significantly associated with shorter survival. Post-treatment D-dimer levels (adjusted hazard ratio [HR] 1.031, 95% confidence interval [CI] 1.011–1.051) were more significant than baseline D-dimer levels to predict reduced survival in multivariate model. In 76 patients with CSM, baseline D-dimer level was a significant predictor of reduced survival in both univariate and multivariate model (adjusted HR 1.128, 95% CI 1.055–1.207). Among the survivors, the D-dimer levels during follow-up until 5 months after stroke onset were associated with death within the following month.

Conclusions

Our data provide evidence that hypercoagulability is an independent predictor of death after stroke in patients with active cancer. Effective correction of hypercoagulability might play a protective role for survival in these patients.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PREDICTORS OF 1-YEAR HOSPITAL READMISSIONS AFTER ISCHEMIC STROKE

A Leitão ¹, A Brito ², JN Alves ³, JM Amorim ⁴, R Costa ⁵, J Pinho ³, I Pinho ¹, C Ferreira ³

Abstract

Background

Hospital readmissions after stroke occur up to 37% of patients during the first year. Identification of causes and predictors of readmission are important to improve health care planning and reduce morbidity, mortality and costs associated with ischemic stroke.

Methods

Retrospective cohort of consecutive ischemic stroke patients admitted in Hospital de Braga during 2013 who survived index hospitalization. Clinical and imagiologic information was collected using the electronical clinical record. Information concerning 1-year hospital readmissions in all regional hospitals was assessed using the electronic Health Data Platform. Descriptive, univariate and multivariate survival analysis with Cox regression model was performed in SPSS.22®.

Results

Among the 480 patients included in the study (50.6% of female sex, median age 79 years - interquartile range 68–85), 165 patients (34.4%) had at least 1 hospital readmission during the first year after stroke. The main causes of readmissions were infectious disease (43%), ischemic stroke recurrence or transient ischemic attack (13.5%), cardiac disease (6.5%), systemic extracranial hemorrhage (6.1%), trauma (6.1%). The most frequent localization of infection was respiratory (76.2%) and urinary tract (17.5%). Global 1-year mortality was 21.5% and mortality associated with readmission was 38/165 (23%). The multivariate survival analysis using 1-year readmission as endpoint revealed that intravenous thrombolysis (hazards ratio = 0.37, 95%CI = 0.17–0.83, p = 0.016) and functional independence 3 months after stroke (hazards ratio = 0.40, 95%CI = 0.20–0.79, p = 0.008) were the only independent predictors of hospital readmission.

Conclusions

Treatment with intravenous thrombolysis and 3-month functional independence are independently associated with a lower likelihood of hospital readmission during the first year after ischemic stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ATTENTIONAL NETWORK FUNCTIONS IN PATIENTS WITH ASYMPTOMATIC CAROTID ARTERY STENOSIS

C Lovig ¹, Á Csathó ², L Szapáry ¹, A Nagy ², A Trunk ³, P Csécsei ¹, E Lovadi ¹, K Tótsimon ⁴

Abstract

Background

By narrowing a major artery in the neck, carotid stenosis (CS) decreases the cerebral blood supply. Therefore, CS might cause cognitive deterioration even if the patient is asymptomatic, that is free of symptomatic cerebrovascular diseases, such as stroke or transient ischemic attack. In line with this, recent evidences suggest that asymptomatic CS might be an independent risk factor of impairments in attentional functions. Attention, however, is a complex process involving multiple components, and no studies have been addressed to the question of how the different attentional components are affected by an asymptomatic CS condition.

Methods

To explore this issue, in the current study, attentional functions of patients with asymptomatic CS (N = 25) were examined and compared with a matched group of healthy individuals. Participants in both groups completed a set of questionnaires (e.g. Beck Depression Inventory) and performed the Attentional Network Task (ANT). As a combination of a cued reaction time task and a flanker task, ANT provides measures for three different components of attention: alerting, orienting and executive control.

Results

The analyses showed that the effect of cuing is significantly different in the two groups: In contrast to healthy individuals, for CS patients, alerting cues before the targets did not improve performance.

Conclusions

This finding generally suggests that alerting attentional function might be sensitive to a CS induced decrement in blood supply. No similar effect of asymptomatic CS was found for orienting and executive functions.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PREDICTIVE VALUE OF 24H VERSUS 5-7 DAY INFARCT VOLUME IN PATIENTS WITH ACUTE ISCHEMIC STROKE

H Marquering ¹, A Bucker ², AM Boers ³, J Bot ⁴, A Yoo ⁵, O Berkhemer ², LA van den Berg ⁶, D Beumer ⁷, H Lingsma ⁸, P Fransen ⁹, W van Zwam ¹⁰, R van Oostenbrugge ⁷, A van der Lugt ¹¹, D Dippel ⁹, Y Roos ⁶, C Majoie ¹²

Abstract

Background

Infarct volume at 5–7 days is a valuable radiological outcome measure in patients with acute ischemic stroke. 24 h infarct volume is a potentially valuable alternative due to greater availability and earlier prognosis. In this study we aimed to compare the predictive value of 24 h infarct volume compared to the 5–7 days infarct volume.

Methods

From the MR CLEAN database of patients with acute ischemic stroke due to anterior circulation proximal artery occlusions, we retrospectively selected 282 patients who received a NCCT scan at 24 hours and at 5–7 days to determine the lesion volumes in these images. Lesion volume at 24 h and at 5–7 days were included in multivariate regression analyses to determine its association with mRS at 90 days. We calculated the R² to determine the predictive value of these measures.

Results

Hundred-and-forty-seven patients were included. Mean age was 66 (range 26–85) years, median admission National Institutes of Health Stroke Scale score was 17 (range 4–29), 132 (90%) patients received intravenous thrombolysis and 67 (46%) were received intra-arterial treatment (IAT). Median lesion volume was 35.4 (IQR:19.3–88.0) mL and 56.3 (IQR:29.9–116.4) mL, at 24 hours and 5–7 days follow-up respectively. Lesion volume at 24 h and at 5–7 days were both independently associated with favourable outcome: p = 0.001, R²= 0.40 and p < 0.001, R²= 0.44 respectively.

Conclusions

Infarct volume growth after 24 h is common. 24 h Infarct volume is independently associated with outcome, however, the association of 5–7 infarct volume with functional outcome is slightly stronger.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

STROKE SURVIVORS DISMISSED TO THEIR HOMES - ARE THEY AT INCREASED RISK FOR NURSING HOME PLACEMENT?

S Mathisen ^1,², JP Larsen ¹, M Kurz ^1,²

Abstract

Background

Stroke is one of the leading causes for nursing home placement (NHP). Little is known about the prognosis for the stroke patients that are initially discharged to their homes.

Methods

All stroke patients in the municipality of Stavanger, Norway between January 1^st 1996 and March 31^st 2004 were included and followed until death or May 31^st, 2012. Time intervals for NHP were compared to an age- and sex matched, stroke-free control cohort. Logistic regression analysis was used to assess risk factors affecting time to NHP.

Results

452 patients were included. 48 patients (10.6%) were directly placed in a nursing home, while 401 patients (88.7%) were discharged to their homes either directly (44.7%) or after initial rehabilitation (55.3%). Of the patients initially discharged to their homes, 29.7% needed NHP at a later time point as compared to19.9% of the stroke-free controls (p < 0.001). In univariate analyses age, gender, living alone, previous cardiovascular disease, not smoking and stroke severity were associated with NHP. Logistic regression analysis showed that only age (p < 0.001) was a risk factor for NHP. Mean age at NHP and death and length of NHP did not differ between stroke patients and stroke-free controls.

Conclusions

Almost 90% of the stroke patients could be discharged to their homes but there was higher need for NHP in the long run as compared to the stroke-free control group. The length of NHP was equal indicating that stroke patients dismissed to their homes may have a good prognosis regarding NHP and survival.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ABCD3-I SCORE IN POSTERIOR CIRCULATION TIA AND MINOR STROKE

B Matosevic ¹, M Knoflach ¹, L Seyfang ², J Willeit ¹, S Kiechl ¹, W Lang ³, F Julia ³

Abstract

Background

Every fifth ischemic stroke or transient ischemic attack occurs in the vertebrobasilar territory. Scores, like the ABCD3-I score, estimating the ischemic stroke risk after TIA were created and validated for all TIA patients, we want to assess the predictive capability of ABCD3-I score for recurrence of early ischemic stroke during stroke unit stay in patients with TIA or minor stroke (MiS) in the posterior circulation treated on Austrian stroke units.

Methods

Prospective Study enrolling patients with TIA or MiS between 2010 to 2013 using the web-data-base of the Austrian Stroke Unit Network. 857 patients with POCS were included in the study.

Results

Median length of stay on stroke units was 2 (IQR 1–4). Early stroke occurred in 2.1%. ABCD3-I scores were distributed as follows: 0–3 14.5%, 4–5 31.3%, 6–7 37.5%, 8–13 16.7%. There was a clear trend to increased risk for early or late ischemic stroke with increasing score points (0.8% in 0–3 points group, 2.8% in patients with 8–13 points). In multivariable analyses of all individual score components only dual TIA emerged as independent and significant predictor for early stroke (OR 2.2 CI 1.1-4-5).

Conclusions

In patients with vertebrobasilar TIA or MiS treated on stroke units a higher ABCD3-I score was correlated with an increased risk for stroke recurrence. Especially recurrent TIAs prior to the index event were associated with a high risk.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

COAGULATION MARKERS AT ADMISSION EARLY PREDICTORS OF INCREASED MORTALITY IN ISCHEMIC STROKE PATIENTS

V Melnyk ¹, L Sokolova ¹, O Savchuk ²

Abstract

Background

The system of hemostasis directly involved in the pathogenesis of stroke. It is known that some hemostasis markers associated with risk of stroke, but their influence on the outcome stroke insufficiently studied

Methods

The study involved 87 patients with ischemic stroke (48(55.2%) women and 39(44.8%) men). Immediately on admission all patients underwent blood sampling for study markers of hemostasis. To identify predictors of deaths we identified patients with hyperfibrinogenemia (>3.5 g/l), a higher concentration of Soluble fibrin complex (SFC) (>4,0 mg/100 ml), increased activity of factor X (>100%), reduced trombin time (TT) (<14,0 s.), protrombin time (PT) (<11,0 s.) and activated partial tromboplastin time (aPTT) (<25,0 s.).

Results

Despite the ongoing intensive therapy of ischemic stroke 15(17.2%) patients died within the first two weeks (average 5,3 ± 1,9 day) - 10(20.8%) women and (12.8%) men. In patients who survived, at admission to hospital recorded significantly lower concentration SFC (3,31 ± 1,4 mg/100 ml 95%CI 3,09–3,67) compared with patients who died (3,83 ± 1,5 mg / 100 ml 95% CI 3,57–4,29; p = 0.033). In patients who died, on admission to hospital have been registered significantly higher activity X factor compared with patients who survived (105,13 ± 31,0 and 88,13 ± 30,1% respectively, p = 0,049) and was reduced aPPT (20,17 ± 3,2 and 25,01 ± 4,6 s, respectively, p = 0,041).

Conclusions

Predictors of fatal ischemic stroke are the following parameters of the hemostasis at admission patient in the hospital: hyperfibrinogenemia (OR [95%CI] = 1.3, p = 0.01) and increased concentration SFC (OR [95%CI] = 1.9, p = 0 01), increased activity of factor X (OR [95%CI] = 3.1, p = 0.03) and shortened aPTT (OR [95%CI] = 2.1, p = 0.01).

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EFFECT OF EARLY ENTERAL NUTRITION ON CLINICAL OUTCOMES IN PATIENTS WITH ACUTE ISCHEMIC STROKE

A Mizuma ¹, S Netsu ¹, M Sakamoto ², S Takizawa ¹

Abstract

Background

Early enteral nutrition (EEN; nutrition start within 48 hours) was reported to reduce the incidence of infection and the length of intensive care unit (ICU) / hospitalization. On the other hand, the relationship between EEN and aspiration pneumonia risk / outcome is unclear.

Methods

This study was a retrospective study and the subjects were selected from 1511 consecutive acute ischemic stroke patients admitted to the our hospital between April 2009 and March 2014. 517patients (197 females; 73 years ± 13) were recruited from the criteria as follows; admitted within a week after onset of ischemic stroke and detected the ischemic lesion by MRI. We also excluded patients with severe patients (NIHSS scores <4 and >22, severe consciousness disturbance, comorbid of aspiration pneumonia and discharge of less than a week. We evaluated the aspiration pneumonia incidence within 14 days from admission, divided into two groups based on the nutrition start time; EEN group and late enteral nutrition (LEN; nutrition start later than EEN). We also compared between the two groups about

Background and the ICU / hospitalization.

Results

The incidence of aspiration pneumonia was lower in EEN group than in LEN group (13.8% vs 61.4%, p < 0.001). The length of stay ICU and hospitalization were also shorter in EEN group than in LEN group (ICU; 4 days vs 8 days, p < 0.001, hospitalization; 30 days vs 43 days, p < 0.01). LEN was independently associated with the incidence of aspiration pneumonia(odd ratio 2.41 [1.39–4.19], p < 0.01).

Conclusions

EEN might be effectiveness in relation to aspiration pneumonia prevention and good outcome.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

HEPATITIS C VIRAL LOAD AS A PREDICTOR OF SHORT TERM OUTCOME OF FIRST EVER ACUTE ISCHEMIC STROKE

A Mohamed ¹, G Gharib Fawi1 ¹, H Hazim Kamal Elhewig ¹, H Hassan, M Elnady ¹, AE Alaa eldin Sedky Bekhit Farrag ¹, H Hesham, M Hefny ², S Safaa Khalaf ³

Abstract

Background

Cerebrovascular disease is a great health burden in the current decades. It is well documented that Hepatitis C Virus (HCV) infection has a part in the development of carotid atherosclerosis.

Methods

Method: Out of 210 stroke patients attended Neurology department, 60 patients recently diagnosed with acute ischemic stroke who fulfilled the inclusion criteria were enrolled in our study and divided into 41 patients with chronic hepatitis C virus and 19 without. Stroke severity was categorized into mild; moderate and severe. The status of the liver was evaluated by U/S and PCR. The patients were followed up 3 months to determine the outcome by using the Modified Rankin Scale and graded as favorable (mRS < 3) or unfavorable (mRS ≥ 3). The relationship between HCV RNA level and stroke outcome was determined.

Results

At the end of 3 months post stroke; the outcome was favorable in 35% and unfavorable in 65 %. The high level of HCV RNA in patients is an independent predictor of stroke functional outcome (P < 0.007) and the mortality 3 months post stroke (P < 0.001).

Conclusion

In stroke patients with chronic HCV, the high viremia is an independent predictor of outcome of acute ischemic stroke and mortality after controlling for confounder.So treatment of chronic hepatitis C virus with the new oral antiviral drugs especially in Egypt would be helpful to lessen the danger of stroke and its poor functional outcome.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

HDL PARTICLE SIZE AND STROKE OUTCOME IN 237 PATIENTS

E Ong ¹, E Meseguer ², L Sissani ², B Lapergue ³, S Smaoui ², D Diallo ⁴, O Meilhac ⁵, E Bruckert ⁶, JB Michel ⁴, P Amarenco ²

Abstract

Background

High-density lipoproteins (HDL) may have a neuroprotective role. Small HDL particles have distinct biological activities as compared to their large counterparts. The aim of this study was to determine whether the HDL particle size in patients admitted in a stroke unit for thrombolysis alert was associated with outcome.

Methods

This study included all consecutive patients admitted for suspicion of acute stroke and rtPA thrombolysis eligibility between 2008 and 2013 at Bichat Hospital. Plasma samples were collected from all patients within 4.5 hours of symptom onset before any treatment. Three groups of HDL according to size (small, intermediate and large) were obtained using the Lipoprint System®. A favorable outcome was defined by a mRS ≤ 2 at 90 days.

Results

HDL lipoprotein profiles were analysed for 237 patients (ischemic stroke n = 170, stroke mimics n = 47, brain haemorrhage n = 20). The HDL profile was not associated with baseline characteristics including high blood pressure, diabetes and statin treatment. Among patients who actually received rtPA treatment (n = 142, 83.5%), the percentage of small HDL subfraction was higher in patients with a favorable outcome at 90 days (median[IQR], 17% [14–24] versus 13% [9–16], P < 0.0001) with no impact on hemorrhagic transformation (figure 1). Same results were obtained in patients with and without arterial occlusion.

graphic file with name 10.1177_2396987316642909-fig80.jpg

Conclusions

In patients who received rtPA, small HDL sub-fractions were associated with a favorable outcome whereas large HDLs were associated with poor outcome. These results suggest a neuroprotective effect of small HDL subfractions.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

VENOUS THROMBOTIC RECURRENCE AFTER CEREBRAL VENOUS THROMBOSIS: A LONG-TERM FOLLOW-UP STUDY

P Palazzo ^1,², P Agius ¹, J Ciron ¹, M Lamy ¹, JP Neau ¹

Abstract

Background

After cerebral venous thrombosis (CVT), the risk of venous thrombotic events was estimated at 2–3% for a new CVT and 4–7% for extra-cranial events. However, due to the lack of prospective studies, clinical course of CVT is still largely unknown. We aimed to evaluate thrombosis recurrence rate in a cohort of CVT patients with a long-term follow-up, and to detect predisposing factors for recurrence.

Methods

Consecutive CVT patients with complete clinical, radiological, biological and genetic data were systematically followed-up by 6-month neuroimaging, neurological outpatient evaluations and/or telephone follow-up. New venous thrombotic events were detected after hospital readmission and imaging confirmation.

Results

One hundred eighty-six patients (mean age 45 ± 18years, 68%female) with angiographically-confirmed CVT were included. Etiology was found in 73% of patients. Coagulation abnormality and JAK2 gene mutation were detected in 20% and 9%, respectively. Pharmacological cause was observed in 43% of patients, mainly (90%) represented by hormonal therapy. Mean follow-up length was 87 months (1–247 months). Mortality rate was 2.5%/year, with 2% in-hospital mortality. Annual thrombotic recurrence rate was 2.2%(1.77–2.61), mainly (55%) occurred in the first 24 months. Cerebral venous thrombosis reoccurred in 6 patients (annual rate 0.5%[0.29–0.67]), while 21 subjects (annual rate 1.7%[1.33–2.07]) had an extra-cranial venous thrombosis. Age (RR1.02, CI1.00–1.05, p = .01) and a previous venous thrombotic event (RR2.94, CI1.28–6.72, p = .01) were independently associated with recurrence.

Conclusions

In our cohort of CVT patients followed-up for more than 7 years, annual venous thrombosis recurrence rate was 0.5% and 1.7% for cerebral and extra-cranial localization. Age and a previous venous thrombotic event were independently associated with venous thrombosis recurrence.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PREDICTING POST-STROKE DEPRESSION IN THE ACUTE PHASE OF STROKE

A Palmieri ¹, I Zordan ¹, FM Farina ¹, F Viaro ¹, C Baracchini ¹

Abstract

Background

Post-Stroke Depression (PSD) is a dreadful complication among stroke patients as it is a predictor of poor outcome and reduced compliance to rehabilitation programs. Its early identification is still problematic but could lead to an appropriate treatment. The aim of this pilot study was to identify in the acute phase possible predictors of PSD.

Methods

We enrolled prospectively all ischemic stroke patients admitted to our Stroke Unit in a seven-months period, excluding patients too ill to participate, on antidepressants, with cognitive decline (MMSE < 21) and/or significant neuropsychological disorders. We assessed depression using the Beck Depression Inventory within the first week and at 6–10 weeks from stroke onset.

Results

Among thirty consecutive stroke patients (mean age 70 ± 10 years; 67% men), the incidence of PSD was 37% (11/30) at 6–10 weeks after stroke. Univariate regression analysis showed that incidence of PSD was significantly higher in patients with history of obesity (p = 0.03), dyslipidemia (p = 0.05), neurological comorbidities (p < 0.01), left hemisphere (p = 0.02) or subcortical lesions (p < 0.01), disabling stroke (p = 0.02). Conversely, functional independence on “Dressing” (item of the Barthel Index) was found to be protective against PSD (p = 0.05).

Conclusions

PSD is an under-recognized complication of stroke, regardless of its negative role on clinical outcome; we disclosed a surprisingly high incidence (37%) of PSD already detectable at 1 month. The suggested correlation between PSD and dyslipidemia, obesity, left subcortical lesions indicates that a more strict screening for depression should focus on these patients. Finally, our data disclosed a protective factor of PSD, that is the ability of dressing, confirming previous reports.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

REVIEW OF ACUTE STROKE 30-DAY MORTALITY IN A COMPREHENSIVE STROKE CENTRE

KR Sindhu ¹, AI Syeda ¹, A Parry-Jones ^1,², J Molloy ¹, PJ Tyrrell ^1,², V Papavasileiou ¹

Abstract

Background

For the period 04/2013–03/2014, Sentinel Stroke National Audit Programme (SSNAP) data analysis revealed a 30-day standard mortality ratio (SMR) close to the higher part of the control limits in Salford Royal Foundation Trust (SRFT), (Salford, UK), after case-mix adjustment.

The aim of the present study was to identify potential factors that could have influenced the SMR.

Methods

SSNAP data were reviewed and all acute stroke admissions in SRFT between 01/04/2013–31/03/2014 were retrieved. Patients who died within 30-days of either an acute ischaemic stroke treated with intravenous thrombolysis (IVT-AIS) or intracerebral haemorrhage (ICH) were retrospectively reviewed on electronic patient records, by 2 of the co-authors. Key-point variables from local, national and international guidelines were recorded and analyzed. SSNAP data analysis between 30-day survivor and mortality subgroups was also performed.

Results

Stroke mortality was higher in older patients, those that were more dependent pre-stroke and those with more severe strokes. No significant time differences (door-to-imaging, door-to-needle, door-to-stroke-unit) were observed between the mortality and survivor subgroups. Thrombolysis checklist was properly filled in, in IVT-AIS cases.

Regarding blood-pressure-reading frequency, local protocols were significantly violated in all subgroups. Similar violations were observed in the reversal of VitK anticoagulation in ICH and glucose management in IVT-AIS patients.

Conclusions

Stroke mortality in SRFT was associated with variables which have a proven impact on it. However, local protocol violations were noted and their effect on the increased SMR needs to be established through future prospective studies.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

12-LEAD ELECTROCARDIOGRAM AND THE RISK OF FUTURE CARDIOVASCULAR EVENTS AFTER EARLY-ONSET STROKE

J Pirinen ^1,^2,^3,⁴, J Putaala ^3,⁴, K Aarnio ^3,⁴, AL Aro ¹, J Sinisalo ¹, M Kaste ^3,⁴, E Haapaniemi ^3,⁴, T Tatlisumak ^3,^4,⁵, M Lehto ¹

Abstract

Background

Ischemic stroke (IS) in a young patient is a disaster and leads to substantial socioeconomic burden. In those patients recurrent cardiovascular events will further add detrimental impact. Identifying the patients with high risk of such events is therefore important. Prognostic relevance of electrocardiography (ECG) has not yet been investigated in this population.

Methods

We analyzed ECG parameters in 690 consecutive IS patients aged 15 to 49 years. Standard 12-lead ECG was obtained 1 to 14 days after onset of stroke symptoms. Adjusted for demographic factors, comorbidities and stroke characteristics, Cox proportional hazards models were constructed to identify independent ECG parameters associated with the long-term risks of (1) composite of any cardiovascular event, (2) cardiac events, and (3) recurrent stroke.

Results

During a median follow-up of 8.8 years, 182 patients (26.4%) experienced a cardiovascular event, 100 patients (14.5%) had a cardiac event, while 101 (14.6%) suffered from recurrent stroke. Independent ECG parameters associated with recurrent cardiovascular events were: bundle branch blocks (hazard ratio 3.9, 95% confidence interval 2.1–7.4), P-terminal force (3.0, 1.6–5.7), left ventricular hypertrophy (1.8, 1.2–2.7) and a broader QRS complex (1.2 per 10 ms, 1.1–1.3). In addition to these, a longer PR-time, a longer QTc and P-wave duration >120 ms were associated with increased risk of cardiac events. None of the ECG parameters were independently associated with recurrent stroke.

Conclusions

Standard 12-lead electrocardiogram is a useful tool to assess cardiovascular event risk but cannot to be used to evaluate recurrent stroke risk in young patients with IS.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

NOVEL PREDICTIVE MODELS FOR RARE OUTCOMES: POTENTIAL APPLICATIONS IN ACUTE ISCHEMIC STROKE

P Pordeli ¹, CD D'Esterre ¹, C Batchelor ², M Najm ¹, E Fainardi ³, M Rubiera ⁴, A Khaw ⁵, J Mandzia ⁵, JJS Shankar ⁶, AM Demchuk ⁷, T Lee ⁸, MD Hill ⁷, TT Sajobi ⁷, BK Menon ⁷

Abstract

Background

Parenchymal hematoma type-2 (PH-2) is a rare but devastating complication in the setting of acute ischemic stroke. Existing statistical models for outcome prediction such as logistic regression (LR) often yield low sensitivity in detecting such rare outcomes. There is therefore a need for developing robust statistical methods capable of accurately predicting such rare but life threatening events.

Methods

We develop a clinical risk prediction tool based on novel weighted and resampling based methodologies for prediction of rare stroke outcomes (such as PH-2) that could be applied in the clinical setting. Specifically, we develop a robust LR method that adopts under-sampling techniques and prevalence-weighted approaches and compare this to conventional LR in predicting rare outcomes in stroke. F1-score (a weighted average of sensitivity and precision that measures accuracy of the prediction model) is used to compare the predictive performance of these models.

Results

The robust LR method yields higher predictive accuracy in small sampled studies with very low rarity percentages than conventional LR. For rare outcomes with prevalence lower than 7%, in samples with less than 500 observations, the robust LR method increases F1-score by 20% over other models (Table 1).

graphic file with name 10.1177_2396987316642909-img22.jpg

Conclusions

The novel robust rare event LR method we develop along with under-sampling is recommended for predicting rare stroke outcomes like PH2 in small-sample sized studies.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CAN SOLUBLE ST2 PREDICT STROKE OUTCOMES? A FEASIBILITY STUDY

AML Quek ¹, B Leung ², HL Teoh ¹, B Chan ¹, V Sharma ¹, R Seet ¹

Abstract

Background

Accumulating data implicate the immune system in stroke pathogenesis. Although soluble ST2 (sST2) has emerged as a potential biomarker in cardiovascular diseases, its significance in patients with ischemic stroke is not known. We aim to assess levels of sST2 stroke patients and examine its feasibility to predict stroke outcomes.

Methods

This is a case-control comparison of sST2 levels in stroke patients and non-stroke controls. Thirty-five patients (mean age, 60.6 years) diagnosed with ischemic stroke at the National University Hospital, Singapore, were recruited. Clinical information relating to stroke severity and mechanisms were systematically collected. Statistical significance was considered when p < 0.05.

Results

Mean age of stroke patients was 60.6 years and median NIHSS 4.3. Ten (33%) patients had cardioembolic stroke etiology, 8 (27%) had large artery disease and 6 (20%) had lacunar stroke and the remaining (20%) had stroke of undetermined etiology. Compared with non-stroke controls, stroke patients had higher levels of sST2 (mean 712 vs 32 pg/ml, p < 0.001). On univariate analysis, moderate correlation was observed between sST2 levels and NIHSS (r = 0.31, p = 0.02). Stroke patients with cardioembolic stroke etiology had higher soluble ST2 levels compared with strokes of other etiologies.

Conclusions

These findings support the feasibility of studying sST2 in ischemic stroke. As sST2 appears to correlate with predictors of stroke outcomes, it is possible that sST2 may be useful as a surrogate marker of functional recovery and recurrent vascular events. Further studies that assess the prognostic significance of sST2 and long-term recurrent vascular events are needed.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CHANGES IN FUNCTIONAL OUTCOME OVER FIVE YEARS AFTER STROKE

Å Rejnö ¹, S Nasic ², K Bjälkefur ³, E Bertholds ¹, J Poucette ⁴, K Jood ⁵

Abstract

Background

Data on changes in long-term post-stroke functional outcome is limited. The aim of this study was to analyze changes in functional outcome over five years after stroke in a large unselected cohort of hospitalized stroke patients.

Methods

All patients who were independent in activities of daily living (ADL) and admitted to a Stroke Unit at Skaraborg Hospital for acute stroke in 2007 to 2009 (n = 1875) were followed annually over five years using a postal questionnaire. Baseline data at acute stroke and status three-month post stroke was obtained from the Swedish Stroke Register. Case-fatality was assessed by linkage to the Swedish Population Register. ADL dependency was defined by dependence in dressing, toileting or indoor mobility.

Results

Case-fatality at 3 months, one and five years were 16.4%, 23.2%, and 50.0%, respectively. The response-rate was >90% at each time-point. The proportions of survivors, who reported ADL dependency at 3 months, one, and five years, were 25.1%, 22.3%, and 24.8%, respectively. The cumulative proportion of independent survivors who deteriorated to dependency was 5.7% at one, 10.9% at two, 16.9% at three, 21.6% at four, and 26.7% at five years post stroke. Independent predictors of deterioration to dependency were age (HR, per year 1.10; 95% CI 1.08–1.12), smoking (HR 1.81; 95% CI 1.21–2.68), diabetes (HR 1.43; 95% CI 1.07–1.91), and anticoagulation treatment at discharge (HR 0.70; 95% CI 0.50–0.99).

Conclusions

Deterioration from ADL independency to dependency occurred at a constant rate throughout out follow-up, while the proportion of survivors with ADL dependency remained unchanged.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

STROKE RISK IS LOW AFTER TRANSIENT ISCHEMIC ATTACK IN PATIENTS TREATED AS EMERGENCY

OM Rønning ¹, T Vigen ¹, B Thommessen ¹

Abstract

Background

Recurrence risk after transient ischemic attack (TIA) ranges from 5% to 20% per year with the highest risks the first days after the event. The lowest risks are seen after acute admission and treatment in specialist stroke services. Urgent assessment and initiation of secondary prevention in specialist centres may reduce the early risk of stroke after TIA up to 80%. The aim of this study was to assess the risk of recurrent stroke in urgent treated TIA patients admitted to an acute stroke unit.

Methods

The policy of Akershus University hospital is that all TIA patients should be admitted for urgent examination and treatment as in-hospital patients. We retrospectively identified all TIA patients hospitalised from January 1^st 2013 until December 31^st 2013 and collected data from their medical records. Readmission data was registered until December 31^st 2015.

Results

The total number admitted was 259, 129 females and 130 males. The mean age was 70.7 years ranging from 21 to 102 years. The proportion of patients with TIA duration <10 minutes was 14%, 10–60 minutes 33% and >60 minutes 54%. Nine patients (3,5%) had a recurrent stroke. There were no recurrences the first 48 hours, two between 2 and 30 days, and 7 after 30 days. The median duration from TIA until recurrent stroke was 110 days.

Conclusions

Urgent treatment of patients with TIA is associated with very low early stroke recurrence. One year follow up also showed that the risk of stroke was modest the first year after TIA.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

MICRORNA-150 ADDS PROGNOSTIC INFORMATION AFTER ACUTE ISCHEMIC STROKE

N Scherrer ¹, Y Devaux ², F Fays ³, O Collignon ³, B Mueller ⁴, A Luft ¹, M Christ-Crain ⁵, M Katan ¹

Abstract

Background

MicroRNAs (miRNAs) are involved in post-transcriptional gene regulation influencing disease progression and prognosis. MiR-150 regulates proinflammatory cytokines, mediators of cellular communication in the ischemic brain, as well as vessel integrity. We aimed at evaluating the incremental prognostic value of miR-150 after ischemic stroke.

Methods

In a prospectively enrolled ischemic stroke cohort, levels of miR-150 were measured within 72 hours of symptom onset in 329 patients. The primary endpoint was functional outcome (modified Rankin Scale score <3 or 3–6), the secondary endpoint was mortality within 90 days. Logistic regression and cox proportional hazards models were fitted to estimate odds ratios (OR), respectively hazard ratios (HR) and 95% confidence intervals (CI) for the association between miR-150 and the primary and secondary endpoints. The discriminatory accuracy was assessed with the area under the receiver-operating-characteristic curve (AUC) and the incremental prognostic value was estimated with the net reclassification index (NRI).

Results

After adjusting for demographic and vascular risk factors, lower miR-150 levels were independently associated with mortality (HR 0.21 [95% CI, 0.08–0.51], p = 0.001) but not functional outcome (OR 1.13 [95% CI, 0.56–2.29], p = 0.74). Adding miR-150 to the multivariate model improved the AUC from 0.91 (95% CI, 0.90–0.93) to 0.92 (95% CI, 0.90–0.93), LRT-p-value < 0.001, and resulted in a NRI of 45.7% (95% CI, 0.28–0.67).

Conclusions

In patients with ischemic stroke, miR-150 is a novel prognostic biomarker, improving risk classification beyond traditional risk factors.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

STROKE SEVERITY AND ITS OUTCOME MAY BE ASSOCIATED WITH SYSTEMIC INFLAMMATION, INFECTIONS OF DIFFERENT TYPES AND IMMUNOSUPRESSION

E Sidorovich ¹, T Amvrosieva ², N Goncharova ³, S Likchachev ¹, Z Bogush ², U Shabalina ⁴, I Petrovich ⁴

Abstract

Background

Data are available for the role of systemic inflammation, immunosupression, prior acute and chronic infections including herpes virus activation in the ischemic stroke (IS) pathogenesis

Methods

Our objective was to identify the relationship between these factors and IS severity and its outcome in 192 patients.

Systemic inflammation was assessed by the hsCRP grades (grade 0 <1,0 mg/l, grade 1–1,1-1,9 mg/l, grade 2 -2,0–2,9 mg/l, grade 3 - 3,0–10,0 mg/l, grade 4 - ≥10,1 mg/l);

Prior acute and chronic infections were graded according to their gravity (grade 0 – no infection, grade 1 - nasopharyngitis, urethritis, herpes labialis, etc; grade 2 – tonsillitis, bronchitis, cystites; etc, grade 3 -pneumonia, pyelonephritis, etc).

Immunosuppression was evaluated by the level of CD3+, CD3+CD4+ T lymphocytes (grade 0 – no decrease, grade 2 - less than 57,7% and 33,5% respectively).

IgM being present to herpes simplex virus corresponded to grade 1, no IgM – to grade 0.

Results

The patients with total score of ≥7 (n = 64) had more severe IS (NIHSS 14,0 ± 6,0 vs 9,3 ± 5,6, P = 0,00007) and higher mortality rate within 30 days, 90 days, 1 and 2 years following IS stroke (18,7%, 25,0%, 26,6%, 37,5%) compared to the patients with total score of ≤6 (5,5%, 8,6%, 10,9%, 14,8%, Р < 0,05, respectively); within the first 30 days and 2 years following IS onset OR were 3,98; 95% CI 1,49–10,7 and 3,44; 95% CI 1,7–6,95.

Conclusions

The data confirmed a need for comprehensive assessment of systemic inflammation, infections and immunosuppression so that to improve the prognostic and therapeutic strategy in IS patients

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

INFLUNCE OF IN-HOSPITAL MEDICAL COMPLICATIONS ON LONG - TERM OUTCOME IN ISCHEMIC STROKE PATIENTS TREATED WITH INTRAVENOUS THROMBOLYSIS

M Stefanovic Budimkic ¹, T Pekmezovic ², L Beslac-Bumbasirevic ³, M Ercegovac ³, I Berisavac ³, P Stanarcevic ⁴, V Padjen ⁴, D Jovanovic ³

Abstract

Background

It is unclear whether medical complications during hospitalization have an impact on ischemic stroke (IS) outcome over a longer follow-up period in patients treated with intravenous thrombolytic treatment (IVT). The aim of this study was to evaluate the impact of in-hospital medical complication on long-term outcome in acute IS patients treated with IVT.

Methods

This matched cohort study included 259 patients with acute IS treated with thrombolytic treatment plus standard care and 259 patients treated only with standard care alone, who were matched by age, sex and stroke severity. Main outcome measures were excellent functional outcome (modified Rankin scores 0 and 1) and death from all causes assessed more than one year after the stroke

Results

Fifty-nine (22.8%) patients in IVT-group and 88 (34.0%) patients in non-IVT group experienced one or more medical complications (OR 0.57; 95% CI 0.39–0.84). The median follow-up period was 3 years (range 1 to 7 years). Patients with in-hospital medical complications had lower possibility for excellent functional outcome after follow-up period (HR 0.58; 95% CI 0.41–0.83). In multivariate Cox proportional-hazards regression model medical complications during hospitalization were independent predictors of 30 day-mortality (HR 1.87; 95%CI 1.01–2.90) and long-term mortality (HR 2.80; 95% CI 1.45–5.23) after stroke.

Conclusions

The occurrence of in-hospital medical complications was less frequent in thrombolyzed patients and was associated with lower possibility for excellent functional outcome and higher mortality rate in long term outcome after IS.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE RELATIONSHIP BETWEEN POSTSTROKE EPILEPTIC SEIZURES AND ACUTE ISCHEMİC STROKE TREATMENT

Y Tehli ¹, G Tekgol Uzuner ¹, N Uzuner ¹

Abstract

Background

The risk factors for developing poststroke seizures include cortical involvement, anterior hemisphere location, and possibly cardioembolic etiology. However, the effect of the acute treatment of the ischemic stroke on the poststroke epilepsy is not clear. Therefore, we have investigated the effect of the acute ischemic stroke treatments on poststroke epilepsy.

Methods

Between 2012 and 2014 all ischemic stroke patients were scanned at our stroke unit. After application of the exclusion criteria, 299 eligible patients have been followed for one year. The average age of the patients was 63.6 ± 0.6 (172 male and 127 female). Intravenous thrombolytic treatment gave 80 patients, 28 patients underwent endovascular intervention, and the remaining 191 patients were treated with the antithrombotic (antiaggregant or anticoagulant) regimen.

Results

Eight patients who are given intravenous thrombolytic treatment, 8 patients treated with endovascular intervention and 36 patients under antithrombotic stroke regimen have an epileptic seizure after ischemic stroke. The epileptic seizures after the ischemic stroke occurred with a significantly lower frequency (p < 0.003) when intravenous thrombolytic treatment were given comparing to endovascular intervention or antithrombotic regimen. Similar results were seen in patients with early epileptic seizures after ischemic stroke. The patients with delayed epileptic seizures were not different between treatment modalities.

Conclusions

Intravenous thrombolytic treatment not only provides excellent prognosis after ischemic stroke but also have a protective effect on the postepileptic seizures. This effect was significantly seen in the early epileptic seizures.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CLINICAL CHARACTERISTICS OF NONCONVULSIVE STATUS EPILEPTICUS IN POST STROKE SEIZURE

S Tomari ¹, T Tanaka ¹, N Kazuyuki ¹, T Kazunori ¹

Abstract

Background

Status epilepticus (SE) in post stroke seizure (PSS) includes convulsive SE (CSE) and nonconvulsive SE (NCSE). However, clinical characteristics of NCSE in PSS still remain unclarified.

Methods

We retrospectively enrolled the patients with SE in PSS between April 2010 and September 2015. SE was classified into CSE and NCSE. We compared etiology, culprit stroke lesions, medical comorbidities (chronic kidney disease, liver dysfunction, chronic obstructive pulmonary disease, malignancy) and neurological outcome between two groups. Poor neurological outcome was defined as an increase of Glasgow Coma Scale by one or more between before admission and at hospital discharge.

Results

Of 320 PSS patients, 40 patients presenting SE (26 men, 74.9 ± 10.3 years old) were studied. CSE occurred in 26 and NCSE in 14 patients. 7 patients included in NCSE shifted from CSE to NCSE after admission. Patients with NCSE more frequently had history of cardioembolic stroke (CSE 12% vs. NCSE 36%, P = 0.10), frontal lesions (CSE 31% vs. NCSE 71%, P = 0.021) and had medical comorbidities (CSE 12% vs. NCSE 43%, P = 0.044) than those with CSE. NCSE in PSS was not a predictor of poor neurological outcome (CSE 46% vs. NCSE 50%).

Conclusions

Patients with NCSE more frequently had previous cardioembolic stroke, frontal lesions of stroke and medical comorbidities than those with CSE in PSS.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ROUTINE SERUM C-REACTIVE PROTEIN IS AN INDEPENDENT PREDICTOR OF BASELINE STROKE SEVERITY IN ACUTE ISCHEMIC STROKE

M Chondrogianni ¹, C Liantinioti ¹, C Zompola ¹, G Papadimitropoulos ¹, A Papa ^1,², S Triantafyllou ¹, A Kleisoura ¹, A Katsanos ^1,³, A Roussopoulou ^1,⁴, K Voumvourakis ¹, G Tsivgoulis ¹

Abstract

Background

Increased level of serum C-reactive protein (CRP) is a systemic marker of inflammation and is being currently considered as an important risk factor for cardiovascular events and stroke. We sought to evaluate the association of CRP with stroke severity in the setting of acute ischemic stroke (AIS).

Methods

Consecutive AIS patients were prospectively evaluated over a three-year period in a tertiary-care stroke center. Baseline stroke severity was assessed using NIHSS-score. Moderate-to-severe stroke was defined using a cut-off of ≥10 points in NIHSS-score. Routine serum-CRP was measured as standard of care in AIS patients within 48 hours from hospital admission. The laboratory cut-off for elevated CRP level was >6 mg/dL. Statistical analyses were performed using Spearman’s correlation coefficient (r) and multivariable logistic regression models.

Results

A total of 186 AIS patients (66% men, mean age 57 ± 12 years) with available routine serum-CRP during the first 48 hours of hospitalization were evaluated. Elevated CRP was identified in 68 individuals (36%; 95%CI: 29%-43%) and was more prevalent in patients with moderate-to-severe stroke (27% vs. 8%; p = 0.001). Among patients with elevated CRP, baseline stroke severity correlated positively with CRP levels (r: +0.352; p = 0.004). Elevated CRP was independently associated with a higher likelihood for moderate-to-severe stroke in multivariable logistic regression models adjusting for demographics, stroke subtype and vascular risk factors (OR: 4.53, 95%CI: 1.10–18.66; p = 0.037).

Conclusions

Elevated CRP is an independent predictor of baseline stroke severity in AIS. The increase in serum CRP in acute cerebral ischemia may reflect the extent of underlying brain tissue damage.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

3-MONTH OUTCOME PREDICTION AFTER ACUTE ISCHEMIC STROKE: COMPARISON OF MODELS BASED ON DATA AVAILABLE AT ADMISSION AND 24 HOURS

C Isabel ¹, G Turc ¹, P Seners ¹, JL Mas ¹

Abstract

Background

Most prognostic models designed to predict 3-month outcome after acute ischemic stroke (AIS) rely on data available at admission. However, those models are sometimes complex and have imperfect predictive abilities. Our goal was to determine if a simple model based on data available at 24 hours could have an excellent discriminative ability (AUC-ROC > 0.90) for poor outcome (mRS > 2) prediction.

Methods

Two cohorts of patients presenting within 6 hours of AIS in our center (2003–2014) were analyzed: patients receiving intravenous thrombolysis (IVT+) and those without recanalization therapy (IVT-). In each cohort, clinical prognostic models were built, based on data available at admission and at 24 hours, using stepwise logistic regressions. We subsequently assessed the impact of adding the DWI-ASPECTS score (≤5 vs. >5) into each model.

Results

In the IVT+ cohort (n = 421), the clinical model based on data at 24 hours (NIHSS, age) had a better discriminative ability than the model based on data at admission (NIHSS, age, glucose level, pre-AIS mRS): AUC-ROC = 0.92 vs 0.79 (P < 0.001). In the IVT- cohort (n = 324), the clinical model based on data at 24 hours (NIHSS, age) also showed a better discriminative ability than the model based on data at admission (NIHSS, age, glucose level): AUC-ROC = 0.94 vs 0.88 (P = 0.008). Adding the 24-hour DWI-ASPECTS variable to the model based on age and 24-hour NIHSS did not improve its predictive ability.

Conclusions

A simple prognostic model based only on age and NIHSS score 24 hours after AIS allowed an excellent discriminative ability for 3-month mRS > 2 prediction.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE ROLE OF PERFUSION ALGORITHM, COVERAGE SIZE AND PERFUSION MISMATCH IN SELECTION OF PATIENTS FOR ACUTE STROKE TREATMENT

I van den Wijngaard ¹, W MJH ², J Boiten ³, A Algra ⁴, B Velthuis ⁵, M van Walderveen ⁶

Abstract

Background

Controversy exists whether CT perfusion (CTP) improves identification of acute ischemic stroke (AIS) patients likely to respond to recanalizing treatment strategies. Our aim was to assess the effect of acute stroke treatment on clinical outcome for patients in CTP target and non-target mismatch subgroups, using 2 CTP algorithms and a range of coverage sizes.

Methods

– Patients with anterior circulation stroke underwent whole brain CTP < 9 hours after symptom onset. Coverage sizes of 4, 6, 8 and 12 cm were simulated. Infarct core according to algorithm A was a relative cerebral blood volume reduction of >40% and for B a relative cerebral blood flow reduction of ≥50%. Patients were classified into 3 groups (1) target mismatch (mismatch ratio ≥1.8, volume ≥15 mL, core <70 mL), (2) no target mismatch (mismatch ratio <1.8 or volume <15 mL, core <70 mL) and (3) large core (≥70 mL). Good clinical outcome was a score on the modified Rankin scale of ≤2. With logistic regression we evaluated the effect of acute stroke treatment on outcome in the 3 subgroups for 4 cm and 12 cm coverage size.

Results

144 patients were included. With 12 cm perfusion coverage size, irrespective of the applied algorithm, we observed no differences in risk of good outcome between treated and untreated patients in the 3 subgroups (Table). Similar results were shown with a coverage size of 4, 6 and 8 cm.

Conclusions

Despite the use of different perfusion algorithms and coverage sizes, CTP does not improve identification of AIS patients likely to respond to acute stroke treatment.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CLINICAL EVOLUTION OF PATIENTS WITH ISCHEMIC STROKE AS A FUNCTION OF AGE

AB Vena ¹, S Cambray ², J Molina ³, L Colas ², J Sanahuja ³, A Quilez ³, C Gonzalez ³, P Gil ³, I Benabdelhak ³, G Mauri ³, F Purroy ³

Abstract

Background

To analyse the predictors and characteristics of the evolution of patients that have experienced ischemic stroke (IS), as a function of age.

Methods

Observational study of consecutive ischemic stroke patients admitted to a hospital with access to Stroke Unit and fibrinolytic therapy (FT), regardless of age. Two groups were defined: patients 80 or younger and patients over 80 years-old (30.3%). The clinical characteristics, etiology, management, and evolution (mortality and a score >2 on the modified-Rankin-scale [mRS] at discharge) were all compared.

Results

A total of 740 patients were included in the study. Female sex, atrial fibrillation, cardioembolic etiology, greater stroke severity and mortality were more common among patients >80years-old. Administration of FT and the activation of the stroke-protocol were higher in this group. Basal-NIHSS-score was a common-predictor of death and mRS > 2 at discharge (area under the ROC curve of 0.82 and 0.87). The development of febrile-syndrome (OR 3.03;1.34–6.86; p = 0.008) and a history of ischemic-heart disease (OR1.59;1.01–2.30; p = 0.014) were predictors for mRS > 2, while a total anterior circulation infarction (TACI) (OR2.39; 1.43–3.98; p = 0.001) and the development of cardiac failure (OR6.24;1.01–38.40; p = 0.048) were predictors of death. Age was not an independent predictor of clinical evolution.

Conclusions

In an academic Hospital with access to stroke-unit and FT regardless of age, initial clinical-severity and the development of medical complications were more important predictive factors for an IS patient’s clinical evolution than age.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

IS COMA ASSOCIATED WITH ADVERSE OUTCOME OF BRAIN HERNIATION AFTER INTRACEREBRAL HEMORRHAGE?

M Xu ¹, M Liu ¹, R Yuan ¹

Abstract

Background

Reports published on brain herniation after intracerebral hemorrhage (ICH) are relatively small size and case series mostly. In our present large retrospective cohort study, we aimed to describe the clinical information, subtype of etiology and the relationship of coma at onset and on admission with outcome.

Methods

Based on our prospective database, the rates of poor outcome (mRS ≥ 4) and mortality at 90-day were compared in patients with and without coma at onset and on admission. Multivariable logistic regression was used to determine the effect of coma on outcome, patients with different stages of consciousness were further analyzed to determine the effect of disease severity on outcome.

Results

172 subjects with brain herniation after acute ICH were studied from 2305 ICH patients in our prospective database. Of these 172 patients, with the incidence of coma after onset and on admission of 85.6% and 81.4%, the morbidity of 90-day was 92.3% and mortality was 83.9%. Coma at onset was associated with poor outcome (P = 0.007) and was not with mortality. And coma on admission was associated with 90-day poor outcome and mortality (P = 0.011, P = 0.024, respectively). Multivariable logistic regression further verified the results. Moreover, patients who underwent puncture drainage or craniotomy evacuation of hematoma had a better outcome compared with those without (P < 0.001).

Conclusions

The mortality of brain herniation is extremely high, and coma has a close relationship with outcome. Under this condition, emergent surgery could increasingly decrease the mortality of 90-day. And surgical treatment should be used emergently to save life for patients with brain herniation.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE ASSOCIATION BETWEEN ESTIMATED GLOMERULAR FILTRATION RATE AND SHORT-TERM CLINICAL OUTCOMES IN ACUTE ISCHEMIC STROKE PATIENTS

S Yu ¹, MY Eun ², KH Cho ¹

Abstract

Background

Chronic kidney disease (CKD) is an established risk factor for cardiovascular disease and stroke. We evaluated whether estimated glomerular filtration rate (eGFR) was an independent predictor of clinical outcomes after acute ischemic stroke.

Methods

We included consecutive patients with acute ischemic stroke who were admitted to our hospital. Patients with thrombolysis were excluded. Patients were categorized into five groups according to eGFR ≥ 90, 60–89, 45–59, 30–44, <30 mL/min/1.73 m². The effects of eGFR on poor functional outcome at discharge defined as modified Rankin Scale score of 3 to 6 and in-hospital mortality were evaluated using logistic regression analyses.

Results

Among 2254 patients, 1420 were included for analysis. There were 479 (33.7%) patients with poor functional outcome at discharge and 32 (2.3%) patients died during hospitalization. In the univariate logistic regression analyses reduced eGFR was associated with poor functional outcome at discharge (p < 0.001) and in-hospital mortality (p = 0.001). However, there were no significant associations between eGFR and poor functional outcome or in-hospital mortality in the multivariable analyses after adjustment of clinical and laboratory variables.

Conclusions

Reduced eGFR was associated with poor functional outcome at discharge and in-hospital mortality but not an independent predictor in patients with acute ischemic stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

LONG-TERM CARDIOVASCULAR RISK PREDICTION AFTER TRANSIENT ISCHEMIC ATTACK

A Zabalza de Torres ¹, A Ois Santiago ¹, A Moreira Villanueva ¹, P de Ceballos Cerrajería ¹, L Diez Porras ¹, M Serra Martinez ¹, C Avellaneda Goméz ¹, J Roquer González ¹

Abstract

Background

The aim of our study is to determinate which is the long-term cardiovascular risk (stroke and non-stroke events) after a transient ischemic attack (TIA) and to analyze the associated factors.

Methods

Prospective observational study of consecutive patients with TIA recruited from 06/2006 to 06/2014 at a single tertiary stroke center with a folloup up until 06/2015. The study endpoint was presentation of a NVE (vascular death, nonfatal stroke or myocardial infarction, and hospitalization for other atherothrombotic events) after 90-days from TIA onset, defined according to the REACH study criteria. We analyzed age, sex, vascular risk factors, stroke subtype according to SSS-TOAST criteria (cardioaortic, large artery atherosclerosis, unclassified (more than one causal mechanism), small artery disease and undetermined (without cause) stroke categories). and other clinical data mainly based on ABCD TIA scores.

Results

Of a total of 3766 patients we include 545 patients with TIA (Mean follow-up 42.77 ± 27.5 months). A NVE was detected in 104 patients (18.6%), 0.049 events per patient/year, (51% of them cerebrovascular). Multivariate analysis showed an associations with NVE and: previous vascular disease (coronary or peripheral artery disease) HR: 1.6 (1–2.5), large artery atherosclerosis subtype, HR: 4.3 (1–18.4) and cardioaortic embolism subtype, HR: 2.6 (1.4–4.8).

Conclusions

The long term risk of vascular events after TIA is 0.049 per year. Patients with peripheral or coronary arterial disease and those with atherosclerotic or cardioaortic etiologies are at high risk.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CEREBROVASCULAR DISEASE LOAD IS THE BEST PREDICTOR OF 12 MONTHS STROKE RECURRENCE

A Zachariadis ¹, D Lambrou ¹, G Ntaios ², P Michel ¹

Abstract

Background

We aimed at identifying epidemiological, clinical, pathophysiological and radiological predictors of stroke recurrence after an acute ischemic stroke in patients hospitalized at a stroke center.

Methods

Of 3’246 consecutive patients admitted to a single stroke center registry (ASTRAL), we analyzed the recurrence data (ischemic stroke, retinal infarction, intracerebral and subarachnoid hemorrhages) during the first 12 months. Multiple demographic, epidemiological, clinical data, cerebrovascular risks factors, stroke mechanism, co-morbidities, laboratory and radiological data collected during the initial event, were analyzed in univariate comparison and a Cox-regression analysis.

Results

229 patients (7.05%) presented at least one ischemic (91.3%) or hemorrhagic (8.7%) recurrence within the first 12 months. In the univariate analysis (UVA), the predictors for a recurrence were previous cerebrovascular events (OR 1.55), history of coronary artery disease (1.41) or cancer (2.71), pretreatment with antiplatelets (1.54), rare stroke mechanism (3.27), unknown stroke mechanism (1.64), simultaneous anterior plus posterior circulation stroke (4.15), chronic stroke lesion (OR 1.94) and leukoaraiosis (OR 1.45), and significant cervico-cerebral arterial pathology (1.24). Conventional risk factors or comorbidites were not found to have a significant effect on the prediction of a recurrence. The results of the Cox-regression analysis will also be presented.

Conclusions

In a large cohort of acute ischemic stroke, preexisting clinical and radiologically cerebrovascular disease, but not conventional risk factors, were the most important predictors of stroke recurrences. In addition, cancer history, rare stroke causes and multiterritorial stroke confer a particularly high recurrence risk. Such information may be useful to inform patients about recurrence risk and to target secondary prevention.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EXTERNAL VALIDATION OF THE ISAN, A2DS2 AND AIS-APS SCORES FOR PREDICTING STROKE-ASSOCIATED PNEUMONIA

E Zapata-Arriaza ¹, F Moniche ¹, I Escudero-Martínez ¹, M Prieto-León ¹, MD Jiménez-Hernández ¹, J De la Torre Laviana ¹, O Uclés Cabeza ¹, A Ollero Ortiz ², JA Sánchez-García ³, G Sanz-Fernández ⁴, MÁ Gamero-García ⁵, MÁ Quesada-García ⁵, M Romera-Tellado ⁶, C De la cruz Cosme ⁷, J Montaner ¹

Abstract

Background

The ISAN, A2DS2 and AIS-APS scores were created to predict stroke-associated pneumonia (SAP), one of the most important medical stroke complications. The purpose of this study was the external validation of all such scores in a large acute stroke population.

Methods

Patients with ischemic or hemorrhagic stroke were prospectively collected in the multicenter SIPIA project (Stroke Induced Pneumonia In Andalucía) between October-2014 and December-2015. Receiver operating characteristic curves and linear regression analyses were used to determine discrimination ability of the scores. Hosmer-Lemeshow goodness-of-fit test and the plot of observed versus predicted SAP risk were used to assess model calibration.

Results

Among 125 included patients, SAP rate was 16.3 %. SAP was related to age >80 y (p < 0.001), stroke unit hospitalization (p = 0.045), dysphagia (p = 0.046), smoking (p = 0.027), renal failure (p = 0.022) and higher NIHSS scores. Higher ISAN, A2DS2 and AIS-APS scores were related with SAP (p < 0.001). The C statistic was 0.82 (95% CI, 0.72–0.92) for the ISAN score, 0.77 (95 % CI, 0.65–0.90) for the A2DS2 score and 0.81 (95% CI, 0.70–0.91) for AIS-APS score; suggesting excellent discrimination. The A2DS2 and AIS-APS scores showed good calibration (Cox and Snell R2 = 0.177) and ISAN score demonstrated an excellent calibration (Cox and Snell R2 = 0.222). A2DS2 score showed high sensitivity (85%), and AIS-APS and ISAN high specificity (92.2% and 89.3%, respectively).

Conclusions

In our cohort, the external validation of ISAN, A2DS2 and AIS-APS scores have demonstrated their accurate prediction of SAP and the ability of these scores as screening tools to better manage such post-stroke pneumonia

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

FUNCTIONAL INDEPENDENCE LEVELS AFTER STROKE

NB Rangel ¹, A da Costa ¹, L Abou ¹, F Romaguera ¹, SM MICHAELSEN ¹

Abstract

Background

This study aimed to identify the level of independence in individuals post-stroke on different strata of chronicity.

Methods

The level of functional independence was assessed through motor FIM considering the following parameters for Self-care (SC-FIM); Locomotion (LOC-FIM) and Motor (MOT- FIM):

Results

Conclusions

Our results showed that after six months of stroke more than half of the patients continue requiring some help in their self-care and locomotion.

Table 1.

Baseline Characteristics

	Total sample (n = 149)	at 3 m (n = 69)	3 to 6 m (n = 41)	6 to 12 m (n = 39)
Age (years) Mean ± SD (Min-Máx)	62,7 ± 13,1 (22–92)	65 ± 13 (33–92)	61 ± 12,6 (28–85)	60,5 ± 13,5 (22–81)
Gender M n (%)	84(56)	33(48)	28(68)	23(59)
Gender F n (%)	65(44)	36(52)	13(32)	16(41)
Hemiplegia R; n (%)	76(51)	42(61)	18(44)	16(41)

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Table 2.

Independence Level - Functional Independence Measure (FIM)

	Total sample (n = 149)	At 3 m (n = 69)	3 to 6 m (n = 41)	6 to 12 m (n = 39)
SC FIM
Mean ± SD	27,9 ± 11,0	26,2 ± 11,4	29,5 ± 10,3	29,2 ± 10,2
INDEP. (> 35) n (%).	59(39)	24(35)	19(46)	16(41)
MOD. DEP. (22–35) n (%)	45(37)	18(26)	13(32)	14(36)
COMP. DEP. (< 21) n(%)	45(30)	27(39)	9(22)	9(23)
LOC FIM
Mean ± SD	8,4 ± 4,4	8,0 ± 4,5	8,5 ± 4,3	8,8 ± 4,0
INDEP. (> 12) n (%).	56(38)	24(35)	17(41)	15(38)
MOD. DEP. (6–11) n (%)	42(28)	17(25)	11(27)	14(36)
DEP. COMP. (< 5) n(%)	51(34)	28(40)	13(32)	10(26)
MOT FIM
Mean ± SC	56,2 ± 25,1	52,7 ± 25,7	54,2 ± 24,2	64,5 ± 22,9
INDEP. (> 78) n (%).	39(26)	15(22)	10(24)	14(36)
MOD. DEP. (46–78) n (%)	50(33)	21(30)	13(32)	16(41)
COMP. DEP. (< 45) n(%)	60(40)	33(48)	18(44)	9(23)

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Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

STROKE IN PREGNANCY AND PUERPERIUM

A Arsovska ¹

Abstract

Background

Pregnancy and puerperium could increase the risk of stroke. The reported incidences of stroke during pregnancy and puerperium range from 5 to 67 per 100,000 deliveries or pregnancies. Aim of this paper is to investigate the occurence and type of stroke during pregnancy and puerperium in our group of patients and to analyze the associated risk factors.

Methods

A retrospective analysis of 763 stroke female patients hospitalized during a 5 year period was made. Of them, 4 patients were pregnant (last trimester) and 7 patients were in puerperium, respectively. Stroke type, age and associated risk factors were statistically analyzed.

Results

Mean age of the identified patients was 28+-4 years. Ischemic stroke (region of posterior cerebral artery) was present in 2 pregnant patients; cerebral venous thrombosis was discovered in 2 pregnant and 7 puerperal patients. Associated risk factors included eclampsia, hypercoagulability, hypertension and infections (p < 0,05).

Conclusions

Identification of potential risk factors is important to prevent occurence of stroke in pregnancy and puerperium.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

SEX AND AGE DIFFERENCES IN ACUTE ISCHEMIC STROKE

E Conde Blanco ¹, MD Moragues Benito ¹, E Villarreal Vitorica ¹, RM Diaz Navarro ¹, I Legarda Ramirez ¹, S Tur Campos ¹, C Jimenez Martinez ¹

Abstract

Background

A wide variety of factors influence stroke prognosis and are associated with neurological disability. We aim to determine sex influence in ischemic stroke stratified by age.

Methods

Retrospective analysis of a prospective cohort study of patients diagnosed of ischemic stroke at Son Espases Hospital (Spain) from 2012 to 2014. A multivariable analysis was performed to investigate the association of gender and stroke severity at admission (National institute of Health Stroke Scale (NIHSS)) and ninety-day outcome using the modified Rankin Scale (90-Day mRS) stratified into age groups.

Results

We included 1,112 patients diagnosed of ischemic stroke, 397 women (35, 70%) and 715 men (64, 29%), mean age 68.01 ± 0.41 years. Possible confounders, including stroke subtype and severity, risk factors, and stroke treatments were adjusted. No gender difference was found at admission NIHSS and 90-Day mRS in patients aged 18 to 45 and 46 to 65. In patients older than 65 years, females showed higher NIHSS scores at admission (x:10.71 ± 0.92) and worse functional outcome in 90-Day mRS (x:2.84 ± 0.14). Cardioembolic stroke (CE) was the overall most observed etiology (24, 34%), and the leading cause of stroke in women (33, 75%), with an increasing incidence with age. Patients older than 65 years with CE showed greater NIHSS scores at admission and higher 90-Day mRS (p < 0.001), with no sex differences.

Conclusions

Females older than 65 years have higher stroke severity and neurological disability than men of the same age, independently of possible confounders. CE incidence increases with age and has worse functional outcome in older patients.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

OUTCOME OF PREGNANCY FOLLOWING ARTERIAL ISCHEMIC STROKE

M El Amrani ¹, S Lanthier ¹

Abstract

Background

Safety of pregnancy following stroke is largely unknown. Objective: To describe outcome of post-stroke pregnancy.

Methods

Women with first-ever arterial ischemic stroke before age 45 were identified from stroke database review (2001–2015) and interviewed directly or by phone.

Results

From 221 potential participants, 22 were deceased (4 less than 1 month post-stroke, 4 from recurrent stroke, 14 from other causes – none related to pregnancy/postpartum), 2 declined study participation, and 56 were lost to follow-up. In 141 interviewed women, age at stroke was 2–45 years (median: 34). Thirty-four women had 55 pregnancies during 2.0–33.6 years of follow-up (median: 7.7). Ten of them had 14 voluntary abortions, three on medical advice. Seven had 12 miscarriages (one woman with six). Twenty-five had 20 vaginal and 9 caesarian deliveries, despite medical advice against pregnancy in 4 women. Stroke-to-delivery intervals were 1.3–20.2 years (median: 4.5) and stroke etiology was undetermined (n = 5), artery dissection (n = 5), isolated oral contraceptives (n = 6), other prothrombotic states (n = 2), and cardioembolic, atherosclerosis, arteriolosclerosis, vasculitis, reversible cerebral vasoconstriction, migraine, and cocaine (1 each). Twenty-seven of 29 newborns had a normal 10-minute APGAR score. Two others died from nuchal cord complication. Among 107 women without post-stroke pregnancy, 25 desired childbearing. Eleven of them received medical advice against pregnancy. During follow-up, stroke recurred in 7/34 women with post-stroke pregnancy (aside pregnancy/puerperium in all instances) and in 26/107 without post-stroke pregnancy.

Conclusions

Many women surviving stroke desire childbearing. Despite variable residual risk associated with stroke etiology, maternal and neonatal outcome of pregnancy is often favorable.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

RECURRENT REVERSIBLE CEREBRAL VASOCONSTRICTION SYNDROME FOLLOWING CAROTID ENDARTERECTOMY - PROBLEM OF ENDOGENOUS AUTOREGULATION?

D Fitas ¹, M Carvalho ², P Castro ², P Abreu ², G Moreira ³, R Santos ⁴, E Azevedo ²

Abstract

Background

Carotid endarterectomy (CEA) remains the gold standard treatment to high-grade carotid stenosis.

Methods

A 55-year-old woman with bilateral internal carotid artery stenosis (75–80% in the right and 65–70% in the left, ECST method) underwent right CEA because of transient episodes in the left body. Few days after, she developed episodes of right-sided headache, apathy and somnolence. Brain CT showed right frontotemporal oedema. Laboratory test was normal. Initial transcranial Doppler ultrasound (TCD) showed increased right middle cerebral artery blood flow velocity (VMCA). The first diagnosis made was probable reperfusion syndrome. Two weeks after CEA, she developed sensory-motor deficits on the left side of the face and left hand (2/5 MRC grade). TCD monitoring showed gradual increase of VMCA and of Lindegaard index (LI), reaching 217 cm/s and 4.1, respectively, at 17^th day. Empirical oral nimodipine 60 mg was initiated.

Results

CT-angiography was done revealing segmental narrowing involving segments of the right anterior and middle cerebral arteries. Diagnosis of reversible cerebral vasoconstriction syndrome (RCVS) was made. DTC monitoring showed gradual normalization of V_MCA and LI. CT-angiography several months later showed reversal of segmental narrowing. One year after right CEA, she underwent left CEA. Once again, the surgery was complicated by a RCVS, with good clinical recover

Conclusions

RVCS is a rare but threatening complication of CEA which may follow a reperfusion syndrome. We showed a probable case of autoregulation deficiency of vascular tone and de importance of TCD for monitoring cerebral hemodynamics and vasospasm.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PULSATILE TINNITUS CAUSED BY A DILATED LEFT PETROSQUAMOSAL SINUS

DC Jianu ¹, SN Jianu ², F Dan ¹, L Petrica ³, M Poenaru ⁴

Abstract

Background

The emissary veins, like the petrosquamosal sinus (PSS), are residual valveless veins which connect the intracranial dural venous sinuses and the extracranial venous system. Rarely, they may cause pulsatile tinnitus (PT).

Methods

We used high-resolution computed tomography (HRCT), magnetic resonance imaging (MRI)/ MR-venogram and laboratory tests.

Results

A 22-yr-old woman developed in the first week of puerperium worsening headaches, vomiting, and diplopia, and the accentuation of a PT in the left ear that she presented for 8 years. The clinical examination findings 9 days after delivery were unremarkable, with the exception of a left sixth nerve palsy, and a peculiar sensibility of the left temporo-mandibular joint. High-resolution computed tomography (HRCT) revealed an osseous canal in the air cells of the left temporal bone compatible with a PSS. CT and magnetic resonance imaging/ MR-venogram detected signs of thrombosis of the superior sagital sinus, and of the left lateral sinus. Laboratory tests revealed congenital “severe” thrombophilia. We used antithrombotic therapy (body weight-adjusted subcutaneous low-molecular weight heparin, followed by indefinite therapy with warfarin), and the headaches, vomiting, and diplopia resolved within 4 days of treatment. A follow-up MR-venogram performed 2 weeks later indicated complete recanalization of the intracranial dural venous sinuses. The PT was improved after 2 weeks of medical therapy, so she could adapt to it without intervention on the PSS.

Conclusions

PSS could be identified in her case on HRCT.The early initialization of an efficient medical therapy had a great impact on her favorable evolution.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EARLY OUTCOME OF WOMEN WITH ACUTE STROKE DURING PREGNANCY AND PUERPERIUM

N Blagojevic ¹, M Bogicevic ¹, M Stefanovic Budimkic ², DR Jovanovic ²

Abstract

Background

Previous studies of acute stroke (AS) during gestational period are scarce and inconclusive. The aim of this study was to investigate the early outcome of AS occurring during pregnancy and puerperium, and to compare it with the outcome of young female patients with AS occurring beyond gestational period.

Methods

A total of 84 patients suffering from AS during pregnancy and puerperium were matched with another 84 young female patients with AS onset beyond this period. All patients were hospitalized at our department in a period from 1989–2014. Functional outcome using modified Rankin scale (mRS) at the end of hospitalization was recorded.

Results

No difference between two groups of patients was found in excellent functional outcome (mRS ≤ 1) (52.4% gestational AS vs. 44% non-gestational AS, p = 0.29), favorable functional outcome (mRS ≤ 2) (58.5% gestational AS vs. 61.3% non-gestational AS, p = 0.72) and in death (11% gestational AS vs. 5.3% non-gestational AS, p = 0.20). Multivariate logistic regression analysis showed no statistically significant difference between the two groups of AS patients in excellent functional outcome (OR 0.74, 95%CI 0.29–1.83), good functional outcome (OR 0.97, 95%CI 0.38–2.49) or death (OR 0.35 95%CI 0.03–3.61) when they were adjusted by age, presence of hypertension and smoking, mean arterial pressure, etiology and type of stroke.

Conclusions

Although AS with onset in pregnancy and puerperium has its clinical and diagnostic specificities, there is no difference in an early outcome among patients with AS during and beyond gestational period.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE EFFICACY OF INTRAVENOUS THROMBOLYSIS IN WOMEN WITH ACUTE ISCHEMIC STROKE

DR Jovanovic ¹, M Stefanovic Budimkic ¹, T Pekmezovic ², L Beslac-Bumbasirevic ¹, P Stanarcevic ¹

Abstract

Background

Women and men with acute ischemic stroke (IS) treated with intravenous thrombolysis (IVT) had similar outcomes. However, it is unclear whether women treated with IVT have better prognosis compared with those treated with standard care. The aim of this study was to compare the outcome of acute IS women treated with IVT with those treated with standard care alone.

Methods

This matched cohort study included 79 females with acute IS treated with IVT plus standard care and 79 females treated with standard care alone, who were matched by age, sex and stroke severity. Functional outcome of patients were assessed by modified Rankin score (mRS). Main outcome measures were excellent functional outcome (mRS 0–1), good functional outcome (mRS 0–2) and death from all causes at 3 months after stroke onset.

Results

Women with IS treated with IVT had a higher chance to have an excellent outcome (59.5% with IVT vs. 35.4% without IVT; p = 0.001) or good functional outcome (64.6% with IVT vs. 48.1% without IVT; p = 0.023) and no difference in death at 3 months. However, when this two groups in multivariate analysis were adjusted for potential confounders there was no difference in excellent functional outcome (OR 1.67, 95% CI 0.60–4.63), good functional outcome (OR 0.59; 95% CI 0.16–2.14) or death (OR 0.44, 95% CI 0.1–1.96) at 3 months.

Conclusions

There is still a doubt if the female patients with acute IS have any benefit from intravenous thrombolysis at 3 months.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

LUCKY 13 - A CASE OF COMBINED THROMBOLYSIS AND THROMBECTOMY TREATMENT OF ACUTE ISCHEMIC STROKE IN EARLY POSTPARTUM PERIOD

S Klimosova ¹, M Sercl ²

Abstract

Background

Pregnancy and puerperium are well known sex- related risk factors of ischemic stroke. Very few data were published on acute stroke treatment in this risk group. Safety and efficacy of intravenous alteplase in the early postpartum period (<14 days after delivery) have not been well established. According to literature there are only 2 case reports of acute stroke reperfusion therapy in mothers in the early postpartum period, neither of whom received intravenous alteplase.

Methods

31 year old female, smoker, family history of cardiovascular disease, was admitted 13 days after uneventfull delivery for acute onset dysarthria, left facial weakness, left hemiparesis and hemihypestesia, NIHSS 10. Head CT was normal, CT angiography showed occlusion of right MCA -M2 segment.

Results

Systemic thrombolysis with alteplase was started after consultation with gynecologist 75 min from symptom onset (door-needle time 30 min). Mechanical embolectomy was indicated based on persisting M2 occlusion on diagnostic subtraction angiography. Complete recanalisation (TICI 3, stent retriever, 1 passage, door-groin time 55 min) was reached 120 min from symptom onset. Follow up CT scans found no pathology, neuro exam was normal, NIHSS 0. Groin hematoma appeared upon verticalization 16 hours after thrombectomy, with no signs of pseudoaneurysm on ultrasound exam. Laboratory examinations were positive for hyperlipidaemia, negative for thrombophilia genetic mutations and vasculitis.

Conclusions

This is to our knowledge the first published case of combined thrombolysis - stent retriever thrombectomy in early puerperium. Carefull evaluation of bleeding risk and not only postpartum day count will decide on alteplase use in our future cases.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

IS NOCTURNAL BLOOD PRESSURE A RISK FACTOR FOR ISCHAEMIC STROKE IN YOUNG WOMEN? POPULATION BASED STUDY

MM Kubiak ¹, NG Lovett ¹, RM Wharton ¹, SM Lyons ¹, KK Lau ¹, M Wilson ¹, F Cuthbertson ¹, AJS Webb ¹, PM Rothwell on behalf of the Oxford Vascular Study ¹

Abstract

Background

The risk of ischaemic stroke in young women is relatively high compared with risk of acute coronary events. Nocturnal blood pressure (BP) is a particularly strong risk factor for stroke, but ambulatory BP-monitoring (ABPM) is not recommended as part of young stroke investigations. We studied nocturnal BP and diurnal pattern in patients with recent TIA or stroke in relation to age and sex.

Methods

Consecutive patients with TIA and non-disabling stroke (Oxford Vascular Study) had 24-hour ABPM at one-month follow-up. Diurnal SBP pattern was classified in relation to daytime mean SBP as nocturnal dipping (≥10% fall) or non-dipping (<10% fall).

Results

Of 1011 patients (mean/SD age = 68.6/12.8) with TIA or minor stroke who had ABPM, 462 were female (143 aged <65 years; 42 aged <50 years). Non-dipping increased with age in women, from 14.3% at <50 years to 63.0% at ≥75 years (p < 0.001). The odds of non-dipping in women versus men was 0.37 (0.13–1.07, p = 0.066; 14.3% vs 31%) at age <50 years. However, this low rate of non-dipping in younger women increased steeply in the peri-menopausal age range: 29.2% at 50–54 years; 35.1% at 55–64; 54.1% at 65–74.

Conclusions

Nocturnal non-dipping pattern of SBP is not associated with stroke in young women. In fact, non-dipping rates appear to be lower in women in the pre-menopausal age range than in men.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EFFECT OF SEX AND ATRIAL FIBRILLATION ON INITIAL STROKE SEVERITY RESULTS FROM THE AUSTRIAN STROKE REGISTRY

C Lang ¹, L Seyfang ², J Ferrari ¹, T Gattringer ³, K Willeit ⁴, M Brainin ⁵, W Lang ¹, M Knoflach ⁴

Abstract

Background

Patients with atrial fibrillation (AF) present with more severe ischemic strokes. This association is independent of age, but little is known about the effect of sex in this context.

Methods

Information of adults with ischemic stroke treated on Austrian stroke units between March 2003 and November 2015 was prospectively documented in the Austrian Stroke Unit Registry. AF (both intermittent or persistent) was either previously known or diagnosed during hospitalisation.

Results

Of the 76929 ischemic stroke patients with complete dataset 36302 (47.2%) were women. 21376 (27.7%) were diagnosed with AF. Median (IQR) NIHSS was 4 (1 – 8) in the whole population. In multivariate logistic regression analysis a significant interaction between sex and AF independent of age, previous disability, smoking status, dyslipidaemia, prior myocardial infarction and diabetes mellitus was observed (P < 0.001). In patients with AF median (IQR) NIHSS was 8 (3–16) in women and 5 (2 – 12) in men whereas in patients without AF median (IQR) NIHSS was 3 (1–7) in women and 3 (1 – 6) in men.

Conclusions

In our large cohort we confirm that patients with AF have more severe strokes. Interestingly women with AF presented with a significantly higher initial NIHSS compared to men with AF. No relevant sex differences in stroke severity were observed between men and women without AF.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

LONG-TERM OUTCOME AFTER ACUTE LACUNAR STROKE IN PATIENTS WITH CEREBRAL SMALL VESSEL DISEASE - THE GENDER EFFECT

A Pavlovic ¹, T Pekmezovic ², N Sternic ¹

Abstract

Background

Gender is a significant determinant of long-term functional outcome and survival after stroke. Acute lacunar stroke is more frequent in men than women, but long-term outcome in the light of gender differences has been rarely reported.

Methods

A cohort of small vessel disease (SVD) patients presenting with their first acute lacunar stroke has been evaluated 4 years after the qualifying event for the presence of depression and cognitive decline (CD). Gender differences were assessed.

Results

A total of 136 female and 158 male patients were analyzed. No difference was detected between the groups in regard to age (p = 0.709) or frequency of common vascular risk factors (RF) (p > 0.1 for all). At the baseline assessment, women had more severe strokes than men with mean modified Rankin scale (mRS) score of 2.6 (1.4 in men, p < 0.0001). All parameters of SVD on MRI scans were more severe in females, including measures of white matter lesions and total number of lacunar infarcts (LI) (p < 0.0001 for all). On follow up, CD was more frequently detected in women than men (78.7% vs 51.2%, p < 0.0001), which was not the case for depression (p = 0.654). Parameters independently associated with female gender in multivariate regression analysis were severity of MRI lesions (OR 1.38, 95%CI 1.17–1.62; p < 0.0001), CD (OR 1.85, 95%CI 1.06–3.24; p = 0.032), total number of LI (OR 0.74, 95%CI 0.59–0.92; p = 0.008) and mRS score (OR 8.35, 95%CI 5.04–13.84; p < 0.0001).

Conclusions

More severe brain lesions attributed to SVD in women than in men were associated with CD and were not explained by RF differences.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

SEX DIFFERENCES IN HEALTH-RELATED QUALITY OF LIFE (HRQOL) IN THE LONG-TERM AFTER STROKE: THE INTERNATIONAL STROKE OUTCOMES STUDY

H Phan ¹, L Blizzard ¹, A Thrift ², D Cadilhac ², J Sturm ³, V Konstantinos ⁴, C Anderson ⁵, V Feigin ⁶, Y Bejot ⁷, N Cabral ⁸, A Carolei ⁹, S Olindo ¹⁰, P Rothwell ¹¹, M Correia ¹², P Appelros ¹³, R Vibo ¹⁴, C Minelli ¹⁵, M Reeves ¹⁶, S Gall ¹; INSTRUCT study group¹

Abstract

Background

The reasons why women have poorer HRQoL post-stroke than men are uncertain. We examined this in a large, international collaborative study of stroke outcomes.

Methods

Individual participant data on strokes (ischemic and hemorrhagic) from 1993–2013 were obtained from high-quality incidence studies from Australasia, Europe, South America and the Caribbean. Data obtained included socio-demographics, stroke-related factors and pre-stroke health. HRQoL utility scores were calculated from the EQ5D, SF6D and AQoL at 1 year (3 studies) and 5 years (3 studies) post-stroke. Random-effects linear regression estimated pooled unadjusted and adjusted mean differences (MD) in HRQoL utility scores for women compared to men for confounding factors including age, pre-stroke dependency, stroke severity, comorbidities and post-stroke functional status.

Results

Women had lower pooled mean utility scores (unadjusted) than men (1 year: n = 1,219, MD −0.11 [95% CI −0.12; −0.03]; 5 years: n = 1,057: MD −0.07 [95% CI −0.12; −0.03]). These differences were attenuated after adjustment for confounding factors (1 year: MD −0.03 [95% CI −0.06; 0.00]; 5 years: MD −0.04 [95% CI −0.06; −0.01]. Results were similar when using EQ5D utility scores mapped from the modified Rankin Scale (1 year: 8 studies, n = 4,082, unadjusted MD −0.07 [95%CI −0.10; −0.04] and adjusted MD −0.04 [95%CI −0.05; −0.02]; 5 years: 5 studies, n = 2,335, unadjusted MD −0.08 [95%CI −0.11; −0.04] and adjusted MD −0.06 [95%CI −0.10; −0.02]).

Conclusions

Poorer HRQoL was consistently observed in women after stroke. It was mostly attributable to their advanced age and greater severity of stroke, although these did not fully account for the sex differences in HRQoL.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

SEX DIFFERENCES IN STROKE: EPIDEMIOLOGY, THROMBOLYSIS, OUTCOMES, DISABILITY AND SURVIVAL. EBRICTUS STUDY (2006-2015)

ML Queralt-tomas ¹, JL Clua-espuny ², MA Gonzalez-henares ¹, A Panisello-tafalla ¹, R Ripolles-vicente ², T Forcadell-arenas ¹, VF Gil-guillen ³, J Lucas-noll ¹

Abstract

Background

The aim of this study was to raise awareness of the greater burden of disability in women is predicted to be even higher in the future.

Methods

Multicentre study of consecutive adult patients with first-event stroke between 04/2006–06/2015 in primary care health area. Analyzed demographics, NIHSS, co-morbidities, prescription, thrombolysis, disability score, and survival for five years postroke.

Results

1678 cases were included [men 54.1%, p 0.004]. The women were older [76.09 ± 11.7, p < 0.001]. The incidence describes sex differences, but not in adjusted rate [W 11.7/10⁴(CI95% 10.3–13.2), M 11.5/10⁴/year(CI95% 9.8–13.1)]. Men had higher cardiovascular risk (p < 0.001) and highest overall mortality at 65–79 years [37.1/10⁴ CI95% 26.2–49.3]. 10.32% died first month and 44.9% at five years without differences in adjusted mortality rates. The adjusted YPLL <70 years was significantly higher in men [12.0(CI95% 10.7–13.3) vs 6.5(CI95% 5.6–7.4 6.5)]. Women had poorer prestroke Barthel score and worsened (75.8 vs. 83.1) at postroke.

8.6% were treated with thrombolysis without differences. The NIHSS score (p 0.036) was higher in women as well their survival [0.81 ± 0.06 vs 0.43 ± 0.02, p 0.012]. The mortality was increased in men IR = 3.2 [CI95% 1.2–8.0, p 0.01], associated to sex [OR 1.12 IC95 % 1.05–1.20] and secondary cardiovascular prevention one year [OR 0.13 IC95 % 0.06–0.28] poststroke.

Conclusions

The cardiovascular risk should account for much of the sex differences in fatality. The women had poorer functional outcomes but longer life expectancy if treated with thrombolysis. Clearly, more studies need to improve life expectancy for men and reduce the burden of disability for women.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

SEX DIFFERENCES IN ISCHEMIC STROKE SEVERITY (NIHSS): THE INTERNATIONAL STROKE OUTCOMES STUDY (INSTRUCT)

M Reeves ¹, S Gall ², H Kim Phan ², L Blizzard ², AG Thrift ³, D Cadilhac ³, J Sturm ⁴, C Anderson ⁵, V Konstantinos ⁶, V Feigin ⁷, Y Bejot ⁸, N Cabral ⁹, A Carolei ¹⁰, S Olindo ¹¹, P Rothwell ¹², M Correia ¹³, P Appelros ¹⁴, R Vibo ¹⁵, C Minelli ¹⁶

Abstract

Background: Women have worse outcomes following stroke than men which has been explained in part from confounding by age, pre-stroke function, comorbidities, and possibly stroke severity. We examined sex differences in initial National Institutes of Health Stroke Scale (NIHSS) score among patients with ischemic stroke identified in population-based cohort studies.

Methods: The International Stroke Outcomes Study (INSTRUCT) comprised individual-level data from 8 population-based stroke incidence studies conducted in Australasia, Europe and South America between 1996–2013. Data on demographics, pre-stroke function (dependency), comorbidities, ischemic stroke subtype (TOAST), and initial NIHSS score were harmonized between studies. Pooled unadjusted and adjusted relative risk (RR) estimates of severe stroke (NIHSS > 7, versus ≤7) for women compared to men were generated using random effects log-binomial regression models.

Results: A total of 4726 patients with first-ever ischemic stroke and NIHSS data recorded were included. The pooled crude RR for severe stroke in women compared to men was 1.28 (95% CI 1.17–1.39) (Figure). This sex difference was attenuated after adjustment for confounding factors but remained statistically significant (RR 1.13, 95% CI 1.04–1.23). Age, pre-stroke dependency, and subtype significantly confounded the association between sex and stroke severity.

Conclusions:

graphic file with name 10.1177_2396987316642909-fig81.jpg

In these population-based stroke incidence studies, women presented with more severe ischemic strokes than men. The greater severity in women was partly explained by greater age, poorer pre-stroke function and subtype.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

GENDER-RELATED DIFFERENCES IN POLISH ACUTE STROKE PATIENTS TREATED WITH INTRAVENOUS THROMBOLYSIS

W Fryze ¹, A Wiśniewska ¹, M Wiszniewska ², M Karliński ³, P Sobolewski ⁴, A Członkowska ⁵

Abstract

Background

Gender-dependent differences are observed in many epidemiological studies concerning stroke. It has been also suggested that women may benefit less from intravenous thrombolysis. We aimed to investigate gender differences Polish ischaemic stroke patients treated with intravenous alteplase.

Methods

This is a retrospective multicentre analysis of 1830 consecutive ischaemic stroke patients treated with alteplase from 2004 to 2012 in Poland, whose data were prospectively recorded in the Safe Implementation of Treatments in Stroke - International Stroke Thrombolysis Registry. Main outcome measures were functional independence (modified Rankin Scale score 0–2) at 3 months, symptomatic intracerebral haemorrhage by SITS definition within 36 hours after treatment and 3-month mortality.

Results

Studied population included 819 (44.8%) women. They were older than men (median age 74 vs 67; p < 0.01) and more often suffered from hypertension (78.3% vs 70.1%; p < 0.01). Women more often suffered from cardio-embolic strokes (34.7% vs 27.1%; p < 0.01) and had more severe baseline neurological deficit (median National Institutes of Health Stroke Scale score 13 vs 11; p < 0.01). We found that women less often achieved functional independence (46.5% vs 53.3%; p < 0.01) and had higher 3-month mortality (26.0% vs 19.7%; p < 0.01). However, there were no differences in occurrence of symptomatic intracerebral haemorrhage (2.0% vs 1.5%; p = 0.36).

Conclusions

Our data suggest that long-term outcome after ischaemic stroke treated with alteplase may be less favourable in Polish women than in Polish men. Therefore, closer evaluation of this problem is needed.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

AN UNUSUAL CAUSE OF EMBOLIC STROKE IN A 44 YEAR OLD MAN

D Addala ¹, V Nelatur ¹

Abstract

Background

A 44 year old male presented an hour after sudden word finding difficulty. CT head was normal and thrombolysis led to complete resolution of symptoms. He had a history of treated testicular cancer several years ago, but was in good health. He did not smoke but on probing, admitted to recent inhalational cocaine use.

Methods

MRI Brain revealed bilateral (mostly left hemispheric), areas of restricted diffusion (Figure 1). MRA of the extracranial arteries showed no abnormality, and cardiac monitoring showed no PAF.

graphic file with name 10.1177_2396987316642909-fig82.jpg

Results

Echocardiography revealed a mobile mass at the aortic root. A CT Aortogram to further characterize this showed a limited intimal tear within the ascending aorta (Figure 2). He denied chest pain at any point, and was discharged on dual antiplatelet therapy. A repeat CT Aortography at 3 months showed resolution of the tear, and he remained asymptomatic.

graphic file with name 10.1177_2396987316642909-fig83.jpg

Conclusions

Cocaine use is associated with strokes, as well as aortic dissection in the young but our patient had an unusual cause of stroke after cocaine, namely a self-limiting aortic tear, which likely led to embolization to the brain. This illustrates the importance of a thorough history and investigation in young stroke patients.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

SPINAL CORD INFARCTION MIMICKING ISCHEMIC STROKE: A CASE REPORT

AA Al Najjar-Carpentier ¹, S Smoui ², M malau ³, A GORDGI ², M LEVASSEUR ², B kourouma ²

Abstract

Background

Introduction Medullary infarction (MI) is a rare pathology often with a polymorphic presentation. We report a rare case of a clinical presentation mimicking stroke.

Methods

Observation A dyslipidaemic man, aged 54, while seated and resting presented suddenly with rather violent posterior neck pain that spread along the spine and associated with right ataxic hemiparesis with paraesthesia when bending his neck, followed by a vomiting episode without headache. The initial NIHSS score was 4. An initial thrombolysis alert was triggered. During the MRI, the patient presented two brief episodes of loss of consciousness, without post-critical confusion, associated with bradycardia at 40. The brain MRI was normal, as was the CT angiography of the supra-aortic trunks. A lumbar puncture was normal. Given the persisting neck pain, spinal MRI was performed revealing a hyper signal in the anterior portion of the spinal cord resulting in a cervical medullary infarction. The outcome was favourable with complete regression of the deficit.

Results

Discussion In our case, the unilateral deficit pointed to acute stroke, as MI most often results in para- or tetraplegia with metameric pain. The puzzling initial discomfort resulted in a diagnostic delay.

Conclusions

Acute MI is a rare pathology that can mimic stroke in exceptional cases. It should be suspected in acute stroke presenting with posterior neck pain even when the deficit is unilateral. An additional spinal cord MRI is urgently required.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CONVEXITY SUBARACHNOID HAEMORRHAGE DUE TO EXTRACRANIAL INTERNAL CAROTID ARTERY OCCLUSION

JN Alves ¹, M Rodrigues ¹, C Machado ¹, J Rocha ², J Pinho ¹, C Ferreira ¹

Abstract

Background

INTRODUCTION

Spontaneous convexity subarachnoid hemorrhages (cSAH) are usually related to amyloid angiopathy or with reversible cerebral vasoconstriction syndrome. Very few cases of cSAH associated with proximal large vessel stenosis/occlusion are reported in literature.

CASE-REPORT

A 69 year-old hypertensive and dyslipidemic man presented with frequent falls, with no preferential side, over the previous seven days. There were no complaints of headaches, focal neurological symptoms, loss of conscience or trauma, namely head trauma. Neurological examination revealed an isolated left central facial palsy. CT scan showed a recent right capsulo-lenticular infarction and the presence of subarachnoid hemorrhage in the right fronto-parietal convexity. MR-Angiography revealed an right internal carotid artery atheromatous occlusion with leptomenigeal anastomosis emerging from the external carotid artery. There was also an asymptomatic left internal carotid artery high-grade stenosis and intracranial stenosis (right V4 and basilar artery). The patient was discharged under dual antiplatelet and high-intensity statin therapy.

CONCLUSION

Internal carotid artery occlusion is a rare cause of spontaneous cSAH. In this case, we propose that cSAH was the result of the rupture of fragile leptomeningeal collaterals.

Methods:

Results:

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ISCHEMIC STROKE IN A YOUNG CANNABINOID USER: THE VASOCONSTRICTION MECHANISM

J Araújo ¹, H Vilaça ², AF Santos ¹, F Sousa ¹, AS Costa ¹, J Pinho ¹, J Rocha ³, C Ferreira ¹

Background

Introduction: Recent studies suggest a relationship between cannabinoid consumption and ischemic stroke in young patients. Cerebral vasoconstriction has been proposed as a potential mechanism and cannabis use is a trigger factor for reversible cerebral vasoconstriction syndrome (RCVS).

Clinical case: A 26-year-old man with a history of hashish use (4–5 cigarettes per month) and sporadic excessive alcohol intake. Two weeks before admission, he had a thunderclap headache episode. Two days before admission, four hours after smoking hashish, he referred a sudden-onset impaired visual perception. Neurological examination revealed a left homonymous hemianopia. MRI revealed recent ischemic lesion in right ACP territory and in ipsilateral ACP/ACM watershed area, and MR-angiography showed diffuse irregularities of the anterior and posterior circulation; CSF and a complete laboratory study were normal; urine screened positive for cannabis. Prednisone and nimodipine were started and left hemianopia resolved gradually. 48 hours later, he presented right homonymous hemianopsia, complex visual function impairment and pure alexia. MRI revealed new left temporo-parieto-occipital ischemic lesions and diffuse worsening of arterial irregularities. Cyclophosphamide was started for vasculitis suspicion. The patient recovered gradually, and he was discharged at home with oral steroids and was recommended stop smoking. Follow-up MR-angiography revealed marked improvement of arterial irregularities.

Conclusion: This case exemplifies RCVS as a mechanism of ischemic stroke in cannabis users. At an early stage the differential diagnosis is difficult, particularly with isolated CNS vasculitis. Follow-up imaging to evaluate the reversibility of vascular abnormalities is essential.

Methods:

Results:

Conclusions:

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

INFECTIVE ENDOCARDITIS AND STROKE: OVERVIEW AND A CASE REPORT

C Brunner ¹, R Wunn ², F Gruber ¹, M Sesum ³, G Ransmayr ¹, M Vosko ¹

Abstract

Background

In patients with infective endocarditis (IE) neurologic complications are the most frequent extracardiac symptoms and occur in about 25–70%. Mortality is higher in those patients with neurologic events than those without. Clinical manifestations of neurologic disease include ischemic or hemorrhagic stroke, infected intracranial aneurysm, meningitis and brain abscess. 48%-80% of cerebral embolization are clinically silent.

The risk of developing neurologic events depends on characteristics of the vegetation and duration of antibiotic treatment. Larger, left-sided vegetations on mitral valve are more likely to embolize. Anticoagulation at time of acute brain embolization is a risk factor for hemorrhagic complications.

Methods

We present a literature overview of common clinical manifestation and management of neurologic complications in IE as well as a case report of a 61 year old woman with a prosthetic aortic valve infection and hemorrhagic stroke.

Results

The patient was admitted due to fever, tachycardia and fatigue. She was sufficiently anticoagulated with warfarin. Echocardiography revealed vegetations of 12 mm of size located on the prosthetic aortic valve. Few days after admission the patient developed Broca aphasia and right sided hemiplegia. MRI showed haemorrhagic transformation of an ischemic lesion in the territory of MCA left. Anticoagulation was reduced to prophylactic dose for 2 weeks. Cardiac surgery was contra-indicated. The anticoagulation with LMWH dosed at the low therapeutic level monitored by Factor X-activity continued until the resorption of intracerebral bleeding.

Conclusions

Neurologic complications of IE has significant impacts for clinical decision making.

Management of neurologic complications is challenging and interdisciplinary approach is needed for patient tailored therapy.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

IODINE CONTRAST CT ANGIOGRAM PRECIPITATING ANEURYSM THROMBOSIS AND RUPTURE?

L calviere ¹, N Raposo ¹, AC Januel ², D brauge ³, A viguier ¹, F bonneville ², JF albucher ¹, T Geeraerts ³, C cognard ², JM olivot ¹

Abstract

Background

A 44–year-old patient underwent a head non-contrast CT and CT angiogram to explore vertigo. These examinations incidentally revealed a non-thrombosed 20 mm fusiform aneurysm of the left P4 segment of posterior cerebral artery (PCA) (Fig A).Next day the patient experienced an unusual worsening headache. He was admitted in our stroke unit 72 hours later.

Methods

The clinical neurological exam was normal. Non-contrast CT showed a spontaneous hyperdensity of the aneurysm, suggesting of acute thrombosis (Fig B). MRI with MRA confirmed the ongoing thrombosis of the aneurysm. MRI (FLAIR and T2*) and CSF analysis (including chromoprotein assay) revealed no subarachnoid bleeding.

Results:

graphic file with name 10.1177_2396987316642909-fig84.jpg

Few hours before the scheduled therapeutic occlusion of the left PCA, the patient experienced an excruciating thunderclap headache, and became rapidly comatose. The CT revealed a Fisher 4 subarachnoid hemorrhage associated with an intraparenchymal temporo-occipital hematoma and an acute hydrocephalus complicating the rupture of the aneurysm (Fig C). Despite the emergent management of this massive hemorrhage (PCA clipping, ventricular derivation and decompressive craniectomy) the patient died one month later.

Conclusions

This case illustrates the imminent risk of rupture and emphasizes the need for the emergent exclusion of these thrombosing aneurysms even in the absence of bleeding. We speculate that the acute thrombosis and the secondary rupture could have been potentially precipitated by iodine contrast injection.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

SUSAC'S SYNDROME: ATYPICAL FIRST NEUROLOGIC PRESENTATION WITH ACUTE CONFUSION AND GAIT DISTURBANCE

Z Čarnická ¹, Z Goldenberg ¹, J Thurzová ¹, V Vestenická ¹, P Bluska ², P Šiarnik ¹

Abstract

Background

Susac’s syndrome is a rare microangiopathy, which consists of the clinical triad of hearing loss, partial vision loss and encephalopathy. Magnetic resonance imaging (MRI) findings show characteristic corpus callosum involvement. Fluorescein angiography shows branch retinal artery occlusions (BRAO). The pathogenesis of this syndrome is still poorly understood. It is difficult to evaluate the results of treatment, but some patients seem to respond to treatment with intravenous methylprednisolone, cyclophosphamide or immunoglobulin.

Methods

Presentation of patient´s clinical course, investigations and treatment.

Results

Authors report 36-years old patient with acute onset of confusion, cognitive deficit, severe ataxia and gait disturbance. MRI demonstrated acute multiple infarctions in the corpus callosum, cerebrospinal fluid showed elevated protein levels and mild pleocytosis and fluorescein angiography showed multiple bilateral BRAOs. Patient received corticosteroids with positive, however transient effect on the clinical status. Treatment with intravenous immunoglobulins lead to a more sustained improvement.

Conclusions

Otherwise unexplained acute onset of confusion, without vision or hearing losses in young patients, with characteristic MRI and CSF changes, should lead to a workup towards establishment of diagnosis of Susac’s syndrome.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

SIMULTAGNOSIA AFTER PULMONARY TUMOR RESECTION DUE EMBOLIC SOURCE: A CASE PRESENTATION AND EVOLUTION

J Celis ¹, S Urrego ¹, D Diaz ², P Bedoya ², J Ortega ³, H Ortega ³, A Londoño ³, R Zapata ⁴, S Velez ⁵, A Porras ⁵, J Uribe ⁵

Abstract

Background

Agnosia is the inability in processing sensory input, different types, most due lesions in occipitotemporal border. Simultagnosia inability to process different images presented simultaneously, patient can not recognize figures superimpossed; this presents as part of the Ballint Sindrome or brain injury.

Methods

Case: 36 YOF progressive dyspnea, weightloss, hemoptysis; work up disclosed pulmonary right lesion. Was undergoing surgery for resection. At ICU awakened blind and drowsy, responded to call, touch, pain, mild right paresis, no visual respond, pupils reactive, fundoscopy normal, gaze to right. CT showed hypodense lesions in frontal bilaterally, right parietal and occipital mainly right side cortices. Improved her visual deficit from totally blind to see some light, identifies and count fingers, with Poppelreuter test identified only fork, Navon´s figures idenfied small letter forming big, hemineglect at Clock Manos, figures copy and Rey figure showed absence in details. Boston test 15 errors. 1.5 months later no hemineglect in Clock, better figures copy, no change in Navon; Poppelreuter identified fork, knife, scissors. MRI showed lesions bioccipital, bigger right; small right basal, bifrontal and right parietal cortical. Final pulmonary diagnosis was pulmonary blastoma.

Results

Agnosia means lack of knwoledge despite having sensory basic pathway, no connection with memory systems occipital are the most frequent. Simultagnosia due brain injury as here with many embolic ischemic lesions with improvement in visual deficit was the main manifestation despite multiple injuries in different territories. Brain plasticity accounts for the recovery.

Conclusions

Evaluating patients with cortical lesions, specially occipital-temporal neuropsychological assessment crucial for better evaluation, diagnosis and rehab.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

LEFT MIDDLE CEREBRAL ARTERY INFARCTION DUE TO RECURRENCE OF COMMON CAROTID ARTERY DISSECTION WHICH HAD PREVIOUSLY RESOLVED

Y Collins-Sawaragi ¹, K King ¹, G Gunathilagan ¹

Abstract

Background

A 61 year old lady presented with her second episode of left middle cerebral infarction due to a recurrence of the left common carotid artery dissection which had previously recanalised with enoxaparin and warfarin treatment. Her past medical history is significant for paroxysmal atrial fibrillation on warfarin treatment, hypertension and familial hypercholesterolaemia.

Methods

The first left MCA infarction confirmed by CT and MRI caused dysphasia and right sided limb weakness. CT and MRI angiogram confirmed left ICA occlusion 2.6 cm above the aortic arch secondary to a dissection. Her symptoms completely resolved apart from occasional right leg weakness when tired and post-stroke fatigue.

Follow up CT and USS 3 months later showed successful recanalisation of the left ICA with enoxaparin and warfarin. Detection of a right ICA stenosis was treated successfully with carotid endarterectomy 1 year after her stroke.

Results

Unfortunately the patient represented 23 months after her first stroke with right sided limb weakness, headache, left eye visual disturbance and subsequently developed mixed dysphasia. CT and MRI confirmed another left MCA infarction. MRI suggested signal void in the left ICA cavernous sinus and CTA later confirmed a complete occlusion of the left common, internal and external carotid arteries 12.8 mm from the origin secondary to a dissection. Latest USS shows recanalisation of these arteries.

Conclusions

Recurrent carotid artery dissection is a rare occurrence with only a few cases described in the literature. Dissection of the same vessel after complete recanalisation of the artery is even rarer.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE IMPORTANCE OF RECOGNISING "RED FLAGS" IN THROMBOLYSIS TREATMENT OF ACUTE ISCHAEMIC STROKE

S Coote ¹, T Frost ¹, G Yip ¹, H Dewey ¹

Abstract

Background

Decisions about thrombolytic therapy are time critical, so there is a risk that warnings or ‘red flags’ to treatment may be overlooked or discounted in the haste to save the brain. Post-treatment ‘red flag’ symptoms may be readily ascribed to stroke without consideration of alternative diagnoses.

Methods

This case report will describe a patient with a missed spontaneous cervical spine epidural haematoma (SSEH) and the consequent neurological deterioration following thrombolysis.

Results

Mrs X, a 70 year old woman with a history of neck pain, presented with sudden onset right arm and leg hemiplegia with facial sparing, dysarthria and worsening neck pain. Multimodal CT imaging was reported as normal and the patient was thrombolysed with a diagnosis of a lacunar stroke. She deteriorated over the next 12 hours with persisting neck pain, left sided weakness, urinary retention, hypotension and quadraparesis. MRI showed a C2-C7 epidural haematoma. Retrospective review of the initial CT showed a subtle cervical hyperdensity consistent with SSEH. New symptoms following thrombolysis were considered in isolation; the possibility of spinal cord compression was not considered until quadraparesis developed.

Conclusions

Sudden severe hemiplegia with facial sparing is an uncommon presentation of acute spinal cord pathology. ‘Red flags’ at presentation (e.g. neck pain, normal imaging) did not prompt re-evaluation of the stroke diagnosis. Subsequent ‘red flags’ in the patient’s condition following thrombolysis were not appreciated as severe or linked. Pre-thrombolysis assessment must always include consideration of ‘red flags’ for stroke mimics. New symptoms following thrombolysis should prompt diagnostic review.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

A CASE OF POSTERIOR REVERSIBLE ENCEPHALOPATHY SYNDROME (PRES) TREATED WITH PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY

F Corea ¹, A Maselli ², F Falcinelli ³, S Micheli ⁴, L Lentischio ⁵, R Zava ⁵, S Stefanucci ⁴, M Zampolini ⁴

Abstract

Background

A 64-year-old man was admitted to our hospital for sudden loss of consciousness and seizures. After therapy convulsions disappeared and his consciousness recovered to alert within 2 hours after onset, this was followed by a delirium state. Neurological examination showed no other abnormal findings.

Methods

Elevated blood pressure was documented up to 250–300 of SBP. In brain magnetic resonance imaging (MRI), fluid-attenuated inversion recovery, showed high signal intensities in white matter in the brainstem, bilateral occipital and parietal lobes. Renal angiography showed isolated stenosis in the left renal artery. These findings seemed incompatible with other conditions (e.g. dissection, vasculitis).

Results

Our diagnosis was posterior reversible encephalopathy syndrome (PRES) induced by hypertension due to renal artery stenosis. Renal artery stenosis was treated with plain balloon angioplasty. After angioplasty with stenting, hypertension and high signal intensity at brain MRI were clearly improved.

Conclusions

We would like to emphasize that renal artery angioplasty should be considered as an option for patients with PRES and malignant hypertension.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE ROLE OF IMPLANTABLE LOOP RECORDERS IN PRESUMED CRYPTOGENIC STROKE IN THE VERY YOUNG: A CASE REPORT

W Davison ¹, S Das ², R Chowdhury ²

Abstract

Background

A 25 year old male was admitted with sudden onset right sided weakness and dysphasia. CT head on admission showed no evidence of haemorrhage and the presentation was within four and a half hours so thrombolysis was administered. Post thrombolysis MRI brain confirmed an acute infarct in the left middle cerebral artery territory and standard secondary prevention was commenced.

The patient had a history of childhood acute lymphoblastic leukaemia treated with cranial radiotherapy. Studies have shown increased rates of ischaemic stroke in adults who have received cranial radiotherapy. There is also a link with haemorrhagic stroke, with MRI scans post radiotherapy demonstrating micro-haemorrhages within the radiation field.

Methods:

Results

Micro-haemorrhages were present on the neuroimaging of our patient. However, extensive testing for a cause of the stroke was inconclusive. Further imaging excluded carotid stenosis. 24 hour ECG and seven day ECG showed sinus rhythm. Echocardiogram was normal. Blood tests for diabetes, hypercholesterolaemia, vasculitis, thrombophilia, hyperhomocysteinaemia and HIV were all negative.

Conclusions

It was concluded that this was a case of idiopathic stroke with previous cranial radiotherapy as a contributory factor. However, because larger arterial occlusion is often due to thromboembolism further investigation for a paroxysmal arrhythmia was deemed necessary. The CRYSTAL AF and EMBRACE studies both demonstrated an increased diagnostic yield with prolonged ECG monitoring using implantable devices. A loop recorder was implanted in this patient and after nine months of monitoring this revealed paroxysmal atrial fibrillation. He has since been commenced on anticoagulation and remains well.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

BRAIN ABSCESS OF REMOTE PARENCHYMAL HEMORRHAGE FOLLOWING INTRAVENOUS THROMBOLYSIS IN ACUTE ISCHEMIC STROKE

M Dias ¹, C Casimiro ², P Canhão ³

Abstract

Background

Brain abscess after non-traumatic intracerebral hemorrhage is rare. We present a case of infection of remote parenchymal hemorrhage (PHr) after treatment with intravenous recombinant tissue-type plasminogen activator (IV-tPA) for ischemic stroke.

Methods

Clinical case description

Results

A 62-year-old immunocompetent man was admitted with right middle cerebral artery territory ischemic stroke (NIHSS 16). IV-tPA treatment was started 135 minutes after symptom onset and was suspended 45 minutes later due to lingual angioedema controled with clemastin and metilprednisolone. Brain CT at 24 hours showed acute lenticulo-capsulo-caudate ischemic infarct and a PHr on the cortico-subcortical right paracentral lobe region (non-symptomatic). On the following ten days neurological condition improved (NIHSS 4). Stroke etiology was right internal carotid artery stenosis (80–90%).

On the twelfth day after stroke, the patient developed fever, headache and neurological deterioration (NIHSS 15). Brain CT showed increased perihematomal edema. Physical examination and workup to investigate the source of fever were negative (including blood cultures and transesophageal echocardiography). Empirical antibiotherapy with Ceftriaxone 1 g once daily was started. Due to worsening of consciousness state, brain MRI was repeated and suggested brain abscess on the PHr location. Stereotactic biopsy and hematoma drainage were performed, leading to isolation of Klebsiella pneumoniae. Ceftriaxone 2 g 12 h/12 h was started and maintained for 6 weeks with significant clinical improvement (NIHSS 3).

Conclusions

We have not found other reported cases of brain abscess complicating parenchymal hemorrages after IV-tPA. This patient had no predisposing factors for infection besides transitory corticotherapy. Delayed neurological worsening and fever should raise suspicion of this potential fatal condition.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ACUTE INTERNAL CAROTID ARTERY DISSECTION AND STROKE IN FIBROMUSCULAR DYSPLASIA

C Eaves ¹

Abstract

Background

Introduction

Fibromuscular dysplasia is a rare, non-atherosclerotic vascular disease. It can occur in any artery but most commonly in the carotid and renal arteries.

This is a case report of a stroke secondary to a thrombotic shower from a left internal carotid artery dissection. Appearances on carotid angiogram were highly suggestive of fibromuscular dysplasia.

Methods

Case presentation:

A 42-year-old female with a history of migraine and hypertension presented with a one-week history of right arm numbness and headache. She developed an expressive dysphasia and right-sided weakness. Initial CT head was unremarkable but carotid dopplers and CT angiogram revealed occlusion of the left internal carotid artery with a possible trickle of flow. Carotid angiogram confirmed a left internal carotid artery dissection and a short segment of corrugated vessel in the right internal carotid artery with a typical ‘string of beads’ appearance, suggestive of fibromuscular dysplasia. There was no evidence of the disease in the renal arteries on CT angiogram.

A heparin infusion was initially started but this was changed to high dose aspirin when Vascular Surgeons recommended a conservative approach.

Results

During her admission, the right-sided weakness worsened and a repeat CT head showed several foci of ischaemia in the left frontal lobe suggestive of a thrombotic shower.

Conclusions

This case highlights fibromuscular dysplasia as a rare cause of stroke in young adults. There should be a multi-disciplinary approach to the management of the condition between both Stroke physicians and Vascular Surgeons.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PONTINE STROKE AND AIRWAY COMPROMISE IN A CASE OF TETRALOGY OF FALLOT

C Eaves ¹

Abstract

Background

This is a case of acute pontine stroke, complicated by airway compromise in a patient with corrected Tetralogy of Fallot. Respiratory impairment is an important potential complication of stroke, particularly pertinent to brainstem events.

Tetralogy of Fallot is a rare, congenital heart disease. Even after surgical repair, patients remain at increased risk of cardiac arrhythmias; yet little is known to what extent this translates into an increased risk of stroke.

Methods

A 51-year-old female with a history of corrected Tetralogy of Fallot, atrial flutter and a permanent pacemaker presented with collapse, left-sided weakness, dysarthria and dysphagia. CT head revealed an acute infarct in the right side of the pons. There was no vascular abnormality on CT angiogram and ECHO showed corrected Tetralogy of Fallot, normal left ventricular function and severe pulmonary regurgitation. During the admission she had a cardiac arrest, likely secondary to respiratory compromise but recovered quickly after one cycle of cardiopulmonary resuscitation.

Results

The patient was on warfarin prior to admission but was non-compliant, creating a therapeutic dilemma given the lack of evidence for novel oral anticoagulants (NOACs) in congenital heart disease.

Conclusions

This case highlights the risk of stroke in Tetralogy of Fallot and the propensity of brainstem lesions to cause respiratory compromise. It also draws attention to the paucity of evidence that surrounds the use of NOACs in congenital heart disease.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

BILATERAL SUDDEN DEAFNESS: A RARE PRESENTATION OF VERTEBROBASILAR ISCHEMIA

S Figueiredo ¹, P Barros ², S Ferreira ³, S Castro ⁴, D Seixas ⁴, M Veloso ²

Abstract

Background

The internal ear is particularly vulnerable in vertebrobasilar ischemia, due to the absence of collateral circulation. However, deafness is a rare presentation of a vascular event in the posterior circulation.

Methods

52 year old man with past smoking habits and diabetes. Admitted at our hospital with STEMI and submitted to PCI. An hour after, sudden bilateral deafness and diplopia were noticed. Neurological examination revealed severe bilateral hearing loss, dysarthria, complex ophtalmoparesis and left homonymous hemianopsia (NIHSS 4). Cerebral CT showed no acute lesions; Angio-CT of the supra-aortic vessels demonstrated suboclusive stenosis of the middle portion of the basilar artery. Thrombolytic was contra-indicated (elevated APTT). It was decided not to proceed to thrombectomy due to low NIHSS. The patient started non-fractioned heparin with complete resolution of neurological deficits in 24 h. Angio-MRI at 48 h showed areas of recent ischemia in the territory of both PICAS. He repeated the Angio-CT where recanalization of the basilar artery was evident, with persistent focal stenosis proximally to the emergence of both AICAS. Audiometry detected mild sensorineural hearing defect. Patient was discharged at 9 days under triple therapy.

Results:

Conclusions

The internal auditory artery contributes with the main blood supply to the vestibulocochlear nerve. It usually emerges from the AICA, though it can originate from the PICA or the basilar artery. In this case we assume that an embolic thrombus in the basilar artery with extension to the AICAS ostium, leading to internal ear hypoperfusion, was the most probable cause for the hearing loss.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CONVEXAL SUBARACHNOID HEMORRHAGE AND STENO-OCCLUSIVE CAROTID ARTERY DISEASE

T Gattringer ¹, C Enzinger ¹, S Fandler ¹, M Beitzke ¹, K Niederkorn ¹, F Fazekas ¹

Abstract

Background

Convexal subarachnoid hemorrhage (cSAH) is an increasingly recognized type of non-traumatic, non-aneurysmal subarachnoid bleeding, which in the elderly has been associated predominantly with cerebral amyloid angiopathy (CAA). However, cSAH may also occur in the setting of steno-occlusive carotid artery disease for different reasons including misdiagnosis.

Methods

We here report three different clinical cases with cSAH in association with carotid artery disease.

Results

Case #1: cSAH in the context of disseminated cortical superficial hemosiderosis (possibly due to CAA) imitating transient ischemic attacks (TIAs) in a male patient, 80 years. This patient underwent carotid thromboendarterectomy (TEA) because of repeated TIAs, which were related to a moderate ipsilateral extracranial carotid artery stenosis. After TEA recurrent transient focal neurological deficits persisted and a cSAH could be identified as the most likely cause.

Case #2: A 60 year old male patient developed ipsilateral cSAH in parallel with a cerebral hyperperfusion syndrome five days after TEA for a symptomatic high-grade extracranial internal carotid artery stenosis.

Case #3: 70 year-old male patient with recurrent unilateral leg weakness and contralateral cSAH distant to a severe distal intracranial carotid artery stenosis. This setting suggests ruptured dilated collateral vessels following severe hypoperfusion as a putative mechanism.

Conclusions

Steno-occlusive atherosclerotic disease of the internal carotid artery may be mistaken as the cause of transient focal neurologic deficits due to cSAH and appears also to be a thus far underrecognized cause of cSAH. This etiologic diversity of cSAH needs close clinical attention because of largely differing consequences for patient management.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

DELAYED CAPSULAR WARNING SYNDROME AFTER A RECURRENT CAPSULAR TIA

M Gonzalez Delgado ¹, R García ², PS Lozano ³, E Santamarta ⁴, S Calleja ³

Abstract

Background

Capsular warning syndrome (CWS) has been described as a distinct form of TIAs which leads to early capsular infarction in a high proportion of cases. The time frame is usually quite brief (<72 hours). Several hypotheses about the etiology of CWS have been described.

Methods

A 57 year-old male presented a right arm paresis lasting for 5 minutes. Five minutes later, he suffered from a right arm paresthesia lasting for 30–40 minutes. Cranial MRI did not revealed ischemic lesions. The patient was discharged home with acetyl salicylic acid and atorvastatin. Three months later the patient presented a fluctuating right faciobrachial hypoesthesia, with a posterior worsening (leg hypoesthesia and right hemiparesis). Cranial MRI at this time showed a left capsulothalamic stroke.

Results

We would like to emphasize two aspects in our patient. On the one hand, the first episode did not accomplish the classical definition of CWS, as there were only two neurological transient episodes, which could be considered as capsular TIAs. On the other hand, a classical CWS that resulted in a left capsulothalamic stroke was seen three months later. This chronological evolution may points toward an unstable hemodynamic process with an underlying high degree atherosclerotic disease in small intracranial vessels, such as may occur in large artery disease, such as carotid artery high degree stenosis.

Conclusions

CWS is a broader syndrome than initially described. This case may support the pathophysiological mechanism of unstable hemodynamic process with an underlying high degree atherosclerosis of intracranial small vessel disease.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CAROTID WEB- AN USUAL CAUSE OF STROKE

D Hayden ¹, E Kavanagh ², S Murphy ³

Abstract

Background

A case of a carotid web at the origin of the internal carotid artery is reported.

Methods

An 85 year old, right handed male was pre-alered to the stroke team with sudden onset right hemiparesis. He had a history of prior smoking, hypertension, dyslipidaemia and prostate adenocarciinoma. On arrival his NIHSS was 6.

Results

CT head demonstrated established lacunar infarcts bilaterally. Intravenous tPA was given, with a door-to-needle time of 21 minutes. CT angiography was performed and a shelf-like projection arising from the posterior wall of the proximal left internal carotid artery was noted. This finding was confirmed on MR angiography. MRI head demonstrated the presence of acute infarcts in the left parietal lobe in the distribution of the left MCA.

A carotid web is a thin intra-luminal filling defect along the posterior wall of the carotid bulb. In a recent series, 7 cases of carotid web were identified prospectively, of which 5 had recurrent stroke. In a retrospective series from the same authors, carotid webs were identified in 7/576 ischaemic stroke patients. Two of these 7 patients had acute stroke in the vascular territory of the carotid web

Conclusions

Carotid web is an uncommon but potentially under-diagnosed cause of ischaemic stroke. Carotid webs may contribute to recurrent stroke risk, however the optimal management strategy is unknown.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ISOLATED MIDDLE CEREBRAL ARTERY DISSECTION PRESENTED WITH CRESCENDO TRANSIENT ISCHEMIC ATTACK

M ismail ¹, R Van Dijk ², A Abdul'Hamid ¹

Abstract

Background

Only limited numbers of cases of isolated middle cerebral artery dissection has been reported as a cause of acute cerebrovascular accident.

To our knowledge, no case of crescendo transient ischemic attack caused by middle cerebral artery dissection has been reported

Methods

We describe a case of patient presented with recurrent TIAs affecting the left middle cerebral artery region that occurred over four days in a middle age man with no history of head injury or other possible risk factors apart from tobacco and alcohol misuse.

CT Angiography with a contrast suggested eccentric narrowing of left M1 (1). He underwent Magnetic resonance examination on 3 Tesla with T1 FLAIR pre and post gadolinium for vessel wall and Swan, which revealed multiple acute/subacute tiny multiple embolic infarcts in the left side (2). A thin slice T1 FLAIR pre and post gadolinium demonstrates eccentric enhancing lesions in the posterior-superior wall of the left distal M1, confirmed on thin slice sagittal T2 (3).this Combined with CTA finding was most consistent with left M1 dissection likely caused embolic infarcts in the left MCA territory.other cerebral vessels was normal.

Patient started on dual antiplatelet therapy and had no further TIAs until he left the hospital after 5 days with no neurological deficit.

Results:

graphic file with name 10.1177_2396987316642909-fig85.jpg

graphic file with name 10.1177_2396987316642909-fig86.jpg

graphic file with name 10.1177_2396987316642909-fig87.jpg

Conclusions

Although spontaneous isolated middle cerebral artery dissection is rare cause of acute stroke, we advise that the possibility of MCA dissection should be considered in relatively young patients with suspicious imaging

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PRIMARY VASCULITIS OF CENTRAL NERVOUS SYSTEM WITH MULTIPLE GRANULOMATOUS LESIONS: DIVERSE NEUROLOGIC SYMPTOMS AND DIFFICULTIES IN DIFFERENTIAL DIAGNOSIS

M Jakusova ¹, Z Goldenberg ¹, J Thurzova ¹, V Belan ²

Abstract

Background

Primary cerebral vasculitis is an uncommon condition with difficult differential diagnosis. The autoimmune inflammation usually involves small and medium vessels and is restricted only to central nervous system. The condition has a diverse presentation including space-occupying lesions, encephalopathy, visual disturbances and seizures. Various imaging methods have been used in the differential diagnostics including angiography, cerebral single-photon emission computed tomography (SPECT) as well as laboratory examination of cerebrospinal fluid (CSF) and antibody screening. Despite the wide range of diagnostic methods brain biopsy is often needed to confirm the diagnosis.

Methods

Authors present a case report of 28 year old male with acute onset of visual pseudohalucinations and paresthesias and work-up that lead to confirmation of the diagnosis.

Results

Magnetic resonance imaging (MRI) demonstrated multiple contrast enhancing lesions with perifocal oedema. In differential diagnosis we considered infectious etiology, atypical form of multiple sclerosis (MS), initially even multifocal high-grade tumor. Diagnosis of cerebral vasculitis was confirmed on brain biopsy after all previous non-invasive investigations provided negative results. The patient received corticosteroid treatment with regression of lesions on MRI, and positive effect on clinical symptoms.

Conclusions

Primary vasculitis of central nervous system should be considered in cases of brain lesions with atypical clinical presentation, absence of systemic symptoms and contradictory findings of imaging studies.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

DIAGNOSIS AND SURGICAL TREATMENT OF THE CAROTID BODY PARAGANGLIOMAS: A REPORT OF FIVE CASES

DC Jianu ¹, SN Jianu ², F Dan ¹, L Petrica ³, O Cretu ⁴

Abstract

Background

Carotid body paragangliomas (CBPG) represent a rare form of neoplasm arising from neural crest paraganglia cells, with slow growth, giving rise in time to external compression, and/or involvement of the carotid arteries, and neighboring craniofacial nerves.

Objectives To find specific clinical signs, and to compare the different imaging techniques, in order to elaborate a strategy for the management of CBPG.

Methods

We retrospectively analyzed demographics data, clinical characteristics, imaging features, Shamblin classification, surgical treatment modalities, and neurological complications of five patients with histopathological confirmed CBPG. Their evaluation included extracranial color Doppler ultrasonography (ECDUS), with a 7.5–10 MHz linear array transducer, combining B mode and Color Doppler/pulsed-wave Doppler ultrasound, magnetic resonance imaging-MRI (1.5T), magnetic resonance angiography (MR-A), and digital subtraction angiography (DSA).

Results

All CBPG were clinically represented by a painless unilateral neck mass. There was no evidence of functional tumor. One patient had two localizations, the second was a glomus tumor of the left prelacrimal sac, and another one had a family history for CBPG. All 5 neck tumors were diagnosed during ECDUS corroborated with MRI and MR-A; DSA was used only in 2 patients. As per Shamblin classification all CBPG were type II. No preoperative embolization was performed in any case before complete subadventitial excision of the tumor. Postoperatively, 3 of them presented transient cranial nerve deficits. No stroke occurred.

Conclusions

Early diagnosis of CBPG was possible in our pts using ECDUS, MRI, and MR-A. Early surgery minimized the risk of complications associated with large CBPG.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

REPEATED SUBARACHNOID HEMORRHAGE DUE TO RELAPSED ACUTE PROMYELOCYTIC LEUKEMIA

SD Kang ¹

Abstract

Background

Most causes of subarachnoid hemorrhage (SAH) are trauma or vascular abnormality. However, there are possibilities of other diseases causing spontaneous SAH.

Methods

Forty-one year old male patient came to emergency department due to bursting headache. He had a history of acute promyelocytic leukemia which was confirmed complete remission about one month after chemotherapy and he has received the maintenance chemotherapy for 15 months after remission. The admission brain CT showed cortical SAH, and CT angiogram and digital subtraction angiogram were non-specific. After conservative treatment, he was discharged. However, he came to emergency department again due to bursting headache 4 months later.

Results

Brain CT showed the same cortical SAH as the brain CT 4 month ago. Brain MRI revealed cortical enhancement which was strongly suggested leptomeningeal seeding. The author suspected the cause of repeated SAH as the relapsed acute promyelocytic leukemia. Cerebrospinal fluid study showed cytospin blastic cell. Relapsed acute promyelocytic leukemia was confirmed at the bone marrow biopsy by hemato-oncologist.

Conclusions

Repeated SAH without vascular abnormality is very rare. However, clinicians should keep in mind that leptomeningeal metastasis due to leukemia can be one of the causes of repeated SAH.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CEREBRAL AMYLOID ANGIOPATHY-RELATED INFLAMMATION; A CASE SERIES

S Kelly ¹, E O'Brien ¹, K Khadjooi ¹, H Markus ¹, N Hannon ¹, E Warburton ¹, P Martin ¹

Abstract

Background

Cerebral amyloid angiopathy (CAA) is a common cause of lobar haemorrhage and is associated with Alzheimer’s disease in elderly patients. Cerebral amyloid angiopathy-related inflammation (CAARI) is felt to be due to an autoimmune response to beta-amyloid in arterial vessel walls and is thought to be very rare. We present 6 cases with features consistent with CAARI.

Methods

See case

Results

The patients were aged between 66 years and 85 years and 50% were female. None of them had a pre-existing history of dementia. Table 1 illustrates the presenting features.

CT brain imaging showed vasogenic oedema in the parieto-occipital region {5/6(83%)} with one patient displaying frontal low densities. MRI brain with gradient echo, performed in 5/6 of the patients, demonstrated white matter oedema and multiple microbleeds. The remaining patient had an acute lobar haemorrhage, typical of CAA three months later. Interval imaging had shown almost complete spontaneous resolution of the oedema just prior to the haemorrhage. One patient underwent a brain biopsy, demonstrating beta amyloid-laden vessels consistent with CAARI.

High dose oral steroids, tapered over weeks-months were given to 5/6 (83%) with rapid neurological recovery over days. The vasogenic oedema also significantly improved on MRI; the microhaemorrhages were unchanged. After relapsing off steroids, one patient required cyclophosphamide treatment and subsequently azathioprine.

Conclusions

CAARI is a reversible cause of encephalopathy and seizures and should be considered in all patients with unexplained vasogenic oedema on brain imaging.

Presenting symptoms	Number of patients
Seizures	4/6 (67%)
Subacute cognitive decline	2/6 (25%)
Non-specific headache	2/6 (25%)
Amyloid spells	4/6 (67%)

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Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

STROKE, RARE CLINICAL MANIFESTATION OF GRAVES' DISEASE ACCOMPANIED BY MOYAMOYA DISEASE

MK Kim ¹, SK kwon ²

Abstract

Background

Moyamoya disease (MD) is a cerebrovascular disorder characterized by stenosis or occlusion of the terminal portions of the internal carotid arteries. The pathogenesis of MD and its relationship with thyrotoxicosis is not clearly known. We experienced a rare case of Graves’ disease accompanied by MD presented as stroke.

Methods

A 20-year-old female was admitted because of throat discomfort and dysphonia developed 5 days ago. She had been suffered from hyperthyroidism for 3 years and had history of irregular medication. A blood examination showed suppressed TSH and elevated triiodothyronine and thyroxine levels. She was posive for anti-thyrotropin receptor antibody. MRI showed focal hyperintense lesion in the left frontal cortex and deep white matter and SPECT revealed decreased blood flow in the left middle cerebral artery territory after diamox administration. 4 vessel angiogram shows severe stenosis involving cavernous portion with collateral vessels giving puff of smoke appearance. She was diagnosed as acute ischemic stroke associated with MD and thought to have concurrent Graves’ disease. She underwent antithyroid drug and antiplatelet therapy. After improvement of thyroid function followed by antiplatelet therapy, throat discomfort and dysphonia were improved.

Results

Sympathetic hyperstimulation caused by hyperthyroidism might contribute to development of intracranial arterial stenosis and thyrotoxic states itself could accelerate the progression of the intracranial arterial occlusion in MD. Coexistence of MD and Graves’ diseas is extremely rare, but it would be worthy of paying attention.

Conclusions

In patient with uncontrolled Graves’ diseases with atypical central nervous system associated symptoms, MD or ischemic stroke should be considered in mind.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CASE STUDY OF THE USE OF ULTRASOUND AND STRUCTURED LIGHT PLETHYSMOGRAPHY IN THE ASSESSMENT OF PNEUMONIA AND RESPIRATORY DYSFUNCTION EARLY AFTER STROKE

A Kouzouna ¹, C Roffe ², N Watson ³, J Alexander ⁴, G Francis ⁵, W Lenney ⁵, AD Pandyan ¹

Abstract

Background

Pneumonia is a common cause of death after a stroke and is associated with increased morbidity and longer length of hospital stay. Early detection could allow patients to make a better and faster recovery from their stroke. This case study shows how ultrasound (US) and structured light plethysmography (SLP) can be used to assess respiratory dysfunction after stroke.

Methods

A 77 year old male patient with dense right hemiplegia was recruited 8 hours after admission, as part of a larger on-going observational study, on the acute stroke unit of the Royal Stoke University Hospital. Routine assessments included auscultation of the chest, blood tests and chest radiography. For this study, US and SLP were conducted alongside the routine clinical assessment at baseline, then twice per week until discharge, and finally at 90+/-30 days.

Results

The patient had clinical and radiological evidence of aspiration pneumonia on the day of admission leading to severe respiratory dysfunction and marked hypoxia requiring high concentrations of oxygen. SLP showed a Cheyne-Stokes breathing pattern during the episode of pneumonia and asynchronous breathing due to diaphragmatic paralysis. US accurately detected the presence of consolidation in the lungs correlating with the baseline chest radiograph. Subsequent US scanning over 2 months of hospital stay showed spontaneous reversal of the right diaphragmatic paralysis and resolution of the pneumonia.

Conclusions

This case study identified transient diaphragmatic paralysis as a key contributor to respiratory failure. It also demonstrates the potential of ultrasound and SLP in detecting respiratory disease and dysfunction in acute stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

BASILAR OCCLUSION &NDASH; SHOULD THE CLINICAL PICTURE OR THE RADIOLOGICAL IMAGING LEAD TO THERAPY DECISION?

G Behzadi ¹, L Fjetland ¹, MW Kurz ², K Kurz Daehli ¹

Abstract

Background

Basilar thrombosis is associated with high morbidity and mortality. Symptoms vary and comprise motor deficits, dysarthria, vertigo, visual disturbances, and altered consciousness. Factors associated with poor outcome are older age, higher stroke score, and longer time to treatment. In clinical praxis treatment with intravenous thrombolysis (IVT) or endovascular therapy (EVT) is often withheld in older patients with complete clinical brainstem dysfunction.

Methods

Description

Results

A 80 year old male patient was falling on the table while eating supper. He was unconscious and his wife called the emergency services directly under suspicion of a cardiac arrest. The arriving emergency doctor found the patient unconscious, with enlarged pupils unresponsive to light, and without respiration but with normal pulse. The patient was intubated and shipped to the Stavanger University Hospital, arriving less than one hour after onset. A CT scan was performed immediately, including perfusion and angiography series. While there was no infarct demarcation, perfusion series showed a perfusion deficit in the complete posterior circulation with distinct penumbra. Angiography revealed basilar occlusion. IVT was administered immediately, yet EVT was withheld due to complete perfusion deficit in the posterior circulation, complete clinical brainstem dysfunction, and older age. MRI the day after showed a complete recanalization and only small diffusion lesions mainly in the thalami bilaterally. The patient got a good clinical outcome despite of initial bilateral oculomotor affection.

Conclusions

Despite of complete brainstem dysfunction aggressive recanalization therapy should be considered if radiological imaging shows lack of infarction and distinct penumbra.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ACUTE ISCHEMIC ARTERIAL STROKE AND VENOUS CEREBRAL THROMBOSIS: MORE THAN AN INCIDENTAL FINDING?

L Leitão ¹, P Pita Lobo ¹

Abstract

Background

Cerebral venous thrombosis (CVT) is an uncommon cause of stroke and its co-occurrence with an ischemic stroke is rare.

Methods

Case report.

Results

A 67-year-old women, with hypertension and stable chronic myeloid leukemia controlled with imatinib, was admitted with sudden right side weakness. There was no smoking history, head trauma or infection. Examination revealed global aphasia and right hemiparesis with facial involvement. The brain CT depicted an acute stroke in the left middle cerebral artery (MCA) territory and raised the suspicion of CVT of the right lateral sinus. The second brain CT demonstrated the CVT progression to the sagittal sinus. Venous and arterial brain MRI confirmed: left MCA acute ischemic stroke, thrombus in the internal carotid artery extending to MCA (M1) and acute thrombosis of right jugular vein, lateral and sagital sinus without venous infarcts. Conventional angiography was suggestive of left carotid dissection and showed the CVT.The extensive cardiac study was normal. Peripheral thrombosis was excluded. Occult neoplasia was not found. The laboratory data revealed a transient thrombocytosis (maximum platelet count: 527000) and an elevation of VIII factor (145%). The patient was treated with heparin.

Conclusions

Despite being well recognized the increased risk of thrombotic events in myeloproliferative disorders, at the best of our knowledge this is the first case of a concomitant CVT and carotid dissection, in this setting. A plausible explanation is based on the synergistic effect between the raised VIII factor and transient thrombocytosis and/or an not yet identified paraneoplastic syndrome with vascular fragility.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THALAMIC STROKE - A POTENTIAL DIFFERENTIAL DIAGNOSTIC PROBLEM

C Lovig ¹, E Lovadi ¹, L Szapáry ¹, P Csécsei ¹, ZN Karádi ²

Abstract

Background

We present a double case study of a 68 year-old male and a 94-year-old female patient with multiple vascular risk factors treated in our Stroke Care Department. They presented with very dissimilar clinical picture: the male patient had ptosis, gaze palsy, lower cranial nerve lesion and hemiparesis, while the female patient experienced aphasia and disorientation; however a temporary disturbance of consciousness, described as slight somnolence, appeared as the initial symptom in both patients. On admission, based on these symptoms, the diagnosis was likely to be myasthenia gravis on one hand or meningo-encephalitis on the other.

Methods

The various neurological symptoms led to further diagnostic approaches and thalamic involvement was detected by cranial imaging in both cases.

Results

Atrial fibrillation and small vessel disease were identified as possible etiologic factors of the ischemic stroke at the thalamic site. Clinical course was characterized by gradual improvement, as a relatively good outcome with mild residual disability following rehabilitation was seen in both patients.

Conclusions

We would like to highlight the various and sometimes unusual clinical manifestations of thalamic ischemia, which potentially causes differential diagnostic difficulties and delayed initiation of the adequate treatment.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

REPERFUSION THERAPIES IN WAKE-UP STROKE

PL Martínez Ulloa ¹, R Vera Lechuga ¹, A Cruz Culebras ¹, A De Felipe-Mimbrera ¹, MC Matute-Lozano ¹, A Escobar Villalba ¹, P Pérez Torre ¹, E Monreal Laguillo ¹, J Masjuan Vallejo ¹

Abstract

Background

Wake-up stroke (WUS) represents 8-27% of all ischemic strokes. The unknown time of symptom onset has been established as a contraindication for reperfusion treatment. However, in recent years, neuroimaging techniques have improved the burden of treatment of these patients. We reviewed our experience in selected cases.

Methods

Retrospective review of patients with WUS treated with iv thrombolysis and/or endovascular treatment in our stroke center during the period 2007–2015. We collected baseline data, neuroimaging, treatment related complications and functional prognosis.

Results

We collected 36 case. The mean age was 66.7 ± 14.4 years (58% male). The most frequent risk factors were hypertensión (63.9%), dyslipemia (50%) and atrial fibrillation (44.4%). The median baseline NIHSS score was 15 (11–21). The baseline ASPECTS score on CT was >7 in 30 cases (83.3%). Multimodal TC was performed in 35 cases (97.2%). In 29 (80.6%) major vessel occlusion could be observed. Carotid stroke was the most frequent (80.5%). 13 patients (36%) were treated with iv tPA and 23 patients (64%) with endovascular treatment. Functional independence at 3 months was achieved in 22 (61.1%). Symptomatic hemorrhagic transformation occurred in one patient (2.8%). Mortality rate was 8.3%.

Conclusions

Patients with WUS may benefit from reperfusion therapies with the adequate clinical and neuroimaging selection. Good functional outcome was achieved in high percentage of patients with reduced mortality at 3 months.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ATRAUMATIC CONVEXAL SUBARACHNOID HEMORRHAGE IN A PATIENT WITH INTRACRANIAL ATHEROMATOUS STENOSIS

AI Martins ¹, J Sargento-Freitas ¹, L Almendra ¹, F Silva ¹, B Rodrigues ¹, C Machado ¹, GC Santo ¹, L Cunha ¹

Abstract

Background

Atraumatic convexal subarachnoid hemorrhage (cSAH) is an unusual presentation of cerebrovascular disease. Whereas there are a few cases in literature of cSAH in patients diagnosed with atheromatous plaques or occlusions of extracranial arteries, there are no previous reports of isolated intracranial atheromatous disease and cSAH.

Methods

All the clinical information presented in this case was obtained upon the archives of the Coimbra University and Hospital Center.

Results

Male, 54 years old, with known smoking habits and poorly controlled hypertension and dyslipidemia. Patient developed an holocranial headache followed by, 2 days later, a right visual field defect and a fluctuating speech defect (characterized by alexia and agraphia). Head computerized tomography (CT) scan revealed a cSAH near left rolandic sulcus. At day 4 symptoms recurred and CT scan showed two left parietal and parieto-occipital cortico-subcortical hypodense lesions. Repeated evaluations with transcranial color-coded Doppler (TCCD) identified focal acceleration at the distal portion of middle cerebral artery’s (MCA) M1 segment, with an attenuated flow downstream. The patient underwent digital subtraction angiography that did not revealed aneurysms and confirmed the presence of a severe focal stenosis in distal MCA’s M1 segment, with an atheromatous appearance. Control CT scan showed total reabsorption of the bleeding. Six months post-event the patient still detained a right inferior quadrantanopia and the severe MCA stenosis evaluated by TCCD with no new symptoms.

Conclusions

We present a case of a non-traumatic and non-aneurysmatic convexal subarachnoid hemorrhage in a patient diagnosed with a severe atheromatous stenosis in the ipsilateral middle cerebral artery

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

HEMICRANIECTOMY FOR CEREBRAL INFARCTION CAUSING MASS EFFECT FOLLOWING AIR EMBOLISM

A McDonough ¹, S Cullivan ¹, S Costello ¹, S McNally ², J Harbison ¹

Abstract

Background

Large cerebral infarctions may result from non-thrombotic causes where interventions such as thrombolysis or thrombectomy are not indicated. Decompressive hemicraniectomy is a recognized and effective intervention in reducing mortality in cases of cerebral oedema following thrombotic MCA occlusion.

Methods

We present the case of a subject undergoing successful hemicraniecomy for cerebral infarction from air embolism.

Results

A previously well 56 year old woman, underwent elective CT guided biopsy of a suspicious lung mass. During the procedure, she had a respiratory arrest. An CT brain performed after resuscitation showed extensive air embolism of vessels in the right hemisphere and left frontal lobe, a rare but recognized complication of lung biopsy. She was intubated and treated with 100% oxygen but deteriorated neurologically and a subsequent CT brain at 48hours showed extensive right cerebral oedema with significant mass effect. Because of her deteriorating condition decompressive hemicraniectomy was suggested but literature review revealed no record of its use in this context. After discussion with her family and neurosurgical colleagues, hemicraniectomy was performed in light of her likely poor prognosis otherwise. The procedure was performed without complication and the subject improved substantially. The hemicraniectomy was reversed after 12 weeks and at 3 months the subject remained in rehabilitation with a left hemiplegia, (Rankin 4) but with preserved language and cognitive function.

Conclusions

Decompressive hemicraniectomy can be considered as an option in the treatment cerebral oedema secondary to infarction resulting from cerebral air embolism in circumstances where medical therapy is ineffective.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PERCUTANEOUS ANGIOPLASTY AND STENTING IN A YOUNG PATIENT WITH BILATERAL POST-TRAUMATIC INTRACRANIAL INTERNAL CAROTID ARTERY DISSECTION

AC Mergeani ¹, A Dimitriade ², B Dorobat ², O Rusu ¹, O Bajenaru ¹, F Antochi ¹

Abstract

Background

Intracranial ICDs (internal carotid artery (ICA) dissection) are less frequent than extracranial ones though it is possible that these are underestimated due to the lack of specific imagistic features. Intracranial ICD generally affects more younger patients, being usually associated with large strokes and having high mortality rates.Intracranial ICD usually involves supraclinoid portion of the artery and often extends to the internal carotid bifurcation and sometimes into the anterior and middle cerebral artery.

Methods

We present the case of a 18 year-old female without any medical history admitted to our hospital for cervical and cerebral trauma due to a car accident with tetraparesis predominantly affecting the upper limbs, areflexia and urinary disturbances.

Cerebral and cervical region MRI and MR-angiography with iv contrast showed the presence of bilateral intracranial ICD with multiple areas of ischemia in ICA territory. Digital substraction angiography (DSA) confirmed the presence of bilateral intracranial ICD with hemodynamic significant stenoses.

Results

Percutaneous angioplasty and stenting was performed for the intracranial part of left ICA in the distal segment from carotid canal with good intracerebral filling and for the intracranial right ICA. The patient received duble antiplatelet treatment (aspirin and clopidogrel) with improvement of the neurologic deficits. Control DSA performed 7 days later confirmed the patency of both ICA with good intracerebral filling.

Conclusions

We choose to present this case to emphasize the importance of endovascular treatment in cases of post-traumatic intracranial ICD taking into account the high mortality and morbidity of these types of dissections.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

A RARE PRESENTATION OF STROKE: SPONTANEOUS BASILAR ARTERY DISSECTION

D Necioglu Orken ¹, Z Tanriverdi ¹, B Aydin Islam ¹, M Korkmaz ¹, E Uysal ², C Orken ³

Abstract

Background

Basilar artery (BA) occlusion due to intracranial dissection is rare. Clinical symptoms and signs depend on the location of occlusion and the extent of the infarction. We present here a young patient with intracranial BA occlusion due to spontaneous BA dissection with excellent recovery.

Methods

A 21 year-old male came to ER with vertigo, nausea, and vomiting a slurred speech. He had no history of any medical problem and drug use. He was a player in his a school rugby team. On neurologic examination his speech was dysarthric. He had horizontal nystagmus and couldn’t swallow. He had a right side dysmetria, hypotonia and gait ataxia. Diffusion-weighted MR images show restricted areas in the right side of the pons, vermis and the cerebellar hemisphere. MRA shows lack of flow in distal BA. Mid-arterial phase digital subtraction angigraphy images show absent cephalad flow in the BA distal to the anterior inferior cerebellar artery suggesting BA occlusion(Image-1).

graphic file with name 10.1177_2396987316642909-fig88.jpg

We didn’t detect any cardiac, arterytic, vasculitic or hematologic disease. We started antiplatelet therapy. The patient recovered completely. A repeated MRA, 1 month later, showed the recanalisation of BA (Image-2).

Results

Isolated BA dissection is uncommon and associated with significant morbidity and mortality. There have been inconsistencies on the prognosis and management of acute BA dissection.

Conclusions

Cerebral BA dissection should be considered as a possible cause in young patient with brainstem stroke, particularly when conventional cardiovascular risk factors are absent.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CEREBRAL VENOUS THROMBOSIS AFTER SPINAL ANESTHESIA: A CASE REPORT

D Necioglu Orken ¹, N Kuloglu-Pazarci ¹, Z Tanriverdi ¹, M Korkmaz ¹, E Kivrak ¹, E Uysal ²

Abstract

Background

Lumbar puncture (LP) is performed in medicine for diagnostic and therapeutic purposes. The main complication of the procedure is post-lumbar puncture headache. We present a case with post LP headache after spinal anesthesia progressing to CVT.

Methods

A 23 years old male without known medical problem underwent pilonidal sinus surgery under spinal anesthesia. On the second day of his operation he noticed diffuse, throbbing headache, nausea and vomiting when he stand up, which improved on supine position. When he attended to ER a diagnosis of post lumbar puncture headache was made and treated with analgesics and bed rest. Two days later his complaints was not improved and headache became persistent all day and lost postural character. Then he started to complain double vision when he looks right. On neurologic examination, he had bilateral papilledema and right sixth nerve palsy. Axial unenhanced cranial CT image shows areas of abnormal hyperattenuation consistent with thrombi in the right transverse sinus and the sigmoid sinus. Axial T1-weighted and T2 weighted MR images show a thombus in the right transverse and sigmoid sinuses. MRV shows a lack of flow in the right transverse sinus and the sigmoid sinus (Image-1).

graphic file with name 10.1177_2396987316642909-fig89.jpg

Low molecular weighted heparin was started.

Results

We describe a case of CVT developed post spinal anesthesia, initially suggested as post lumbar puncture headache because of its positional character.

Conclusions

If the headache lose the orthostatic character after lumbar puncture, treating clinician must be alert that the patient may have developed CVT.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CORTICAL HAND KNOB STROKE: REPORT OF 22 CASES

P Orosz ¹, I Szőcs ¹, G Várallyay ², I Zsigmond ², G Rudas ², A Folyovich ³, D Bereczki ¹, I Vastagh ¹

Abstract

Background

Cortical representation of hand movements is located in the precentral gyrus, known as ‘hand knob’ area. Hand weakness due to vascular damage of this territory is a rare but well defined entity, also called ‘pseudoperipherial palsy’, as hand knob stroke patients can present with mimicking peripherial palsies of the hand. Hypertension and atherosclerosis seems to be the most prevalent risk factors. Although embolic origin has been suggested to be the most likely stroke etiology, the underlying mechanism remains controversial. Most patients demonstrate good clinical outcome. Herewith we report 22 cases of cortical hand knob stroke.

Methods

Eleven female and 11 male patients were admitted to our ward between 2007 and 2015 with pure distal arm palsy. Ischemic lesions in the precentral gyrus were detected by either computed tomography (CT) or magnetic resonance (MR) imaging, atherosclerotic changes in the supraaortic arteries were evaluated by carotid Doppler, CT or MR angiography.

Results

Atherosclerosis was present in 19 patients, 17 of them had hypertension. Sixteen of the 19 atherosclerotic patients were hypothesised to have arterio-arterial embolization, 2 of them had cardioembolic source and one had patent foramen ovale as additional risk factors. One of the 3 non-atherosclerotic patients had proven antiphospholipid syndrome, while two of them had undetermined origin of stroke. Short-term outcome was benign in every patient, but we lack long-term follow up data.

Conclusions

Hand knob infarction has to be considered in the differential diagnosis of distal arm palsies especially in patients with risk factors of hypertension and atherosclerosis.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

STROKE, CARDIOPATHY AND RENAL IMPAIRMENT IN A YOUNG MALE: WATCH BEYOND THE ENDOTHELIUM

B Oyanguren ¹, E Alegria ², M Eimil ¹, M González-Salaices ¹, C López de Silanes ¹, MJ Gil ¹, S Muñiz ¹, O Trabajos ¹, R Segoviano ³

Abstract

Background

Fabry Disease (FD) is a rare X-linked metabolic disorder, which produces a wide variety of symptoms due to glucolipids` endothelial pathological storage. It may eventually shorten life expectancy should replacement therapy not be promptly started

Methods

We present a 39-year-old non-smoker man who was admitted to our Stroke Unit following a sudden onset of right hemiparesis (1 + 0) and disarthria (1) 24 hours prior to admission. National Institute of Stroke Scale (NIHSS) was 2. Angiokeratomas were noted on both thighs (figure 1). Plain CT head showed a hipodense lesion on the left thalamus. Diffusion weighted MRI confirmed an acute ischemic stroke (figure 2). Carotid duplex US was normal, whereas high pulsatility indexes were seen on transcranial doppler US. Transthoracic echocardiogram showed left ventricular hypertrophy (figure 3). He was discharged five days later asymptomatic, on aspirin. A 21-day-electrocardiogram-recording showed atrial fibrillation (AF) and thorough blood tests (thrombophilia, immunology, serologies) proteinuria (225 mg/l).

Results

In view of multiorganic involvement, a storage disorder was suspected and FD screening was performed. Alfa-galactosidasa-A enzyme´s activity was found to be low and genetic studies showed a mutation in GLA gene (Leu387Pro). His brother, aged 38, who also suffered from AF and renal disease, was positive for this mutation too. They are both on oral anticoagulants and about to begin enzymatic replacement therapy with agalsidase.

Conclusions

FD should be suspected in young males presenting with neurologic, cardiologic, cutaneous and renal impairment, especially if other family members are also affected. Replacement therapy must be rapidly initiated since it may improve outcome.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

WATCH OUT IN SUBSEQUENT CENTRAL AND PERIPHERAL EMBOLISMS

B Oyanguren ¹, AI Franco ², M González-Salaices ¹, M Eimil ³, C López de Silanes ¹, MJ Gil ¹, LI Casanova ¹, S Muñiz ¹, O Trabajos ¹

Abstract

Background

Embolic phenomena are common in patients with malignancies. However, presenting as subsequent central and peripheral embolisms is infrequent and may be lethal.

Methods

We present 2 cases.

Results

A 71-year-old-female (A) and a 58-year-old-male with atrial fibrillation (B) were admitted to our Stroke Unit following a sudden onset of intense headache (A) and left hemihypoesthesia (B). B had suffered bilateral pulmonary embolisms (PEs) and proximal deep venous thrombosis (DVT) four days before, while on acenocumarol (INR 3.5); he had been changed to rivaroxaban and a Cava vein´s philtrum (CVP) had been placed. In A, CT head showed minor right parietal SAH (figure 1a) and MRI-angiogram right transverse and superior longitudinal sinuses thrombosis (figure 1b-c). In B, CT head showed a right MCA stroke (figure 2). Both were treated with subcutaneous heparin. Neurosonology and transesophageal echocardiogram were normal (B). Pancreatic adenocarcinoma was discovered (B) and chemotherapy was started. However, he died one month later due to abdominal sepsis. In A, a thyroid carcinoma was found. She was discharged on acenocumarol one week later, awaiting surgery. Nevertheless, she was readmitted to the Intensive Care Unit the following week due to a large retroperitoneal haematoma (INR 4.5, hemoglobin 6 g/dl); anticoagulation was stopped and blood transfusion initiated. 48 hours later she suffered right leg DVT and bilateral PEs. CVP was placed. She was discharged twenty days later on anticoagulation, and thyroid surgery was performed the following month.

Conclusions

Subsequent central and peripheral embolic events suggest underlying malignancy. Given its poor prognosis, it must be treated promptly.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

MECHANICAL THROMBECTOMY AS RESCUE THERAPY IN A PEDIATRIC STROKE

M Padroni ¹, A De Vito ², O Marcello ³, C Azzini ², E Fainardi ³, M Borrelli ³, E Groppo ¹, A Saletti ³, V Tugnoli ²

Abstract

Background

Acute ischemic stroke (AIS) in patients younger than 18 years old is a rare condition but it can result in significant morbidity. Thrombolytic therapy with intravenous (IV) recombinant tissue plasminogen activator (rtPA) is actually considered the main intervention for the management of pediatric stroke patients, despite lack of safety and efficacy data. Recently, successful endovascular treatments in children have been reported. There are no published case reports of children undergoing combined IV and endovascular therapies for AIS.

Methods

We describe a case of a 14 years-old child with AIS due to right intracranial internal carotid artery T occlusion that was successfully treated with IV thrombolysis and rescue mechanical thrombectomy.

Results

NIHSS at onset was 22. ASPECTS (Alberta Stroke Program Early CT score) was 9, CT perfusion showed hypoperfusion in the right middle cerebral artery territory with a wide area of ischemic penumbra. Post-procedural recanalization was assessed as TICI 2b. Three months mRS was 1. The follow-up MRIs showed a right fronto-temporal infarct, compatible with the core region on CT perfusion maps at onset, and a progressive complete recanalization of the right distal carotid and M1 middle cerebral artery at 6 months, suggestive of a dissecative etiology. No hemorrhagic complications have been reported.

Conclusions

Mechanical thrombectomy may be considered as rescue therapy in pediatric AIS.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

TRIPLE TREATMENT OF ACUTE ISCHEMIC STROKE: A PRELIMINARY CASE REPORT

M Padroni ¹, C Azzini ², A Saletti ³, E Sette ², L Borgatti ³, A De Vito ², L Traina ⁴, S Ceruti ³, E Fainardi ³, V Tugnoli ²

Abstract

Background

Urgent carotid surgery after intravenous (IV) thrombolysis in acute ischemic stroke (AIS) is being performed more frequently in stroke centers to reduce the risk of early recurrent stroke. However its therapeutic role is still questioned. Mechanical thrombectomy could be a rescue therapy after IV thrombolysis, even if also its role in direct bridging appears to be promising. There are no published case reports of patients with AIS treated with combined IV and endovascular therapies and urgent carotid endarterectomy.

Methods

We describe the case of a patient with AIS due to atheroembolic right middle cerebral artery (MCA) occlusion in preocclusive internal carotid artery stenosis treated with IV thrombolysis, mechanical thrombectomy and urgent carotid endarterectomy.

Results

NIHSS at onset was 14, ASPECTS (Alberta Stroke Program Early CT score) was 7, CT perfusion showed hypoperfusion in all the right MCA territory with a wide area of ischemic penumbra. This patient was treated with IV thrombolysis and mechanical thrombectomy in direct bridging, reaching a complete recanalization of the right MCA with major neurologic improvement. Four hours later she underwent right carotid endarterectomy to remove the source of potential embolisation. At discharge NIHSS = 2, mRS = 1. No haemorrhagic complications occurred, either intracranial or at the surgical site. There was neither peri-operative stroke nor recurrent stroke within 3 months of surgery.

Conclusions

This case supports the safety and efficacy of urgent carotid surgery even after combined IV and endovascular therapies for AIS.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

A NEWLY DEVELOPED FLOW-DIVERTER (FLOWISE) STENT: A FIRST EXPERIENCE IN HUMAN

KY Park ¹, BM Kim ², DJ Kim ², DI Kim ³

Abstract

Background

We developed a new flow diverter (Flowise) and here we reported a first experience of Flowise in human.

Methods

Flowise is a partially retrievable flow diverter by waving 48 strands of niti/Pt wire. The Flowise is compatible with any microcatheter having 0.027” inner diameter and is retrievable until <70% deployment.

Results

A 56-old female patient visited our hospital due to headache. Digital subtraction angiography (DSA) showed an unruptured paraclinoid ICA aneurysm with a maximal size of 8.1 mm. Before the procedure, the patient had been prescribed with dual antiplatelets for 7 days. A Verifynow (Accriva, USA) did not show any antiplatelets resistance. Under the general anesthesia and systemic heparinization, 7F Shuttle guiding sheath (Cook medical, IN, USA) and 5F Navien distal access catheter (Ev3, CA, USA) was placed in left internal carotid artery (ICA). An Excelsior XT 027 microcatheter (Stryker, CA, USA) was navigated carefully along the distal ICA and middle cerebral artery (MCA). Flowise 4/20 was deployed between cavernous ICA and just proximal to posterior communicating artery origin by careful push and pull technique. For more stent apposition, conventional balloon angioplasty was performed using Hyperform 4/7 (Ev3, CA, USA). After balloon angioplasty, final DSA showed intraaneurysmal contrast stagnation. Delayed DSA did not show any thromboembolism and in-stent thrombus. There were no hemorrhagic and ischemic complications during the procedure.

Conclusions

A newly developed partially retrievable flow-diverter (Flowise) appeared to be a feasible treatment option.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ENDOVASCULAR TREATMENT IN RUPTURED MIDDLE CEREBRAL ARTERY DISSECTION FOCUS ON ARTERIAL CONTINUITY PRESERVATION

SK Park ¹, HW Ro ²

Abstract

Background

Rupture of spontaneous dissecting aneurysm of middle cerebral artery (MCA) is rare and the etiology remain obscure although the risk of rebleeding is greater than saccular aneurysm. Until now, most of reports about a treatment of dissecting rupture of anterior circulation are about surgical trapping or wrapping.

Methods

22-year-old female presented sudden stuporous mental change following severe headache and left side hemiparesis. CT showed a diffusion subarachnoid hemorrhage (SAH) and diffusion MR showed diffusion restriction at right putamen and internal capsule. There was no definite vascular abnormal finding except mild irregularity of right MCA (M1) on initial digital subtraction angiography (DSA). However, dissecting aneurysm was reported on 6-hour follow up DSA. We performed stent assisted coil embolization was done and double stent was applied for the effect of flow diversion. There was small remnant area of dissecting aneurysm, it was disappeared at 60-day and 12 –month follow up DSA.

Results

We performed 5 times DSA after endovascular therapy within four weeks. Fortunately, there was no further growth of aneurysm or dissection in follow up DSA. Long term follow up angiography was done at 6 and 12 month after therapy and remnant aneurysm disappeared. There was no irregularity on vessel wall and dissecting area was considered to have successful endothelialization.

Conclusions

We report a successful treatment about SAH due to rupture of spontaneous MCA dissection with endovascular technique. Flow diversion using stent assisted coil embolization is a good therapeutic option preserving arterial contituity

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

AN UNUSUAL CASE OF SARCOIDOSIS PRESENTING AS A STROKE MIMIC

M Parkinson ¹, M Duncan ², J Gemmill ³, S Ghosh ¹

Background

A previously healthy 46 year old presented with sudden onset right facial droop, hemiparesis, speech disturbance, apraxia and altered mental status. She appeared euphoric, disinhibited and displayed difficulty comprehending and obeying simple commands. She described a four week preceding history of fatigue, low grade fever and arthralgia. C-Reactive Protein (CRP) and Erythrocyte Sedimentation Rate (ESR) were elevated. Her focal neurological symptoms resolved within 48 hours of admission and complete examination of the nervous system was otherwise unremarkable. Cardiovascular and respiratory exams also yielded no abnormality, with an absence of palpable lymphadenopathy or cutaneous lesions.

An admission CT was normal and magnetic resonance imaging was performed to further investigate clinical suspicion of embolic phenomenon or encephalitis. Diffusion weighted imaging demonstrated increased signal involving several discrete segments of the cortex in the left temporal parietal lobe and periventricular matter of the left parietal lobe. An echocardiogram performed concurrently unexpectedly demonstrated severe systolic impairment and severe left ventricular cavity dilation, with no evidence of thrombus.

Eight months later she presented with pyrexia, cognitive disturbance. CRP and ESR remained elevated. Computed tomography of her chest, abdomen and pelvis illustrated significantly enlarged anterior neck nodes with potentially abnormal subcentimetre nodes and hepato-splenomegaly.An ultrasound guided biopsy of a level V node confirmed non-necrotic epitheliod cell granulomas highly suggestive of systemic sarcoidosis.

Discussion:

Neurological involvement is present in less than 10% of cases of sarcoidosis. Although granulomatous involvement of cerebral blood vessels is described in neurosarcoidosis presentations with stroke like symptoms do not regularly appear in the literature.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

FAR BEYOND THE THERAPEUTIC WINDOW IN MIDDLE CEREBRAL ARTERY STROKE THROMBECTOMY: A CASE REPORT

L Perez-Carbonell ¹, S Trillo Senin ¹, C Aguirre Hernandez ¹, E Barcena Ruiz ², A De Felipe-Mimbrera ³, S Bashir Viturro ¹, JL Caniego Monreal ², J Vivancos Mora ¹

Abstract

Background

Our aim is to present a case in which a thrombectomy for middle cerebral artery (MCA) stroke was performed exceeding the protocolized window time for endovascular revascularization.

Methods

This case involves a 34-year-old male, smoker, who presented speech impairment that started at 8am. He did not seek medical advice until 10 pm, when he went to a hospital where a score of 5 in the NIHSS was documented. A CT perfusion scan and CT-angiography (CTA) were performed, showing an occlusion at segment M1 of the left MCA and perfusion mismatch. The patient was transferred to our hospital, where a new CTA confirmed the previous diagnosis and revealed prominent collateral circulation (CC) on the left hemisphere. At that time, 19 hours after symptoms onset, and given the patient’s clinical stability, a conservative approach was preferred. In the following hours, as he experienced progressive clinical worsening (NIHSS 10), a DWI MRI was run showing similar findings. Endovascular treatment was then performed.

Results

Complete revascularization was successfully achieved 28 hours after stroke onset. In the following weeks the patient maintained a progressive improvement, with NIHSS of 1 and mRS 2 at three months. A previous intracranial stenosis was diagnosed as the stroke's etiology and it was probably related to the CC grade.

Conclusions

In exceptional cases, due to a prominent CC that ensures brain parenchyma perfusion in stroke, certain patients could benefit from endovascular treatment beyond the established window.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EARLY DIFFUSION WEIGHTED IMAGING NEGATIVITY IN ANTERIOR CHOROIDAL ARTERY INFARCTS

S Peters ¹, T Singh ¹, D TIrschwell ¹, S Khot ¹

Abstract

Background

Ischemic symptoms with early false-negative diffusion weighted imaging (DWI) have been well described in the posterior circulation, but less commonly in the anterior circulation.

Methods

Three patients demonstrated acute anterior choroidal artery (AChA) ischemia on brain MRI despite initial negative imaging.

Results

An 82-year-old woman presented with right leg and arm weakness. Brain MRI 4 hours following symptom onset revealed no changes on DWI despite persistent deficits and a NIH Stroke Scale (NIHSS) score of 3. The NIHSS worsened to 5 and a repeat MRI at 24 hours showed a clear posterior internal capsule infarct. A 51-year-old man was treated with intravenous alteplase after abrupt onset left hemiparesis and a NIHSS of 3. Brain MRI 12 hours after onset was normal but a 48 hour repeat MRI showed a posterior internal capsule infarct. A 39-year-old woman had multiple stereotyped transient episodes of hemiparesis, facial droop and dysarthria (maximum NIHSS 10) in the setting of cocaine use without evidence of DWI restriction despite a perfusion mismatch in the AChA territory.

Conclusions

AChA infarcts are an important but overlooked subset of early DWI-negative infarct. Our patients with early false-negative DWI imaging demonstrated subsequent infarction or perfusion abnormality in the setting of fluctuating or worsening symptoms. The axonal makeup of the internal capsule may be relatively resistant to early focal ischemia of the AChA and early oligemia may be clinically symptomatic with minimal DWI abnormality. This prolonged timeline may have implications for early intervention with blood pressure and anti-thrombotic agents.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

AN APPARENT STROKE IN A YOUNG PATIENT

J Turner ¹, A Pitt Ford ¹, I Kane ¹

Abstract

Background

A 23 year old, previously fit and well female, presented to the emergency department with sudden onset right-sided weakness, neglect and dysphasia. She arrived 1 hour 20 minutes after symptom onset with a NIHSS of 18. Collateral history revealed that the patient developed right facial twitching followed by right-sided weakness. She may have briefly lost consciousness. She was taking venlafaxine for depression and smoked cigarettes.

Methods

CT brain showed an area of acute infarction in the inferior part of the left central sulcus. [figure 1]

graphic file with name 10.1177_2396987316642909-fig90.jpg

However, CT changes were too developed for time of onset. CT angiogram was normal. She was not thrombolysed because of the mismatch between imaging and history and concern regarding seizure activity. She then had a spreading focal seizure treated with benzodiazepines and levetiracetam.

Results

MRI brain showed no restricted diffusion but white matter enhancement of the left central sulcus and right occipito-parietal region. Lumbar puncture, autoimmune profile and infection screen were normal. This is being investigated as a low-grade tumour. Symptoms slowly resolved and she was discharged 6 days after presentation.

Conclusions

In this case imaging could have supported the diagnosis of stroke and this lady could have been thrombolysed. Symptoms and time of onset did not fit with the development of apparent infarct on CT. This case highlights the importance of correlating the history with the imaging.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PARADOXICAL NEOPLASTIC EMBOLISMS IN A 52-YEAR OLD FEMALE MIMICKING CEREBRAL VASCULITIS

H Richter ¹, M Ribitsch ¹, F Härtig ¹, U Ziemann ¹, S Poli ²

Abstract

Background

Prior to admission, the patient complained of chronic cough, fatigue and weight-loss over the course of months. When she progressively developed left-sided hemiparesis and severe dysarthria, neuroimaging was performed in a peripheral neurological unit, which revealed multiple bihemispheric supra- and infratentorial DWI-hyperintense lesions. Standard neurosonological examination was unremarkable. With differential diagnosis of systemic or cerebral vasculitis the patient was referred to our department for further evaluation.

Methods

Cerebral angiography was suggestive of small vessel vasculitis. However, cerebrospinal fluid analysis was normal and the number of DWI-hyperintense lesions increased despite anti-inflammatory therapy with high-dose corticosteroids. Microembolic signals (MES) were detected by transtemporal ultrasound. Whilst transcranial bubble-test was highly positive (proving relevant veno-arterial shunting), transoesophageal echocardiography failed to visualise a patent foramen ovale. Chest CT showed a giant pulmonary arteriovenous malformation (AVM), bronchiolitis as well as hilar and epigastric lymphadenopathy. Assuming direct AVM-related or paradoxical embolism underlying the cerebral infarcts, the patient underwent embolisation of the AVM, after which MES ceased. Following transient right-sided hemiparesis and paroxysmal atrial fibrillation, follow-up MRI was performed. Interestingly, no new DWI-hyperintensities, but growth and circular contrast enhancement of all pre-existing lesions were noted. Whole-body CT featured progression of lymphadenopathy and bronchiolitic changes.

Results

Lymph node biopsy revealed a highly proliferative pulmonary adenocarcinoma. Cerebral DWI-lesions were interpreted as metastases in the context of multi-organ affection and dissemination via the AVM. Our patient underwent whole-brain irradiation and chemotherapy.

Conclusions

This case report illustrates a rare but important differential diagnosis of stroke in a young female mimicking cerebral vasculitis.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

LIMB SHAKING PHENOMENON: AN UNCOMMON PRESENTATION OF SEVERE CAROTID STENOSIS

A Rani ¹, Y Duodu ¹, Y Behnam ¹

Abstract

Background

The usual manifestation of neurovascular event is that of negative phenomenon. However, positive symptoms have been observed in patients with significant carotid artery stenosis. We present a case of a man who presented with unilateral recurrent limb shaking episodes followed by flaccid paralysis secondary to stroke.

Methods

A 64 year old gentleman presented with an acute onset of right sided arm clumsiness and dysarthria. He had no significant past medical history apart from being a heavy smoker.

Initial examination revealed mild dysarthria and abnormal semi-purposeful movement of his right arm and leg. He was normoglycemic and had regular pulse. Blood pressure recorded was 148/82 with no postural drop evident.

He developed right hemiparesis and expressive dysphasia overnight. MRI brain showed restrictive diffusion in the left ACA and MCA territory.

MRA of his neck vessels revealed total occlusion of right carotid artery and 80% stenosis of his left carotid artery.

Due to severity of his stroke, he was managed conservatively with planned carotid revascularisation at a later stage.

graphic file with name 10.1177_2396987316642909-fig91.jpg

Results

Limb shaking is an unusual presentation of transient neurovascular event. Management involves improving cerebral blood flow with the option of surgical revascularisation in selected cases.

Conclusions

Recognition of such rare presentation is vital to guide management strategies to reduce the risk of further ischemic event.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

AMYLOID ANGIOPATHY HEMORRHAGE COMPLICATED WITH BRAIN ABSCESS - A CASE REPORT

E Roci ¹, O Taka ², A Rroji ³, R Alimehmeti ⁴, M Petrela ⁴

Abstract

Background

We report on a 70 y.o. male admitted at our hospital with aphasia, right hemiplegia, altered state of consciousness and cahexia.

graphic file with name 10.1177_2396987316642909-fig92.jpg

Methods

He had been diagnosed 7 months earlier with amyloid angiopathy with multiple lobar microbleeds. In the following 2 months he had manifested repeated episodes of fever in the setting of UTI. 4 months before coming to our attention he was admitted to another hospital for a left intraparenchymal hemorrhage. Subsequently there followed no improvement and was transferred to our hospital. CT on admission showed a large round lesion at the same site of the previous haemorrhage, which was confirmed to be encephalitis towards abscess formation in MRI.

graphic file with name 10.1177_2396987316642909-fig93.jpg

graphic file with name 10.1177_2396987316642909-fig94.jpg

Results

After 4 weeks of antibiotic treatment with partial clinical improvement he underwent neurosurgical drainage. Patient general condition gradually improved and was discharged home with a remaining right hemiparesis

Conclusions

Brain abscess should be considered as a potential cause of neurologic deterioration in patients with amyloid bleeds and septicaemia.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CARDIOEMBOLIC STROKE CAUSED BY CARDIAC METASTATIC MELANOMA, A CASE REPORT

M Rosón González ¹, L Castillo Moreno ¹, M Villa Lopez ¹, A Perez Rodriguez ¹, A Arbex Bassols ¹, P Pire García ¹, A Mendez Burgos ¹, P Bandres Hernández ¹

Abstract

Background

We report a case of a 69-years-old male with a history of cardiac metastasis of melanoma, admitted to our emergency department with focal neurological deficit suggestive of acute ischemic stroke (IS).

Methods

The patient had personal history of atrial fibrillation, anticoagulated with Low-Molecular-Weight Heparin (LMWH), and nodular melanoma on lumbar region that had metastasized to the lung and heart. He came to our emergency department showing a five hours evolution of right leg plegia. The emergency basal and vascular craneal Computed Tomography (CT) showed no acute changes. He did no receive acute treatment because he did not meet criteria of intravenous fibrinolysis or neurointerventional intraarterial treatment.

Results

At admission in our department, he was clinically stable. Cranial Magnetic Resonance Imaging showed multiple acute infarcts on both cerebral hemispheres, the biggest on left cerebral anterior artery territory. Left ventricle was infiltrate by intracardiac tumor, observed in echocardiogram and chest CT. Two days later, the patient presented global aphasia and clinical worsening sencondary to a new fatal IS. He died three days later.

Conclusions

Cerebral embolism of intracardiac metastatic melanoma is a extremely rare cause of stroke. Cardioembolic etiology account for between a third and a fourth of all acute IS. Among these, tumor embolism are infrecuent and myxomas and heart fibroelastomas are more likely to embolize. The most common cardiac metastasis are hematological tumors, lung neoplasm and melanoma. We should thinck about tumoral embolism in a patient with focal neurological deficit and melanoma metastatic history.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

OPTIC NERVE SHEATH DIAMETER MEASUREMENT FOLLOWING HEMATOMA EVACUATION AND DECOMPRESSIVE CRANIECTOMY IN A PACIENT WITH INTRACEREBRAL HEMORRHAGE

G Silva ¹, M Uehara ², L Duarte ², R Valiente ², F Carvalho- ², M Miranda Alves ²

Abstract

Background

Optic nerve sheath diameter (ONSD) measurement have recently gained importance as a method for monitoring intracranial pressure (ICP) ✓ How ONSD returns to normal after intracranial hypertension resolves and clinical value of its variations, however, is yet to be investigated in real neurocritical scenarios. Our objective was to describe the evolution of ONSD measurements in a patient with intracranial hypertension treated with decompressive craniotomy.

Methods

Case Report and review of the literature

Results

A 62 year-old male with medical past of untreated arterial hypertension was referenced to our Neurology department, with unintelligible speech and right-sided weakness 12 hours before admission. Neurological examination revealed somnolence, slurred speech, right hemiplegia and Babinski sign. Cranial computerized tomography showed a large intracerebral hemorrhage, originating from the left thalamus and extending to frontal, temporal lobes and left ventricle. On admission, ONSD revealed a right diameter of 0.57 cm, and 0.58 cm on the left.Clinical condition further deteriorated, and hematoma evacuation combined with decompressive craniectomy was performed. Eight hours after surgery, ONSD was 0.42 cm on the right and 0.43 cm on the left eye.

Conclusions

Increased ONSD on ultrasound has been recorded in ICP conditions. Reports of correlation between ONSD and ICP variation based on real neurocritical scenarios are less robust. We report normalization of ONSD occurring after hematoma evacuation and decompressive craniectomy. ONSD measurement is a low cost, easy-to-use bedside method, not only in intracranial hypertension diagnosis, but also in recording return to normal values.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ENDOVASCULAR STROKE TREATMENT IN LOW-GRADE GLIOMA PATIENT

J Stanarcevic ¹, A Zecevic ¹, S Djokovic ², S Culafic ³, M Savic ¹

Abstract

Background

Late occurrence of stroke in adult patients with precedent low-grade glioma (LGG) is underestimated. Consequently, there is limited data regarding treatment of acute stroke in this population.

Methods

We present a case of a 67 year old man with an acute onset of right sided hemiparesis and aphasia. Patient had a history of a brain surgery due to right frontal LGG fifteen months prior to current symptoms, followed by radiotherapy, with no residual neurological deficit. Current brain imaging revealed right frontal postoperative sequel with no signs of tumor tissue, and angiogram revealed complete left sided middle cerebral artery (MCA) occlusion in M1 segment.

Unusual co-morbidity prolonged treatment decision-making process during which time patient was deteriorating. Thrombectomy was performed seven hours after symptom onset, reaching TICI 2b.

Results

Initial NIHSS score of 14 reduced to 1, with a complete functional recovery by discharge, remaining unchanged beyond 90 days follow-up.

Conclusions

Making a decision regarding specific stroke treatment in this patient population is impeded by lack of data. However, it is reasonable to expect good outcome in carefully selected patients. Our case reflects both of these statements and emphasizes a need for reliable records of similar events.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THERAPEUTIC CHALLENGES OF A VERTEBRAL ARTERY ANEURYSM CAUSING RECURRENT ISCHEMIC STROKE YEARS AFTER ENDOVASCULAR TREATMENT

D Strambo ¹, L Peruzzotti-Jametti ¹, A Semerano ¹, G Fanelli ², F Simionato ³, E Rinaldi ⁴, V Martinelli ¹, R Chiesa ⁴, G Comi ¹, M Bacigaluppi ¹, M Sessa ¹

Abstract

Background

Extracranial vertebral artery aneurysms are a rare cause of embolic stroke: the therapy options are often debated and long-term complication may occur.

Methods

A 59-year-old man affected by neurofibromatosis type 1 came to our attention for ischemic stroke recurrence in the posterior circulation six years after the endovascular treatment of a giant, partially thrombosed aneurysm, located at the origin of the left extracranial vertebral artery. The procedure had consisted in parent artery occlusion, which was obtained through the deposition of GDC vortex spirals in the proximal segment of the left vertebral artery. The aneurysm appeared excluded at follow-up MR angiographies.

Results

After the new ischemic event Cerebral angiography and Color Doppler Ultrasound disclosed a unique haemodinamic condition, developed over the years, that was responsible for the new embolic event: the aneurysm was rehabitated in its distal portion by reverse blood flow coming from the patent vertebrobasilar axis and in the left vertebral artery the blood flow was alternately directed to the aneurysm and backwards to the basilar artery, resulting in a biphasic Doppler signal. Surgical ligation of the distal left vertebral artery and definitive excision of the aneurysm were thus performed.

graphic file with name 10.1177_2396987316642909-fig97.jpg

Conclusions

Complete exclusion of the aneurysmatic sac from the blood circulation is advisable to achieve the full resolution of the embolic source and to avoid long-term complications.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CASE OF TWO LEARNING POINTS

C Hedley ¹, A Sivagnanaratnam ¹, WJ sze ¹, J Platt ¹, R Singh ¹

Abstract

Background

There is growing evidence that essential hypertension is being diagnosed in younger patients of an Asian or Afro-Caribbean

Background.

Methods

A 45 year old Indian gentleman with no past medical history presented with sudden onset of right sided headaches and left sided arm and leg weakness. He had a GCS OF 11, BP of 165/102 mmHg, left sided power of 0/5 UL & LL, left sided sensory loss and severe upward gaze palsy bilaterally. His CT head showed right thalamic haemorrhage with mass effect and hydrocephalaus. Initial management included BP control with labetalol infusion, insertion of Extra Ventricular Drain and high dependency care management. He was started on Amlodipine and Ramipril to control his BP. He underwent investigations for secondary causes of hypertension. MRA of renal arteries showed bilateral renal artery stenosis of 50%. We have rationalised his anti-hypertensive medications and he will be followed up by renal physicians. His weakness improved with a power of 5/5 UL and he was able to stand with assistance on discharge. However his bilateral upward gaze palsy persisted.

Results:

Conclusions

Learning point 1- In our clinical practice we have not come across severe upward gaze palsy secondary to thalamic haemorrhage. However we learnt that the most common oculomotor disturbance in thalamic stroke is an upward gaze palsy due to involvement of the intralaminar and part of the dorsomedial nucleus.

Learning point 2- This case illustrates the importance of investigating for secondary causes of hypertension in a young patient regardless of their ethnic race and

Background.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

NILOTINIB ASSOCIATED WITH ISOLATED ACCELERATED CERVICOCEPHALIC ATHEROSCLEROSIS

M Tetreault ¹, C Chayer ², S Lanthier ¹, L Busque ³, C Constance ⁴

Abstract

Background

Nilotinib is used for treatment of chronic myeloid leukemia (CML). Well-documented potential toxicity include accelerated atherogenesis of coronary and lower limb arteries, owing to LDL elevation, insulin resistance and inhibition of discoidin domain receptor 1 and 2 kinase. By contrast, only 3 patients were reported with concomitant cerebrovascular disease.

Methods

Case report.

Results

A non-smoker woman had been treated for CML with imatinib followed by nilotinib, each for 4 years. During clinical follow-up, she denied angina or intermittent claudication, body mass index was 42 kg/m², blood pressure and glycated hemoglobin were repeatedly normal, and low-density lipoprotein was 3.07–3.96 mmol/L. She presented at age 43 with left-sided superior quadranopia and hypoesthesia. Blood pressure was persistently elevated. Brain magnetic resonance imaging documented acute and subacute right-sided infarcts of the thalamus and temporal and occipital lobes. Computed tomography angiogram revealed moderate to severe stenosis of the carotid siphons, posterior and middle cerebral arteries, and basilar artery consistent with atherosclerosis. Cervical arteries were less affected. Electrocardiogram, 48-hour cardiac monitoring, treadmill stress test, transthoracic echocardiography and duplex ultrasound of the lower limb arteries were normal. Glycated hemoglobin was 0.049 mmol/L. Low-density lipoprotein was 3.24 mmol/L. Prothrombotic, inflammation and infection work-up was unremarkable. Cervicocephalic atherosclerosis was by exclusion attributed to nilotinib toxicity, considering that other vascular risk factors were few. Nilotinib was replaced with dasatinib. Patient was discharged with aspirin, clopidogrel, amlodipine, perindopril and rosuvastatin.

Conclusions

Accelerated cervicocephalic atherosclerosis without evidence of concomitant lower limb or cardiac involvement may occur in patients treated with nilotinib.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

HEMATOMYELIA MIMICKING ACUTE BRAINSTEM STROKE

B Hörmanseder ¹, S Einsiedler ¹, G Schustereder ¹, D Oel ¹, H Lugmayr ², R Topakian ¹

Abstract

Background

We report a rare case of acute hematomyelia mimicking brainstem stroke and prompting acute stroke work-up.

Methods

Case Report.

Results

Case: An 84-year-old woman with a long-standing history of severe cervical facet syndrome was admitted to the emergency department with suspected acute basilar artery thrombosis. Her clinical presentation included sudden-onset neck and occipital pain, quadriplegia, and transient impairment of speech, swallowing, and vital signs (stupor, hypotension, and bradycardia). Her symptoms had emerged immediately after a cervical facet joint infiltration procedure performed without imaging guidance in her orthopedist´s practice. She was first believed to have suffered a vasovagal syncope elicited by the painful infiltration, but observation of quadriplegia led to rapid transfer of the patient to our hospital after prenotification of the stroke neurologist on duty. Acute stroke magnetic resonance imaging of the brain and brain-supplying arteries was unremarkable, but depicted an intramedullary hematoma with surrounding edema at the C3-C4 level that was confirmed by subsequent imaging of the cervical spine. Following discontinuation of aspirin and a five-day course of high-dose IV dexamethasone, the resolution of symptoms was quick but incomplete with residual mild right-sided hemiparesis and diffuse right arm dysesthesias.

Conclusions

Although facet infiltrations are being widely performed in every-day clinical routine by physicians of various specialties, reports on life-threatening hematomyelia are rare. Comprehensive magnetic resonance imaging helps depict this differential pitfall of stroke and avoid IV thrombolysis.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

REVERSIBLE SPLENIAL LESION PRESENTING AS ACUTE STROKE MIMIC: LYME NEUROBORRELIOSIS?

G Schustereder ¹, B Hörmanseder ¹, B Pischinger ¹, S Einsiedler ¹, H Lugmayr ², R Topakian ¹

Abstract

Background

Various disorders, including metabolic and infectious ones, can lead to stroke-like scenarios with (transient) lesions of the splenium of the corpus callosum on diffusion-weighted imaging. We report a patient who presented with a stroke-like sudden onset of right-sided hemiparesis who underwent IV thrombolysis with complete restitution. Further work-up revealed an infectious etiology of the splenial lesion on MRI, possibly Lyme neuroborreliosis in an endemic area.

Methods

Case report.

Results

Case: A 55-year-old woman presented with stroke-like sudden onset of right-sided hemiparesis. She reported some accompanying headache. Stroke risk factors were negative apart from history of migraine without aura. She underwent stroke imaging and received IV thrombolysis with complete restitution within hours. However, an atypical lesion on MRI in the splenium of the corpus callosum prompted further work-up including CSF examination, which revealed marked lymphocytic pleocytosis, protein elevation and high values of IgG, IgM, and IgA, as well as elevation of the biomarker CXCL13. Despite extensive work-up for potential infectious, lymphoproliferative and autoimmune causes, a clear diagnosis could not be made. Very early Lyme neuroborreliosis in an endemic area was suspected. A pragmatic approach of IV ceftriaxone for 3 weeks was followed by complete normalization of all CSF and MRI findings.

Conclusions

Stroke physicians should be aware of stroke mimics with transient splenial lesions, which may be due to a plethora of other disorders including infectious ones.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CEREBRAL VENOUS THROMBOSIS IN A PATIENT TAKING THALIDOMIDE FOR MULTIPLE MYELOMA

C Umerah ¹, N Mustafa ¹, W Gaba ¹

Abstract

Background

Cerebral venous thrombosis (CVT) is a relatively uncommon form of stroke. Thalidomide is commonly used for treatment of Multiple Myeloma, but with increased risk of thrombosis, especially when used in combination with steroids, or other chemotherapy agents.

Methods

Case Report:

We present a case of multiple myeloma on Thalidomide, who subsequently developed CVT.

A 37-year-old Asian male with multiple myeloma diagnosed in July 2015 presented with headache, left hemiparesis and focal seizures. He was started on Bortezomib, Dexamethasone and Thalidomide shortly after diagnosis without any prophylactic anticoagulation.

He presented with aforementioned symptoms seven days after his second chemotherapy cycle in August 2015 and was managed with a phenytoin infusion. CT head showed multiple high-density lesions (Fig A) reported as likely myeloma deposits.

On further discussion with Radiology, a CT venogram was performed, demonstrating filling defects in the saggital, transverse and sigmoid sinuses, extending into the proximal internal jugular veins bilaterally consistent with extensive CVT. Thalidomide was withdrawn and the patient was initiated immediately on therapeutic LMWH which has been continued.

The patient made a good recovery, recently completing a sixth cycle of chemotherapy, with Bortezomib, Cyclophosphamide and Dexamethasone. His most recent MRV in December 2015 demonstrates return of flow in venous sinuses, and no residual thrombosis, with resolution of previous superficial haemorhages.

Results

graphic file with name 10.1177_2396987316642909-fig98.jpg

Conclusions

Patients receiving thalidomide or in combination should be carefully monitored for thromboembolic events.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CROSSED APHASIA FOLLOWING A RIGHT THALAMIC HAEMATOMA: INSIGHTS OF A CASE STUDY

R VERONICA ¹, C IULIAN DAN ², B LIVIU ³, T CORNELIA ⁴, C IRINA ⁵

Abstract

Background

The term crossed aphasia has undergone important changes in meaning during the last century. Individual cases of aphasia after a right hemisphere lesion in a right-hander have rarely been reported. Based on the scarce evidence of neurocognitive manifestations in dextral patients with right thalamic lesions, we aimed to discuss a case study of a patient with right thalamic haematoma and language impairment.

Methods

We describe the case of a female patient, 76 year-old, right-handed, who developed a sudden left hemiparesis with sensitive impairment and mutism.

Results

The case study reveals no previous cardiac or vascular known pathology, nor documented cerebro-vascular events (anamnesis and imagery). The patient had no family history of left handeness or ambidexterity. The CT cerebral scan performed few hours after the onset of the symptoms showed a localized right thalamic haematoma, highely suggested of a hypertensive etiology. The initial neuropsychological exam described mutism with spared verbal comprehension, with gradual improvement of the neurolinguistic abilities of the patient. A three month control, showed overall improvement of the neurocognitive impairment, including aphasya.

Conclusions

Crossed aphasya in dextrals following a right thalamic lesion, is rare. The study of this case report highlights the coexistence of an oral versus written language dissociation and a 'mirror-image' lesion-aphasia profile. Cognitive and neurovascular corelations implying right thalamic stroke still represent a challenge concerning the underlying mechanisms involved, including neuroplasticity phenomena.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CAROTID REOCCLUSION AFTER ENDARTERECTOMY IN A PATIENT WITH A MUTATION FOR MTHFR A1298C POLYMORPHISM

S Vidale ¹, S Bellocchi ², R Caronno ³, M Arnaboldi ¹

Abstract

Background

Significant carotid stenosis is a well-documented risk factor for ischemic stroke and carotid endarterectomy (CEA) or carotid artery stenting (CAS) are effective preventive procedures. The incidence of carotid restenosis after CEA is variable from 0.6% to 8%.

Methods

We report a case of a complete early carotid occlusion after CEA in a patient with a following diagnosis of hyperhomocysteinemia due to a homozygous mutation for MTHFR A1298C polymorphism.

Results

A 79-years old woman was admitted to the Neurosurgical Department to perform a CEA because of a progressive carotid stenosis. The procedure was conducted under general anesthesia and continuous electroencephalographic monitoring. During the intervention, the ulcerated plaque was completely removed and without complications post-intervention. At 3-months radiological follow-up, the ColorDoppler Ultrasound Scan and the CT angiography detected a complete occlusion of the treated carotid artery. The patient started promptly a double antiplatelet therapy. At complete blood thrombophilic screening a significant hyperhomocysteinemia was detected. A following genetic test revealed a homozygous mutation for MTHFR A1298C polymorphism. The patient started immediately folic acid associated to pyridoxine. At following radiological follow-ups the condition remained stable without neurological events.

Conclusions

The identification of hyperhomocysteinemia before CEA could lead to a prompt treatment with pyridoxine and folic acid or 5-methyltetrahydrofolate in the case of gene polymorphisms. This therapy could contribute to a reduction of the homocysteine levels and the risk of an early carotid restenosis, consequently.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CEREBRAL VENOUS SINUS THROMBOSIS IN PATIENT WITH INTRACRANIAL HYPOTENSION AFTER EPIDURAL ANESTHESIA

K Wiegler Beiruti ¹, K Galina ¹, R Shahien ¹

Abstract

Background

Cerebral venous sinus thrombosis (CVST) is a rare complication in patients with intracranial hypotension (IH). It requires prompt diagnosis and treatment due to its potential morbidity. The wide variety of clinical and radiographic manifestations contributes to the frequent diagnostic difficulties and initial misdiagnosis is common. Prognosis is better in comparison to arterial stroke and treatment is based on full anticoagulation.

Methods

We report here on a patient who developed IH followed by CVST after epidural anesthesia.

Results

A 22-year-old post-partum woman who underwent epidural anesthesia suffered the next day from severe orthostatic headache. She was treated by epidural blood patch with partial and temporary improvement. Non-contrast brain CT revealed bilateral mild subdural collection and hyperdense sign of cortical veins. The patient was diagnosed with severe IH post epidural anesthesia followed by bilateral subdural fluid collection and CVST. IH was treated conservatively and cortical vein thrombosis with heparin. Brain MRI showed cortical vein thrombosis with magnetic susceptibility effect on T2* susceptibility weighted imaging and left frontal infarct. Initial treatment with heparin was followed by warfarin. Her neurological condition improved gradually, headache resolved and she was discharged without any sequelae.

Conclusions

CVST is an uncommon but important complication affecting patients with IH. It may be explained by the dilatation of the intracranial veins with stasis, vein traction with endothelial damage and decrease in CSF volume. In our case CVST coexists with subdural collection secondary to intracranial hypotension. The treatment is therefore challenging due to the potential risk of subdural collection growth with anticoagulation.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

LARGE VESSEL VASCULITIS PRESENTING AS VISUAL DISTURBANCE AT A TIA CLINIC - BEWARE CAROTID BRUITS

F Wright ¹

Background

Syncope and presyncope represent a significant percentage of TIA mimics referred to rapid access services in the UK.

We present a case of large vessel vasculitis presenting with presyncopal visual disturbance and syncope in the presence of bilateral carotid bruits. We demonstrate the utility of FDG-PET (fluorodeoxyglucose positron emission tomography) scanning to diagnose disease activity in cases with no systemic symptoms and no raised inflammatory indices. A phenomenon commoner in male patients

Methods

A 36 year old male was referred for cerebrovascular clinic assessment after developing presyncopal bilateral visual blurring and several episodes of syncope in the presence of loud bilateral carotid bruits. He smoked with no other vascular risk factors. There were no constitutional features typical of vasculitis and inflammatory markers were not elevated.

MRA demonstrated extensive extracranial vascular occlusive disease with no enhancement. PET scanning confirmed high FDG uptake within the walls of the thoracic aorta and its main branches consistent with large vessel arteritis.

graphic file with name 10.1177_2396987316642909-fig99.jpg

Results

Whilst an unreliable indicator of severity of arterial disease, carotid bruits, particularly in young patients, should not be ignored. Without treatment this patient may have sustained a significant arterial ischaemic event

Conclusions: FDG-PET scanning is helpful in diagnosing and monitoring large vessel vasculitis particularly in cases with minimal systemic symptomatology and inflammatory marker responses prior to immunospupressive therapy

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

LEFT ATRIAL MYXOMA AND ISCHEMIC STROKE: TWO CASE REPORTS

M Xifaras ¹, M Michailidou ¹, E Tzika ¹, K Kontokostas ¹, E Kerezoudi ¹

Abstract

Background

Primary cardiac tumors were found in 0.02% of the population in large autopsy series and in approximately three quarters of instances these tumors were histologically benign. Atrial myxoma is a benign and the most common tumor of the heart and a source of emboli to the central nervous system. About 75% of the cases occur in the left atrium.

Methods

This report presents two cases of ischemic stroke induced by a left atrial myxoma. A 41-year-old woman was transferred to our hospital with right hemiparesis. The neurological and radiological findings indicated that she had suffered ischemic stroke with recent multiple infarcts in the left cerebral hemisphere. She had no vascular risk factors or any history of cardiac disease. Workup for a possible rheumatologic disorder or for thrombophilic risk factors was negative. In the second case a 63-year-old woman suffered an acute stroke with right hemiparesis due to a left hemispheric infarct. Her past medical history was significant for atrial fibrillation, hypertension and dyslipidemia.

Results

Transthoracic echocardiography, thorax CT and heart MRI in both of them identified a left atrial myxoma which was not prolapsing through the mitral valve.

Conclusions

Complications in the central nervous system can be the initial manifestation of atrial myxoma in 25% of patients, as it is an important source of cerebral embolism. Young adults with stroke and without cardiovascular risk factors in particular should be investigated for cardiac myxoma. Atrial myxoma is a rare but treatable cause of cardiogenic stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ULTRASOUND AS A METHOD TO DIAGNOSE GIANT CELL ARTERITIS COMPLICATED BY STROKE

S Andole ¹, M Krommyda ², N Gadapa ²

Abstract

Background

We present two cases wherein diagnosis of GCA and prompt treatment was possible without any significant but uncommon complications such as Stroke. We have successfully reduced the need for biopsy, which is the gold standard but may lead to a false negative test. The sensitivity and specificity for detection of GCA is in the order of 88% and 96% respectively.

Methods

Both these male patients who are 69 and 79 year old were referred to medical emergency team following throbbing headaches and visual disturbance of 2 to 3 days duration. They both had previous medical histories of hypertension and Polymyalgia rheumatica which was diagnosed several years ago and were not on any active treatment.

They were seen by primary physician and were already suspected to have had possible GCA.Duplex Doppler Ultrasound with imaging showed halo sign on Superfical Temporals.

Results

A B mode colour Duplex Doppler which was used to image the artery and assess for wall inflammation (or "Halo sign" - dark hypoechoic area around the vessel lumen probably due to arterial wall oedema) was identified in both the patients. The halo was present in two planes and is circumferential. There was no flow occlusion or limitation which could have led to stroke or other skin complications.

Conclusions

Ultrasound Duplex of Superficial Temporal Artery is non invasive and reliable way of diagnosing Giant Cell Arteritis (GCA). Increasing and reliable use of vascular technology in identifying otherwise complex conditions is now embedded in guidelines of many Professional Performance Societies.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE VALUE OF CARDIAC TROPONIN I AMONG BULGARIAN ACUTE ISCHEMIC STROKE PATIENTS

S Dakova ¹, K Ramshev ², Z Ramsheva ³

Abstract

Background

Elevated troponin levels after acute ischemic stroke are common and associated with increased risk of death and cardiac complications. The aim of the study was to investigate if the elevated levels of cTnI in Bulgarian ischemic stroke patients are relevant to predict higher hospital mortality

Methods

We have retrospectively investigated 2561 patients from 11.2012 to 11.2014. Brain CT and MRI were used on admission and 218/2561 of them were diagnosed as(AIS).The severity of neurological deficit were scoring based on NIHSS. The patients' functional condition was assessed on discharge by modified Rankin scale(mRS). Troponin I was monitored on the 1st, 3rd and 5th day. Exclusion criteria were SAH or ICH, renal failure, acute coronary syndroms, acute PE

Results

The average age of patients was 75,27 ± 12,6(SD) years.The age of men was 72,64 ± 13.50(SD)years, and of women 75,27 ± 12,67(SD)years. In hospital mortality among patients was 43.6%(95/218). The number of discharged patients were 123/218 (56.4%).The cTnI was investigated on the 1st, 3rd and 5th day.The established upper limit of cTnI was 0.06 mg/l.We found higher levels in 47.2% (103/218) on admission, in 119/218 (54,6%) on the 3rd day and on the 5th day in 93/218.Among patients with higher cTnI on admission those who died in hospital were 73/103 (70.9%), on the 3rd day 91/119 (76.5%), and 77/93 82.8%.Mortality rate was statistically and significantly higher in patients with levels of cTnI upper than 0.06 ng/ml

Conclusions

The study showed increased levels of cTnI in patients with AIS died in hospital.Those results gave us the ground to use cTnI for early stratification of high risk patients

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

DETECTING SUBDURAL HEMATOMA USING MICROWAVE TECHNOLOGY

J Ljungqvist ¹, S Candefjord ², M Persson ², T Skoglund ¹, M Elam ³

Abstract

Background

In 2014 we reported “proof-of principle” results showing that microwave-based brain scans on patients hospitalized for stroke were capable of differentiating hemorrhagic from ischemic strokes (Persson et al, 2014). From start, one major aim of this project has been to develop a system suitable for prehospital investigation of patients with suspected stroke or traumatic brain injury (TBI). This abstract reports results from our first clinical study on TBI patients.

Methods

After ethical/regulatory review, 20 patients (12 male; age 54–90) admitted for neurosurgical treatment of chronic subdural hematoma have been investigated, and compared to 17 age/gender-matched healthy controls. The classification algorithm was trained on measurements from patients with confirmed diagnosis, using a leave-one-out procedure. The classification accuracy was evaluated using the area under receiver operating characteristic (ROC) curve (AUC).

Results

For selected parameter settings an AUC of 0.94 for a frequency interval of 0.60–1.30 GHz was obtained. For example, the ROC point at 95 % sensitivity gives 71 % specificity. These parameter settings as well as the high AUC value needs to be confirmed on larger patient populations.

Conclusions

This pilot study indicates that a microwave-based brain scan has the capacity to identify traumatic intracranial bleedings. Chronic subdural hematomas requiring treatment are often large, but microwave-scattering patterns may be more complex due to hematoma changes over time. We are presently planning a trial on acutely hospitalized TBI patients with/without intracranial hemorrhage according to CT.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

REMOTE ISCHAEMIC CONDITIONING AFTER STROKE TRIAL (RECAST)

T England ¹, A Hedstrom ¹, S O'Sullivan ¹, R Donnelly ¹, N Sprigg ², P Bath ²

Abstract

Background

Brief, repeated episodes of limb ischaemia and reperfusion (remote ischaemic conditioning, RIC) applied after ischaemic stroke may protect the brain from further damage.

Methods

We performed a pilot blinded sham-controlled trial in patients with acute ischaemic stroke, randomised 1:1 to receive four 5-minute cycles of RIC in the non-paretic arm within 24 hours of ictus. The primary outcome was tolerability and feasibility. Secondary outcomes included safety; clinical efficacy at Day 90 (mRS, NIHSS) and putative biomarkers (pre- and post-intervention, Day 4). Statistical significance was taken at p < 0.05.

Results

26 patients (13 RIC, 13 sham) were recruited at mean 16.3 hours (SD 5.9) post onset, age 76.2 (10.5), BP 159/83 (25/11) and NIHSS 7.4 (5.6). RIC was well tolerated: 49/52 cycles competed in full; average 3.8 cycles/patient. 3 patients experienced vascular events in the sham group: 2 ischaemic strokes and 2 myocardial infarcts versus none in the RIC group (p = 0.076, log-rank test). Compared to sham, there was a significant decrease in Day 90 NIHSS in the RIC group: mean difference −3.5, 95% confidence interval (CI) −6.5 to −0.4, p = 0.016 (adjusted for age and baseline NIHSS). There was no effect on Day 90 mRS. Plasma analysis showed significantly raised total heat shock protein (HSP) 27 (p < 0.05, repeated 2-way ANOVA) and phosphorylated HSP27 (p < 0.001) in the RIC group compared to sham.

Conclusions

RIC after acute stroke is well tolerated and appears safe and feasible. RIC may improve neurological outcome and protective mechanisms may be mediated through HSP27. A large trial is now warranted.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

A MULTICENTRE RANDOMISED PLACEBO-CONTROLLED TRIAL TO ASSESS THE EFFECT OF DEPROTEINIZED HEMODERIVATE IN PATIENTS WITH POST-STROKE COGNITIVE IMPAIRMENT (ARTEMIDA STUDY)

A Guekht ¹, I Skoog ², A Korczyn ³, V Zakharov ⁴, S Edmundson ⁵

Abstract

Background

Post-stroke cognitive impairment (PSCI) is a common consequence of stroke and contributes substantially to its burden. To date no drug treatment has shown convincing clinical evidence of restoring cognitive function or preventing further decline after stroke. Deproteinized hemoderivate (Actovegin) demonstrated multifaceted effects in animal models and promising efficacy in pilot clinical studies. However, its effect in PSCI was not assessed in the form of long-term, prospective, large scale clinical trial.

Methods

Patients with ischaemic stroke were recruited from 33 hospitals in 3 countries. Within seven days of stroke onset patients were randomized to Actovegin (2000 mg/day for up to 20 intravenous infusions followed by 1200 mg/day orally) or placebo for a six-month treatment period and a follow up for six months. The primary endpoint was the change from baseline in the Alzheimer’s disease Assessment Scale (ADAS-Cog+) at 6 months. Secondary endpoints were Montreal Cognitive Assessment; dementia diagnosis (ICD-10); NIHSS; Barthel Index; EQ-5D; Beck Depression Inventory. Safety assessment included reported adverse events.

Results

A total of 503 subjects were randomised. There was a significant difference in favor of Actovegin vs. placebo in the ADAS-Cog+ change from baseline at 6 months (LS mean difference −2.3 (95% (CI −3.9, −0.7); p = 0.005). Several secondary outcome parameters confirmed superiority of Actovegin vs placebo. Recurrent ischaemic stroke was the most frequently reported serious adverse event, with a non-significantly higher numbers on Actovegin vs. placebo. The safety experience was consistent with the known safety and tolerability drug profile.

Conclusions

Actovegin improves cognitive outcomes in patients with ischaemic stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

COMPARISON OF CLINICAL AND NEUROSONOLOGICAL PARAMETERS IN DIABETIC AND NON-DIABETIC STROKE PATIENTS

I Meyer ¹, O Bill ¹, M Mazya ², P Michel ¹, T Taborda Prazeres Moreira ², L Hirt ¹

Abstract

Background

Patients with diabetes may develop early cerebrovascular disease manifesting as a higher burden of atherosclerosis. We hypothesised that diabetics in an acute stroke population would differ in cervical vessel ultrasound pathology compared with non-diabetics from the same cohort.

Methods

We retrospectively analysed all acute ischemic stroke patients from the ASTRAL registry who underwent precerebral neurosonology within 7 days of symptom onset and compared clinical and neurosonological data between diabetics and non-diabetics: blood flow velocities and degree of stenosis, pulsatility index (PI) and resistivity index (RI) for both common (CCA) and internal carotid artery (ICA), intima-media thickness (IMT), plaque morphology (heterogeneity, ulceration, thrombi, echo-lucency).

Results

On univariate analysis, diabetic stroke patients (n = 320) have significantly (p < 0.001) more cardiovascular co-morbidities including hypertension, hypercholesterolemia, obstructive apnea syndrome, obesity and peripheral artery disease compared to non-diabetics (n = 1185). Highly significant (p < 0.001) neurosonological results are shown in the graph. Hyperechogenic plaques were also more significantly detected in diabetics (p = 0.01), while all other parameters were not significant.

graphic file with name 10.1177_2396987316642909-fig100.jpg

Conclusions

The results suggest that diabetics suffering from an acute stroke exhibit a higher neurosonological atherosclerotic burden compared to non-diabetics. This may be a direct cause of diabetes or of confounding factors, such as the higher prevalence of other cerebrovascular risk factors in diabetics, and is currently under study.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

HIGH sLOX-1 AND LOW NO LEVELS IN ACUTE ISCHEMIC STROKE PATIENTS WITH INTERNAL CAROTID ARTERY STENOSIS

S Muengtaweepongsa ¹

Abstract

Background

Soluble LOX-1 (sLOX-1) and NO are potential biomarkers for vascular oxidative stress that affect to atherosclerotic plaque. Atherosclerotic narrowing of the internal carotid artery is a well-known cause of acute ischemic stroke (AIS).

Objectives: To measure serum sLOX-1and NO levels in acute ischemic stroke patients with or without ICA stenosis after 24 hour-stroke symptom onset.

Methods

118 patients with AIS within 24 hours after the symptom onset. Peripheral venous blood of patients was collected and measured blood sugar, cholesterol, triglyceride, HDL-c, and LDL-c concentrations by standard laboratory techniques, and serum sLOX-1 and NO concentrations by ELIZA kits. Internal carotid artery of all patients were measured stenosis by ultrasound carotid duplex and then the patients were divided into two groups i.e. non-internal carotid stenosis (NICAS, n = 65) and internal carotid stenosis (ICAS, n = 53).

Results

Baseline characteristics were not significantly different between NICAS and ICAS except LDL-c levels. Serum NO level was significantly reduced in ICAS (50.09 ± 7.36 µmol/l) when compared with NICAS (54.85 ± 11.81 µmol/l). Soluble LOX-1 was increased significantly in ICAS (1.82 ± 0.34 ng/ml) compared with NICAS (1.13 ± 0.40 ng/ml).

Conclusions

High sLOX-1 levels and lower NO levels are associated with AIS patients with ICAS. These parameters may become the novel potential biomarkers for predicting acute ischemic stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

HEAD POSITION IN STROKE TRIAL (HEADPOST) PILOT PHASE RESULTS ¹Clinica Alemana - Universidad del Desarrollo, Internal Medicine, Santiago, Chile ²University of Sydney, Sydney Medical School, Sydney, Australia³The George Institute for Global Health, Neurological & Mental Health Division, Sydney, Australia⁴Fukuoka University, Preventive Medicine and Public Health, Fukuoka, Japan⁵Hospital Clinico Dr. Lautaro Navarro Avaria, Medicine, Punta Arenas, Chile⁶Hospital de Clinicas de Porto Alegre, Neurology, Porto Alegre, Brazil⁷Royal Prince Alfred Hospital, Neurology, Sydney, Australia⁸Universidad de Chile, Neurological Sciences, Santiago, Chile

V Olavarria ¹, A Brunser ¹, P Muñoz-Venturelli ^1,², H Arima ^2,^3,⁴, F Gonzalez ¹, J Gaete ⁵, S Martins ⁶, L Billot ^2,³, C Anderson ^2,^3,⁷, P Lavados ^1,⁸

Abstract

Background

Controversy exists over the optimal head position in acute ischemic stroke (AIS) patients in the first 24–48 hours. Interventions that augment cerebral blood flow (CBF) could be beneficial. The simplest way to do this could be to place the head in “lying flat” rather than “sitting up” position. Potential benefits may be offset by an increased risk of pneumonia or cardiac failure.

Aims: HeadPoST Pilot was designed to determine the safety, feasibility and potential efficacy of the “lying flat” compared to the standard “sitting up” head position in AIS patients.

Methods

International, cluster randomized, open, blinded endpoint assessment, active-comparative proof of concept clinical trial. Patients were included within 12 hours of symptom onset, anterior circulation infarction, NIHSS > 1, and adequate transcranial Doppler (TCD) sonographic window. Main efficacy outcome was mean CBF velocity in the “lying flat” compared to the “sitting up” head position assessed by TCD to the middle cerebral arteries. Secondary objectives were safety and neurological status at 7 days, and disability at 90 days.

Results

From January 2013 to July 2015, 94 patients were randomized to 48 clusters in 3 centers. No safety concerns were raised by the DSMB. The main results will be presented at the conference

Conclusions

The lying flat head position is a safe, low cost, widely applicable, nursing intervention to increase CBF in AIS and may improve clinical outcomes (HeadPoST-Pilot, ClinicalTrials.gov Identifier NCT01706094).

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

SPECIFIC POINT-OF-CARE TESTING OF COAGULATION IN PATIENTS TREATED WITH NON-VITAMIN K ANTAGONIST ORAL ANTICOAGULANTS (SPOCT-NOAC)

F Härtig ¹, C Spencer ¹, A Peter ², H Richter ¹, M Ribitsch ¹, M Ebner ¹, B Ingvild ³, J Kuhn ³, D Pearman ⁴, T Peveto ⁴, J Spencer ⁴, C Zürn ⁵, U Ziemann ¹, S Poli ⁶

Abstract

Background

Non-vitamin K antagonist oral anticoagulants (NOAC) increasingly replace vitamin K antagonists for prevention of thromboembolism e.g. in atrial fibrillation (AF). For those patients annual stroke risk remains 1–2% (ischemic) and 0.2–0.5% (haemorrhagic) and their risk for any major bleeding 2–3.5%. Subsequently, stroke and emergency physicians face a growing number of NOAC-treated patients with acute (cerebro-)vascular complications. Rapid assessment of coagulation in NOAC-treated patients is vital prior to thrombolysis or urgent surgery, but sensitivity/specificity of existing point-of-care testing (POCT) is suboptimal. For the first time we evaluate NOAC-specific POCT.

Hypothesis: Ecarin clotting time (ECT)- and anti-Xa activity (aXa)-POCT accurately predict plasma concentrations of dabigatran and apixaban/edoxaban/rivaroxaban.

Methods

SPOCT-NOAC is a prospective, non-randomized, four-arm parallel group, observational study. 160 patients undergoing NOAC therapy will be enrolled (N = 40 per NOAC). Six blood samples are collected from each patient: before NOAC intake, 30 min, 1, 2, and 8 h after intake and at trough. NOAC plasma concentrations are determined using mass spectrometry.

Results

Currently 138 blood samples of 23 dabigatran-treated patients, 66 of 11 apixaban-patients, and 54 of 9 rivaroxaban-patients have been analysed. Dabigatran-concentrations ranged from 0–371 ng/mL and ECT-POCT from 20–219 s. Apixaban- and rivaroxaban-concentrations ranged from 0–246 and 0–354 ng/mL and aXa-POCT from 43–438 s and 41–537 s. Pearson’s correlation coefficient was 0.94 for ECT-POCT/dabigatran-concentrations, and 0.61 and 0.63 for aXa-POCT/apixaban- and rivaroxaban-concentrations, respectively.

Conclusions

This is the first study evaluating NOAC-specific POCT. Preliminary results show excellent correlation between ECT-POCT and dabigatran. Relevant dabigatran-concentrations (>50 ng/mL) were detected in 100%. More pioneering results on NOAC-specific POCT will be presented.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

MULTI-STATE MODELS FOR THE ANALYSIS OF LONGITUDINAL MODIFIED RANKIN SCORES APPLIED TO THE STROKE OXYGEN STUDY

J Potts ¹, J Belcher ¹, C Roffe ¹, J Sim ²

Abstract

Background

Multi-state models can be used to describe transitions through a series of states, including death, during a continuous period of time. This method is demonstrated in relation to the modified Rankin Scale recorded at 90, 180, and 365 days from the Stroke Oxygen Study (n = 8003).

Methods

A multi-state model that only allowed transitions to adjacent states was used. Covariates included in the model were the intervention received (continuous oxygen or no oxygen) and the National Institutes of Health Stroke Score at baseline, which is an accepted indicator of stroke severity. The inclusion of covariates was determined using a likelihood ratio test.

Results

The likelihood ratio showed that only the covariate for treatment was not significant in the model (p = 0.55). This is reflected in the hazard ratios and 95% confidence intervals presented below, showing the chance of moving to the next state for those receiving continuous oxygen compared to control. Prevalence plots suggested a reasonable model fit to the data.

graphic file with name 10.1177_2396987316642909-fig101.jpg

Conclusions

Although the effect of treatment in the model was non-significant, this method gives us a new way of thinking about how to analyse scales whose ordinality may be questionable, with a simple and meaningful interpretation.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EFFECTS OF SURFACE COOLING ON STROKE OUTCOME TRIAL (COOL): RESULTS OF A SAFETY AND FEASIBILITY STUDY

RJ van Hooff ¹, A De Smedt ¹, J De Keyser ¹, R Brouns ¹

Abstract

Background

Fever is an independent predictor of poor outcome in patients with acute stroke. Experimental data and clinical studies indicate that therapeutic hypothermia has neuroprotective effects. Our previous pilot study in healthy volunteers demonstrated that inducing surface cooling by application of EMCOOLS Brain.Pad™ is safe.

Methods

Surface cooling was induced by applying EMCOOLS Brain.Pad™ during 60 minutes within 24 hours after symptom onset in patients with acute stroke. Tolerance of cooling was assessed by a questionnaire (Bedside Shivering Assessment Scale (BSAS)) every 15 minutes and a checklist of side-effects. Assessing safety, we measured vital parameters (blood pressure, heart rate and blood oxygen saturation) every 5 minutes, starting 5 minutes before application of the pads. Uniquely, cerebral blood flow was continuously monitored with transcranial Doppler. Assessing efficacy, we measured temperature at 4 key locations (inguinal, mastoid, tympanic and temporal) at the same interval.

Results

Twenty patients were included. Median NIHSS score on admission was 8. A significant drop in temporal temperature and tympanic temperature (37.2 vs. 36.6°C and 36.8 vs. 36.4°C; both p < 0.001) was noted. Surface cooling had no impact on other vital parameters or cerebral blood flow. Maximum median BSAS score was 1. Apart from transient erythema of the skin, no side effects were noted.

Conclusions

Induction of mild hypothermia through surface cooling with EMCOOLS Brain.Pad™ is well tolerated, feasible and safe. A significant decrease of 0.6°C temporal temperature was noted during cooling. Potential effects on stroke outcome still need to be addressed.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

RELIABILITY OF STROKE SEVERITY ASSESSMENT VIA TELEMEDICINE BY NON-STROKE EXPERTS USING THE UNASSISTED TELESTROKE SCALE

RJ van Hooff ^1,², K Guldolf ¹, F Vandervorst ¹, L Yperzeele ^2,³, A De Smedt ^1,², A Valenzuela Espinoza ^2,⁴, J De Keyser ^1,², R Brouns ^1,²

Abstract

Background

Timely assessment of stroke severity is pivotal for adequate therapy decision making. Prehospital telestroke enables stroke neurologists to be virtually present in the ambulance, facilitating early, specialized stroke treatment during transportation to the hospital. Remote assessment of stroke severity with the NIHSS has several drawbacks, which has led to the development of the Unassisted TeleStroke Scale (UTSS). The goal is to evaluate whether the UTSS can reliably be obtained by non-stroke experts (i.e. neurologists in training) unexperienced in telemedicine care.

Methods

Twenty-eight patients admitted to the Stroke Unit of the Universitair Ziekenhuis Brussel for suspicion of acute stroke were assessed via bedside examination using NIHSS and via teleconsultation by stroke neurologists using UTSS. Two non-stroke experts used blinded recordings of teleconsultations for evaluation of the UTSS. Scale reliability was assessed by inter-rater and intra-rater variability, internal consistency, and rater agreement. Concurrent validity was evaluated by comparing UTSS with NIHSS.

Results

Results of the inter-rater variability were excellent (ρ = 0.94 between non-stroke experts, and ρ = 0.95 and 0.93 between stroke neurologists and each non-stroke expert, P < 0.001 for all). The intra-rater variability of the two non-stroke experts was also excellent (ρ = 0.98 and 0.92, P < 0.001 for both). Internal consistency of the UTSS and the agreement among raters for the total UTSS score were excellent. The UTSS correlated strongly with the NIHSS.

Conclusions

These results indicate that the UTSS is a robust scale that can easily and reliably be obtained without need for extensive training or specific expertise. Findings require confirmation in a larger cohort.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

BLOOD PRESSURE AND STROKE RECURRENCE AFTER TRANSIENT ISCHEMIC ATTACK: THE FUKUOKA STROKE REGISTRY

K Wakisaka ¹, T Kuwashiro ², T Ago ³, N Makihara ¹, H Takaba ¹, M Yasaka ², M Kamouchi ⁴, Y Okada ², T Kitazono ³

Abstract

Background

We investigated whether blood pressure in the acute phase could be a predictive factor of the subsequent stroke recurrences in transient ischemic attack (TIA) patients.

Methods

Of 6,336 stroke patients registered in the Fukuoka Stroke Registry from June 2007 to May 2012, we evaluated clinical characteristics on admission and clinical courses of 606 TIA patients who sought medical attention within 24 hours of onset. We divided the patients into five quintiles (Q1, Q2, Q3, Q4, and Q5 in an ascending order) according to their mean systolic blood pressure (mSBP) for 3 or 7 days after TIA onset, and investigated the risk of stroke recurrences in each group within one year after TIA.

Results

Of the 606 patients, 79 (13.1%) suffered stroke recurrences during the first year after TIA. The age- and sex-adjusted Cox proportional hazards model showed that hazard ratio (HR) of stroke recurrences in the first year after TIA for Q5 vs. Q1 patients was 2.03 (95% confidence interval [CI] 1.12–3.82, p = 0.020) for 3-day mSBP and 2.60 (95% CI 1.37–5.19, p = 0.003) for 7-day mSBP. After adjustment for multiple confounding factors (risk factors for stroke, TIA symptom, and duration), HR for Q5 vs. Q1 was 1.93 (95% CI 1.06–3.66, p = 0.032) for 3-day mSBP and 2.53 (95% CI 1.33–5.08, p = 0.004) for 7-day mSBP.

Conclusions

A high blood pressure in the acute phase of TIA is associated with an increased risk of 1-year stroke recurrence.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CAUSES OF DISAGREEMENT IN MODIFIED RANKIN SCALE (MRS) SCORES IN THE CLOT LYSIS EVALUATION OF ACCELERATED RESOLUTION OF INTRAVENTRICULAR HEMORRHAGE III (CLEAR-III) TRIAL; THEMATIC ANALYSIS

A Wilson ¹, H Butorova ², J Dawson ³, DF Hanley ⁴, K Lane ⁴, TJ Quinn ³, G Yenokyan ⁵, - CLEAR -, III Investigators ⁴, KR Lees ¹

Abstract

Background

Inter-rater disagreement in mRS scoring is common in stroke trials but reasons for disagreement are poorly understood. During central adjudication of video recorded mRS assessments system in large clinical trials, multiple experienced raters provided scores independently, recording scoring comments concurrently. We performed thematic analysis of these comments to identify factors contributing to disagreement or uncertainty.

Methods

We included mRS assessments where there was disagreement between the site score and first central adjudication score. These assessments were then independently scored by 4 trained raters. Raters’ comments were examined (HB, AW and JD) and subjected to thematic analysis. Initial data coding was performed followed by generation of themes (HB), which were reviewed, refined (HB, JD, AW) and described across each boundary.

Results

318 mRS assessments were included, among which the four raters agreed completely in 103 and showed some disagrement in 215 instances (table 1). Disagreements were most common in the mid range of the scale. Themes of disagreement related to variation in interpretation of reports of mild symptoms, activity or mobility loss; presence of features from more than one mRS category; presence of cognitive impairment; and instances where the relationship between reported limitations and index stroke was unclear.

graphic file with name 10.1177_2396987316642909-fig102.jpg

Conclusions

We identified common themes of disagreement which will inform improvements in mRS training documents and may strengthen quality of mRS assessments in clinical trials.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CENTRAL ADJUDICATION OF MODIFIED RANKIN SCORES (CARS) IN THE CLOT LYSIS EVALUATION OF ACCELERATED RESOLUTION OF INTRAVENTRICULAR HEMORRHAGE III (CLEAR-III) TRIAL

A Wilson ¹, J Dawson ¹, DF Hanley ², K Lane ², K McArthur ¹, TJ Quinn ¹, S Mayo ³; CLEAR-III Investigators², KR Lees ¹

Abstract

Background

The CLEAR-3 trial utilised central adjudication of video recorded mRS assessments. This guaranteed blinding, and facilitated continuous quality control and consistent consensus review of difficult cases. We evaluated performance of this system.

Methods

Videoed mRS assessments were uploaded to the CARS portal by the site. They were then quality checked and assessed by a single trained rater, if necessary following translation of the audio component. If this 1st rater mRS score matched the local site score this common score was assigned. If there was disagreement, the assessment underwent 4 further independent ratings before committee discussion and consensus scoring. We assessed agreement rates and timelines for adjudication.

Results

1180 assessments were uploaded from 9 countries. 344 required committee review (80% overall agreement). Delay to final adjudicated mRS score was under 4 hours (table). Committee review assigned a different score to the site in 68% (n = 237) of cases (20% overall) and changed the categorical trial outcome in 8% (19 cases; 2% overall) (mRS 3 vs 4 [n = 5] or 4 vs 3 [n = 14]).

graphic file with name 10.1177_2396987316642909-fig103.jpg

Conclusions

CLEAR-III was the first international trial to utilise the CARS system. Central adjudication of mRS assessments is feasible, can be delivered rapidly, with good reliability in large international, multi-centre clinical trials and has an impact on the assigned scores of a magnitude that would influence trial interpretation.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

STUDY PROTOCOL OF “FIND TECHNOLOGY”: A RANDOMISED CONTROL TRIAL INVESTIGATING THE FEASIBILITY AND EFFICACY OF CONTROLLER-FREE INTERACTIVE DIGITAL TECHNOLOGY IN AN INPATIENT STROKE POPULATION

ML Bird ¹, J Cannell ², M Callisaya ³, E Moles ², K Lane ², A Tyson ², A Rathjen ², S Smith ⁴

Abstract

Background

Stroke is a frequently occurring event, often leaving a legacy of high burden. Activity in rehabilitation has the potential to improve physical outcomes, but the dose of such rehabilitation is typically poor. The aim of this study was to determine if new technology using controller-free games may increase client engagement, activity levels and physical outcomes.

Methods

In an RCT design, clients with recent stroke in an acute hospital setting will be allocated to either intervention (program based on stroke-specific software utilising controller-free motion capture software and commercially available hardware) and a 1:1 session of individualised therapy OR control situation (group exercise session) and a 1:1 individualised therapy session. Matched levels of time will be spent for the intervention and control. All participants will undergo a measurement session at study entry, and one after an 8-week period or prior to discharge if sooner, by a physiotherapist blinded to group allocation measuring upper and lower limb function, balance and mobility. As well, pain, fatigue, enjoyment, perception of benefits and ease of use of the system will be measured at each session.

Results

Differences in activity during the week and while in therapy will be compared using t-tests. Repeated measures analysis of variance will be used to compare changes over time and between group (intervention versus control). Sample size calculations require recruitment of 74 participants.

Conclusions

This study will provide quantifiable information regarding the differences in activity levels and outcomes from using controller-free video game technology in rehabilitation compared to usual rehabilitation.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

MEASURING FATIGUE AND PERCEIVED EXERTION IN REHABILITATION

ML Bird ¹, M Callisaya ², C Roberts ³, E Moles ⁴, K Lane ⁴, J Cannell ⁴, K Ahuja ¹

Abstract

Background

Fatigue post stroke is a major issue, distressing to individuals and without any evidence-based treatment. Impacts of fatigue on the exertion possible in rehabilitation is not known, and this is problematic when rehabilitation requires high levels of activity to drive neuroplasticity. This study aims to validate an electronic tool to measure fatigue and perceived exertion in people undergoing rehabilitation and describe the relationship between fatigue and exertion in this population.

Methods

Thirty-three adults (78.1 ± 10.8 years) undergoing rehabilitation participated in a randomised crossover trial measuring fatigue and perceived exertion after a one-hour physiotherapist supervised exercise session. Participants completed a visual analogue scale for fatigue and BORG exertion on paper and electronically (using an iPad) in a randomised order. Validity for fatigue and exertion was measured using Bland Altman (limits of agreement and bias). Regressions analysis described relationships and Odds Ratio’s calculated

Results

For fatigue there was a small negative bias (±SD of bias) towards the iPad (−3.02 ± 6.57) with limits of agreement between −15.90 and 9.86. For exertion there was a small bias (± SD of bias) towards the iPad (0.03 ± 1.29) with limits of agreement between −2.49 and 2.55. Although people with higher levels of fatigue reported higher levels of perceived exertion (OR 2.1; 95%CI 0.78 to 5.96), this result was not statistically significant (p = 0.14), perhaps due to small sample size.

Conclusions

Using electronic data collection tools to measure fatigue and exertion in clinical populations is valid. Further research to investigate the relationship between fatigue and perceived exertion is warranted.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

LONG-TERM FOLLOW-UP EFFECTS OF ADDITIONAL CORE STABILITY EXERCISES TRAINING ON IMPROVING DYNAMIC SITTING BALANCE FOR STROKE PATIENTS. A RANDOMIZED CONTROLLED TRIAL

R Cabanas Valdés ¹, A German Romero ¹, M Girabent Farrés ², C Bagur Calafat ¹, MF Caballero Gómez ³, UC Gerard ⁴

Abstract

Background

Core stability exercises (CSE) are an effective treatment for improving dynamic sitting balance, standing balance, gait and activities of daily living (ADL) in sub-acute phase but few long-term follow-up studies exist. The aim of this study is to compare the effectiveness of additional CSE on dynamic sitting balance, standing balance, gait and ADL at 3 months post intervention

Methods

Long-term follow-up analysis of a simple blinded randomized controlled trial (ClinicalTrials.gov # NCT01864382) conducted at 2 rehabilitation hospital centers. Control group and experimental group underwent conventional therapy for five days/week for five weeks and in addition the experimental group performed CSE for 15 min/day. Outcome measures were taken after training and three months later. The primary outcome measures was the change in dynamic sitting balance assessed by Trunk Impairment Scale (S-TIS) and Function in Sitting Test (FIST) and secondary outcome were changes in standing balance and gait as evaluated by Berg Balance Scale (BBS), Tinetti Test, Brunel Balance Assessment (BBA), Postural Assessment Scale for Stroke and ADL via Barthel Index. Comparisons were performed between groups using Mann-Whitney U test

Results

A total of 68 subjects completed the 3-month follow-up (36 in the experimental group and 32 in the control group). The changes in total score S-TIS (P < 0.003), its subscale dynamic sitting balance (P < 0.026), FIST (P < 0.009), BBA stepping section (P < 0.002), BBS (P < 0.009) and Tinetti gait subscale (P < 0.044) showed significant differences between both groups

Conclusions

Additional CSE exercises have a positive effect on sitting balance, standing balance and gait at 3 months post intervention.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EFFECT OF PROGNOSTIC FACTORS ON THE LONG-TERM EFFICACY OF MLC601 (NEUROAID) IN THE CHIMES-E STUDY

N Venketasubramanian ¹, CF Lee ², C Chen ³; CHIMES-E Study Investigators⁴

Abstract

Background

The CHInese Medicine NeuroAiD Efficacy on Stroke recovery- Extension (CHIMES-E) Study is among the few stroke trials with long-term outcome data. We evaluated the recovery pattern and the influence of prognostic factors on the treatment effect of MLC601 over 2 years.

Methods

CHIMES-E evaluated the long-term outcome of subjects (age ≥ 18, NIHSS 6–14, pre-stroke mRS ≤ 1) with ischemic stroke included in a randomized double-blind placebo-controlled trial of MLC601 for 3 months (M). Standard stroke care and rehabilitation were allowed. mRS was assessed in-person at M3 and by telephone at M1, M6, M12, M18 and M24.

Results

CHIMES-E included 880 subjects, mean age 61.8 ± 11.3 years, 36% female, mean NIHSS 8.6 ± 2.5. Baseline characteristics were balanced between treatment groups. The proportion of subjects improving to mRS 0–1 increased over time in favor of MLC601 most obviously at M3 and M6, thereafter remaining stable up to M24, while the proportion deteriorating to mRS ≥ 2 remained low. Subjects with ≥2 prognostic factors of poorer outcome at M3 (older age p < 0.01, female sex p = 0.06, higher NIHSS p < 0.01, treatment delay p < 0.01) showed greater benefit: OR at M3 1.65 (1.12–2.42); M6 1.78 (1.19–2.66); M12 1.90 (1.27–2.85); M18 1.65 (1.11–2.46); M24 1.39 (0.94–2.07).

graphic file with name 10.1177_2396987316642909-fig104.jpg

Conclusions

MLC601 provided persisting benefits after a stroke with more subjects improving to functional independence at M3 and M6 than placebo, which remained stable subsequently up to M24. Subjects with poorer prognosis show greater treatment effect.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

DURABILITY OF BENEFICIAL EFFECT OF MLC601 (NEUROAID) ON FUNCTIONAL RECOVERY AMONG STROKE PATIENTS FROM THE PHILIPPINES IN THE CHIMES AND CHIMES-E STUDIES

JC Navarro ¹, HH Gan ², AY Lao ³, AC Baroque II ¹, JHB Hiyadan ⁴, CL Chua ⁵, MC San Jose ⁵, JM Advincula ⁶, CF Lee ⁷, C Chen ⁸, N Venketasubramanian ⁹; CHIMES and CHIMES-E Study Investigators¹⁰

Abstract

Background

The pre-specified analysis of the Philippines (PH) data in the CHInese Medicine NeuroAiD Efficacy on Stroke recovery (CHIMES) Study showed significant benefit of MLC601 at month (M) 3. We aimed to assess the effect of MLC601 on long-term functional recovery in the PH cohort.

Methods

The CHIMES-E (extension) Study evaluated the long-term effects of MLC601. All subjects were allowed standard stroke care and rehabilitation. Modified Rankin Score (mRS) and Barthel Index (BI) were assessed in-person at M3 and by telephone at M6, M12, M18 and M24.

Results

The 378 subjects included in CHIMES-E from PH (mean age 60.2 ± 11.1; 46% female) had more women (p < 0.001), worse baseline NIHSS (p < 0.001) and longer onset to treatment (p = 0.002) compared to other countries. Baseline characteristics were similar between MLC601 (n = 192) and placebo (n = 186) groups. Odds ratios at M3 in favor of MLC601 peaked at M6, mRS shift 1.53 (1.05–2.22), mRS dichotomy 0–1 1.77 (1.10–2.83), BI ≥ 95 1.87 (1.16–3.02), and persisted at M12, M18, and M24. There were 2 recurrent strokes and 16 deaths (7 vascular) in the MLC601 group compared to 1 recurrent stroke and 14 deaths (4 vascular) in the placebo group. Other illnesses were similar between treatment groups.

graphic file with name 10.1177_2396987316642909-fig105.jpg

Conclusions

The beneficial effect of MLC601 on functional recovery and independence seen at M3 in the PH cohort is durable up to 2 years after a stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

A PILOT INVESTIGATION OF THE APPLICATION OF CATHODAL TRANSCRANIAL DIRECT CURRENT STIMULATION TO THE CONTRALESIONAL PRIMARY MOTOR CORTEX PLUS UPPER LIMB REHABILITATION POST-ACUTE STROKE

J Garcia-Vega ¹, G Gregory ², C Lind ³, D Blacker ⁴, S Ghosh ⁵, I Cooper ², B Singer ⁶

Abstract

Background

The purpose of this study was to investigate the efficacy and feasibility of applying cathodal transcranial direct current stimulation (ctDCS) concurrently with upper limb (UL) rehabilitation, and to measure motor recovery in the affected UL both clinically and using transcranial magnetic stimulation (TMS), in a post-acute (7–15 days) stroke cohort and four months post-stroke.

Methods

Design: Double-blind, sham-controlled, randomized, multisite, pilot study.Subjects were randomised to receive 10 sessions of ctDCS (1 mA) or sham tDCS to the contralesional primary motor cortex (M1) plus concurrent UL therapy for 30 minutes over a two-week period.

Results

Twelve participants completed the study. Ten participants demonstrated significant motor gains in the UL immediately post intervention and at three month follow-up, however there were no statistical differences between groups at any time point. The trend of improvement varied between groups. It was feasible to assess motor recovery over a three month period post intervention, apart from TMS assessments which were limited by logistical issues.

Conclusions

It was feasible to conduct a multisite rehabilitation trial involving patients as early as seven days post-stroke, across at least five sites. A phase II trial would depend on adequate funding, the allocation of trained staff, and the addition of more recruitment sites. Efficacy findings were inconclusive due to the unexpected improvement seen in the sham group in the present study which would indicate that this sample may be insufficient to establish the additional benefit of ctDCS to ten 30-minute sessions of UL therapy in the first month post-stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

USE OF DEVICES WITH VISUAL BIOFEEDBACK IN EARLY REHABILITATION OF THE PATIENTS SUFFERING A STROKE

T Gueye ¹

Abstract

Background

The aim of our investigation was to explore the effect of rehabilitation devices with visual biofeedback in stroke patients in early rehabilitation. In two clinical trials we compared in each fifteen patients after stroke using or robotic device Armeo Spring Power® (functional training for upper extremity) or Home balance® (Nintendo system for balance training) to control groups with only conventional physiotherapy.

Methods

The intervention lasted three weeks. The first experimental group performed upper limb functional training of hemiparetic hand together with conventional physiotherapy, control group only conventional physiotherapy (the therapeutic hours were same in both groups, 45 minutes twice a day, 4 times a week). The second experimental group performed balance training on Home balance system together with conventional physiotherapy, control group only conventional physiotherapy. Cognitive screening test MoCA, Berg Balance Scale, Rivermead index of mobility (RIM), Timed Up and Go test, and Functional Independence Measure (FIM) were assessed before and after the intervention.

Results

For group with upper extremity training we assessed also Franchay arm test. For upper limb functional training both groups demonstrated an improvement in Franchay arm test and FIM, but no statistically significant differences were found between the experimental and control groups. For group performing balance training improvement in RIM and Berg Balance Scale was most significant, but again no significant differences between the experimental and control groups.

Conclusions

Even if the improvement was similar to that achieved with conventional physical therapy alone, we found difference in patients’ adherence to a therapy and motivation with devices using visual biofeedback.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

INFLUENCE OF MONOSIALOTETRAGEKSOZIALGANGLIOSIDES AND CITICOLINES ON RECOVERY OF ALFAMOTONEURON`S FUNCTIONS AND COGNITIVE IMPAIRMENTS IN PATIENTS WITH ACUTE HEMISPHERIC ISCHEMIC STROKE

F Gumerova ¹, G Rakhimbaeva ¹, M Ataniyazov ¹

Abstract

Background

Citicoline being intermediate in the generation of phosphatidylcholine from choline improves the clinical outcome of ischemic stroke by reduction lesion`s size. Gangliosides are components of neurons membranes and also have a positive effect on neurons recovery subjected to ischemia.

Methods

The study involved 50 patients. During 10 days 25 patients in the first group received monosialotetrageksozialgangliosides, 25 patients from the second group received citicolines. Efficiency of drugs was assessed baseline and after treatment according to Barthel`s active life assessment and Mini Mental State Examination(MMSE) scales.

Results

Before treatment, the restriction of motor functions in patients from the first group was estimated at 49.7 ± 4.37 points, after treatment rates were 70.5 ± 4.75.In patients from the second group before treatment limitation of muscle activity was estimated at 48.9 ± 2.91 points, after completing of treatment – at 73.7 ± 3.88 points by Barthel`s scale. Cognitive performance in the first group improved from 21.3 ± 0.43 to 22.6 ± 0.51. In the second group: from 22.04 ± 0.39 to 24.2 ± 0.45 points.

Conclusions

Citicolins showed better results in recovery of motor activity and cognitive finctions in patients with acute ischemic hemispheric stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

DIFFERENCES IN RECOVERY OF UPPER EXTREMITY FUNCTIONING AFTER ISCHEMIC AND HEMORRHAGIC STROKE - PART OF THE SALGOT STUDY

P Hanna C ¹, A Opheim ¹, Å Lundgren-Nilsson ¹, M Alt Murphy ¹, A Danielsson ¹, K Stibrant Sunnerhagen ¹

Abstract

Background

It is unclear if and how the type of stroke influences the recovery of motor function after stroke. The purpose was to assess if there are differences in extent of change in upper extremity motor function and activity capacity, in persons with ischemic versus hemorrhagic stroke during the first year post stroke.

Methods

117 persons with stroke (ischemic n = 98, hemorrhagic n = 19) and reduced upper extremity function 3 days after onset were consecutively included to the Stroke Arm Longitudinal Study at the University of Gothenburg (SALGOT) from a stroke unit. Upper extremity motor function and activity capacity were assessed at 6 time points during the first year; age and initial stroke severity were recorded. Possible differences between groups in extent of change over time of upper extremity motor function and activity capacity were analyzed with the Mixed models repeated measurements.

Results

Significant improvements were present in function and activity in both groups within the first month (p = 0.001). Higher age and more severe stroke had a negative impact on recovery in both groups. Larger improvements of function and activity were seen in persons with hemorrhagic stroke, both from 3 days to 3 - and 12 months, and from 1 month to 3 months. Both groups reached similar level of function and activity at 3 months post stroke.

Conclusions

Poor initial motor function or activity capacity could mislead expertise and exclude persons with hemorrhagic stroke from further intensive rehabilitation.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE FACTORS ASSOCIATED WITH RETURN TO WORK AFTER STROKE: A NATIONAL SURVEY

F Horgan ¹, C Brannigan ¹, M Walsh ¹, R Galvin ², C McCormack ³, EJ Morrissey ³, C Macey ³, M Delargy ⁴, J Morgan ⁴, F Ryan ⁵

Abstract

Background

About 20–25% of stroke survivors are of working age. The aim of this national survey was to explore the factors related to returning to work after stroke from the stroke survivors’ perspective.

Methods

Community dwelling stroke survivors were recruited through stroke support groups, healthcare professionals, community and rehabilitation hospitals and non-statutory organisations. Two previously validated questionnaires, were adapted for the Irish setting. Pre and post stroke working hours were compared using a Wilcoxon matched-pairs signed-rank test. Associations between gender, geographical location, employment support and the importance of return to work were investigated using univariable logistic regression. Explanatory variables that reached a threshold p-value of ≤0.15 in the univariate analysis were entered into a multivariable logistic regression model and results were expressed as adjusted odd ratios (adjORs).

Results

A total of 122 stroke survivors with a median age of 52 years, completed the survey. Of those who worked prior to their stroke, 61% returned to work. There was a significant association found between the level of perceived employer support and return to work (adjOR = 5.78, 95% CI = 1.64, 20.38, p = 0.006). The most common problems limiting the stroke survivor’s ability to work were mental fatigue (84%), physical fatigue (78%) and difficulties with thinking (78%).

Conclusions

The level of perceived employer support was associated with returning to work after stroke. In addition, mental fatigue, physical fatigue and difficulties with thinking affected the majority of stroke survivors’ ability to work.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ADEQUACY OF REHABILITATION INTERVENTIONS AT SIX MONTHS POST-STROKE; FINDINGS FROM THE ASPIRE-S STUDY (ACTION ON SECONDARY PREVENTION INTERVENTIONS AND REHABILITATION IN STROKE)

F Horgan ¹, P Hall ², D Williams ³, A Hickey ⁴, L Brewer ², L Mellon ⁴, E Dolan ⁵, PJ Kelly ⁶, E Shelley ⁷

Abstract

Background

Few studies have assessed the profile and adequacy of access to rehabilitation services after ischaemic stroke both in the inpatient and community setting.

Methods

The aim of the ASPIRE-S (Action on Secondary Prevention interventions and Rehabilitation in Stroke) study was to assess the secondary prevention and rehabilitation profile of patients six months following hospital admission for stroke. A Rehabilitation Prescription was also completed before hospital discharge for each participant, and adherence to this prescription was assessed at six months to determine whether patients received their recommended rehabilitation needs.

Results

Two hundred and fifty six patients were recruited to ASPIRE-S. The average age was 69 years (SD 12.8). The majority (n = 221, 86%) were referred to the hospital multidisciplinary team, 59% (n = 132) were referred to all services (physiotherapy [PT], occupational therapy [OT], speech and language therapy [SLT]). 54% (n = 119) of patients (seen by the multidisciplinary team) were referred for further rehabilitation in the community on discharge. Of these 119 patients 112 (95%) recalled receiving community rehabilitation services. Most (68%) patients were referred for several disciplines (PT OT SLT). 61 patients (51%) reported a delay in services.

Conclusions

A significant number of patients (57%) did not receive the therapy recommended on discharge. Future initiatives should include the development of policies, which support more effective, equitable multidisciplinary rehabilitation for stroke patients in the community.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ASSOCIATION BETWEEN TOTAL-TAU AND BRAIN ATROPHY ONE YEAR AFTER FIRST-EVER STROKE

H Ihle-Hansen ¹, G Hagberg ¹, AR Øksengård ¹, MW Fagerland ², B Thommessen ³, K Engedal ⁴, B Fure ⁵, P Selnes ³

Abstract

Background

There is increasing evidence that degenerative and vascular dementias share pertinent pathological mechanisms. Brain atrophy (as visualized on structural MRI) and pathological cerebrospinal fluid (CSF) concentrations of microtubule-associated protein tau (T-tau) and phosphorylated microtubule-associated protein tau is thought to indicate neurofibrillary degeneration whereas decreased CSF β-amyloid reflects amyloid deposition. In this study, we aimed to explore the association between CSF T-tau and brain atrophy, measured as ventricular volume and total brain volume, one year post-stroke.

Methods

We included 210 patients with first-ever ischemic stroke or transitory ischemic attack without pre-existing cognitive impairment. After 12 months, subjects underwent MRI and CSF biomarkers were assessed. Using SIENAX (part of FSL), ventricular CSF volume and total brain volume were estimated and normalized for subject head size. The association between T-tau as explanatory variable and ventricular and total brain volume as outcome variables were studied using linear regression.

Results

182 patients completed the follow-up. 44 had a lumbar puncture. Of these, 31 had their MRI with identical scan parameters. Mean age was 70.2 years (SD 11.7). Ventricular and total brain volume on MRI was significantly associated with age, but not with gender. In the multiple regression model, there was a significant association between T-tau and both ventricular and total brain volume (p = 0.021 and p = 0.011).

Conclusions

T-tau measured one year post-stroke is associated with larger ventricle volumes and less global brain volume, both measures of brain atrophy. The findings indicate that there is a progressive degeneration with loss of neurons one year post-stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CHARACTERISTICS OF POST-STROKE PATIENTS EVALUATED WITH VASCULAR COGNITIVE IMPAIRMENT HARMONIZATION STANDARDS (VCIHS)

S Jee ¹, MK Sohn ¹

Abstract

Background

To investigate the associations between scores of K-VCIHS-NP domains and characteristics of post-Stroke patients, inpatient rehabilitation outcome.

Methods

A retrospective study reviewed 64 subacute stroke patients (mean/SD age, 66.6/11.5 years; 18.7% female; 81.2% ischemic stroke, less than 3 months of onset duration) who were admitted to rehabilitation center and underwent evaluation using the 60-min protocol of the K-VCIHS-NP. Cognitive impairments in language, visuospatial function, or memory dowere defined as a score of less than −2.0 standard deviation (SD)in each domain-specific test. Cognitive impairment in the frontal executive domain was defined as a score of less than the −2.0SD in 2 or more of the 5 frontal domain-specific tests.

Results

The number of impairment of each four specified cognitive domains were 37 (68%) in memory domain, 38 (70%) in visuospatial domain, 14 in language domain, and 38 (70%) in executive domain among 64 subjects.VCI was diagnosed in 54 patients (84%). Executive function/activation showed the lowest average value of Z-score /SD (−3.79 / 3.50). Digit Symbol Coding Test for executive function/activation was associated with LOS (CI = −0.2940), initial MRS (CI = −0.303), initial /at discharge MMSE (CI = 0.392 /0.273), MBI (CI = 0.370 / 0.274). Executive domain test correlated with MBI gain.

Conclusions

Stroke patients performed the psychometric assessments that detected neurocognitive deficits, which included executive function. This study shows that Digit Symbol Coding Test for executive function/activation is related to participants' deterioration in functional performance and post-stroke length of hospital stay.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

LONG TERM EFFECTS OF SYSTEMIZED REHABILITATION PROGRAM ON FUNCTIONAL RECOVERY IN MILD STROKE PATIENTS

EK Kang ¹, L HeyJean ², K Seongheon ³

Abstract

Background

Mild stroke patients (initial National Institutes of Health Stroke Scale, NIHSS: 0–6) have not been regarded as active candidates for systemized rehabilitation program because of their benefits of natural neurologic recovery. This study was purpose to elucidate the long term effects of systemized rehabilitation program on functional recovery in mild stroke patients.

Methods

A total of 152 mild stroke patients (105 males, age 71.8 ± 11.7 years old) admitted in a Regional Cerebrovascular Center with completion of 12-month follow-up were recruited. Application of systemized rehabilitation program (Rehab-Pro) was classified with status of transfer to rehabilitation department or discharge to other rehabilitation hospital from acute stroke center. Functional recovery state was evaluated using modified Rankin score (mRS) at the time of discharge, 1, 3, and 12 months after discharge.

Results

Recruited patients were classified into Rehab-Pro group (n = 35) and non-Rehab-Pro group (n = 117). In Rehab-Pro group, compared to mRS of discharge (2.9 ± 0.3 [mean ± SE]) mRS of 1 month (2.3 ± 0.2, p = 0.007), 3 months (2.1 ± 0.2, p = 0.001), and 12 months (2.1 ± 0.3, p = 0.009) were significantly decreased. In non-Rehab-Pro group, mRS of 1 month was significantly increased compared to mRS of discharge (0.9 ± 0.1 vs. 0.7 ± 0.1, p = 0.013) without any improvements at 3 and 12 months.

graphic file with name 10.1177_2396987316642909-fig106.jpg

Conclusions

Mild stroke patients with systemized rehabilitation program showed long-term functional recovery, while those without this program showed inverse functional deterioration at 1 month after discharge, with implicating the benefits of systemized rehabilitation in mild stroke patients.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE IMPACT OF CO-OCCURRENCE OF DYSARTHRIA AND APHASIA ON FUNCTIONAL RECOVERY IN POST-STROKE PATIENTS

G Kim ¹, EK Kang ¹

Abstract

Background

The fact that post-stroke patients often experience co-occurrence of both dysarthria and aphasia emphasizes the necessity of considering both aphasia and dysarthria in post-stroke patients. The purpose of this study was to elucidate the impact of co-occurrence of dysarthria and aphasia on functional recovery in post-stroke patients.

Methods

Medical records of 130 patients who admitted to department of rehabilitation medicine were reviewed retrospectively, which included the results of primary screening test and secondary definite examinations for language problems. Functional outcomes were assessed longitudinally using functional ambulation category (FAC), Mini-Mental State Examination-Korean version (MMSE-K), European Quality of Life-5 Dimensions 3 level version (EQ-5D-3L), Korean version of modified Barthel index (K-MBI) and Motricity index (MI) of hemiplegic side.

Results

Patients were classified in to 4 groups with regarding their language function: aphasia only (A, n = 9), dysarthria only (D, n = 12), both aphasia and dysarthria (AD, n = 46) and none of them (N, n = 55). The initial scores of functional outcome in AD were significantly different compared to N and A. In terms of within groups, there were significant improvements in all outcome measurements in group AD and N. In terms of between groups, there were significantly different improvements in K-MBI and TCT index. There were no significant differences in MMSE-K, MI, EQ-5D-3L and FAC between groups.

graphic file with name 10.1177_2396987316642909-img23.jpg

Conclusions

Functional recovery in post-stroke patients is different according to the co-occurrence of dysarthria and aphasia, which may affect the initial functional status in post-stroke patients.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

FACTORS AFFECTING THE EARLY RECOVERY OF BALANCE FUNCTION IN STROKE PATIENTS

S Kim ¹, J Sungju ¹, S Min Kyun ¹

Abstract

Background

To find factors affecting early recovery of balance function in stroke patients

Methods

Medical records of 362 stroke patients admitted to rehabilitation department from May 1, 2014 to April 31, 2015 were reviewed retrospectively. Patients were included if Berg balance scale (BBS) was reported below 20 points of at initial evaluation, and improvement to acceptable balance (>20 points) until 2 months after transfer to rehabilitation department. And they were divided into 2 groups (early recovery group, who improved within 4 weeks from the onset; late recovery group who improved after 4 weeks from the onset). Demographic, clinical characteristics, rehabilitation characteristics, and electrophysiological data were compared.

Results

Twenty out of 52 patients were enrolled to the early recovery group. Patients with early recovery in balance function were more frequent in ischemic stroke (85.0%) than hemorrhagic stroke (15.0%) (p < 0.05). Patients with late recovery tended to be complete lesion in tibial somatosensory evoked potential (SSEP) than those with early recovery (p < 0.05). Time from onset to transfer in rehabilitation department was significantly shorter in stroke patients with early recovery (p < 0.05).

Conclusions

Our study suggests that recovery rate of balance function was slow for patients with hemorrhagic stroke. And slow recovery can be thought by SSEP of lower extremities which was considered for the predictive factor in recovery of balance function. The significant delay of transfer time to the rehabilitation department can attribute the slow recovery. Further studies with a larger sample size are needed for generalized conclusions.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EFFICACY OF "INTERFACE BRAIN - COMPUTER AND EXOSKELETON" COMPLEX IN POST STROKE REHABILITATION

A Kondur ¹, S Kotov ¹, L Turbina ¹, E Biryukova ², P Bobrov ³, A Frolov ³, M Kurganskaya ³, O Pavlova ³

Abstract

Background

The brain-computer interface (BCI) and robots (exoskeleton) is a new developing area in neurorehabilitation. Neurophysiological prerequisites for the development of BCI are based on motor imagery and EEG reactions - event-related desynchronization and event-related synchronization, decreasing or increasing of μ-rhythm in the in the brain’s regions that represent the hand.

Methods

We have observed 40 patients (mean age 51.3 ± 5.5 years) after ischemic (36) and hemorrhagic (4) stroke in the period from 2 months to 4 years. Standard protocol included EEG registration during the experimental session as well as movement registration of the health and the paretic arms before and after the set of experimental sessions. Online recognition of imagery movement was carried out with the EEG-based BCI. There were 20 patients in main group, 10 – in control group, and 10 – in the comparison group. Patients received 10 sessions lasting 45 minutes for 2 weeks. We used Ashworth, Fugl-Meyer, ARAT, Barthel and modified Rankin scale.

Results

All patients of main group reported a significantly better improvement in motor function and disability, in the control group - a slight improvement, in the comparison group - without any changes.

Conclusions

The study revealed that the rehabilitation procedure using BCI and the exoskeleton has a positive impact on the rehabilitation process in patients after stroke. All patients of main group had positive results in the movement recovery, disability and daily activity. The using of "BCI and exoskeleton" complex can be used for stroke rehabilitation.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

SPECIALIZED REHABILITATION, STROKE AND ACTIVITIES OF DAILY LIVING IN NINE DIFFERENT CLINICS, SUNNAAS INTERNATIONAL NETWORK (SIN) STROKE STUDY. WHAT INFLUENCE AND PREDICT IMPROVEMENTS?

B Langhammer ¹, K Sunnerhagen ², Å Lundgren-Nilsson ², S Sällström ³, F Becker ⁴, T Zhang ⁵, X Du ⁵, T Bushnik ⁶, M Panchenko ⁷, O Keren ⁸, S Banura ⁹, K Elessi ¹⁰, W Deng ¹¹, S K Johan ⁴

Abstract

Background

Objective: The purpose of the present study was to evaluate specialized rehabilitation in different clinics and the influence on Activities of Daily Living (ADL).

Methods

The design was a prospective, descriptive study of specialized rehabilitation in 230 persons with a primary diagnosis of stroke, treated in nine different rehabilitation institutions in seven countries. ADL was assessed with the Barthel Index (BI) and the Motor Functional Independence Measure (M-FIM) on five occasions.

Results

A total of 230 persons with stroke were evaluated. There were significant differences between the nine institutions in change scores of ADL (p < 0.001, eta square 0.19) at the standardized time point 18–22 days into rehabilitation. The differences remained at discharge, also when controlled for baseline severity and disability (p < 0.001, eta square 0.18; p = 0.001, eta square 0.18 respectively). Six and 12 months post discharge, ADL was maintained for the majority of participants although improvements seemed to slow down and reach a plateau.

Discussion: Possible explanatory factors for the results are the implementation of different models of collaboration in rehabilitation, time in therapy, and length of stay (LOS).

Conclusions

Different rehabilitation models influence improvement in ADL in specialized rehabilitation. A positive predictive factor on improvement in ADL was found to be hours of therapy, negative predictors were level of disability at baseline and LOS.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

INCREASING DOSES OF AUTOLOGOUS BONE MARROW MONONUCLEAR CELLS (BM-MNCS) TRANSPLANTATION IS RELATED WITH STROKE OUTCOME

F Moniche ¹, PH Rosado-de-Castro ², I Escudero ¹, E Zapata-Arriaza ¹, FJ de la Torre-Laviana ¹, R Mendez-Otero ³, M Carmona ⁴, P Piñero ⁵, A Bustamante ⁶, L Lebrato ¹, JA Cabezas ¹, A Gonzalez ⁵, G de Freitas ⁷, J Montaner ⁸

Abstract

Background

BM-MNCs transplantation improves recovery in experimental models of ischemic stroke. Clinical trials are ongoing to test efficacy in stroke patients. However, whether dose of cells is related to outcomes is not known.

Methods

In this study, we performed a pooling data analysis of individual data from two pilot clinical trials with autologous BM-MNCs transplantation in ischemic stroke patients. Follow-up was done for up to 6 months. Dose of cells, route and volume of infarction were analyzed to evaluate their relation to good outcome (m-Rankin scale score 0–2) at 6 months.

Results

Twenty-two patients were included. A median of 153 × 10⁶ (±121 × 10⁶) BM-MNCs was injected. Intra-arterial route was used in 77.3% of cases. A higher number of cells injected were associated with better outcomes at 180 days (390 × 10⁶[320–422] BM-MNCs injected in those patients with mRS of 0–2 at 6 months vs 130 × 10⁶[89–210] in those patients with mRS 3–6, p = 0.015). In the intra-arterially treated patients, a strong correlation between dose of cells and mRS at 6 months was found (r = −0.63, p = 0.006). A cut point of 310 × 10⁶ cells injected predicted a good outcome (mRS of 0–2) with a sensitivity of 80% and specificity of 88.2%.

Conclusions

Similar to preclinical studies, higher dose of autologous BM-MNC seems to be related to better outcome in stroke patients, especially when more than 310 × 10⁶ cells are injected. Further studies are warranted to confirm these data.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

AN AUDIT OF ACUTE STROKE PATIENTS AND ACCESS TO STROKE SPECIALIST PHYSIOTHERAPY IN SELECTED ACUTE HOSPITALS IN IRELAND

A O'Neill ¹, C Prendergast ², G Harte ³, H Kavanagh ⁴, A McAuliffe ⁵, J O'Connell ⁵, A Donohue ⁶, F Kinsella ⁵, S Ryan ⁷

Abstract

Background

Introduction: A collaboration of senior stroke physiotherapists from the Dublin Area Teaching Hospital and Louth Hospital groups liased to audit their treatment activity with the acute stroke population. This comprised 6 acute hospitals and a total of 360 patient

Methods

Methodology: An audit was conducted from March 1^st 2015 - May 31^st 2015. This audit captured patient demographics, gender, age, stroke type and discharge outcome. It recorded average number of days in acute inpatient rehabilitation and the average number of minutes of treatment received. This information was inputted to an excel programme and the data analysed.

Results

The total group population was 360 patients, 182 male and 178 female. 265 patients with an infarct, 55 patients with hemorrhage and 39 with a clinical stroke. Average duration of acute rehabilitation was 12.5 physiotherapy treatment days and average minutes of rehabilitation was 307. Patients with haemorrhage required more physiotherapy. 152 patients (42%) were discharged home either without need for follow up physiotherapy (n = 98) or with community physiotherapy (n = 54). Of the 98 patients, a higher number (n = 76) with an infarct where discharged home compared to hemorrhage (10) and clinical stroke (12). 85 patients (24%) received further inpatient rehabilitation following discharge from the acute stroke unit and 9 patients (2.5%) where discharged to residential care.

Conclusions

This audit provides a comprehensive analysis of an acute stroke population and the physiotherapy input received. Further analysis is planned to link the data to clinical guidelines and practice.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

“THE NATURE STROKE STUDY” (NASTRU), NATURE-BASED REHABILITATION OF POST STROKE FATIGUE - A RANDOMIZED CONTROLLED TRIAL

AM Pálsdóttir ¹, K Stigmar ², M Åström ³, P Grahn ¹, B Norrving ⁴, H Pessah-Rasmussen ⁵

Abstract

Background

The NASTRU study examines whether nature-based rehabilitation (during 10 weeks), as add-on to standard care may improve post-stroke fatigue (primary end point), function, participation, depression and work ability after stroke.

Methods

Randomized controlled trial with follow up 8 and 14 months after inclusion by assessor blinded to treatment group. The nature-based rehabilitation was supported by a multimodal team in a specially designed garden. The interventions was grounded in occupational therapy and environmental psychology. The last follow-ups were conducted in November 2015.

The baseline and outcome measures were: Mental Fatigue scale; Occupational Value Assessment with predefined items; Physical Activity Scale for the Elderly; Modified Rankin Scale; Montreal Cognitive Assessment; Fugl-Mayer assessment arm/hand; Timed up and Go; Hospital Anxiety and Depression Scale; EQ-5D and Work Ability Index.

Results

A total of 101 patients were randomized; 51 to intervention and 50 to control group. 73 patients, (67% females, mean age 70 years, range 51–82 years) were included 3 months post stroke (sub-acute subgroup) and 28 participants, (46% females, mean age 69 years, range 59–79 years) were included >2 years after stroke (chronic sub-group).

The change of the outcome over time will be compared between the groups as well as between the subgroups. The results are expected to be fully analyzed by April 2016. Final results will be presented.

Conclusions

The results from this study will add to the scientific knowledge on possible alternative to treat post-stroke fatigue and could contribute to better treatment options.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EFFICACY CEREBROLYSIN IN ACUTE ISCHEMIC STROKE PATIENTS SUFFERING FROM PARKINSONISM

N Rashidova ¹, K Khalimova ¹, G Rakhmatullaeva ¹, R Matmurodov ¹, A Kadirova ¹

Abstract

Background

To assess the efficacy of Cerebrolysin and piracetam on the NIHSS and the infarct size in patients with acute ischemic stroke suffering from parkinsonism

Methods

This open study enrolled a total of 110 patients, aged 60–75 years. Patients were randomly assigned to treatment with 30 ml Cerebrolysin for 10 days (n = 36) or 20 days (n = 42) or piracetam 20%-10 ml for 10 days (n = 32) as control group. Study endpoints were the NIHSS score and the infarct volume as measured by MRI at day 20 post-stroke

Results

Study endpoints were the NIHSS score and the infarct volume at day 20 days. At baseline, the overall mean NIHSS score was 13; 42.5% of patients scored ≤14 on admission, 57,5% of patients had consciousness impairment of different severity (NIHSS score <14) (Fig.1).

graphic file with name 10.1177_2396987316642909-fig107.jpg

The results of NIHSS score at day 20 for piracetam showed 11, for Cerebrolysin group at day 10–7, for Cerebrolysin group at day 20 – 6, which was significant different with control group. The findings of the infarct volume were in the line with improved neurologic and functional status. Onset in infarct volume decreased by 24,4% in the 10 days - Cerebrolysin group and by 29,1% in the 20 day –Cerebrolysin group. Treatment with pyracetam decreased in the infarct volume by 5,4%, and showed no changes in the neurologic and functional status (Fig.2)

graphic file with name 10.1177_2396987316642909-fig108.jpg

Conclusions

Cerebrolysin treatment was more efficacious as compared to piracetam in the treatment of acute ischemic stroke in patients suffering from parkinsonism. Cerebrolysin was safe and well tolerate neuroprotection therapy

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

AN ASSESSMENT OF NEUROTROPHIC THERAPY EFFECT ON CILIARY NEUROTROPHIC FACTOR LEVEL IN PATIENTS WITH POST STROKE APHASIA AND DIABETES MELLITUS

V Shishkova ¹

Abstract

Background

An important role in the maintenance and regulation of the functional integrity of the nervous system playing neurotrophic factors. including ciliary neurotrophic factor. It is found that the mechanism of neuronal cell death largely depends of deficiency of neurotrophic effects.This is particularly important in patients with diabetes mellitus.Cerebrolysin is a compound with neurotrophic and neuroprotective activity.We carried out an open randomized controlled study to explore the changes in the rate of speech recovery and CNTF concentrations in patients with left-hemisphere stroke and diabetes mellitus type2 who received cerebrolysin

Methods

A study included 60 inpatients of the Center of Speech Pathology and Neurorehabilitation. Neuropsychological examination was performed at baseline and after the treatment was completed. We determined aphasia type and quantitatively assessed speech in scores which reflected the severity of speech impairment. CNTF serum concentrations were measured.

Results

Clinical efficacy of cerebrolysin (intravenously in dose 20 ml in 100 ml of physiological solution, 5 days a week, during 4 weeks) used in addition to standard neurorehabilitation measures in patients with post stroke aphasia of different severity was demonstrated. This treatment was most effective in patients with very marked and marked speech impairment that was confirmed by the maximal possible improvement of speech during the first course of neurorehabilitation measures. A significant increase in CNTF concentrations was an additional evidence of this improvement.

Conclusions

The use of cerebrolysin in the complex treatment of patients with post stroke aphasia of different severity improves the prognosis of their rehabilitation.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

INFLUENCE OF INFORMING PATIENTS WITH STROKE ABOUT ENVIRONMENT DURING HOSPITALIZATION FOR POST-STROKE DEPRESSION PROPHYLACTIC

A Shmonin ¹, M Maltseva ², E Melnikova ³

Abstract

Background

The patient is experiencing stress from lack of information about the environment surrounding after hospitalization, with total dependence on it can be a factor that exacerbates depression provoking risk of its development.

Aim: To test how early and complete information for the patient with stroke about contextual factors influences on post-stroke anxiety and depression.

Methods

43 patients (men and women aged 65–76 years) with stroke or hemorrhage took part in research. The main group patients no later than 2 days from the start of hospital got psychologist interview (n = 22). During the conversation, patients received information about the address and location of the hospital on their home, on which floor of the building where the entrance, how they will be treated, duration of the treatment and any manipulation would produce.

Results

In group where patients were not informed about the environment developed clinically significant anxiety and depression assessed with Hamilton scale (HAM) (for depression 18 (17, 19) points, and for anxiety - 15 (14, 16) points 3 months late after stroke. Informed patients have normal level of anxiety - 4 (4, 5) points 3 months after stroke. Depression at the informed group have been identified at discharge - 6.5 (6, 7) points on 3 months (p < 0.001).

Conclusions

Early and complete information for the patient with stroke about contextual factors (date, hospital environment and medical information) has a positive effect on reducing anxiety and reduces the risk of post-stroke depression.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

"ICF-READER" - AN SOFTWARE FOR REHABILITATION DIAGNOSIS AND ICF ASSESSMENT

A Shmonin ¹, M Maltseva ², V Nikiforov ³, E Melnikova ⁴

Abstract

Background

International Classification of Functioning (ICF) is key instrument for work with rehabilitation diagnosis but ICF is very difficult for real practice apply. It’s important for stroke rehabilitation.

Our aim: to do simple and convenient software for working with rehabilitation diagnosis and ICF assessment.

Methods

The software was made for large clinical trial “Development Of MEdical rehabilitation in Russia” (DOME). The program "ICF-reader" can help to generate documentation for the adoption of the patient or the patient's discharge or transfer, encrypts the personal data of the patient and creating a database of patients, help to evaluate the scales and safe medical history. The program accumulates and analysis of all the data about patient who get rehabilitation after stroke.

Results

The program «ICF-reader» has some options: give simple assessment of patient with ICF from domains list, give assessment with ICF core set (set uses for different diagnosis and clinical situation), give prompts based on case history and the severity of the patient's condition, give transfer scales assessment into ICF diagnosis. The program also provides an opportunity to encrypt Rehabilitation diagnosis QR-codes. ICF-reader help planning of rehabilitation based on the ICF diagnosis. ICF assessment patient with stroke using ICF-reader takes to 10 min.

Conclusions

The program “ICF-reader” provides new opportunities to work with ICF and reduces the time to work with rehabilitation diagnosis.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

DEVELOPMENT OF POSTSTROKE SWALLOWING FUNCTION AND FACTORS ASSOCIATED WITH ITS RECOVERY AT THREE MONTHS

N Vilardell Navarro ¹, L Rofes ², O Ortega ³, V Arreola ³, A Martin ³, D Álvarez-Berdugo ³, D Muriana ⁴, V Casado ⁴, ML Sebastian ⁴, E Serrano ⁴, AM Ciurana ⁴, A Pradas ⁴, E Vilardell ⁴, MP Fossas ⁴, E Palomeras ⁴, P Clavé ³

Abstract

Background

The natural history and spontaneous recovery of poststroke oropharyngeal dysphagia (OD) are not fully understood. The aim was to describe the development of poststroke swallowing function and factors associated with its spontaneous recovery at 3 months.

Methods

OD was assessed within 48 hours of admission and at 3 months with the volume-viscosity swallow test (V-VST). Demographic, clinical and neurotopographical variables were collected to assess factors associated with recovery of poststroke OD.

Results

We included 247 poststroke patients (PSP) (73.1 ± 13.5 years, 52.6% male). Incidence of OD on admission was 40.1% (8.9% impaired safety, 5.7% impaired efficacy and 25.5% both impairments). At 3 months, OD prevalence was 42.1% (2.5% impaired safety, 22.3% impaired efficacy and 17.4% both), due to a) spontaneous improvement of safety of swallow in 42.4% of PSP with OD on admission, associated with age (<75 years), no previous heart diseases, lack of medial cerebral artery affection and good functional status at 3 months; and b) appearance of new signs of impaired efficacy of swallow in 25.9% of PSP, related to suboptimal functional status and higher risk of malnutrition and institutionalization.

Conclusions

Spontaneous recovery of impaired safety of swallow occurred in 42.4% of PSP and was associated with age, clinical factors (heart diseases and functional status) and stroke location. However, 25.9% of PSP developed new impairments in efficacy of swallow associated with suboptimal functional status and risk of malnutrition. Our results suggest that regular monitoring of OD would improve PSP outcome.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CAN OCCUPATIONAL THERAPISTS USE VIDEO TECHNOLOGY TO ASSESS A PATIENT'S HOME AFTER STROKE?

N Walmsley ¹, RH Harris ², A Bhalla ³

Abstract

Background

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Guidelines recommend that stroke patients should receive therapy for 45 minutes daily (ISWP 2012; NICE 2013). The challenge for Occupational Therapists (OTs) on an Acute Stroke Unit is to balance the provision of therapy to patients, alongside discharge planning.

Access visits (AVs) assist OTs with the identification of home modifications needed to enable patients to manage safely on discharge including assisting with determining whether the home environment accommodates patients’ ongoing rehabilitation needs. However they are time consuming.

This study aims to determine whether an OT assessing a patient’s home remotely by watching a video recording, is as accurate as OTs assessing a home in-person (standard practice).

Methods

This diagnostic accuracy comparison study compared the proportion of agreement between the two types of assessment by comparing the total number of problems and recommendations identified by an in-person AV with the remote assessment of a video recording.

9 stroke patients were recruited from an inner city ASU.

Results

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1. Accuracy:

The remote video assessment attained sensitivity of 78.6% (95% CI 71.3–85.9) specificity 76.5%

2. Time:

The in-person AV average time taken to complete the visits was 71.2 minutes (mean) compared to the remote video AV average length of time being 34 minutes.

3. Inter rater reliability

Only a moderate inter-rater reliability was found between the two blinded remote AV assessors. (kappa = 0.4)

Conclusions

Potential for OTs to use remote video AVs to assess patient’s homes remotely (over 70% accurate) and they are more time efficient. However only a moderate inter-rater reliability was found between OTs.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

SPECIFICITIES OF STROKE RISK FACTORS IN ARAB COUNTRIES: THE OPTIC REGISTRY AND PERFORM TRIAL

H Abboud ¹, L Sissani ², L Julien ², A Arauz ³, MG Bousser ⁴, A Bryer ⁵, A Chamorro ⁶, M Fisher ⁷, I Ford ⁸, P Lavados ⁹, A Massaro ¹⁰, MM Collazos ¹¹, H Mattle ¹², PM Rothwell ¹³, PG Steg ¹⁴, E Vicaut ¹⁵, B Yamut ¹⁶, P Amarenco ¹⁷

Abstract

Background

Little is known on specificities of stroke risk factors in patients living in Arab countries. We sought to study stroke risk factors, socioeconomic status and major cardiovascular events (MACE) in patients with recent ischemic stroke or transient ischemic attack (TIA) of mainly atherothrombotic origin in Arab vs. nonArab countries

Methods

We performed two separated analyses in 2 similar populations of patients with noncardioembolic ischemic stroke included in the OPTIC registry (n = 3,780 followed 2 years) and in the PERFORM trial (n = 19,100 followed 2 years), with baseline collection of usual risk factors and some socioeconomic variables. Primary outcome event was a composite of nonfatal stroke, nonfatal myocardial infarction and cardiovascular death

Results

All risk factors were more prevalent in patients living in Arab countries but diabetes mellitus appeared the one of the most important concern with more than 40% of patients being diabetics as compared to less than 30% in nonArab countries. MACE were more frequent in Arab vs in nonArab countries in OPTIC and PERFORM (age- and sex-adjusted rate 18.5% vs 13.3%, P = 0.0001; 18.2% vs 9.7% P < 0.0001 respectively). In OPTIC registry, this result remained significant after adjustment on usual risk factors and was attenuated after further adjustment on socioeconomic variables (adjusted-HR 1.24, 95% CI 0.98–1.55, P = 0.07)

Conclusions

Stroke patients living in Arab countries have a very concerning high prevalence of risk factors, such as diabetes mellitus in nearly half of them, and higher MACE rate, partly explained by risk factors but more importantly by high prevalence of poverty and low education level

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ETHNIC DIVERSITY AND ACUTE STROKE FEATURES - A COMPARISON FROM STROKE REGISTRY QATAR

N Akhtar ¹, S Kamran ¹, P Bourke ¹, S Joseph ¹, M Santos ¹, A Salam ¹, D Deleu ¹, A Shuaib ¹

Abstract

Background

Epidemiological studies show that vascular risk factors are the same across the world but their expression may vary between different race-ethnic groups. We determined the risk factors, clinical characteristics, management and outcome of acute stroke between different ethnic groups residing in Qatar.

Methods

Data on 1714 stroke patients admitted between January 2014 and November 2015 were analyzed to compare ethnicity, clinical presentation, risk factor profile, investigations, complications and outcome at discharge and 90 days.

Results

1714 patients were enrolled in the stroke registry. Far Easterns (FEs) had the youngest age at presentation (49.1 ± 9.3) versus Arabs (63.3 ± 14.6), p = 0.001. Arabs had the highest risk of hypertension (77.4%), diabetes (66.6%), prior stroke (21.3%), and coronary artery disease (16.3%), p < 0.001. Intracerebral hemorrhage (ICH) was significantly more prevalent in Far Easterns group (31.9%) vs Arabs (13.1%), p < 0.001, leading to their increased mortality at 90-days (7.2%) vs Arabs (6.1%) and South Asians (3.2%), p < 0.001. Stroke recurrence was more common in Arabs (3.5%) vs Far Easterns (0.5%), p = 0.006. See

Fig 1.

Conclusions

There is a wide variation in the risk factors, presenting features, stroke type and prognosis in ethnic diverse populations. The higher incidence of diabetes in Arabs is alarming. Causes of higher ICH in FEs require further study.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ETIOLOGIES AND PROGNOSIS OF INTRA CEREBRAL HEMORRHAGES IN AN AFRICAN AMERICAN POPULATION

M Agbetou ¹, C Dan ¹, R Dellis ¹, S Mecharles ¹, A Lannuzel ², C Alecu ³

Abstract

Background

In Caribbean space stroke incidence is 50% higher than in Europe. ICH Incidence in Guadeloupe is not known. The aim of our study was to describe the characteristics of ICH in Guadeloupe.

Methods

We performed a retrospective study of all hospitalized patients who presented a no-traumatic ICH during two years (2013–2014). Case were selected in the informatics system using related ICD items, then validated after study of medical folder and imagery lecture. Survivors were contacted by telephone at the end of the study and, if accept, vital status and Rankin scale were assessed.

Results

Between 1418 patients hospitalized for an acute stroke 112 had no-traumatic ICH (7.9%, F/H 1.42 mean age 63.0 +/- 14.7yrs). ICH distribution was: deep 48.2%, sub-tentorial 17.9%, lobar 30.4% and meningeal 3.5%. Emergency mean NIHSS was 10.8 +/-7.9 and mean Glasgow score was 12.4 + /-3.3. At emergency mean SBP was 166+/-35 mmHg, mean MBP was 119+/-25 mmHg, mean pulse pressure was 70+/-24. Severity signs distribution: ventricular contamination 43%, mass effect 79%, cerebral herniation 37%. Vascular imagery detected 7.1% of aneurysm and 7.1% of arterio-venous malformations. During an in-hospital stay of 10.6+/-10.3 days 22 patients died (19.6%). In mean 1.5 y after emergency, between survivors 35 patients or forgivers accepted to respond of our questionnaire: we detected 4.5% of additional death. In survivors the median Rankin scale was 1.5.

Conclusions

This series suggest that ICH is less frequent in African American as compared to Caucasian, suggesting that the epidemiological excess of strokes in this population is related to ischemic strokes.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

OUTCOME AFTER HIGH-RISK TIA OR MINOR ISCHEMIC STROKE: AN OBSERVATIONAL STUDY OF 20,410 PATIENTS IN THE SWEDISH STROKE REGISTER

S Åsberg ¹, B Farahmand ², P Appelros ³, P Hasvold ⁴, S Johansson ⁵, A Terént ¹

Abstract

Background

Patients who experience transient ischemic attack (TIA) or ischemic stroke (IS) are at high risk for subsequent major vascular events, including stroke, myocardial infarction (MI), and death. Our aim was to compare the incidence of major vascular events between patients with high-risk TIA (ABCD2 score ≥4) and minor IS (NIHSS score ≤5) in a nationwide cohort.

Methods

This observational study included TIA and IS patients discharged alive during 2012–2013, with a mean follow-up of 1.9 years. TIA, stroke, and clinical characteristics were identified by the Swedish Stroke Register, and additional data were obtained through record linkages with other national register. Outcomes were assessed by Kaplan-Meier analysis.

Results

We identified 8675 patients with high-risk TIA (mean ABCD2 = 4.9) and 11,735 patients with minor IS (mean NIHSS = 1.8). The TIA population had a higher proportion of women (48.9% vs. 44.6%) and hypertension (87.7% vs. 63.4%) than the IS population, whereas mean age and other vascular risk factors were similar in both groups. At 12 months, 321 (3.8%) strokes, 119 (1.4%) MIs, and 545 (6.3%) deaths had occurred after TIA, and 561 (5.0%) strokes, 139 (1.2%) MIs, and 914 (7.8%) deaths had occurred after IS. For TIA patients, the cumulative incidence of the composite of stroke/MI/death at 1, 3, and 12 months was 1.7%, 3.2%, and 10.0%, respectively. The corresponding numbers for IS patients were 2.0%, 5.0%, and 12.4%.

Conclusions

There were small differences in incidence of major vascular events between patients with high-risk TIA and patients with minor IS.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CARDIOVASCULAR OUTCOMES IN PATIENTS WITH MINOR ISCHAEMIC STROKE OR HIGH-RISK TRANSIENT ISCHAEMIC ATTACK: ANALYSIS OF THE MULTI-CENTRE STROKE REGISTRY DATABASE IN KOREA

HJ Bae ¹, HK Park ¹, JM Park ², TH Park ³, KB Lee ⁴, YJ Cho ⁵, DE Kim ⁶, BC Lee ⁷, KH Yu ⁷, SJ Lee ⁸, J Lee ⁹, C Jae-Kwan ¹⁰, JT Kim ¹¹, JC Choi ¹², S Johansson ¹³, S Kim ¹⁴, H Kim ¹⁵, JS Lee ¹⁶, J Lee ¹⁷, on behalf of the ^15,¹⁷, CRCS-5 Investigators ^15,¹⁷

Abstract

Background

Little is known about cardiovascular events after minor ischaemic stroke (MIS) or transient ischaemic attack (TIA) in Korea. This study aimed to increase this knowledge.

Methods

Data from patients registered in the Clinical Research Centre for Stroke 5th Division registry between November 2010 and October 2013 were used. Major cardiovascular events (stroke, myocardial infarction, all-cause death) at 90 days and 12 months were evaluated.

Results

The study included 9016 patients with MIS (NIHSS score ≤5 [62.7% of all patients with acute ischaemic stroke; mean age: 66 ± 13 years; 61% men]) and 490 patients with high-risk TIA (relevant cerebral artery stenosis ≥50% or acute lesion in diffusion-weighted MRI [29.8% of all patients with TIA; mean age: 63 ± 14 years; 62% men]). At discharge, 95.2% patients were prescribed antithrombotics (aspirin, 75.1%; [monotherapy, 36.1%]; clopidogrel, 34.1%; [monotherapy, 4.9%]), 45.8% antihypertensives, 86.2% statins and 25.3% antidiabetics. Rates of recurrent stroke, myocardial infarction, death and composite measure of events were 4.3%, 0.2%, 2.0% and 5.9% at 90 days, and 6.1%, 0.3%, 4.1% and 9.3% at 1 year, respectively. Mean modified Rankin Scale score was 1.36 at 90 days and 1.29 at 1 year. Incidence of symptomatic intracranial bleeding during hospitalization was 0.43%. Cumulative post-discharge incidence of haemorrhagic stroke was 0.17% at 90 days and 0.31% at 1 year. Similar event rates were observed when applying SOCRATES trial (NCT01994720) exclusion criteria.

Conclusions

A high proportion of major cardiovascular events in the year after MIS or high-risk TIA occurred during the first 90 days. Thus, early preventive therapy is crucial.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CLINICAL PROFILE AND OUTCOME OF ACUTE MYOCARDIAL INFARCT AND ARRHYTHMIAS IN PATIENTS WITH ACUTE HYPERTENSIVE HEMORRHAGIC STROKE

JE Bautista ¹, MC San Jose ¹

Abstract

Background

This study aims to determine the clinical profile and outcome of acute coronary syndrome (ACS) and new-onset arrhythmias among patients with acute hypertensive intracerebral hemorrhage admitted at a tertiary hospital from January – December 2013.

Methods

This is a retrospective descriptive study of adult patients admitted for acute hypertensive intracerebral hemorrhage between January and December 2013 at a tertiary hospital. The following data were collected: age, sex; history of hypertension, diabetes, dyslipidemia, smoking, alcohol intake, heart disease; size and location of intracerebral hemorrhage; ECG changes, arrhythmias, diagnosis of ACS, and number of mortalities during admission. Descriptive statistics were used to characterize patients’ clinico-demographic profile. The incidences of acute coronary syndrome, ECG changes, arrythmias and the mortality rate were determined.

Results

Majority were males older than 45 years. The most common bleed location was capsuloganglionic, most measuring less than 30 cc. History of hypertension was present in 85%, dyslipidemia in 46%, diabetes in 16%, smoking in 36%, alcohol intake in 43%, and heart disease in 1.7%. Arrhythmias were seen in 10% and ischemic changes or ST elevation in 21%. Seven patients were diagnosed with myocardial infarct. None were given antithrombotics. Overall mortality rate was 33% but this increased to 45% in those with ischemia and arrythmias.

Conclusions

Ischemic changes, arrhythmias, and evidence of myocardial infarct may be seen in patients with intracerebral hemorrhage. It is recommended that patients admitted for acute hypertensive intracerebral hemorrhage be monitored for ECG changes which may require further investigation.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ASSOCIATION BETWEEN DIABETES MELLITUS AND INCIDENCE AND CASE-FATALITY OF INTRACEREBRAL HAEMORRHAGE: A NATION-WIDE POPULATION-BASED COHORT STUDY

M Boulanger ¹, R Al-Shahi Salman ², J Kerssens ³, SH Wild ⁴

Abstract

Background

It is unclear whether diabetes is a risk factor for intracerebral haemorrhage(ICH) and for case-fatality after ICH.

Methods

We performed a retrospective cohort study of people aged 40–89 years in Scotland between 2004 and 2013 using linked national population-based data from the Scottish diabetes register, hospital and death records. We calculated the incidence and relative risk (RR) of ICH (defined using International Classification of Diseases codes) for people with type 1 and type 2 diabetes versus the non-diabetic population, using standardisation and quasi-Poisson regression adjusting for age, sex and socio-economic status(SES). We estimated adjusted RRs for 30-daycase-fatality after hospital admission using logistic regression and subsequent correction.

Results

In the Scottish population aged 40–89 years (mid-2009 population estimate 2,634,060), there were 11,130 incident ICH (8,900 admitted to hospital) during ∼26 million person-years of follow-up. Compared to non-diabetic population, the age-, sex- and SES-adjusted rate ratio (RR) for incident ICH was higher in people with type 1 (1.74, 95%CI 1.36 to 2.19), but not type 2 diabetes (1.06, 95%CI 0.99 to 1.12), and the age-, sex- and SES-adjusted RR for 30-daycase-fatality after hospital admission with ICH was higher in people with type 1 diabetes (1.35, 95%CI 1.01 to 1.70), but not type 2 diabetes(1.04, 95%CI 0.96 to 1.13).

Conclusions

Type 1, but not type 2, diabetes is associated with increased incidence and 30-daycase-fatality after ICH compared to non-diabetic population.

Further research is needed to establish whether the association is confounded by other risk factors for ICH and to identify interventions for reducing the excess risk.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

STROKE IN YOUNGER PEOPLE: COMPLEX ‘NON-NEUROLOGICAL’ ISSUES IN ASSESSMENT AND MANAGEMENT

L Chapman ¹, A McDonough ¹, R Mulpeter ¹, J Harbison ¹

Abstract

Background

In the last decade, improvements in investigational techniques have led to a realisation that many strokes in young people result from primarily structural issues e.g. Patent Foramen Ovale (PFO), Cervical Artery Dissection (CAD) than from coagulopathy and haematological disorders. We recognised that many young patients had other complicating factors in their presentation and performed a study of consecutive patients with cerebral infarction or primary intracerebral haemorrhage from a University Hospital Stroke service.

Methods

Medical records for 70 consecutive patients <50 years were reviewed from 2011 to 2015.

Results

Mean age of subjects was 37 years with 63% being male. 63 (90%) subjects suffered cerebral infarction. Commonest causes identified were definite or likely CAD 13 (19%), PFO with confirmed R-L shunt 13 (19%), atrial fibrillation 5 (7%) and venous sinus thrombosis 4 (6%). 3 (4%) were found to have a coagulopathy. Other causative conditions included fibromuscular dysplasia, Reversible Cerebral Vascoconstriction Syndrome and Taysaku’s arteritis.

18 (24%) strokes occurred in people born outside Ireland compared with 4% of our overall patient population (p < 0.0001, Chi Sq). Subjects came from 12 different countries. Management of these patients was frequently complicated by translation issues, lack of previous medical records and absent collateral history.

9 (13%) subjects were alcohol dependent and 9 (13%) subjects were confirmed as having drug associated strokes including cocaine use, cannabis associated intracranial stenosis and heroin related endocarditis. 4 (6%) patients were pregnant or recently post-partum.

Conclusions

Management of younger people with stroke frequently presents challenges beyond determining etiology and addressing neurological deficit.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

STROKE-RELATED MORTALITY IN MEXICO: ANALYSIS OF ADMINISTRATIVE DATA

E Chiquete ¹, F Flores-Silva ¹, I Reyes-Melo ¹, C Cantú-Brito ¹

Abstract

Background

Cerebrovascular disease (CVD) is a growing health problem in countries living the epidemiological transition. In Mexico information on the health burden of CVD is scarce.

Methods

Information provided by the National Health Information System was extracted from the yearly electronic databases on the causes of death. An electronic database was arranged from the 15-year period for direct analysis. Cases of CVD as the main cause of death were identified by means of the International Classification of Diseases 10^th version. All types of CVD were considered. It is presented here the crude number of deaths attributed to CVD, the annual mortality rate, and the proportion of CVD deaths among the other causes.

Results

There were 7,563,143 deaths certificates in the study period. In 1998, 444,629 deaths were registered, which increased to 602,272 in 2012, coinciding with the general population growth (110 million in 2012). The number of CVD deaths rose since 1998 (25,067 deaths) through 2012 (31,901 deaths). The crude mortality rate also showed a significant ascending pattern from 1998 (26.17 per 100,000 inhabitants) to 2012 (28.99 per 100,000 inhabitants) (trend, p < 0.001). The proportion of deaths attributed to CVD from the total registered deaths per year ranged from 5.3% to 5.8%. A decreasing mortality was observed in persons aged >65 years, at the expense of more deaths at younger ages.

Conclusions

Unlike developed countries, in Mexico mortality attributed to CVD is rising, with increasing mortality at younger ages. Appropriate preventive measures at the population level are impending to change this pattern.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ACUTE CEREBROVASCULAR DISEASE IN PREGNANCY AND PUERPERIUM: DESCRIPTION OF CASES FROM A MEXICAN MULTICENTER REGISTRY

E Chiquete ¹, I Reyes-Melo ¹, F Flores-Silva ¹, C Cantú-Brito ¹

Abstract

Background

Pregnancy and puerperium are physiological conditions associated with a high risk of acute cerebrovascular disease (CVD). Comparative data on the association of pregnancy and puerperium among the different types of acute CVD is sparse.

Methods

We analyzed 2000 patients with different types of acute CVD included in a registry conducted in 25 referral hospitals. Research records of cases occurring during pregnancy or puerperium (the first 40 days after delivering) were selected.

Results

We identified 45 (2.3%) women with CVD associated with pregnancy/puerperium (mean age 26.3 years, range: 14–39): 20 (44%) in pregnant women and 25 (56%) during puerperium. A total of 26 (58%) cases corresponded to cerebral vein thrombosis (CVT), 10 (22%) to intracerebral hemorrhage (ICH) and 9 (20%) to acute ischemic stroke (AIS). Compared with puerperium, pregnancy was more common among AIS (56% vs 44%, respectively) and ICH cases (90% vs 10%, respectively), but the inverse characteristic was observed in CVT cases (23% vs 77%, respectively). Ten (22%) patients presented preeclampsia/eclampsia: 7 (70%) in association with ICH, 2 (22%) with AIS and only one (4%) with CVT. The 30-day case fatality rate was 4%, (2 pregnant women: one with ICH and the other with CVT); however, the frequency of women with a modified Rankin scale >2 was 17%; more common among patients with ICH (60%), than in AIS (14%) or CVT (9%) cases.

Conclusions

CVT is the main type of acute CVD occurring during pregnancy or puerperium. Mortality rate is low, but at expense of a significant proportion of disabled young women.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CLINICAL AND PROGNOSTIC FACTORS IN VERY-OLD PATIENTS WITH ISCHEMIC STROKE

P De Ceballos Cerrajería ¹, A Rodriguez Campello ¹, A Zabalza De Torres ¹, C Avellaneda Gómez ¹, M Serra Martinez ¹, J Roquer González ¹

Abstract

Background

The rise in life expectancy in developed countries has produced an increase in the percentage of strokes in the very-old (≥85 years). There are few studies with large series. We describe the clinical and prognostic characteristics of very-old patients with ischemic stroke admitted to our hospital.

Methods

Patients older than 60 years with ischemic stroke between January/2005-October/2015 were prospectively registered. We compare two age groups: 60–84years and ≥85years. We registered demographic data, vascular risk factors, stroke-code activations, severity(NIHSS) and treatment. We evaluate the in-hospital complications, destiny at discharge and outcome(mRS) at 3-months. A multivariate analysis was performed to establish prognostic factors.

Results

From 3620 patients, 910 (25.1%) had ≥85years. In this group there were more women (71.8vs46.5%), higher pre-stroke disability (49.68vs16.9%;p < 0.0001) and more incidence of atrial fibrillation (51.5vs34.6%;p < 0.0001). Stroke severity was higher in very-old (7(3,17)vs4(2,9);p < 0.0001). Cardioembolic TOAST was present in 48.4% of the patients. There were fewer stroke-code activations and alteplase treatments (11.9vs5.9%;p < 0.0001). In the ≥85 years group, there were higher rates of neurological progression, dysphagia and medical complications specially aspiration pneumonia. This group had higher in-hospital mortality and death/disability at 3 months (74.6vs41.6%;p < 0.0001). The age older than 85 years, the initial severity and pre-stroke disability were independent factors associated with poor functional outcome.

Conclusions

In our series the profile of the very-old patients with ischemic stroke is different than younger patients. The age ≥85years is an independent factor of worse outcome in patients with ischemic stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

TIME TRENDS IN ISCHEMIC STROKE INCIDENCE ACCORDING TO AGE GROUPS IN A POPULATION-BASED STUDY

D Degan ¹, R Ornello ², C Tiseo ², F Pistoia ², S Sacco ², A Carolei ²

Abstract

Background

Epidemiological data suggest a decreased incidence of ischemic stroke (IS) over time; however, data on incidence trends in different age groups are conflicting. We evaluated the incidence of IS according to age groups over time in the district of L’Aquila, central Italy.

Methods

We performed a prospective, population-based registry, including all patients with a first-ever IS (FEIS) residing in the L’Aquila district in 2011–2012. Current incidence rates were compared with those obtained in 1994–1998 and already published.

Results

Six hundred thirty-four FEIS (50.2% women; mean age ±SD 75.6 ± 12.8 years) were finally included. The overall annual incidence rate (per 100,000), standardized to the 2011 Italian population, decreased from 266 in 1994–1998 to 98 in 2011–2012 (incidence rate ratio [IRR] 0.37; 95% confidence interval [CI], 0.29–0.47; P < 0.001). The 2011–2012 standardized incidence rate (per 100,000) was 13 in patients aged <55 years with a 18% decrease as compared with 1994–1998 (IRR 0.82; 95% CI, 0.57–1.19; P = 0.302), while in patients aged 55–74 years it was 138 with a 69% decrease (IRR 0.31; 95% CI, 0.27–0.37; P < 0.001), and in patients aged ≥75 years it was 549 with a 63% decrease (IRR 0.37; 95% CI, 0.33–0.42; P < 0.001).

Conclusions

In 2011–2012, compared with 1994–1998, we found a decreased incidence of FEIS among patients aged ≥55 years, as a possible consequence of the effective control of vascular risk factors; the decreased incidence was less prominent in patients younger than 55 years possibly because of a higher prevalence of nonconventional risk factors as compared with older patients.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

HOSPITAL ARRIVAL TIME AS A PREDICTOR OF A BETTER OUTCOME: RESULTS FROM A COMMUNITY-BASED STUDY

R Felgueiras ¹, R Magalhães ², MC Silva ², M Correia ¹

Abstract

Background

Acute stroke treatment has improved over the last years and faster means better. One decade after the first community-based prospective stroke incidence, we intend to describe variables associated with better short-term outcome.

Methods

Data from two prospective community-based studies (first between 1998–2000 and second between 2009–2011) were compared. Based on standard definitions, both hot and cold pursuit sources of information were used for case ascertainment of all first-ever strokes occurring in the city of Porto. Pre-stroke and one month post-stroke modified Rankin Scale scores were recorded for every patient. No-disabling stroke was defined if post-stroke score was less than 2 or did not change after stroke; otherwise they were considered disabling.

Results

A total of 867 patients were included (462 in first study and 405 in second). Age (OR = 1.04, 95%CI 1.03–1.05), number of vascular risk factors (OR = 1.53, 95%CI 1.30–1.79), type of stroke (ischemic versus hemorrhagic) (OR = 0.32, 95%CI 0.21–0.48), number of deficits (OR = 2.37, 95%CI 1.92–2.93), inpatient care (OR = 4.42, 95%CI 3.29–5.94) and time of arrival to hospital (OR = 1.91, 95%CI 1.43–2.55) were predictors of disabling stroke, even after adjustment. Also, in the second study the risk of a disabling stroke decreased with the shortness of time to arrival at the hospital (OR = 0.58, 95%CI 0.35–0.97).

Conclusions

The time between symptoms onset and arrival to hospital is a predictor of stroke disability at one month. The less the time, the lower the probability of a disabling stroke at one month in a community-based study.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

LONG-TERM TRENDS IN PREVALENCE OF PATIENTS HOSPITALIZED WITH ISCHEMIC STROKE IN SWEDEN FROM 1987 TO 2010

KW Giang ¹, Z Mandalenakis ¹, S Nielsen ¹, L Björck ¹, M Adiels ², A Rosengren ¹

Abstract

Background

The prevalence of stroke is expected to increase in the near future due to a higher life expectancy and to a lower mortality rate in the general population, but more recent data are lacking.

Methods

The Swedish inpatient and cause-specific death registries were used to estimate the absolute numbers and prevalence of patients hospitalized with an ischemic stroke (IS) from 1987 to 2010. A jointpoint regression was used to estimate the annual percentage changes (APC) in hospitalization of IS.

Results

The overall absolute numbers of patients with IS increased from 90 047 in 1987 to 137 337 in 2010. During the same period the number of patients ≥85 years increased by 149%. In 1987, the overall prevalence of IS was 1.37%, with no significant change in prevalence until 1992, and then increasing to 1.80% from 1992 to 2001 with an APC of 3.10% (95% CI 2.90 to 3.40). No significant change in overall prevalence (APC 0.10, 95% CI 0.0 to 0.30) was observed from 2001 to 2010. In contrast, the prevalence of IS among patients <45 years increased throughout the period with an average APC of 1.60% (95% CI 1.40–1.80).

Conclusions

The prevalence of IS in Sweden increased until 2001 without further changes after 2001. In patients <45 years of age the prevalence increased substantially without any sign of leveling off. The marked increase in absolute numbers of IS among the very old is consistent with demographic changes in the Swedish population over time.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

STROKE AWARENESS IN ARGENTINA. A PILOT POPULATION-BASED SURVEY USING A BEVERAGE HOME DELIVERY SYSTEM

DE Dossi ¹, MA Hawkes ¹, MF Farez ¹, MM Gomez-Schneider ¹, N Torres ¹, G Povedano ¹, VA Pujol-Lereis ¹, SF Ameriso ¹

Abstract

Background

Stroke awareness data in Latin America is scant. We conducted a pilot study prior to a large public opinion survey. We aimed to test rate of responses to 2 models of questionnaires assessing stroke knowledge in Buenos Aires.

Methods

A total of 2512 multiple choice questionnaires were distributed by personnel delivering water dispensers to family houses at 3 neighborhoods in Buenos Aires representing a wide range of socioeconomic statuses. Filled forms were collected one week later. We used a long and a short version with 20 and 8 questions respectively. Both questionnaires were anonymous and collected information regarding age, sex, nationality, educational level, marital status, monthly salary and health insurance. General questions were done in both, addressing general stroke information, terms usage, vascular risk factors, warning symptoms, and emergency responses in our country. The long questionnaire collected additional information addressing prior knowledge of stroke, potential for disability and mortality of the disease, frequency of medical checks and physical activity, meaning of “transient ischemic attack” and existence of a time dependent fibrinolytic therapy.

Results

A total of 597 surveys were returned (24%). There was a non significant trend for higher rate of responses to short (30%) vs long (20%) versions; without significant differences in the rate of response to short and long questionnaires based on gender, educational level or socioeconomic status.

Conclusions

This pilot study shows the feasibility of using a commercial home access system to assess stroke awareness. The use of a long questionnaire does not significantly impact the rate of response.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ANATOMICAL VARIATIONS OF CIRCLE OF WILLIS AND CEREBROVASCULAR CORELATION, ISCHEMIC AND HEMORRAHGIC STROKE: A CASE -CONTROL STUDY IN ALBANIA

E Harizi ¹, A Rroji ², E Cekaj ³

Abstract

Background

The aim of this study was to asses the association of anatomical variations of circle Willis with cerebrovascular diseases: ischemic and hemorrhagic stroke.

Methods

A case -control study was conducted with same patients in Albania 2012–2013, including 60 patients with stroke (30 patients with ischemic stroke and 30 with hemorrhagic stroke), and 60 controls (individuals without evidence of cerebrovascular accidents, but with tension type headache or vertiginous syndrome).All patients with hemorrhagic stroke underwent a Ct angiography procedure. All patients with ischemic stroke and all controls underwent A MRI angiography

Results

In the overall sample of patients there were 14(23.3%) cases with anatomical variations of circle Willis compared with 10(16.7%) individuals in control group.(P = 0.49.) Within the patients' group, the prevalence of anatomical variants of circle Willis was somehow higher among cases with hemorrhagic stroke compared with cases with ischemic stroke(26.7% versus 20.o%, respectively).There was no evidence of statistically significant difference in the types of anatomical variations of circle of Willis between patients and controls(P = 0.71).Insex and age adjusted relationship models, there was evidence of a non -significant positive relationship between cerebrovascular accidents and anatomical variations of cirlce of Willis(OR = 1.5,95%,CI = 0.6–3.8, P 0.40)

Conclusions

This is one of very reports from Albania shedding light into the association between circle of Willis variations and cerebrovascular diseases, ischemic and hemorrhagic stroke

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

DETERMINING FACTORS FOR TOTAL COSTS IN PATIENTS WITH ACUTE ISCHEMIC STROKE IN KOREA

Y Jung ¹

Abstract

Background

Ischemic stroke is a cost burden disease. The patterns of medical resource use and costs are different by nations, health assurance system, severity of stroke, operation, thrombolysis, and patient’s age. We evaluated the factors that contributing the total costs and utilization of medical resources in hospitalized patients with acute ischemic stroke

Methods

In this retrospective analysis, we evaluated the cost data on 1538 patients who were admitted from March of 2011 to November of 2015 with acute ischemic stroke within 7 days of onset. Age, risk factors for ischemic stroke, length of hospital stay, stroke severity, stroke classification and total costs were evaluated according to medical charts and hospital cost charts.

Results

The mean age of patients was 67.8 years, and 52.8% were female. The total inpatient cost per ischemic stroke event was estimated to be $ 2341 (US $1 was equivalent to Korean Won 882 according to the purchasing power parities (PPP) for GDP of 2014 on the OECD). In multiple regression analysis model, age, stroke severity, length of stay were contributing factors for the total costs. The length of stay was highly correlated with in-hospital total costs in our study (R²= 0.743, p < 0.001).

Conclusions

In our study, age, stroke severity, and length of hospital stay were related with the total costs in patients of acute ischemic stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ASSOCIATION BETWEEN HIGH-SENSITIVITY CRP AT STROKE ONSET AND CLINICAL OUTCOMES AFTER SMALL VESSEL OCCLUSION

F Kiyuna ¹, R Matsuo ², Y Wakisaka ¹, J Kuroda ¹, T Ago ¹, M Kamouchi ², T Kitazono ¹

Abstract

Background

BACKGROUND AND PURPOSE: Inflammatory biomarkers such as high-sensitivity C reactive protein (hsCRP) predict incident or recurrent stroke. However, it is uncertain as to whether they worsen clinical outcomes after acute ischemic stroke or not. This study aimed to elucidate the association between hsCRP and post-stroke clinical outcomes in patients with small vessel occlusion (SVO), most of whom have minor stroke.

Methods: METHODS

Among 9726 patients with acute ischemic stroke registered in the Fukuoka Stroke Registry (FSR) between June 2007 and March 2015, 1261 patients with SVO who had been functionally independent and were hospitalized within 24 hours of onset were included in this study. The patients were categorized into 4 groups according to plasma hsCRP level (Q1 < 0.41, 0.41 ≤ Q2 < 0.89, 0.89 ≤ Q3 < 2.31, 2.31 ≤ Q4 [mg/L]). The association between hsCRP levels and clinical outcomes, including neurological deterioration (≥2 points increase in the NIHSS score during hospitalization) and poor functional outcome (modified Rankin Scale ≥2) at 3 month, were investigated using a logistic regression analysis.

Results: RESULTS

Mean age of the patients was 68.1 ± 11.5 years, and 122 (38.2%) were female. Compared with the bottom quartile, those in the top quartile were at increased risk of neurological deterioration (odd ratio [OR], 1.97; 95% confidence interval [CI], 1.19–3.35) and poor functional outcome (OR, 1.59; 95%CI, 1.06–2.38), even after adjusting for multiple confounding factors, age, sex, initial NIHSS, risk factors, and infection.

Conclusions

CONCLUSION: High plasma hsCRP is associated with unfavorable short-term clinical outcomes after acute ischemic stroke in patients with SVO.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

DIFFERENCES IN THE INCIDENCE RATE OF STROKE AMONG MEN AND WOMEN IN RUSSIA. THE POPULATION-BASED REGISTER 2009-2014

O Klochihina ¹, L Stakhovskay ²

Abstract

Background

The incidence rate of stroke among men and women over 25 years had been studied in Russia during 2009–2014 years.

Methods

The research was performed in different regions of Russia. The method of population-based register was used. An object of the study was personal cases of stroke lasting 28 days among men and women older than 25 years. The diagnoses were formed according to the criteria of the ICD-10. 12 158 868 residents participated in different regions of Russia with 30 079 cases of stroke analyzed; 14239 - among men, 15841 - among women.

Results

According to the European standard, standardized incidence of stroke among men was accounted for 3,83 cases per 1000 population in 2009; 4,15 in 2010; 4,04 in 2011; 4,03 in 2012; 4,25 in 2013 and 4,14 in 2014. No positive changes were observed in the incidence of stroke among men during six years of study. Incidence of stroke among women was 3,29; 2,74; 3,04; 2,58; 2,68; 2,43 per 1000 for 2009–2013 years, respectively. Total change in the incidence of stroke among women in 2009–2014 showed a small fluctuation with the downward trend. The growing differences in the incidence of stroke between men and women were revealed.

Conclusions

The incidence rate of stroke in Russia demonstrates consistent decline for women while for men it stays higher. The obtained data illustrates the need for better stroke prevention and treatment among men. Besides it is necessary to study additional risk factors for stroke among men.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

RELATIONSHIPS BETWEEN ORAL GLUCOSE TOLERANCE TEST RESULTS AND STROKE SUBTYPES AND ISCHEMIC HEART DISEASE INCIDENCE IN A GENERAL URBAN JAPANESE COHORT: THE SUITA STUDY

Y Kokubo ¹, M Watanabe ¹, A Higashiyama ², YM Nakao ², T Watanabe ¹, M Takegami ², Y Miyamoto ^1,²

Abstract

Background

It is not clear that the relationships between impaired fasting glucose (IFG) or impaired glucose tolerance (IGT) and incident cardiovascular disease (CVD) in non-Westerners. We hypothesized that IFG and IGT increase the risk of CVD in Japan.

Methods

We studied 4,288 Japanese individuals (mean age 56.1 years, without stroke or ischemic heart disease, IHD) who completed a baseline survey and a 75 g-oral glucose tolerance test (75 g-OGTT) in the Suita Study in 1990–1996 and were followed until December, 2013 (censored). Cox proportional multivariable-adjusted hazard ratios (HRs) and 95% confidence intervals (95%CI) of CVD were fit for each glucose category: diabetes mellitus (DM), IGT, IFG, and normal glucose tolerance (NGT).

Results

In 67,709 person-years of follow-up, we documented 125 cerebral infarctions, 53 hemorrhagic strokes, 27 unclassified strokes, and 177 IHD events. Compared with the NGT groups, the HRs (95%CI) of the IFG, IGT, and DM groups were 1.34 (1.02–1.74), 1.33 (1.02–1.73), and 2.01 (1.47–2.74) for CVD and 1.49 (1.05–2.12), 1.44 (1.01–2.06), and 2.29 (1.51–3.47) for stroke, respectively. The HRs (95%CI) of the IFG and DM groups were 1.72 (1.08–2.73) and 2.29 (1.29–4.05) for cerebral infarction and 1.21 (0.81–1.81) and 1.90 (1.19–3.03) for IHD, respectively, compared with the NGT group.

Conclusions

In this general Japanese population, IFG, IGT, and DM were risk factors for stroke and CVD. IFG and DM were risks factor for cerebral infarction. To prevent CVD, a 75 g-OGTT should be conducted to identify individuals with high blood glucose levels, to provide the optimal treatment at an early stage.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CARDIOEMBOLIC ETIOLOGY OF ISCHEMIC STROKE IN PATIENTS INDICATED TO ACUTE RECANALISATION THERAPY

M Kral ¹, D Šaňák ¹, T Dorňák ¹, T Veverka ¹, M Hutyra ², A Bártková ¹, D Školoudík ³, P Kaňovský ¹

Abstract

Background

The aim of the study was to assess cardioembolic etiology of ischemic stroke in patients admitted within 6 h after stroke onset.

Methods

In the prospective study (Clinicaltrials.gov No.NCT01541163), the set consisted of 535 acute ischemic stroke patients admitted within 6 h after stroke onset. Neurological examination, brain CT/MR, laboratory, repeated ECG, 24 h ECG, echocardiography, and duplex sonography were performed. The etiology of stroke was assessed using TOAST and ASCOD classifications. Differences in age, gender, time to admission and recanalization treatment between cardioembolic (ASCOD-C1) and non-cardioembolic (ASCOD-C0) strokes were assessed.

Results

According to the TOAST classification, 228 (42.6%) patients were classified as cardioembolic stroke. According to the ASCOD classification, 243 (45.4%) patients were classified as C1 (potentially causal), 48 (8.9%) as C2 (causal link is uncertain), 87 (16.2%) as C3 (causal link is unlikely), 66 (12.3%) as C0 (cardiac pathology not detected), and 91 (17.0%) as C9 (incomplete workup). Atrial fibrillation was detected in 208 (85.6%) out of 243 patients with cardioembolic stroke; it was newly diagnosed after extensive examination workup in 119 (57.2%) patients. Other cause of cardioembolism was present in 35 (14.4%) patients. Patients with cardioembolic stroke were significantly older (72.4 vs. 56.1 years, P < 0.001) and admitted earlier (102 vs. 126 minutes, P = 0.005) than patients with non-cardioembolic etiology of stroke. No differences were detected in gender (56.5% vs. 63.9% males, P = 0.14) and recanalization treatment application (42.2% vs. 41.0%,P = 0.43).

Conclusions

Extensive examination workup increases the percentage of identified cardioembolic etiology of ischemic stroke. Cardiac source was detected in 45% acute ischemic stroke patients. Supported by:FNOl00098892.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ASSOCIATION OF SOCIOECONOMIC STATUS AND FUNCTIONAL OUTCOME AFTER STROKE - THE PROSPECTIVE STROKE COHORT WITH INCIDENT STROKE BERLIN (PROSCIS-B)

T Liman ¹, S Piper ², P Heuschmann ³, S Wiedmann ³, M Endres ²

Abstract

Background

We aimed to analyze the association between patient socioeconomic status (SES) and functional outcome at 12 months after ischemic stroke.

Methods

Data were collected from the Prospective Study with Incident Stroke Berlin (PROSCIS-B; NCT01364168). We used multivariable logistic regression to examine the association between highest education as marker of socioeconomic status and functional impairment after stroke defined by the modified Rankin Scale (0–2 vs 3–6).

Results

From March 2010 to May 2013, 629 patients with first-ever ischemic stroke were included. Information on SES could be obtained in 602 patients. In multivariable analysis adjusted for age, sex, pre-stroke dependency, stroke severity, life style factors, and comorbidities as possible confounding factors, patients with college or university degree had better functional outcome defined as mRS 0–2 at 12 month (odds ratio, 3.4; 95%CI, 1.7–6.7) compared with patients with less education.

Conclusions

Patients with higher education have better long-term functional outcome after stroke independent from patients’ clinical and demographic characteristics.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EPIDEMIOLOGY OF STROKE IN MIDLIFE: HIGH PREVALENCE OF MODIFIABLE STROKE RISK FACTORS

L Lisabeth ¹, L Skolarus ², J Baek ³, D Zahuranec ², E Case ³, L Morgenstern ²

Abstract

Background

While stroke incidence has declined in the USA; incidence during midlife (45–64 years) is stable. We describe the epidemiology of ischemic stroke (IS) in a midlife stroke cohort.

Methods

Data (2000–2012) are from the population-based Brain Attack Surveillance in Corpus Christi Project conducted in an ethnically diverse Texas, USA community. Risk factor prevalence, 1-year recurrence and all-cause mortality risk, and 90-day outcomes were calculated for those 45–64 (midlife) and compared with those >65 using sex and ethnicity adjusted regression models.

Results

Of 4,858 IS, 33% were in midlife. Risk factor prevalence in midlife group: hypertension 74%, diabetes 51%, hyperlipidemia 34%, heart disease 26%, history stroke/TIA 23%, smoking 37%, excess alcohol 10%, atrial fibrillation 4%, median BMI 30 (IQR: 26–35). Diabetes, smoking, and alcohol were more prevalent and BMI higher in the midlife group (p < 0.05). One-year recurrence and mortality in those 45–64 were 8% (95% CI:5%-9%) and 10% (95% CI:8%-11%) respectively. Mortality was lower in the midlife but recurrence did not differ by age. Functional, neurologic and cognitive outcome at 90 days were better in the midlife group, while quality of life did not differ by age.

Conclusions

Midlife stroke patients had higher BMI and more diabetes and smoking than the elderly. The world is in the midst of an obesity epidemic. Further study of obesity and behavioral risk factors and midlife stroke burden is needed. Despite greater disability among elderly stroke survivors, quality of life did not differ by age suggesting midlife stroke survivors may face unique post-stroke challenges.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

STROKE AND RURALITY. ARE HEALTH INEQUALITIES AVOIDABLE?

T López Martínez ¹, S Calleja Puerta ², J Bernardo Cofiño ³

Abstract

Background

Equality in health-assistance time-dependent diseases could be compromised in rural areas due to geographical dispersion and lack of specialized resources. The aim of the present study is to understand health system behavior concerning stroke assistance in rural populations.

Methods

The study is a descriptive-retrospective patient record carried out at Jarrio Hospital (Asturias, North Spain). Electronic medical records of patients suffering stoke in 2013, were reviewed.

Results

N: 126. Mean age: 77.8 years (±20.2); 89.6% ischemic stroke. Arterial hypertension (69%) and atrial fibrillation (22.2%) were the most prevalent risk factors. Only 27.7% patients asked for medical assistance in the first 4.5 hours after the onset of symptoms. There was a significant delay in coast-incident cases (p < 0.042). 12.7% of ischemic stroke were subsidiary of Stroke Code activation, arriving 12.5% of them over the 4.5 hour-limit to referral hospital. 1.58% of strokes received fibrinolysis and intravascular devices were employed in the same percentage. Initial Intensive Care Unit hospitalization was indicated in 32.4% patients. Supraaortic-branchs ultrasonography and echocardiography were performed respectively in 54.4% and 45.2% of ischemic strokes. 28.6% of all stroke cases started intra-hospitalary rehabilitation and the Rankin score was >2 in 71.4% at discharge. 41.1% of cases were readmitted in the first year after discharge.

Conclusions

Lack of specialized resources and health system behavior hinder Clinical Practice Guidelines compliance for stroke management, with poorer results in rural areas. Alternatives such a telemedicine could enhance rural healtht-assistance avoiding health inequalities.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PORTFOLIO OF CEREBROVASCULAR CLINICAL TRIALS CONDUCTION: AN ANALYSIS OF THE CLINICALTRIALS.GOV DATABASE

MJ Machline Carrion ¹, LP Damiani ¹, RD Lopes ², LN Laranjeira ¹, EV Santucci ¹, A Kodama ¹, EA Suzumura ¹, O Berwanger ¹

Abstract

Background

Clinical trials conduction is key to generate evidence to reduce the cerebrovascular diseases’ burden worldwide.

Methods

From an aggregated database comprising 119713 interventional studies registered in the ClinicalTrials.gov until June 26^th 2013, we created a subset of cerebrovascular trials. These studies were categorized according to the area being addressed as acute ischemic stroke treatment, intracerebral hemorrhage, aneurysm and arteriovenous malformation, vascular cognitive impairment, clinical rehabilitation/recovery, cerebral large artery disease, preventive strategies, and emergency systems/quality improvement initiatives. Studies were also analyzed in relation to year of registration and start date, enrollment characteristics, population age and gender, regional distribution, primary purpose, intervention type, intervention model, presence of a data monitoring committee, funding source, phase, allocation, masking and endpoint classification.

Results

The 1023 cerebrovascular trials identified represents 0.85% of the ClinicalTrials.gov database. The trials were predominantly registered after 2004 (95.7%) and 536(52.4%) were closed. Clinical rehabilitation/recovery was the major area being addressed (37.2%). Intervention involved a behavioral approach in 37.76%, and a device/procedure in 34.6%. More than half of the studies (58.6%) anticipated enrolling up to 100. The majority of the trials were conducted in North America, Europe or Oceania (78.4%), with a restricted participation of Latin America (2.9%).

Conclusions

Cerebrovascular trials registered in the ClinicalTrials.gov have increased significantly. However, some findings raised concern: the preponderance of small studies and limited strength of evidence likely to be generated by this portfolio; and the limited participation of regions with an important burden from cerebrovascular diseases as is the case of Latin America.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ASSESSING SHORT FORM VERSIONS OF THE BARTHEL INDEX IN STROKE

R MacIsaac ¹, M Ali ¹, KR Lees ¹, TJ Quinn ¹; On behalf of the VISTA Collaborators¹

Abstract

Background

Shortened versions of the Barthel Index (BI) exist, however utility may be limited by complex scoring. We sought to validate and simplify these short form BI (SF-BI) using archived clinical trials’ data.

Methods

Using data from the Virtual International Stroke Trials Archive (VISTA), we described a SF-BI using factor analyses and sequentially removed components to assess internal consistency. We applied our SF-BI and those SF-BI identified by literature review to our data, assessing agreement (Cronbach’s α) with original BI and correlation with functional outcomes (modified Rankin Scale [mRS], National Institutes of Health Stroke Scale [NIHSS]) and other SF-BI variants. Using an independant rehabilitation dataset, we assessed agreement with BI (original version) and among SF-BI variants; and correlation with Stroke Impact Scale [SIS] and EQ-5D.

Results

Using acute data, (n = 8852) Cronbach’s α = 0.96 for the original BI. Factor analysis suggested an optimal SF-BI comprising bladder, transfer and mobility items. From 3546 titles, we found 3 published SF-BI variants. Each SF-BI demonstrated strong correlation with full BI(ρ ≥ 0.90); mRS(ρ ≥ 0.85); NIHSS(ρ ≥ 0.70); all p < 0.001. Two of these SF-BI also comprised bladder, transfer and mobility items with scoring requiring additional calculation. Our SF-BI was generated using simple summation of component items and performed equally. Using rehabilitation data (n = 332) all SF-BI demonstrated strong agreement with each other and the full BI (all α > 0.96), and strong correlation with other outcome measures (SIS ρ ≥ 0.52, EQ-5D ρ ≥ 0.47).

Conclusions

There is redundancy in the original BI; we described a 3-item VISTA SF-BI that demonstrates internal and external validity and is simple to use in practice.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

TRENDS IN SHORT-TERM AND LONG-TERM CASE FATALITY IN ISCHEMIC STROKE, BY SOCIAL CLASS IN SWEDEN 1987-2010

N Malki ¹, A Ploner ¹, S Hägg ¹, S Tiikkaja ¹, I Koupil ², P Sparén ¹

Abstract

Background

Case-fatality in ischemic stroke (IS) has improved over time. In this study we investigate whether these improvements have been equally distributed across different socioeconomic positions (SEP), for both short and long term case-fatality in IS.

Methods

All Swedish residents born before 1960 were included; individuals who developed IS were selected from the Hospital inpatient register and the Cause of death register. Individuals who died before reaching the hospital or at the disease event day were analyzed separately using logistic regression. Individuals who survived the first day were analyzed using time to event analysis for one year. Flexible parametric models were used to estimate the mortality probability as well as mortality probability differences comparing different SEP groups.

Results

In total 214,866 IS cases where identified. One day mortality probability decreased from 0.13 [95% CI: 0.12–0.15] in 1990 to 0.075 [95% CI: 0.069–0.08] in 2010 for men aged 75 years old in the lowest SEP. For men 75 years old in the highest SEP, the one day mortality probability decreased from 0.11 [95% CI: 0.095–0.12] in 1990 to 0.056 [95% CI: 0.05–0.06] in 2010. However for one year case-fatality there haven’t been any significant improvements.

Conclusions

One day case-fatality in IS have decreased by half from 1990 to 2005 for all SEP groups. In contrary the one year case-fatality haven’t been improved over time. The large socioeconomic inequality in case-fatality for IS, persisted over the study period for both short-term and long-term case-fatality in IS.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CARDIOVASCULAR OUTCOMES IN PATIENTS WITH MINOR ISCHAEMIC STROKE OR HIGH-RISK TRANSIENT ISCHAEMIC ATTACK IN JAPAN: THE FUKUOKA STROKE REGISTRY

R Matsuo ^1,², M Kamouchi ^1,³, F Kiyuna ², T Ago ², T Kitazono ^2,³, on behalf of the, FSR Investigators

Abstract

Background

There are limited data regarding cardiovascular outcomes in patients with minor ischaemic stroke or high-risk transient ischaemic attack (TIA) in Japan. The aim of this study was to elucidate frequency of cardiovascular events during the year after minor ischaemic stroke or TIA.

Methods

Of 7943 patients with acute ischaemic stroke or TIA registered in the Fukuoka Stroke Registry (FSR) between June 2007 and December 2013, 5450 individuals (mean age 70.5 years, 63.7% men) with minor ischaemic stroke (NIHSS score ≤5) or high-risk TIA (ABCD² score ≥4 or stenotic cerebral and carotid arteries) were included in this study. Cardiovascular outcomes, including major cardiovascular events (stroke, myocardial infarction) and all-cause death, at 90 days and 1 year were evaluated.

Results

Of patients with acute ischaemic stroke, 68.4% (4934 patients) had a minor ischaemic stroke, and of patients with TIA, 70.8% (516 patients) had a high-risk TIA. Hypertension, dyslipidaemia, diabetes mellitus and previous stroke were recorded in 80.2%, 55.1%, 33.7% and 18.9% of patients, respectively. Rates of recurrent ischaemic stroke, all-cause death and composite of major cardiovascular events at 90 days were 5.2%, 1.5% and 8.6%, and at 1 year were 8.2%, 4.9% and 15.7%, respectively. Incidence of major bleeding was 1.1% at 90 days and 1.9% at 1 year.

Conclusions

About one in six patients had a major cardiovascular event in the year after minor ischaemic stroke or high-risk TIA. Half of these events occurred during the first 90 days, highlighting the importance of early and sustained preventive therapy.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

STROKE EPIDEMIOLOGY AND CARE IN UKRAINE

T Mishchenko ¹, V Mishchenko ¹, O Kutikov ¹, I Nikishkova ¹

Abstract

Background

Ukraine belongs to the countries with a high incidence of stroke.

Methods

To assess the stroke epidemiology and care in Ukraine, data of governmental statistics for 2014 were used.

Results

The stroke incidence in Ukraine was 266.5 cases per 100,000 with 67% of elderly persons among these cases. A proportion between hemorrhagic stroke and ischemic one was 1:5. The stroke mortality was 84.8 cases per 100,000, including 46.2 due to ischemic stroke, 27.7 due to intracerebral hemorrhage, 2.5 due to subarachnoid hemorrhage, and 8.5 due to stroke of undetermined etiology. A high stroke incidence is stipulated by a certainly significant proportion of elderly persons in the population (27.9%), a great prevalence of arterial hypertension, diabetes mellitus, heart diseases, metabolic syndrome, smoking, alcohol abuse, and a chronic distress situation because of the military conflict on the East of Ukraine.

Stroke care in Ukraine provides at the specialized stroke units (52 units with 2439 beds), neurological departments and intensive care departments of city and regional general hospitals.

Thrombolytic treatment is performed only for 0.3% patients with ischemic stroke.

Conclusions

To improve care provision for patients with stroke it is necessary to establish a network of specialized stroke units having opportunities to perform thrombolytic and endovascular treatment techniques as well as to establish the National Stroke Register which will allow estimating of a current conditions with stroke-related problems in Ukraine.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

RETINAL MICROVASCULATURE AND WHITE MATTER MICROSTRUCTURE: THE ROTTERDAM STUDY

U Mutlu ^1,², LGM Cremers ^1,³, M de Groot ^3,^4,⁵, A Hofman ^1,⁶, WJ Niessen ^3,^4,⁵, A van der Lugt ³, CCW Klaver ^1,², MA Ikram ^1,^3,⁷, MW Vernooij ^1,³, MK Ikram ^1,^8,⁹

Abstract

Background

Microvascular pathology on retinal imaging has been linked to structural MRI markers of microvascular brain damage, including white matter lesions. However, damage to the white matter is often more widespread than is visible as structural MRI markers, and can be detected as microstructural damage. We studied whether retinal vascular calibers are related to normal-appearing white matter microstructure.

Methods

We included 2,436 participants (age ≥ 45 years) from the population-based Rotterdam Study (2005–2009) who had gradable retinal images and brain MRI scans. Retinal arteriolar and venular calibers were measured semi-automatically on fundus photographs. White matter microstructure was assessed using diffusion tensor MRI. We used linear regression models to investigate the associations of retinal vascular calibers with markers of normal-appearing white matter microstructure, adjusting for age, sex, the fellow vascular caliber, and additionally for structural MRI markers and cardiovascular risk factors.

Results

Narrower arterioles and wider venules were associated with poor white matter microstructure: adjusted difference in fractional anisotropy per standard deviation decrease in arteriolar caliber −0.061 (95% confidence interval [CI]: −0.106; −0.016) and increase in venular caliber −0.054 (-0.096; −0.011), and adjusted difference in mean diffusivity per standard deviation decrease in arteriolar caliber 0.048 (0.007; 0.088), and increase in venular caliber 0.047 (0.008; 0.085). The associations for venules were more prominent in women.

Conclusions

Retinal vascular calibers are related to normal-appearing white matter microstructure. This suggests that microvascular damage in the white matter is more widespread than visually detectable as white matter lesions.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

INCIDENCE OF INTRACEREBRAL HEMORRHAGE SUBTYPES: PRELIMINARY DATA FROM A POPULATION-BASED STROKE REGISTRY

R Ornello ¹, D Degan ¹, C Tiseo ¹, F Pistoia ¹, A Carolei ¹, S Sacco ¹

Abstract

Background

Population-based data about subtypes of intracerebral hemorrhage (ICH) are scarce. We aimed to assess the incidence of each etiologic subtype of first-ever ICH in a prospective, population-based stroke registry.

Methods

All patients presenting with a first-ever ICH (code 431, WHO ICD-9) in 2011–2012 and residing in the district of L’Aquila, central Italy, at the time of the event were included in our registry by active monitoring of all inpatients and outpatients health services and of death certificates. The SMASH-U etiologic classification was applied to identify ICH subtypes.

Results

We included 148 patients with ICH (52% men) with a mean age of 75.8 ± 13.2 years. The overall crude annual incidence rate of ICH (per 100,000 person-years) was 24.8 (95% confidence interval [CI] 21.0–29.0); it was 10.2 (95% CI 7.9–13.0) for ICH due to hypertensive angiopathy, 6.7 (95% CI 4.8–9.0) for ICH due to amyloid angiopathy, 2.5 (95% CI 1.5–4.0) for ICH due to medication, 2.4 (95% CI 1.3–3.8) for ICH of undetermined cause, and 1.5 (95% CI 0.7–2.7) for ICH due to structural lesions and systemic/other diseases. The highest 1-year case-fatality rate were those of ICH due to undetermined cause (71.4%) or to systemic/other disease (66.7%) while the lowest was that of ICH due to structural lesions (22.2%).

Conclusions

In our study, ICH due to hypertensive angiopathy was the leading incident type while ICH due to undetermined cause or to systemic/other disease had the highest case-fatality. The etiologic classification of ICH is important in order to improve prevention and prognosis.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

INCIDENCE OF, AND RISK FACTORS FOR, STROKE IN THE GENERAL MALE POPULATION - 48 YEARS OF FOLLOW-UP IN THE STUDY OF MEN BORN IN 1913

CU Persson ¹, L Rusek ², K Svärdsudd ³, A Blomstrand ⁴, C Blomstrand ⁵, PO Hansson ²

Abstract

Background

The aims of the study were to analyze the lifetime risk of stroke and the impact of potential risk factors in a longitudinal follow-up of 50-years old men.

Methods

In 1963, a systematic sample of every third man born in 1913 and living in Göteborg, Sweden (n = 973) were invited to a health examination out of which 855 (88%) participated. These men have been followed from 50 to maximum 98 years of age (until death or up to Dec 31^st in 2011), with repeated medical examinations and data from the National Hospital Discharge and the Cause of Death registers. Medical records have been collected and reviewed for the diagnosis of stroke.

Results

Of the 855 men, 168 (19.6%) suffered from a first-ever stroke during follow-up. Of these, 131 (78.0%) were ischemic, 21 (12.5%) hemorrhagic, while 16 stroke events (9.5%) were non-specified. The risk of stroke increased with age; from 0.47 (95% CI 0–1.13) per 1000 observation years aged 50–54 years to 45.45 (95% CI 1.09–89.81) aged 95–98 years. The total incidence rate was 7.55 per 1000 observation years. From 50 to 98 years of age, the cumulative incidence of stroke was 48.4%. In a multivariate cox regression analysis, based on potential risk factors at baseline, hypertension, low level of education and high level of perceived mental stress were significantly associated with increased risk of stroke during follow-up.

Conclusions

Significant risk factors for stroke during a long time follow-up were hypertension, low level of education and high level of perceived mental stress.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ROLE OF BYSTANDERS IN HELP-SEEKING FOR PATIENTS WITH STROKE/TIA; EFFECT ON HOSPITAL ARRIVAL TIMES

J Redgrave ¹, E Abbey ², N Rugg ³, S Jones ⁴, CL Watkins ⁴, A Majid ⁵, K Harkness ⁶

Abstract

Background

The majority of calls for medical help immediately after a stroke are made by bystanders. However the relationship of these bystanders to the patient, the reasons for their involvement in seeking help, and their influence on hospital arrival times are unclear.

Methods

422 consecutive patients admitted to Hyper-acute Stroke Unit in Sheffield with stroke or TIA were interviewed in 2013–2015. 99 interviews were also undertaken with bystanders who had called for help independently of the patient. Logistic regression was used to assess the relationship between the level of bystander involvement and arrival time

Results

307 (73%) patients had a diagnosis of stroke and 115 (27.3%) had TIA. The mean (±SD) age was 73 years ( ± 14). Median (IQR) delay between onset and hospital arrival was 5 hours (1.4–20.8). In 315 (74.6%) cases, a bystander (usually a son/daughter or a partner/spouse) made the first call for medical help. In 182 cases, the bystander called for help independently of the patient e.g. due to the patient’s incapacity (123, 29.1%) or refusal to call (44, 24.7%). When bystanders sought help independently, the patients were more likely to arrive within 4 hours of symptoms (adjusted OR 3.03, 1.41–6.50, P = 0.004) than in cases when patients themselves called for help.

Conclusions

Bystanders call for help for the majority of patients with stroke/TIA and their influence may result in more rapid admissions to hospital. Sons/daughters and spouses/partners of patients at high risk of stroke may form a useful target group for education around the need for emergency action after a stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

STROKE INCIDENCE IN LA ARAUCANÍA, CHILE DURING 2001-2010

R Rivas ^1,², A Doussoulin ³, C Sabelle ⁴, V Díaz ⁵

Abstract

Background

Stroke is the most common specific cause of death in Chile since 2008, representing roughly 10% of total death. However, the situation in not homogenous in our country. Aim: To determine the incidence of stroke in the Health Service South Araucanía (HSSA) during the period 2001–2010.

Methods

The research is a descriptive Cross-Sectional Study. The study considers the databases of the department of statistics and health information (DEIS) for the years 2001–2010. The population over 15 years who presented an episode of stroke it was considered during the period 2001–2010, which received attention in the HSSA, and its principal diagnosis agree to the criteria of ICD-10.

Results

During the study period was obtained 6548 hospital discharges. There were no significant differences between men and women, in the discharge.The most frequent diagnoses were for male and female ischemic or hemorrhagic stroke and then the intracerebral hemorrhage (ICH). The incidence rate as a condition of discharge and type of stroke was 961.3 (95% CI 950.7 to 972.4). Both men and women, the highest percentage were hospitalized between 1–10 days (75%). The mortality rate at discharge was 18.2%.

Conclusions

The information collected allows complement and have an updated regarding the incidence of stroke in different health centers in our region, the fifth most populous in Chile, with geographic, ethnic characteristics and social own perspective. The incidence rate is higher that we have on PISCIS study (Iquique, Chile) and is very close to Bulgaria. The mortality rate is within the norm for middle and high income.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

IMPACT OF ABDOMINAL OBESITY IN THE ISCHEMIC STROKE RISK

A Rodríguez-Campello ¹, J Jiménez-Conde ¹, E Cuadrado Godia ¹, A Ois ¹, E Giralt-Steinhauer ¹, R Vivanco Hidalgo ¹, P De Ceballos Cerrajería ¹, A Zabalza de Torres ¹, J Roquer ¹

Abstract

Background

Evidence in stroke indicates that the distribution of body fat predicts better stroke risk than total body fat, suggesting that abdominal obesity, as estimated by waist-circumference (WC) or waist-to-height ratio (WHtR), could represent a better marker of stroke risk than body mass index (BMI), because abdominal obesity is an indicator of fat distribution. The objective of our study is to evaluate the impact of abdominal obesity in the ischemic stroke risk independent of BMI.

Methods

We included 388 ischemic stroke patients (<75-years) assessed consecutively in our hospital and 732 controls matched by age and sex. Vascular risk factors and anthropometrical data (waist, weight and height) were registered. It has been performed an analysis to determine the impact of WC and waist-to-height ratio WHtR in stroke. These variables are divided into quartiles and it is made a comprehensive comparative analysis between the two populations, distinguishing between men and women, and adjusting in logistic regression by age and vascular risk factors. It is further performed a logistic regression using dummy variables, to evaluate the association of abdominal obesity BMI adjusted.

Results

If we consider only abdominal obesity, WC acts as a risk factor for stroke in women (OR = 4.4; p = 0.004) but not in men, while in the WHtR there is no evidence association. Abdominal obesity independent of BMI is a risk factor in both sexes, but the strength of the association is significantly higher in women.

Conclusions

Abdominal obesity is associated with ischemic stroke in women. The effect of abdominal obesity differs depending on sex.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

TIME OF PRE-HOSPITAL DELAY IN CROATIAN STROKE PATIENTS

S Rutović ¹, D Kadojić ², M Dikanović ¹

Abstract

Background

Thrombolytic therapy improves outcome after ischemic stroke when applied within 4.5 hours from symptoms onset, but only a minority of patients arrive within that time frame. The aim of this study was to investigate what was the time of delay after acute stroke and which factors contribute to the late arrival.

Methods

In this study time of delay and main reasons for it were evaluated in 200 patients admitted to Osijek University Hospital and General Hospital “Dr Josip Benčević” Slavonski Brod. Average age of all patients was 69.98 years.

Results

The mean interval of time of delay was 502 minutes (254 for hemorrhagic stroke, and 542 for ischemic stroke). Time of delay was shortest in patients with subarachnoid hemorrhage (240 minutes), for large vessel stroke 354 minutes, for cardioembolic stroke 382 minutes and longest in small vessel stroke (804 minutes). Among investigated patients 40% arrived within 3 hours, and another 13% in the next 3 hours. The most frequent reasons for delay were non-recognized symptoms (52.5%), followed by late transport (33.5%) and finally no knowledge about urgency (14%).

Conclusions

Our results show significant prehospital delay for acute stroke patients. This emphasizes the requirement of effective public health activities and efficient system of emergency medicine, which should reduce time of delay and improve outcome.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PROGNOSIS OF CATHETER-RELATED ISCHEMIC STROKE CAUSED BY CORONARY ANGIOGRAPHY AND PERCUTANEOUS CORONARY INTERVENTION

S Saito ¹, T Higuma ², S Hiroshi ¹, M Norifumi ¹, H Joji ¹, K Takaatsu ¹, O Ken ³, Y Minoru ¹

Abstract

Background

It is rarely reported the prognosis of ischemic stroke as the complication of coronary angiography (CAG) and percutaneous coronary intervention (PCI).

Methods

Of CAG (1885 cases) and PCI (1375 cases) that had been performed for 3 years from January 2012 to December 2014, the consecutive 9 patients (0.28%) with iatrogenic symptomatic catheter-related ischemic stroke (CRIS) were enrolled. CRIS was diagnosed by stroke specialists based on clinical course and head MRI and so on. Prognosis was determined on modified Rankin Scale (mRS), and good prognosis was defined as the score less than 2 and poor was more than 3.

Results

Of 9 patients, there were 2 patients caused by CAG and 7 patients due to PCI. All occluded vessel was distal portion and embolism was suggested on MRI image. All patients were treated medically. The occluded territories were middle cerebral artery, 67%; vertebral-basilar artery, 33%; posterior cerebral artery, 33%; and watershed, 22%. Multiple ischemic stroke lesions accounted for 56%. The median [25–75 percentile] of preclinical mRS was 0 [0–1]. The 50 percentile of NIHSS and mRS in onset were 5 [3–6.5] and 4 [2–4] respectively. The central value of mRS at discharge was 2 [1–4]. Although mRS at discharge tended to be improved than mRS at onset (p = 0.0531), there were 3 patients (33%) on poor prognosis in hospital period of an average of 50 days.

Conclusions

Catheter-related ischemic stroke is rare event. If once the complication has occurred, the third is poor prognosis.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

STROKE SEVERITY AMONG YOUNG ISCHEMIC STROKE PATIENTS IN ESTONIA

S Schneider ¹, A Kornejeva ², R Vibo ¹, J Kõrv ¹

Abstract

Background

Previous studies of young ischemic stroke patients in Estonia have found high incidence and mortality rates, however, little is known about the severity of stroke and its associated factors.

Methods

We performed a retrospective study of consecutive patients aged 18–54 years who were treated in Tartu University Hospital and North Estonia Medical Centre from January 2003 to December 2012 and received a discharge diagnosis of ischemic stroke. Stroke severity was stratified according to NIHSS score as mild (0–6), moderate (7–15), and severe (16–42) and age into groups of 18–34, 35–44, 45–49, and 50–54 years. We classified stroke subtypes etiologically according to the TOAST criteria.

Results

We identified 741 patients with first-ever stroke and 96 patients with recurrent stroke, the mean age was 47.2 ± 7.3 years. The majority of patients (66.4%) suffered a mild stroke. Stroke was more severe in men than it was in women (p = 0.04). Severity of stroke subtypes was significantly different (p < 0.0001) with large artery atherosclerosis as the most severe and small vessel disease as the least severe. Stroke was also more severe when involving multiple artery territory (p < 0.0001). There was no significant difference in severity across age groups or first-time and recurrent stroke.

Conclusions

We found that male sex, large artery atherosclerosis and multiple artery territory stroke were associated with a more severe stroke in young patients. Previous studies have confirmed that young patients mostly have a mild stroke, yet to our knowledge stroke severity in subgroups has not been studied before.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

UNCONTROLLED AVERAGE GLUCOSE BEFORE STROKE IS ASSOCIATED WITH SMALL ARTERIAL OCCLUSION IN STROKE SUBTYPES

A Seong Hwan ¹, C In Sung ¹, K Hyun Goo ¹, C Ji Yeon ¹, K Hoo Won ¹, K Jin Ho ¹

Abstract

Background

Diabetes is an independent factor of ischemic stroke. For prevention of ischemic stroke, average glucose level is required to be kept below the Hba1c level of 7%. We hypothesized that uncontrolled glucose before stroke can influence the stroke subtype and clinical outcome in acute stroke patient with diabetes.

Methods

Between March 2008 and December 2013, of acute stroke patients admitted within 7 days from onset, diabetes patients who were medicated with hypoglycemic agent were selected from our stroke registry. The controlled group was defined as those who had average glucose level that was below 7% of Hba1c at admission. Clinical and laboratory data were compared between the controlled and uncontrolled groups.

Results

Of 284 patients, 124 (43.7%) were female and the mean age was 68.5 (SD 9.6). In the controlled group (N = 93), Hba1c level was lower (6.3 vs. 8.1, p = 0.001) than in the uncontrolled group (N = 191). Metabolic syndrome, hyperlipidemia, and previous stroke history were more common in the uncontrolled group. Also, triglyceride, LDL, non-HDL cholesterol, and glucose level at admission were higher. In stroke subtypes, small arterial occlusion was more common (22.6% vs. 39.8%, p = 0.006) in the uncontrolled group. However, there was no difference between controlled and uncontrolled groups in the admission NIHSS (5 vs. 3, p = 0.197), the discharge mRS (2 vs. 2, p = 0.167), and the 3 months mRS (1 vs. 1, p = 0.262).

Conclusions

In acute stroke with diabetes mellitus, uncontrolled glucose before admission was associated with abnormal lipid profile, which may cause more frequent small arterial occlusion.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

TRACHEOSTOMY PLACEMENT FOR STROKE INPATIENTS IN THE UNITED STATES

T Singh ¹, C Creutzfeldt ², D Tirschwell ², S Peters ²

Abstract

Background

After severe stroke, tracheostomy placement may improve patient’s chance of survival, and it quintuples the hospital’s reimbursement rate. Little guidance exists regarding the indication for tracheostomy after stroke. Hypothesizing a substantial variability among hospitals, the goal of this study was to explore tracheostomy practices in US stroke patients.

Methods

Using the 2010–2012 Nationwide Inpatient Sample, we reviewed all patients discharged with stroke, sub-classified as ischemic, intracerebral hemorrhage and subarachnoid hemorrhage. We collected information on demographics, outcome and tracheostomy as defined by ICD-9 procedure codes.

Results

Among 359,411 stroke patients, a tracheostomy placement encounter was found in 7565 patients (1.91% with 2.07% in 2010 and 1.88% in 2012, p < 0.05). The tracheostomy rate ranged from 0% to 9.2% between all hospitals with >50 annual stroke admissions. Among the 8% stroke patients with mechanical ventilation, 15% (range of 0% to 54% between hospitals) underwent tracheostomy. After multivariate analyses, tracheostomy rates were significantly associated with illness severity; younger age; hemorrhagic stroke types; and larger hospitals (all p < 0.05). Urban and teaching hospitals performed more tracheostomies compared to rural hospitals. Blacks, Hispanic, Asian/Pacific Islanders underwent tracheostomy more often than whites (p < 0.05). Women had a lower tracheostomy rate than men (OR 0.92, 95% CI 0.88–0.97). Of the 9% of all patients who died in hospital, 2.72% had received tracheostomy.

Conclusions

Tracheostomy rates vary widely across US hospitals and are associated with stroke type, patient age, gender and race as well as hospital category. The observed variability seems to go beyond purely medical indications, calling for further research.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EARLY COMPLICATIONS AFTER ISCHEMIC STROKE AND STROKE OUTCOME: FIRST RESULTS FROM THE STROKEUNIT PLUS STUDY

J Sobesky ¹, VI Madai ², S Wiedmann ³, M Bauer ¹, I Wellwood ⁴, C Malsch ³, KG Häusler ¹, B Schmitz ⁵, BM Mackert ⁶, HC Koennecke ⁷, DG Nabavi ⁸, C Kleinschnitz ⁹, M Dichgans ¹⁰, M Endres ¹¹, U Dirnagl ¹, PU Heuschmann ³

Abstract

Background

Early complications after ischemic stroke (ECIS) have a relevant impact on stroke outcome. Previous studies showed substantial variation of their frequency and natural course precluding valid modeling of therapeutic strategies. The StrokeUnit plus (SUplus) study intends to deliver comprehensive information on ECIS to inform future therapeutic approaches.

Methods

A multicentre prospective observational study included patients with first ever stroke in 7 German stroke units. Standardized protocols were applied to monitor occurrence of ECIS within the first 7 days of admission or until discharge. Primary outcome (poor outcome) was death or dependency (Rankin Scale >3 or Barthel Index <60) at 3 months. The frequency of 16 predefined ECIS was recorded by clinical definition and their contribution to the primary outcome was calculated by multivariable logistic regression and independent attributable risks (AR), applying sequential attributable fractions.

Results

From 9/2013 to 5/2015, 1202 patients were recruited (mean age: 68 years; 42% female; complete outcome information 90%; median NIHSS on admission: 3). At 3 months 9.2% had poor outcome. Frequencies of complications associated with poor outcome were: urinary tract infection (4.2%), falls (3.4%), evidence of delirium (3.4%) and clinical signs of pneumonia (2.0%). Patients experiencing >1 of these four complications had higher probability of poor outcome (adjusted OR 5.04; 95% CI 3.04–8.37), with AR of 16[IW1] %.

Conclusions

The StrokeUnit plus study presents multicentre standardized frequency estimates of early stroke complications. Initial analyses identified 4 potentially modifiable complications based on clinical surrogate information (explaining up to 16% of poor outcome) as possible treatment targets.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

MULTIMORBIDITY AND POLYPHARMACY IN STROKE. A POPULATION-BASED STUDY IN ARAGON, SPAIN

H Tejada Meza ¹, J Marta Moreno ¹, B Poblador Plou ², J Artal Roy ¹, P Ruiz Palomino ¹, GJ Cruz Velásquez ¹, A Fernández Sanz ¹, A Prados Torres ²

Abstract

Background

Multimorbidity and polypharmacy affects patients by increasing the burden of their symptoms and treatment, being also associated with a worst functional outcome. The aim of this study was to examine the prevalence and influence of multimorbidity and polypharmacy in patients with stroke in Aragón, Spain.

Methods

This is a cross-sectional population-based study of all adult patients registered within the public health service of Aragón with diagnosis of ischemic stroke at 31 of December 2011. The study was conducted based on information obtained from electronic medical records and the primary care pharmacy database. A comparison group without a diagnosis of stroke was selected by simple random sampling. ORs were calculated adjusted for age and sex using logistic regression.

Results

In total, 11558 (1.1%) had a diagnosis of stroke. Of the people with stroke, 89.3% had one or more additional morbities in comparison with 39.6% of those without stroke (OR 3.7; 95% CI 3.3–4.0)(p < 0.01). In the stroke group, 62.5% had a record of 5 or more chronic medications compared with 11% of the control group (OR 5.15; 95% CI 4.8–5.6)(p < 0.05). 18.7% of the patients with stroke had 1 or more hospital admissions in the 3 years follow-up in comparison with 3.7% of those without stroke (OR 3.71; 95% CI 3.2–4.2)(p < 0.05).

Conclusions

Multimorbidity, polypharmacy and hospital admissions are more common in those patients with stroke compared with those without. A greater emphasis on the management of multimorbidity in stroke need to be placed on clinical guidelines and health services to improve patient outcomes.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

UNDETERMINED VS CARDIOEMBOLIC ISCHEMIC STROKE: RESULTS FROM A POPULATION-BASED REGISTRY

C Tiseo ¹, R Ornello ¹, D Degan ¹, F Pistoia ¹, S Sacco ¹, A Carolei ¹

Abstract

Background

Undetermined strokes (UNDS) approximately represent one third of ischemic strokes (IS). The aim of this study was to compare the characteristics of UNDS with those of cardioembolic strokes (CES).

Methods

Prospective population-based registry including all patients with a first-ever ischemic stroke (FEIS) residing in the L’Aquila district in 2011–2012. TOAST criteria were used to determine IS subtypes. Clinical features, risk factors, and prognosis of UNDS were compared with those of CES.

Results

Among 634 patients with FEIS, 220 (34.7%) had UNDS and 220 (34.7%) had established CES. Patients with UNDS (mean age ± SD 76.1 ± 11.4 years) were younger than those with CES (78.9 ± 12.3 years; P = 0.014). The proportion of women was similar in UNDS and CES (50.9% vs 58.6%; P = 0.103). UNDS, when compared with CES, had lower proportions of hypertension (72.7% vs 81.8%), atrial fibrillation (5.9% vs 78.6%), and coronary heart disease (10.0% vs 21.4%) (P < 0.05 in all cases), while the proportions of hypercholesterolemia, diabetes mellitus, cigarette smoking, and alcohol abuse were similar. Patients with UNDS had more POCI (29.5% vs 18.2%;P = 0.005) and less TACI (8.2% vs 21.4%; P < 0.001) than CES. UNDS were associated with a lower stroke severity at onset than CES (median NIHSS score 6, IQR [3–12] vs 10, IQR [4–18]; P = 0.002) and with lower 30-day (16.4% vs 26.8%) and 1-year (24.1% vs 38.1%) case-fatality rates (P < 0.05 in all cases).

Conclusions

According to our findings, UNDS and CES have different clinical features, risk factors, and prognosis, suggesting that in UNDS the cardioembolic etiology is scarcely represented.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PREDICTORS OF ONE-YEAR-FUNCTIONAL OUTCOME AFTER FIRST-EVER ISCHEMIC STROKE IN A POPULATION-BASED STROKE REGISTER

C Urbanek ¹, V Gokel ², H Becher ³, F Buggle ⁴, C Grond-Ginsbach ⁵, A Grau ⁴, A Safer ⁶, F Palm ⁷

Abstract

Background

Estimating functional outcome (FO) in patients may help clinicians to provide effective stroke care, anticipate discharge planning and support patients and family having realistic expectations on long-term outcome.

Methods

Within a population-based stroke registry, we assessed predictors for stroke outcome. All patients with first ever ischemic stroke (FEIS) were included. Poor FO as measured by modified ranking score (mRS) was assessed one year after FEIS. Multivariate logistic regression was used to determine variables associated with 1-year risk of poor FO (=mRS ≥ 3).

Results

Between January 1, 2006 and December 31, 2010, 1547 patients with FEIS could have been registered. One-year follow-up was available in 1370 patients (88.6%, 677 women and 693 men). In multivariate analysis, sex, higher age (75–84 years: OR 3.3,95% confidence interval (CI) 1.9–5.9; ≥85years OR 10.1, 95%CI 4.2–24.4), diabetes (OR 1.9, 95% CI 1.3–2.9), female gender (OR 1.8, 95%CI 1.2–2.7), lack of physical activity prior to stroke (OR 2.2, 95%CI 1.3–3.6), leucozyte count >9 × 1.000/mm³ at admission (OR 1.6,95%CI 1.1–2.4), probable atherothrombotic stroke (OR1.8,95%CI 1.0–3.2), stroke of unknown etiology (OR 5.2, 95%CI 2.1–12.8), NIHSS at admission (OR 1.2 95% CI 1.1–3.3) and mRS ≥ 3 on discharge (OR 8.8, 95%CI 5.4–14.4) independently predicted poor stroke outcome.

Conclusions

We used five-year data from a prospective, population-based stroke registry to detect predictors for poor FO. In addition to previoisly detected factors, we found that lack of physical activity prior to stroke, leucozyte count >9 × 1.000/mm³ at admission and stroke of unknown etiology predict poor FO in FEIS.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ASSESSMENT OF THE INCIDENCE AND TRENDS OF STROKE IN LLEIDA (SPAIN) IN THE PERIOD 2010-2014

AB Vena ¹, J valls ², R Boix ², X Cabre ³, R Piñol ⁴, J Molina ⁵, I Benabdelhak ⁵, J Sanahuja ⁵, F Purroy ⁵, N Lopez ⁶

Abstract

Background

To determine the incidence of stroke in the health area of Lleida in the period 2010–2014 and to assess its trends.

Methods

We conducted a population-based and observational study including the whole population in the health area of Lleida (Spain), with a population around 440,000 people and characterised by a high presence of aged and rural cohorts. All discharge reports were reviewed to detect the cases where stroke was the primary or secondary diagnosis, including all the registries from the reference hospital in the area. Data from the population census was obtained from the local statistics institute. Crude rates and age standardized rates using the European population as reference were assessed

Results

The annual incidence stroke crude rates were 236.97 (95% CI 227.96 – 245.99) and 160.72 (95% CI 153.17–168.27) for males and females respectively. The age-standardized rate, using the European reference population, were 172.42 (95% CI 167.5–177.33) and 85.27 (95%CI 81.86–88.67) for males and females respectively. An increasing trend was observed for males and decreasing for females in the stroke incidence (Annual Percent change [APC] = 1.88%, 95%CI −0.83; 4.66 and APC = −1.11%, 95%CI −4.35; 2.24, respectively). However, these trends did not reach statistical significance(p = 0.18 and 0.5, respectively).

Conclusions

Using gold-standard methods for case ascertainment, our incidence rates were similar to high-income countries. Our data would serve to develop specific health strategies in our region.Using gold-standard methods for case ascertainment, our incidence rates were similar to high-income countries. Our data would serve to develop specific health strategies in our region.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

STRAW &BDQUO;STROKE AWARENESS&LDQUO; - AWARENESS OF STROKE IN A SMALL REGION OF SWITZERLAND IN COMPARISON WITH INTERNATIONAL POPULATION BASED EPIDEMIOLOGICAL STUDIES

J Walch ¹, C Berger ², U Keller ³

Abstract

Background

Stroke is a common vascular emergency (ca.258/100000). In recent years increased efforts had been made to inform the population as well as the emergency medical service and general practitioners (GPs) about stroke symptoms and the need for a quick treatment in specialized hospitals to improve stroke outcome.

The aim of the study was to assess the population´s knowledge about stroke in our region.

Methods

The study was conducted from April until June 2013 in 11 different local GP offices. The questionnaire consisted of 9 questions.

Results

550 people (303 men, 247 women) aged between 18 and 71 years took part in the survey. 12% had no education, 70% had completed professional training and 18% had a university degree.

The majority knew the stroke symptoms of hemiparesis and speech problems but 56 % would go the ophthalmologist because of impaired vision. Also most of the participants would call 911 (86%) though 24% would see their GP first. Only 60% knew about the possibility of an acute medical treatment.

Conclusions

Our results show a good knowledge in terms of common stroke symptoms except for eye symptoms, well in line with international studies. The intention to call 911 is high, but still 24% would consult the GP first, which is an unnecessary loss of time.

More information is needed about atypical stroke symptoms and about the need of a fast transport via 911 to a specialized stroke centre where acute treatment possibilities are available.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

OUTCOMES IN PATIENTS WITH MINOR ISCHAEMIC STROKE: THE CHINA NATIONAL STROKE REGISTRY

Y Wang ^1,^2,³, Y Wang ^1,^2,³, Y Tan ^1,^2,³, Y Pan ^1,^2,³, on behalf of the, CNSR Investigators

Abstract

Background

There are limited data regarding outcomes in patients with minor ischaemic stroke in China. The aim of this study was to elucidate frequency of recurrent ischaemic stroke, stroke-related disability and death up to 12 months after minor ischaemic stroke.

Methods

This retrospective cohort study used data from the China National Stroke Registry. Patients who had a minor ischaemic stroke (NIHSS score ≤5) between September 2007 and August 2008 and who were admitted within 24 hours of symptom onset were included. Frequencies of recurrent ischaemic stroke, stroke-related disability (modified Rankin Scale score ≥3) and all-cause death at 90 days and 1 year were evaluated.

Results

The study included 1913 patients who had a minor ischaemic stroke (mean age: 65.1 years; 63.3% men; mean NIHSS score: 2.5). Hypertension, diabetes mellitus and dyslipidaemia were recorded in 63.3%, 20.2% and 12.9% of patients, respectively. Baseline antihypertensive, antiplatelet, lipid-lowering and anticoagulant therapies were recorded in 48.0%, 18.2%, 3.2% and 1.9% of patients, respectively. Mean duration of hospital stay was 14 days, at a mean cost per patient of 3469.62 Chinese yuan (about 490 Euro). Rates of recurrent ischaemic stroke, disability and death were 10.4%, 16.4% and 4.0% at 90 days, and 13.2%, 17.0% and 6.3%, at 1 year, respectively.

Conclusions

Most cases of recurrent ischaemic stroke, stroke-related disability and all-cause death in the year after minor ischaemic stroke occurred during the first 90 days, and rates remained high in the year after an event, underscoring the importance of early, sustained preventive therapy.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

A NATURAL LANGUAGE PROCESSING ALGORITHM TO IDENTIFY STROKE IN BRAIN IMAGING REPORTS ON A LARGE SCALE

W Whiteley ¹, C Grover ², B Alex ², C Sudlow ¹, G Mair ¹

Abstract

Background

We developed an automated system to read brain-imaging reports, to add validity to stroke diagnoses in electronic health records.

Methods

We obtained anonymised brain-imaging reports from the Edinburgh Stroke Study and NHS Tayside. Iteratively, we developed a rule-based natural language processing (NLP) system to identify stroke and its subtypes in radiologists’ reports of brain CT and MR imaging. We measured system positive predictive value (PPV) and sensitivity of the system by comparing system output with neurologist and neuro-radiologist reading of unseen test data.

Results

We examined 631 NHS Lothian reports during the development of the system (365 developent, 266 unseen test set). In the test dataset, our NLP system had a positive predictive value and sensitivity for ischaemic stroke (n = 176) of 95% and 98%; for haemorrhagic stroke (n = 23) 82% and 100%; and for underspecified stroke (n = 15) of 100% and 93%.

In the combined development and test sets, for ischaemic stroke, NLP had good PPV and sensitivity for deep location (98%, 98%); cortical location (97%, 96%); recent stroke (90%, 100%) and old stroke (98%, 97%). For haemorrhagic stroke, there was more modest PPV, though good sensitivity, for the identification of deep location (81%, 100%), cortical location (86%, 95%); recent stroke (78%, 100%) or old stroke (84%, 88%).

Conclusions

It is possible to automate the identification of ischaemic stroke age and location on brain imaging reports with NLP. The identification of haemorrhage is sensitive, though has a poorer positive predictive value.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

NEUROPSYCHIATRIC SYMPTOM CLUSTERS IN STROKE AND TRANSIENT ISCHEMIC ATTACK BY COGNITIVE STATUS AND STROKE SUBTYPE

A Wong ¹, AYL Lau ¹, J Yang ², Z Wang ¹, W Liu ¹, BYK Lam ¹, LWC Au ¹, L Shi ¹, D Wang ¹, WCW Chu ³, YY Xiong ⁴, ESK Lo ¹, LSN Law ¹, TWH Leung ¹, LCW Lam ⁵, AYY Chan ¹, YOY Soo ¹, LKS Wong ¹, VCT Mok ¹

Abstract

Background

The objectives of this study are 1) to examine the frequencies of neuropsychiatric symptom clusters in stroke or transient ischemic attack (TIA) patients by cognitive level and stroke subtype; and 2) to evaluate effect of demographic, clinical, and neuroimaging measures of chronic brain changes upon neuropsychiatric symptom clusters.

Methods

518 patients in the Stroke Registry Investigating Cognitive Decline (STRIDE) study were administered the Neuropsychiatric Inventory (NPI) 3–6 months after stroke or TIA. NPI symptoms were classified into four symptom clusters (Behavioral Problems, Psychosis, Mood Disturbance & Euphoria) derived from a confirmatory factor analysis of the 12 NPI items. Multivariate logistic regression was used to determine independent associations between demographic, clinical and neuroimaging measures of chronic brain changes (white matter changes, old infarcts, whole brain atrophy, medial temporal lobe atrophy [MTLA] and frontal lobe atrophy [FLA]) with the presence of NPI symptoms and symptoms clusters except euphoria.

Results

50.6% of the whole sample, including 28.7% cognitively normal and 66.7% of patients with mild cognitive symptoms had one or more NPI symptoms. Frequencies of symptom clusters were largely similar between stroke subtypes. Patients with TIA had less frequent mood disturbance compared to those with cardioembolic stroke and intracranial haemorrhage. Stroke severity at admission and MTLA were the most robust correlates of symptoms. FLA was associated with behavioral problems cluster only.

Conclusions

Frequency of neuropsychiatric symptoms increased with level of cognitive impairment but was largely similar between stroke subtypes. Stroke severity and MTLA were associated with multiple neuropsychiatric symptoms.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CAN ROUTINELY-COLLECTED PRIMARY CARE DATA BE USED TO MEASURE VISIT-TO-VISIT BLOOD PRESSURE VARIABILITY IN LARGE EPIDEMIOLOGICAL STUDIES?

R Woodfield ¹, C Sudlow ^1,²

Abstract

Background

Blood pressure variability (BPV) may be an independent risk factor for stroke. We explored the potential of using routinely collected coded primary care data to estimate visit-to-visit BPV in UK Biobank (UKB, a prospective study of 503,000 UK adults recruited in middle-age).

Methods

We analysed data from 9,947 Welsh participants with linked primary care data (∼47% UKB Welsh population). We identified participants in whom visit-to-visit BPV could be measured using coded systolic blood pressure values (BP), and explored the influence of frequency of visits with coded BP values on: participant characteristics; time between visits; mean BPV; standard deviation of BPV (SD BPV). We also calculated within-individual agreement between coded BP and UKB baseline assessment BP (Intra-class correlation coefficient, ICC).

Results

68% participants had sufficient coded data to estimate BPV (≥3 visits with coded BP before recruitment). Participants with more visits had increased prevalence of vascular disease, increased mean BPV, reduced SD BPV, and reduced time between visits. SD in within-participant BPV ranged from ∼7 mmHg to ∼5 mmHg. ICC between coded BP and baseline assessment BP was 0.53 (95% CI 0.52–0.55).

Conclusions

Visit-to-visit BPV was captured in the majority of participants. Selecting participants with more visits reduced generalizability, but there was good variability in BPV amongst those selected, and reasonable agreement between coded BP and an independent reference standard. Routinely collected coded primary care data should enable exploration of associations between BPV and stroke in a ‘real-world’ setting, and in larger numbers than previously possible.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EFFECT OF CONFOUNDING ON PERFORMANCE OF ORDINAL ANALYSIS METHODS IN STROKE STUDIES - A SIMULATION STUDY

T Zonneveld ¹, A Aigner ², R Groenwold ³, A Algra ⁴, P Nederkoorn ¹, U Grittner ⁵, N Kruyt ⁶, B Siegerink ⁵

Abstract

Background

Consensus is lacking regarding the optimal method to analyze the ordinal modified Rankin Scale (mRS), used to assess functional outcome in most acute stroke studies. The ordinal logistic regression (OLR) is often applied, whereas the non-parametric Mann-Whitney measure (MWM) has also been suggested. However, it is unclear how these compare regarding confounding adjustment. Therefore, we aim to quantify the performance of OLR and MWM in different confounding conditions.

Methods

We set up a simulation study comparing OLR and MWM performance in two scenarios, assuming no causal exposure-outcome relationship, making the observed effect estimates a quantification of the bias. We simulated 0–5 dichotomous, and 0–5 continuous confounders which were partitioned into quartiles for MWM adjustment. For comparability, OLR odds ratios were transformed to the MWM.

Results

MWM performs similar to OLR when up to five dichotomous confounders are added (figure 1). The MWM is more biased when adjustment for two or more continuous confounders is warranted (figure 2).

graphic file with name 10.1177_2396987316642909-fig110.jpg

graphic file with name 10.1177_2396987316642909-fig111.jpg

Conclusions

We suggest OLR as the preferred mRS analysis method when adjustment for multiple continuous confounders is warranted. Additional scenarios, based on clinical cohorts and propensity scores, will be presented at the conference.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

NEUROPROTECTIVE EFFECT OF ISCHEMIC PRECONDITIONING VIA MODULATING THE EXPRESSION OF ADROPIN AND OXIDATIVE MARKERS AGAINST TRANSIENT CEREBRAL ISCHEMIA IN DIABETIC RATS

O Altintas ¹, M Kumas ², MO Altintas ³, T Asil ⁴

Abstract

Background

Ischemic preconditioning (IPreC) can render the brain more tolerant to a subsequent potential lethal ischemic injury. Hyperglycemia has been shown to increase the size of ischemic stroke and worsen the clinical outcome following a stroke, thus exacerbating oxidative stress. Adropin has a significant association with cardiovascular disease, especially with diabetes. In this study, we aimed to evaluate the role of the IPreC due to modulating the expression of adropin and oxidative damage markers against stroke by induced transient middle cerebral artery occlusion (MCAo) in streptozotocin (STZ)-induced diabetic rats.

Methods

72 male Spraque Dawley rats were allocated to 8 groups (Sham, DM, IPreC, MCAo, DM + IPreC, DM + MCAo and DM + IPreC + MCAo). In order to evaluate alternations of anti/oxidative status and adropin level, we induced transient MCAo seven day after STZ-induced diabetes(DM). Also we performed IPreC 72 hours before transient MCAo to assess whether IPreC could have a neuroprotective effect against ischemia-reperfusion injury.

Results

The general characteristics of STZ-treated rats included reduced body weight and elevated blood glucose levels compared to non-diabetic ones. Ischemic preconditioning before cerebral ischemia significantly reduced infarction size compared with the other groups [IPreC + MCAo (27,26 ± 11,22 mm³) vs. MCAo(109,7 ± 17,09 mm³) p < . 001; DM + IPreC+ MCAo (38,70 ± 10,73 mm³) vs. DM+ MCAo(165,87 ± 45,84 mm³) p < . 001, respectively]. The mean total antioxidant status level in IPreC groups was higher than other groups (p ≤ 0.05). Moreover, IPreC considerably decreased mean adropin levels compared with other groups(p ≤ 0.05).

Conclusions

The study results supported the neuroprotective effects of ischemic preconditioning in MCA infarcts correlated with the level of oxidative damage markers and adropin.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PROTECTIVE EFFECT OF ISCHEMIC PRECONDITIONING ON MYOCARDIUM AGAINST REMOTE TISSUE INJURY FOLLOWING TRANSIENT FOCAL CEREBRAL ISCHEMIA IN DIABETIC AND NON-DIABETIC RATS

M Kumas ¹, O Altintas ², M Esrefoglu ³

Abstract

Background

We aimed to evaluate the effect of preconditioning on cardiac tissue induced by cerebral ischemia in diabetic and non-diabetic rats.

Methods

48 male Spraque Dawley rats were divided into 8 groups (Sham, DM, IPreC, MCAo, DM+IPreC, DM+MCAo and DM+IPreC+MCAo group). We induced transient middle carotid artery occlusion (MCAo) seven days after STZ-induced diabetes(DM). Also we performed ischemic preconditioning (IPreC) 72 hours before transient MCAo to assess whether IPreC has protective effect on remote tissue injury. For histopathological evaluation, sections were stained with hematoxylin-eosin and Masson’s trichrome methods.

Results

Histologic architecture of cardiac tissues of IPreC group was similar to that of the sham group. Cardiac tissues of ischemic and diabetic groups showed some severe histopathological alterations including edema, congestion, and mononuclear cell infiltration. The highest mean congestion score (MCS) was of DM+MCAo group (2.60 ± 0.55). IPreC considerably improved congestion in IPreC + MCAo and DM + IPreC + MCAo groups (p = 0.013, p = 0.009; respectively). Diabetes and ischemia caused extensive necrosis throughout cardiac peranchyma. The mean necrosis scores of IPreC + MCAo and DM + IPreC + MCAo group were lower than those of MCAo and DM + MCAo group (p < 0.001, for both). In terms of mononuclear cell infiltration, the mean infiltration scores (MIS) were high in MCAo and DM + MCAo group. In MCAo and IPreC + MCAo groups, MISs were 2.16 ± 0.75 and 0.57 ± 0.53; respectively (p < 0.001). MIS was 2.83 ± 0.41 in DM + MCAo group, whereas 1.57 ± 0.53 in DM + IPreC + MCAo group (p < 0.001). IPreC significantly decreased ischemia-induced infiltration.

Conclusions

Diabetes and cerebral ischemia have hazardous effects on cardiac tissue. Cerebral ischemia in diabetic rats causes histopathological alterations including edema, congestion and infiltration. Preconditioning considerably improves these histopathological findings.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

NEUROPROTECTION OF CHOLESTERONITRONES TREATMENT IN AN EXPERIMENTAL STROKE MODEL

MI Ayuso ¹, R Gonzalo-Gobernado ¹, J Marco-Contelles ², JJ Montoya ³, A Alcázar ⁴, J Montaner ¹

Abstract

Background

To date, no single neuroprotectant agent for stroke has been approved. In the ischemic cascade, oxidative stress and inflammation are two of the most important events that may lead to neuronal damage. Nitrones are organic compounds that act as powerful free radical scavengers and steroids are able to prevent inflammation in the central nervous system. The present research was conducted with the aim to evaluate the potential neuroprotective effect of the treatment with a new steroid-nitrone hybrid in an ischemic stroke model.

Methods

The study was carried out as randomized and double-blind study in ischemic mice using a model of transient focal cerebral ischemia by distal middle cerebral artery occlusion. The treatments were administered at the onset of reperfusion period. Functional improvement was assessed using the grip strength test and brain tissue damage was measured by TTC stain 48 hours after reperfusion.

Results

We found that the CholesteroNitrone treatment significantly improved functional outcome after cerebral ischemia (113.2 ± 5.35 g, n = 9) compared with control group (91.76 ± 2.00 g, n = 9); (p < 0.05). Histological analysis also revealed a significant reduction of infarct volume [16.24 ± 0.85 (n = 9), CholesteroNitrone group vs 19.15 ± 1.08 (n = 9), control group (p < 0.05)].

Conclusions

These results suggest that this new compound could exert neuroprotective effects against cerebral ischemia damage and may be a promising agent for the treatment of ischemic stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

MEASURING CHANGES IN CEREBROSPINAL FLUID DYNAMICS AFTER EXPERIMENTAL STROKE

D Beard ¹, C Logan ¹, D Mcleod ¹, L Murtha ¹, N Spratt ^1,²

Abstract

Background

We have recently shown that intracranial pressure (ICP) increases dramatically 24 hours after experimental stroke in rats, independent of cerebral edema. A possible alternate mechanism for this ICP rise is an increase of cerebrospinal fluid (CSF) volume, which is determined by CSF production and/or CSF drainage. CSF volume is extremely difficult to quantify in vivo in rats and has not been investigated following stroke. Therefore our aim was to measure CSF production and CSF outflow resistance following stroke in Wistar rats.

Methods

First, we validated a newly developed method of lateral ventricle choroid plexus CSF production (Karimy et al. 2015) in control rats (n = 3) by measuring CSF production every 5 minutes for 80 minutes and intravenously administering Acetazolamide (AZM, 100 mg/kg, known to reduce CSF production). CSF outflow resistance was determined using the continuous CSF infusion method (Marmarou et al. 1978) in control (n = 3) and stroke rats (n = 1).

Results

Baseline CSF production was 0.89 ± 0.13 μl/min and decreased to 0.17 ± 0.12 μl/min following AZM infusion (89% reduction vs. baseline; p < 0.01, paired t-test). CSF outflow resistance was 0.162 ± 0.08 mmHg/μl/min in controls and 0.283 mmHg/μl/min ∼ 24 hours after stroke.

Conclusions

Our preliminary data suggest that both CSF production and CSF outflow resistance (both known to influence CSF volume) can be measured in vivo in rats and can be used to investigate the role changes in CSF production and/or outflow resistance play in the edema-independent ICP elevation occurring 24 hours after experimental stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EUROPEAN NEUROLOGISTS OPINION ON CLINICAL INDICATIONS FOR STROKE BIOMARKERS

A Bustamante ¹, T García-Berrocoso ¹, M Katan ², GM de Marchis ³, C Foerch ⁴, M Arnold ⁵, J Montaner ¹

Abstract

Background

Despite many years of research, so far no blood biomarker has been implemented into clinical decision-making algorithms. We aimed to identify which indications are the most relevant from a clinical perspective, in order to guide future research.

Methods

In 2014, an anonymous survey, considering 12 stroke scenarios in which biomarkers were proposed for clinical decision-making, was distributed to stroke neurologists from 16 European countries. Questions were: 1.How useful are blood biomarkers in the following indication? (Indications in Table 1). 2. Would you prefer rather a sensitive or a specific test for this indication?

Results

A total of 214 stroke neurologists answered the survey. All of the proposed indications were considered at least useful by >50% of the participants. Response to reperfusion therapies, secondary prevention, TIA diagnosis, stroke recurrence, etiology discrimination were the indications in which the use of biomarkers was considered useful or very useful by more than 80% of the participants (table 1). No clear preference for sensitivity or specificity was found in most indications.

Conclusions

The majority of stroke neurologist considered biomarkers as useful or very useful in all proposed indications. The results of this survey may be helpful to direct stroke biomarker research towards the most attractive indications.

TABLE 1.

Indications:	Useful/Very useful (%)
Response to reperfusion	82%
Secondary prevention	82%
TIA diagnosis	81%
Stroke recurrence	81%
Etiologic discrimination	75%
Risk prediction (people with vascular risk factors)	74.3%
Global prognosis	74%
Specific complications	72%
Diagnosis	71%
Risk prediction (healthy people)	68.7%
identification of silent infarctions	58.4%
Differentiation ischemic/hemorrhagic stroke	53%

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Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ISCHEMIC PRECONDITIONING mRNA EXPRESSION KINETICS

S Cambray ¹, L Colas-Campas ², J Meneses ², J Molina-Seguín ³, I Benabdelhak ⁴, J Sanahuja ⁴, N Torreguitart ⁵, A Quilez ⁶, C Gonzalez-Mingot ⁶, A Vena ⁷, MP Gil-Villar ⁶, D Buket ⁸, M Yemisci ⁸, T Dalkara ⁸, F Purroy ⁶

Abstract

Background

Ischemic preconditioning (IP) provides an excellent opportunity for new neuroprotective molecules discovering to be used on ischemic stroke patients.

Methods

Mice model of distal manual middle cerebral artery occlusion (MCAo) was managed. Then IP was established with 5 × 2 min occlusions 24h before stroke was performed and assessed by TTC staining. Ischemic cortical region was obtained from 3 different animals at 7 different times and compared to same number of SHAM animals for differential mRNA expression profiles using high density Mouse Gene Expression Microarray (Agilent Sureprint G3). Obtained data was analysed with different software (Gene Ontology, Transfac, Panther and Ingenuity Pathway Analisys) to unveal main pathways, transcription factors, endogenous molecules and drugs that rule neuroprotection and could induce it after ischemic stroke.

Results

Our blind analysis of mRNA array data give us some cytokines (CXCL12, IL6), transcription factors (MEF2C, RelAp65) and pathways (Apoptosis) previously involved on IP mediated neuroprotection that validate our model, moreover previously undescribed transcription factors (Nkx2.5, DMRT4, RP58), soluble cytokines (IL13) and drugs also arose from this analysis. Time course analysis from time zero to 24 h also showed that different pathways are up and down regulated at different times, including apoptosis, autophagocytosis, neuroinflammation and neurogenesis.

Conclusions

Distal MCAo, accurate ischemic region dissection, high density array profiling and blind analysis with data mining programs, showed that IP mediated neuroprotection is a highly dynamic process, involving many different pathways and molecules, but this high heterogeneity can be mostly governed by few transcription factors and drugs.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

NEUROPROTECTIVE EFFECTS OF BAZEDOXIFENE IN EXPERIMENTAL ISCHEMIC STROKE COMPLICATED WITH DIABETES

M Castelló-Ruiz ¹, T Jover-Mengual ², M Jorques ¹, M López-Morales ¹, A Aliena ¹, MC Burguete ², JM Centeno ², FJ Miranda ², G Torregrosa ¹, E Alborch ³, JB Salom ¹

Abstract

Background

We have previously reported that bazedoxifene (BZA), a selective estrogen receptor modulator approved for the treatment of postmenopausal osteoporosis, reduces brain damage in a rat model of transient focal cerebral ischemia. The aims of the present study were: 1) to elucidate the molecular mechanisms involved in the BZA neuroprotective effects, and 2) to assess whether the capacity of BZA to reduce ischemic brain damage is modified by diabetes, a risk factor influencing stroke outcome.

Methods

Normoglycemic and streptozotocin induced diabetic male Wistar rats underwent 60 min middle cerebral artery occlusion, and grouped according to treatment: vehicle (DMSO), BZA (plasma concentration 20.7 ± 2.1 ng/ml) or 17-β-estradiol (E2, plasma concentration 45.6 ± 7.8 pg/ml, positive control). After 24 h of reperfusion, rats were subjected to motor neurofunctional tests, cerebral infarct volume determined by triphenyltetrazolium chloride staining, and brain tissue samples collected for RT-PCR, WB and immunohistochemistry studies.

Results

In neuroprotected normoglycemic rats, treatment with BZA and E2 modulated the expression of the estrogen receptors. BZA increased the expression of ERα and ERβ while E2 only increased expression of ERα. Neither treatment affected the expression of GPER. Both treatments diminished activated caspase-3 and pERK1/2 levels, which were increased by stroke. BZA and E2 significantly improved neurofunctional score and decreased infarct volume in diabetic rats.

Conclusions

Upregulation of ERα and ERβ and subsequent downregulation of ERK1/2 pathway are involved in the neuroprotective effect of BZA on apoptotic cell death induced by ischemic stroke. The neuroprotective effect of BZA is maintained in stroke complicated with diabetes.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

RAPID AND SELECTIVE BRAIN COOLING AND MAINTENANCE OF SELECTIVE COOLING WITH INTRA-CAROTID COLD FLUID INFUSION IS FEASIBLE AND SAFE

J Choi ^1,², S Mangla ³, F Barone ¹, C Novotney ⁴, E Lin ², J Pile-Spellman ^2,⁵

Abstract

Background

The feasibility and safety of rapid and selective brain cooling and maintenance of selective cooling was investigated in pigs using a novel endovascular catheter system.

Methods

After unilateral coil-embolization of the external carotid artery, 13 Yorkshire pigs (37–55 kg) underwent ipsilateral brain cooling with intra-carotid infusion of cold normal saline using the Hybernia Catheter System for 2 hours. Bilateral hemispheric temperatures and core temperature were monitored. Blood samples were obtained to track hematocrit.

Results

Data from 9 pigs were analyzed. The median time to reach target brain temperature of 33°C was 5 minutes (IQR 3.7–10.6). The decrease in temperature of the infused hemisphere was significantly larger compared to the changes of the contralateral hemisphere or the body (Figure). Selective and accurate maintenance of cooling at target temperature was achieved over 2 hours. Total volume input and output were 3.3 ± 1.3 L and 1.1 ± 0.7 L, respectively. Hematocrit decreased slightly from 26.1 ± 2.5% at baseline to 24.2 ± 2.8% (p = 0.045). Gross- and histopathological evaluation of the brain revealed no signs for ischemic or traumatic injury due to the cooling procedure.

graphic file with name 10.1177_2396987316642909-fig112.jpg

Conclusions

Selective brain cooling and maintenance of selective cooling is feasible and safe with intra-arterial infusion of cold fluids in pigs. Brain cooling is achieved rapidly and maintained with the Hybernia Catheter System with moderate fluid volumes despite the existence of an intracranial rete in this large animal model.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE ISCHEMIC PRECONDITIONING-INDUCED NEUROPROTECTION IS CONDITIONED BY THE ARG72PRO P53 POLYMORPHISM

M Delgado Esteban ^1,², R Vecino ^1,², ME Ramos-Araque ^1,², C Rodriguez ^1,², JC Gomez-Sanchez ¹, A Almeida ^1,²

Abstract

Background

Cerebral ischemic preconditioning (IPC) is one of the most important endogenous mechanisms responsible for the increased brain tolerance after stroke. Although IPC has been associated with the activation of pro-survival signals, the mechanism by which preconditioning confers neuroprotection is not yet fully clarified. Recently, we described that the Tp53 Arg72Pro single nucleotide polymorphism regulates neuronal survival after ischemia and functional outcome of stroke patients. Here, we studied the role of the Tp53 Arg72Pro SNP on IPC-induced neuroprotection after ischemia.

Methods

Primary cultured cortical neurons were obtained from p53 knock-in foetuses expressing human polymorphic variants of p53, Arg72-p53 or Pro72-p53. After 9–10 days in culture, neurons were stimulated with subtoxic concentration of N-methyl-D-aspartate (20 µM NMDA; IPC) for 2 h following (IPC + OGD) or not (IPC) by lethal oxygen and glucose deprivation (OGD), during 90 min. In parallel, control neurons were exposed to normoxia.

Results

We showed that IPC prevented OGD-increased mRNA and protein expression of p53 and its targets p21 and Bax in Pro72-p53 neurons. This was not observed in those with Arg72-p53. Furthermore, IPC abrogated Bax expression and the subsequent caspase-3 activation and neuronal apoptosis induced by OGD in Pro neurons. In contrast, the susceptibility of Arg neurons to OGD was not counteracted by IPC, since p53 was stabilized leading to increased Bax levels and the ensuing caspase-3 activation and apoptotic neuronal death.

Conclusions

NMDA preconditioning failed to protect neurons expressing the Arg72-p53 variant against an ischemic damage. Indeed, the Arg72Pro p53 polymorphism modulates IPC-induced neuronal protection by controlling the p53/Bax/caspase-3 pathway.

ISCIII:PI12/00685;RD12/0014/0007;CP0014/00010;JCyL:BIO/SA35/15.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

T-LYMPHOCYTES ARE ESSENTIAL FOR SUCCESSFUL NEUROREGENERATION AFTER ISCHEMIC BRAIN INJURY

K Diederich ¹, A Schmidt ¹, J Strecker ¹, WR Schäbitz ², J Minnerup ¹

Abstract

Background

T-Lymphocytes exhibit great impact on early stroke outcome as recent studies showed that ablation of these cells decrease infarct size and improve neurological deficits in the acute phase after stroke. However, the role of T cells in the sub-acute and chronic phase after stroke is unknown. We assessed the role of T cells on key mechanisms of post-ischemic neuroregeneration and consequently on functional and structural recovery.

Methods

Twenty-four wild-type (wt) and eleven RAG1 -/- mice were subjected to photothrombotic ischemia, a subset of twelve wt and six RAG1 -/- animals underwent training in motorized running wheels starting at day 3 following ischemia until the end of the experiment on day 28. Sensorimotor and cognitive functions were assessed. Newly generated neurons were labeled with 5-Chloro-2′-deoxyuridine and iododeoxyuridine. In a subsequent experiment, seventeen RAG1 -/- mice were subjected to ischemia and underwent training, a subset of ten animals received adoptive transfer of T cells. Functional testing and cellular labeling were performed in analogy to the first experiment.

Results

Rehabilitative training amended sensorimotor and cognitive function following ischemia in wt animals and increased neurogenesis. Training did not induce functional recovery in RAG1 -/- animals and had no effect on the generation of neurons. Adoptive transfer of T cells into immunodeficient mice restored the capacity for regeneration.

Conclusions

We demonstrated, that T cells play a vital role in regeneration after ischemic brain injury. Our findings may provide new insights on the mechanism by which immune cells affect different stages of the pathogenesis of ischemic stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

MANGANESE-ENHANCED MRI FOR THE STUDY OF POST-STROKE COGNITIVE IMPAIRMENT IN A RODENT STROKE MODEL

M El Amki ¹, P Baumgartner ¹, O Bracko ¹, A Luft ¹, S Wegener ¹

Abstract

Background

Cognitive impairment is a serious consequence of stroke in the middle cerebral artery (MCA) territory. However, cognitive symptoms are not easily explained by the stroke lesion itself, which usually does not affect hippocampal or parahippocampal areas. Our goal was to reveal an anatomical and/ or functional link between the sensorimotor and the hippocampal network in a rodent stroke model using manganese enhanced MRI (MEMRI). Furthermore, the effect of a motor rehabilitation algorithm on cognitive symptoms after stroke was investigated.

Methods

Rats were subjected to intraluminal MCAO or sham surgery. Sensorimotor and cognitive deficits were assessed during a 4 week period. After 28 days, we performed structural MRI. Then, MnCl₂ was injected into the entorhinal cortex and MEMRI was performed directly afterwards and 1 day after the injection. In a subset of rats, motor rehabilitation was performed between days 5 and 12 after MCAO.

Results

Stroke induced sensorimotor deficits which correlated to lesion size on d1 and d7. Stroke rats showed cognitive impairment on d7 independent of direct hippocampal affection or lesion size. MEMRI revealed a targeted distribution of the tracer within the hippocampal network including connections to the septal nuclei in sham animals. The Mn-signal pattern was disturbed after MCAO. Motor rehabilitation tends to improve sensorimotor, but not cognitive deficits.

Conclusions

Alterations of the hippocampal network after MCAO can be detected by MEMRI, indicating that thalamic structures are involved in post-stroke cognitive impairment. Further MRI and histological characterization and studies of training effects on this phenomenon are under way.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

HIGHLIGHTING THE IMPORTANCE OF ANGIOGENIN AND CD34+/EPCs AS MOLECULAR AND CELLULAR MARKERS OF ANGIOGENESIS DURING REHABILITATION THERAPY AFTER STROKE

M Gabriel-Salazar ¹, X Buxó ², S Rodriguez ², A Morancho ¹, E Medina ¹, P Martínez-San Segundo ¹, D Giralt ¹, F Ma ¹, A Penalba ¹, C Boada ¹, J Montaner ¹, I Bori ², A Rosell ¹

Abstract

Background

Angio-vasculogenesis is thought to participate in neural plasticity after stroke. However its relationship with rehabilitation therapies is unknown. Our purpose is to study angiogenesis markers at molecular and cellular level in stroke patients during intensive rehabilitation therapy.

Methods

Angiogenin (ANG) actions on endothelial progenitor cells (EPCs) were studied in matrigel assays, in vitro. Moreover, circulating ANG and CD34+/EPCs populations were studied in 17 ischemic strokes receiving intensive rehabilitation therapy (IRT ≥ 3 hours/day and 5 days/week) and 17 healthy volunteers serving as controls. Blood levels of ANG and CD34+/EPCs were measured before IRT together with functional/motor scales (NIHSS, BI, RANKIN, SSQoL, FMA, MRC, FAC, CAHAI and 10 meter walk), and followed-up at 1 and at 3–6 months.

Results

ANG treatment enhanced EPCs ability to shape vessel structures, in vitro, by increasing the number of rings, the endothelial perimeter and the number of connections (p < 0.05, respectively). Before IRT, no differences in ANG were observed between controls and strokes, although CD34+/EPCs were significantly higher in strokes. Interestingly, angiogenic cellular markers CD34+ and CD34+/KDR/CD45- populations remained higher after 3–6 months (p < 0.001 and p = 0.058, respectively) and ANG was increased after 1 month of IRT in strokes versus controls (p < 0.05). Importantly, IRT patients who scored higher at MRC and SSQoL at 6 months presented higher levels of ANG at 1 month (p < 0.05, respectively), whereas the number of CD34+ cells correlated positively with CAHAI score at 3 months (r = 0.557; p = 0.031).

Conclusions

Rehabilitation therapy could modulate angiogenesis markers at molecular and cellular level serving as prognosis biomarkers in rehabilitation programs.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

BRAIN-SPECIFIC PROTEINS NEF3, CARNS1 AND B-SYNUCLEIN COMBINED WITH GFAP AS BIOMARKERS FOR STROKE SUBTYPE DIFFERENTIATION

T García-Berrocoso ¹, V Llombart ¹, D Giralt ¹, A Bustamante ¹, A Penalba ¹, C Boada ¹, M Hernández-Guillamon ¹, J Montaner ¹

Abstract

Background

Ultrarapid differentiation of acute ischemic stroke (IS) and intracerebral hemorrhage (ICH) is essential for an adequate treatment and a better outcome but still requires neuroimaging assessment. Our aim was to build a complete blood biomarker panel applicable in the prehospital setting to accelerate stroke subtype diagnosis.

Methods

Blood samples from 74 stroke patients (40 IS and 34 ICH) showing a NIHSS score >5 were collected in <4.5 h from stroke onset. Brain-specific and glia-specific proteins were identified and filtered from The Human Protein Atlas V13 database. Together with members of the neurofilament family, all these candidates were analyzed by ELISA. For those associated biomarkers, discrimination between IS and ICH patients was assessed by AUC and its sensitivity and specificity were determined.

Results

Circulating levels of C1orf96, β-synuclein and NRGN as brain-specific, CARNS1, ADRB1, CAC1A, EAAT2, OMG, GFAP and JN as glia-specific proteins together with neurofilament NEF3 were analyzed in the whole cohort. IS patients showed increased levels of NEF3 (p < 0.05), β-synuclein and CARNS1 (p < 0.2). Only higher GFAP (p < 0.05) was found increased in ICH patients. Table shows accuracy values for different biomarker combinations.

PPV: Positive predictive value; NPV: Negative predictive value.

graphic file with name 10.1177_2396987316642909-fig113.jpg

Conclusions

A combination of biomarkers including NEF3, CARNS1 and GFAP seems promising to help in guiding stroke management in the prehospital setting.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EFFECT OF ENDOPLASMIC RETICULUM (ER) STRESS AND AUTOPHAGY ON ISCHEMIC NEURONAL DEATH IN VITRO

G Hadley ¹, B Sutherland ¹, M Papadakis ¹, A Neuhaus ¹, Y Couch ¹, K Vekrellis ², A Buchan ¹

Abstract

Background

In the hippocampus, Cornu Ammonis (CA)1 neurons are susceptible to ischemic death while CA3 neurons are resistant¹.We recently discovered that hamartin, an upstream inhibitor of mammalian target of rapamycin (mTOR), can endogenously mediate CA3 resistance through induction of productive autophagy^2,3 but lack of hamartin in CA1 could lead to endoplasmic reticulum (ER) stress and contribute to ischemic neuronal death. Our aim was to assess whether modulation of ER stress and autophagy can directly limit ischemic neuronal death in vitro.

Methods

Primary neuronal cultures from E18 Wistar rat embryos were exposed to 2 h oxygen and glucose deprivation (OGD) or normoxia. After 24 h recovery, cell death was assessed using lactate dehydrogenase release.

Results

The ER stress inducers thapsigargin and tunicamycin, when administered during OGD, increased cell death dose-dependently. 24 h pre-treatment with thapsigargin also produced a dose-dependent increase in cell death following normoxia or OGD. Salubrinal, an ER stress inhibitor, increased cell death at very high doses, which could be attenuated with co-administration of metformin, an autophagy inducer.

Conclusions

The induction of ER stress can lead to cell death following ischemia, but some ER stress activation can trigger autophagy^4,5, which can have protective effects². Understanding the interactions between ER stress, productive autophagy and the mTOR pathway is required to determine appropriate molecular targets for neuroprotection following cerebral ischemia.

References

1. Kirino, T (1982)

2. Papadakis M et al (2013)

3. Di Nardo A et al (2009)

4. Yorimitsu et al (2006)

5. Sakai & Kaufman (2008)

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

VALPROATE REDUCES DELAYED BRAIN INJURY AFTER SPREADING DEPOLARIZATIONS IN A RAT MODEL OF SUBARACHNOID HEMORRHAGE

A Hamming ^1,², A Van der Toorn ², SU Rudrapatna ², L Ma ³, H Van Os ¹, M Ferrari ¹, A Van den Maagdenberg ⁴, A Stowe ³, R Dijkhuizen ², M Wermer ¹

Abstract

Background

Spreading depolarizations (SDs) may contribute to delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage (SAH), which suggests that inhibition of SDs could reduce ischemic damage. We tested whether the SD inhibitor valproate reduces brain injury in a SAH rat model with and without experimental SD induction.

Methods

Rats were randomized in a 2 × 2 design and pre-treated with either valproate (200 mg/kg) or placebo for four weeks. SAH was induced by endovascular puncture of the right internal carotid bifurcation. One day after SAH induction, brain tissue damage was measured with T₂-weighted MRI, followed by cortical application of 1 M KCl or saline for SD induction as control, respectively. MRI was repeated on day three.

Results

In the groups with SD induction, lesion growth between days one and three was 60 ± 75 mm³ in the valproate- versus 241 ± 233 mm³ in the placebo-treated group (p = 0.01) (Figure). In the groups without SD induction, there were no statistically significant differences in lesion growth between the valproate- and placebo-treated groups (9 ± 21 mm³ versus 29 ± 54 mm³, p = 0.69).

Conclusions

In our rat model of SAH, valproate treatment significantly reduced brain lesion growth. Inhibition of SDs may contribute to reducing delayed cerebral ischemia after SAH.

Figure. — Lesion incidence maps. Voxel-based representations of fraction of rats with lesioned tissue identified on T₂ maps at days one and three post- SAH, in the SD groups with valproate or placebo treatment, projected over a rat brain T₂ template. There was significantly less lesion growth in the valproate-treated group than in the placebo-treated group.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

MODULATION OF BETA-AMYLOID(1-40) TRANSPORT BY APOA1 AND APOJ ACROSS AN IN VITRO MODEL OF BLOOD-BRAIN BARRIER

S Fernandez de Retana ¹, A Montañola ¹, J Saint-Pol ², C Mysiorek ², F Gosselet ², J Montaner ¹, M Hernández-Guillamon ¹

Abstract

Background

Cerebral Amyloid Angiopathy (CAA) refers to amyloid-beta (Aβ) deposition in cerebral vessels and is a frequent cause of lobar hemorrhage and cognitive decline. Aβ accumulation in CAA is likely caused by the impairment of its brain clearance, which partly occurs through the blood-brain barrier (BBB). In this context, an in vitro BBB model is a valuable tool for studying the molecular mechanisms that regulate this process. The aim of this project was to study the brain elimination of Aβ across the BBB and its modulation by apolipoproteins ApoA1 and ApoJ/Clusterin.

Methods

The model was based on primary cerebral endothelial cells that were cultured on Matrigel-coated Transwells and treated with fluorescently labeled-Aβ(1–40) to track its efflux across the BBB, which corresponds to traffic from the basolateral (brain) to the apical (blood) compartments.

Results

We observed that the transport of basolateral Aβ(1–40) was enhanced when it was complexed to rApoJ, whereas the complex formed with rApoA1 did not influence Aβ(1–40) efflux. However, the presence of rApoA1 at the apical compartment was able to mobilize Aβ(1–40) from the basolateral side. We also observed that both rApoA1 and rApoJ moderately crossed the monolayer (from blood to brain) through a mechanism involving the LDL receptor-related protein (LRP) family. Whereas the rApoJ efflux transport was increased when it was previously complexed to Aβ(1–40), rApoA1 traffic was restricted when it was bound to the Aβ peptide.

Conclusions

The present study highlights the role of both ApoJ and ApoA1 in the in vitro modulation of Aβ elimination across the BBB.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

LACTATE METABOLISM AND NEUROPROTECTION IN MOUSE MCAO USING HYPERPOLARIZED 13C-LACTATE: A PRELIMINARY STUDY

M Mishkovsky ¹, L Buscemi ², X Castillo ², M Lepore ³, A Comment ⁴, JN Hyacinthe ⁵, L Hirt ²

Abstract

Background

Lactate acts as a neuroprotectant in mouse middle cerebral artery occlusion (MCAO). Hyperpolarized (HP) magnetic resonance after HP-¹³C-labeled L-lactate administration enables in vivo real-time measurement of its biochemical transformations.

Methods

A frozen sodium L- [1- ¹³C]lactate solution was hyperpolarized for 2 hours in a 7 T custom-designed polarizer (196 GHz / 1.00 ± 0.05 K). 30 min MCAO was induced in male C57BL/6 mice with the suture model under laser Doppler blood flow monitoring. Animals were placed into a 9.4 T animal scanner (Varian/Magnex) equipped with a home-built quadrature H - single loop C surface coil. Adjustment and Shimming (FASTMAP) were performed prior to MRI and ¹H MRS in a voxel in the ischemic striatum. Metabolites were quantified using the LC Model. HP-L-[1- ¹³C]lactate solution was injected intravenously. The ¹³C MR spectrum was acquired every 3 s after injection. The lactate concentration was measured in venous plasma after reperfusion and lactate injection.

Results

Endogenous lactate quantification from ¹H MRS showed a strong increase in the ischemic region compared to sham. Infusion of HP-L-[1- ¹³C]lactate lead to ¹³C labeling of pyruvate. The pyruvate-to-lactate ratio was calculated. The labeling of the pyruvate pool was two times higher in MCAO mice compared to sham.

Conclusions

This preliminary study shows that it is feasible to measure lactate metabolism in vivo in a mouse stroke model with intravenous injection of HP-L-[1- ¹³C]lactate, offering new perspectives to understand its biodistribution and neuroprotective effects.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

UNSUPERVISED SOURCE EXTRACTION FROM BRAIN MAGNETIC RESONANCE SPECROSCOPY DATA IN A STROKE RAT MODEL

E Jiménez-Xarrié ¹, V Mocioiu ², M Julià-Sapé ², S Ortega-Martorell ³, AP Candiota ², R Delgado-Mederos ¹, C Arús ², J Martí-Fàbregas ¹

Abstract

Background

Magnetic resonance spectroscopy data results from the combination of heterogeneous signal sources. Convex non-negative matrix factorization (Convex-NMF) is an unsupervised method of source extraction. Moreover, Convex-NMF determines the source contribution for each individual spectrum. The aim of this study was to identify sources present in the stroke rat brain, associating it with its originating tissue.

Methods

Spectra acquired at 7 T (n = 164, TE = 12 ms) from Sprague-Dawley rats subjected to 90-minutes middle cerebral artery occlusion were retrospectively analyzed. Spectra were acquired from 3 tissue types: normal-parenchyma (n = 130), infarct at day 1 (n = 20) and at day 7 ± 1 post-stroke (n = 14). Spectra were analyzed with jMRUI and Convex-NMF software. Statistical analysis of the source presence in each tissue type was performed with Kruskall-Wallis test.

Results

Unsupervised spectral analysis differentiated 3 sources. There was a high similitude among the sources and the mean spectra of the tissue types (Figure 1). Source-1 was the principal source in day 1 post-stroke tissue [median (interquartile range) 85.66% (78.43–92.45%)], Source-2 in day 7 ± 1 post-stroke tissue [100% (85.67–100.00%)] and Source-3 in normal-parenchyma [95.80% (92.42–97.56%)]. The differences of Source-1, Source-2 and Source-3 presence in each tissue type were statistically significant (p < 0.01).

graphic file with name 10.1177_2396987316642909-fig115.jpg

Conclusions

Unsupervised Convex-NMF identifies 3 characteristic sources which correspond mostly to normal-parenchyma and infarct at day 1 and day 7 ± 1 post-stroke. This should allow future predictive work in new stroke cases using (semi)supervised strategies.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ASSESSMENT OF PERCENTAGE INFARCT IN CEREBRAL ISCHEMIC STROKE MODEL IN RATS: COMPARISON OF TTC STAINING AND MRI IMAGING

R Kh ¹, D Singh ¹, U Sharma ², N Jagannathan ², Y Gupta ¹

Abstract

Background

Background: Assessment of cerebral damage after middle cerebral artery occlusion model of ischemic stroke is the critical end point. In our previous studies, we used serial magnetic resonance imaging (MRI) as well as 2, 3–5 triphenyltetrazolium chloride (TTC) staining. In the present study, the correlation of cerebral damage was assessed by the two determinants (MRI and TTC).

Methods

In male Sprague Dawley rats weighing 270 ± 20 g, middle cerebral artery was occluded with intraluminal filament for 90 min. Occlusion was confirmed by laser Doppler flow meter. Only those animals with a minimum occlusion of 80% were included. After 24 h of occlusion, MRI imaging (DWI and T2) was done. Rats were sacrificed immediately after MRI, brains were removed and 6 slices of 2 mm thickness were stained with TTC. The infarct size was assessed by third trained person to avoid bias and the affected area was reported as percentage of ipsilateral hemisphere.

Results

The preliminary experiments show that the reduction in circulation was 82.0 ± 3.4% which was restored to 73.6 ± 3.3% of blood supply on reperfusion. The infarct area at 24 h after occlusion as assessed by DWI was 29.45 ± 0.5%, by T2 imaging was 30.6 ± 1.2% and by TTC staining was 33.01 ± 1.1%. The values were not significantly different.

Conclusions

The findings suggest that since both the techniques provide almost the same information, avoiding TTC staining will reduce the number of animals without compromising on scientific evidence.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ASSESSMENT OF 'ON-TREATMENT PLATELET REACTIVITY' AND RELATIONSHIP WITH CEREBRAL MICROEMBOLIC SIGNALS IN ASYMPTOMATIC AND SYMPTOMATIC CAROTID ARTERY STENOSIS

J Kinsella ¹, WO Tobin ¹, S Tierney ², TM Feeley ², B Egan ², T Coughlan ³, DR Collins ³, D O'Neill ³, J Harbison ⁴, CP Doherty ⁵, P Madhavan ⁶, DJ Moore ⁶, SM O'Neill ⁶, MP Colgan ⁶, M Saqqur ⁷, RP Murphy ¹, N Moran ⁸, G Hamilton ⁹, DJH McCabe ¹

Abstract

Background

The relationship between ‘high on-treatment platelet reactivity (HTPR)’ and micro-embolic signals (MES) on transcranial Doppler ultrasound (TCD) has not been comprehensively assessed in carotid stenosis

Methods

This prospective, observational study assessed platelet function/HTPR and MES in asymptomatic (N = 31) versus ‘early symptomatic’ ( ≤ 4 weeks after TIA/ischaemic stroke; N = 46) and ‘late symptomatic’ (≥3 months; N = 35) moderate or severe ( ≥ 50%) carotid stenosis patients. Longitudinal data from symptomatic patients after symptom onset (N = 35) or carotid intervention (N = 23) were also analysed. Platelet reactivity ex vivo was assessed in whole blood with the PFA-100® (collagen-ADP [C-ADP] and collagen-epinephrine [C-EPI] closure times). Bilateral, simultaneous MCA TCD was performed for 1-hour to classify patients as MES-positive or MES-negative

Results

There were no differences in median PFA-100 closure times/HTPR prevalence between the overall asymptomatic and symptomatic groups. However, aspirin-HTPR prevalence was lower in ‘late symptomatic post-intervention (N = 10)’ than asymptomatic patients (N = 22) on aspirin monotherapy (10% vs. 50% [C-EPI]; P = 0.03). HTPR prevalence decreased in symptomatic patients between early and late phases (63% vs. 34%; N = 35 [C-EPI]; P = 0.017), including those on aspirin monotherapy (N = 13; P = 0.016). There were no differences in HTPR status between asymptomatic versus symptomatic MES-positive or MES-negative subgroups (p ≥ 0.32)

Conclusions

Reduction in HTPR prevalence in symptomatic patients over time may reflect successful removal of the stenosing atherosclerotic plaque in the majority and/or resolution of the acute phase response. Larger, longitudinal studies are warranted to confirm whether medical or carotid interventional treatment may consistently reduce HTPR in symptomatic subgroups to lower levels than asymptomatic patients to enhance stroke prevention

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE ROLE OF KAPPA OPIOID RECEPTOR IN BRAIN ISCHEMIA

R Liu ¹, C Chen ², C Xi ³, X Liang ³, J Ma ⁴, D Su ⁵, T Abel ⁶

Abstract

Background

Our previous studies indicated that highly selective kappa opioid receptor (KOR) could protect the brain, indicating an important role of KOR in brain ischemia. In this study, we investigated the role and related mechanisms of KOR receptor in brain ischemia in a middle cerebral artery occlusion (MCAO) mouse model.

Methods

The MCAO model was established by 120 minutes of ischemia followed by 24 h reperfusion in male adult mice. Various doses of salvinorin A (SA), a highly selective and potent KOR agonist, were administered intranasally 10 min after initiation of reperfusion. Norbinaltorphimine (2.5 mg/kg, i.p.) as a KOR antagonist was administered in one group before administration of SA (50 µg/kg) to investigate the specific role of KOR. After 24 h reperfusion, neurobehavioral outcome was determined. Infarct volume, KOR expression, and Evans blue extravasations in the brain were determined. Immunohistochemistry and western blot were performed to detect the activated caspase-3, IL-10 and TNF-alpha to investigate the role of apoptosis and inflammation.

Results

KOR expression was elevated significantly in the ischemic penumbra area compared to the non-ischemic area as indicated in figure 1. SA reduced infarct volume and improved neurological deficits dose-dependently. SA at the dose of 50 µg/kg protected the vascular integrity, decreased the expression of cleaved casepase-3, IL-10 and TNF-alpha in the penumbra areas. All these changes were blocked or alleviated by Norbinaltorphimine.

Conclusions

KORs up-regulate and play critical role in brain ischemia and reperfusion. KOR activation could potentially protect brain and improves neurological outcome via blood brain barrier protection, apoptosis and inflammation inhibition.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ASPIRATION INCREASES EFFICIENCY OF THROMBECTOMY: EVALUATION OF DIFFERENT STENT-RETRIEVERS AND A PURE ASPIRATION-SYSTEM IN A CIRCULATION MODEL

J Madjidyar ¹, J Hermes ¹, O Jansen ¹

Abstract

Background

Different devices and techniques are available for endovascular treatment of ischemic stroke. In this in vitro study we examined the influence of distal aspiration on the efficiency of mechanical thrombectomy with established stent-retrievers and a pure aspiration system.

Methods

Human blood thrombi were made in a Chandler-loop. The thrombi were placed into the middle cerebral artery of a vascular silicon phantom. A programmable piston pump was used to create physiological flow and pressure. The stent-retrievers Trevo, Solitaire FR, Separator 3D, and Aperio and the ACE aspiration system were used to perform thrombectomy under direct visual control. The retrievers were used with intermediate catheters. The results were analyzed by Mann-Whitney test, Kruskal-Wallis test, and chi-squared test.

Results

20 experiments per stent-retriever (10 without and 10 with additional manual aspiration via a 20 ml syringe) and 10 experiments with the ACE were made, a total of n = 90. The thrombus was pushed by all stent-retrievers against the vessel wall and was retracted along it. Using additional distal aspiration the amount of distal embolism and rate of embolism in new territories was significantly lower than without (p < 0.001). Moreover, additional aspiration reduced the number of passes and the recanalization time. Pure aspiration with ACE showed significantly better results in all above-mentioned categories (p < 0.001).

Conclusions

Distal aspiration with intermediate catheters increased the efficiency of mechanical thrombectomy with stent-retrievers significantly. Pure aspiration with the ACE aspiration system was the most effective method.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

RATS IMMUNOREACTIVITY WITH EXPERIMENTAL ACUTE AUTOHEMORRHAGIC BIHEMISPHERIC STROKE UNDER STAPHYLOCOCCUS INFECTION DURING CYCLOPHOSPHAN-INDUCED SUPPRESSION

O Makarenko ¹, Y Mironyuk ¹, O Molozhavaya ¹

Abstract

Background

The aim of this work was studying of the immunological aspects of hemorrhagic stroke development against the

Background of a staphylococcal infection with cyclophosphan-induced suppression in rats.

Methods

The trials were conducted with white rats. Hemorrhagic stroke modelling and staphylococcal infection were carried out according to the standard method. Cyclophosphan-induced suppression was simulated by a simultaneous one-time introduction (50 mg/ml). The activity of neutrophils in the spontaneous and induced tests of tetrazolium nitroblue (NBT) restoration was investigated. The level of circulating immune complexes (CIC) in the blood serum of rats, the level of anti-brain antibodies (ABA) and proliferative activity of splenocytes in the blast-transformation reaction (BTR) with polytonal T- and B-mitogens were determined.

Results

It was shown that the level of CIC in the blood serum with hemorrhagic stroke under a staphylococcal infection with CIS was lower compared to control, but reduced to a smaller extent under infection with CIS. At determination of the ABA level positive reaction was observed in 83% of experimental animals. Relative mass of thymus and spleen were decreased and increased respectively in experimental group. The proliferative activity of the main populations of lymphoid cells significantly inhibited in the animals, both with stroke under a staphylococcal infection with CIS, and with the infectious process of the staphylococcal infection with CIS, in comparison with the control group of animals.

Conclusions

These data give the chance to draw a conclusion about the development of immunodeficiency in experimental animals.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE EFFECT OF VERAPAMIL ON THE FUNCTIONAL AND STRUCTURAL CHANGES UNDER HEMORRHAGIC STROKE(HS)

O Makarenko ¹, V Koldunov ², V Bibikova ²

Abstract

Background

The influence of Verapamil, as a blocker of Са²⁺ channels, on structural and functional changes and recovery processes against the

Background of HS was the purpose of our work.

Methods

The study has been conducted with 90 rats. HS was simulated according to Makarenko, 2003. Verapamil (0,1 mg/kg) was administrated after HS during 10 days by intraperitoneal introduction. Within a month measured the neurologic status degree, based on the registration of the changes of reflexes: pain, flexor, grasp, turning, support and startle.

Results

The administration of Verapamil showed that any restoration of the support, flexor and startle reflex against the

Background of pharmacocorrection has not been revealed; only a tendency to reflex worsening was noted.

Morphological disorders under hemorrhagic stroke had polymorphic changes: hydropic degeneration of brain tissue, secondary hemorrhages, ischemic lesion of the perifocal area. Acute edema is noted mainly around a hemorrhage zone, in the internal capsule and mesolobus. In the sensomotor cortex of the big brain edema and hypertrophy of neurons during the acute period and pyknosis on the14–30 days were registered, pyknosis of gliocytes, pericellular and perivascular edema on the 21 the brain tissue became spongy. Under HS the dynamics of changes of the brain tissues thickness was from 762,3 kl/mm² in control and decreased by 11,6% on the 3-rd day, on the 21 day – by 14.5%; during Verapamil administration – by 6,83% and 9,47% respectively.

Conclusions

Verapamil reduces neurodegenerative processes in the cerebral cortex of the big brain, but does not reduce the degree of neurologic deficiency.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ULTRASOUND-TARGETED MICROBUBBLE DESTRUCTION TO DELIVER BDNF PROMOTES WHITE MATTER REPAIR IN AN EXPERIMENTAL ANIMAL MODEL OF STROKE

M Gutiérrez Fernández ¹, B Rodríguez Frutos ¹, L Otero Ortega ¹, J Ramos Cejudo ¹, P Martínez-Sánchez ¹, I Barahona Sanz ¹, T Navarro Hernanz ², MDC Gómez de Frutos ¹, E Díez Tejedor ¹

Abstract

Background

Ultrasound-targeted microbubble destruction (UTMD) has been shown to be a promising tool to deliver proteins to select body areas. This study aimed to analyze whether UTMD was able to deliver brain-derived neurotrophic factor (BDNF) to the brain, enhancing functional recovery and white matter repair, in an animal model of subcortical stroke. This treatment could be more effective than BDNF alone.

Methods

White matter subcortical ischemic stroke was induced by endothelin (ET)-1. UTMD was used to deliver BDNF to the brain 24 h after stroke, and blood brain barrier (BBB) leakage was evaluated to analyze safety. Functional recovery, infarct size and white matter repair mechanisms such as tract connectivity repair, myelin formation and white matter-associated markers were evaluated.

Results

UTMD technique was shown to be safe, given there were no cases of hemorrhagic transformation or BBB leakage. UTMD treatment was associated with increased brain BDNF levels at 4 h after administration. Compared with control animals, UTMD-treated rats showed improved functional recovery and higher fiber tract connectivity, myelin formation and white matter repair markers after subcortical stroke in rats.

Conclusions

Targeted ultrasound delivery of BDNF improved functional recovery associated with fiber tract connectivity restoration, increasing oligodendrocyte markers and remyelination compared to BDNF alone administration in an experimental animal model of white matter injury. This tool could be used for treatment not only for subcortical small vessel stroke patients, but also for large vessel stroke in which white matter is affected, in addition to cortical damage.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

NONINVASIVE TREATMENT OF ATHEROSCLEROTIC SOFT PLAQUE WITH NEOVASCULARIZATION USING TRANSCUTANEOUS LOW-LEVEL COMBINED DUAL-FREQUENCY SONICATION ACCOMPANIED BY PESDA MICROBUBBLES ADMINISTRATION

H Mehrad ¹, M Mokhtari-Dizaji ², H Ghanaati ³

Abstract

Background

Most acute cardiovascular events result from the rupture of an atherosclerotic soft plaque. The present study aimed to investigate the effect of low-level combined dual frequency (1 MHz and 150) sonication accompanied by PESDA microbubbles administration on advanced atherosclerotic soft plaque with severe stenosis (>70%) and neovascularization in the rabbit common carotid artery.

Methods

In this experimental study, the common carotid arteries in 17 rabbits were injured perivascularly by liquid nitrogen, followed by a 1.5% cholesterol-rich diet for eight weeks. Histology results showed severe stenosis (>70%) and neovascularization in the rabbits’ arteries. Then animals were randomly divided into three groups including A: a cholesterol-rich diet (n = 7) and evaluation at eighth week, B: control and discontinuation of cholesterol-rich diet (n = 5) and evaluation at twelfth week and C: low-level combined dual frequency sonication accompanied by PESDA microbubbles administration and discontinuation of cholesterol-rich diet (n = 7) and evaluation at twelfth week.

Results

Color Doppler ultrasonography, B-mode ultrasound and histopathology Results showed a significant reduction in the mean value for lipid parameters, blood peak systolic pressure, blood mean pressure, blood mean velocity, mean wall thickness and percentage of luminal cross-sectional area of stenosis and a significant increase in the mean value for blood peak diastolic pressure and blood volume flow in group C compared with the other groups (P < 0.05).

Conclusions

Enhanced anti-angiogenesis effect of cavitating PESDA microbubbles, induced by combined dual-frequency sonication can cause to destroy the plaque microvessels, reduce the lesion macrophages-derived foam cells and significantly dilate the luminal cross-sectional area of stenosis.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THERAPEUTIC APPLICATION OF ELECTROHYDRAULIC SHOCK WAVES AND ULTRASONIC WAVES ACCOMPANIED BY HIGH- DOSE ATORVASTATIN AND PESDA MICROBUBBLES ADMINISTRATION IN LIPID- RICH ATHEROSCLEROTIC PLAQUE REGRESSION

H Mehrad ¹, H Nasrollahi ¹

Abstract

Background

A lipid- rich atherosclerotic plaque may rupture with high risk of subsequent thrombus- mediated acute clinical events such as myocardial infarction and stroke. The present study aimed to investigate the effect of combined electrohydraulic shock wave therapy and ultrasound therapy accompanied by high- dose atorvastatin and PESDA microbubbles administration on lipid- rich atherosclerotic plaque regression in the rabbit common carotid artery.

Methods

Briefly, New Zealand white rabbits underwent primary perivascular cold injury at the right common carotid artery followed by a 1.5% cholesterol-rich diet injury for eight weeks. Then treatment group underwent extracorporeally and simultaneously combined electrohydraulic shock wave (0–20 kv) therapy and ultrasound (3 w/cm², 1 MHz) therapy accompanied by high- dose atorvastatin (5 mg/kg/day) and PESDA microbubbles (100 µl/kg, 2- 5 × 10⁵ bubbles/ml) administration. All of the rabbits’ arteries were imaged by color Doppler ultrasonography weekly, after which the rabbits were sacrificed, and their vessels were processed for histopathology.

Results

Results showed a significant reduction in the mean value for lipid parameters, blood peak systolic pressure, blood mean pressure, blood mean velocity, mean wall thickness and percentage of luminal cross-sectional area of stenosis and a significant increase in the mean value for blood peak diastolic pressure and blood volume flow in group C compared with the other groups (P < 0.05).

Conclusions

Enhanced anti-angiogenesis effect of cavitating PESDA microbubbles, induced by combined electrohydraulic shock wave therapy and ultrasound therapy and the pleiotropic and lipophilic effects of high-dose atorvastatin can cause to destroy the plaque microvessels and reduce the lesion macrophages-derived foam cells.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

SEGMENTATION OF INFARCT ON STRUCTURAL MRI DATA IN RODENT MODELS OF STROKE USING A SEMI-AUTOMATED TOOL

X Milidonis ¹, C McCabe ², M Macrae ², E Sena ¹, M Macleod ¹, I Marshall ^1,³

Abstract

Background

Infarct volume is the most commonly used biomarker in experimental stroke. Yet, manual analysis is the preferred method for its measurement on structural magnetic resonance images. This is time-consuming and subjective, introducing uncertainties in the accuracy and reproducibility of measurements. We examined the feasibility of a simple threshold-based segmentation technique for semi-automated analysis.

Methods

Twenty-one Sprague-Dawley rats were subjected to permanent middle cerebral artery occlusion and underwent T2-weighted imaging at 24 h post-occlusion using a 7 T scanner (16 slices, 0.75 mm thickness). The images were analysed for estimating the volume of the hyperintense infarct via both gold standard manual outlining of the lesion boundary (ImageJ 1.50b) and semi-automated segmentation using a home-made tool (MATLAB® 2014a). Measured volumes and analysis time were compared between methods and the reproducibility of the tool was evaluated.

Results

No statistically significant difference was found between measurements from the two methods (mean ± SD: manual: 274.8 ± 74.0 mm³, tool: 281.5 ± 84.4 mm³; paired Student’s t-test: t = −1.710, p = 0.103). The time for analysis was significantly reduced when the tool was used (median (range) in minutes: manual: 11 (7–13), tool: 4 (2–5); Wilcoxon signed-rank test: Z = −4.046, p < 0.000). The test re-test reliability of the tool was excellent (intraclass correlation coefficient: 0.999 (95% confidence interval: 0.998–1.000)).

Conclusions

The developed technique shows promise in the assisted detection and measurement of the infarct in rodent models of stroke, as it significantly improves analysis speed without affecting quantification accuracy. However, further processing steps must be incorporated before it can be used effectively across different species or imaging time points.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

FUNNEL-FREEZING VERSUS HEAT-STABILIZATION FOR THE VISUALIZATION OF BIOMOLECULES BY MASS SPECTROMETRY IMAGING IN A MOUSE STROKE MODEL

I Mulder ¹, C Esteve ², M Hoehn ³, E Tolner ⁴, A van den Maagdenberg ⁴, L McDonnell ²

Abstract

Background

Tissue preparation is the key to a successful matrix-assisted laser desorption/ionization (MALDI) mass spectrometry imaging (MSI) experiment. Rapid post-mortem changes contribute a significant challenge to the use of MSI approaches for the analysis of peptides and metabolites.

Methods

In this technical note we aimed to compare the tissue fixation method ex-vivo heat-stabilization with in-situ funnel-freezing in a middle cerebral artery occlusion (MCAo) mouse model of stroke, which causes profound alterations in metabolite concentrations. The influence of the duration of the thaw-mounting of the tissue sections on metabolite stability was also determined.

Results

We demonstrate improved stability and biomolecule visualization when funnel-freezing was used to sacrifice the mouse compared with heat-stabilization. Results were further improved when funnel-freezing was combined with fast thaw-mounting of the brain sections.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

INCREASED PLATELET COUNT AND LYMPHOCYTE-PLATELET COMPLEX FORMATION IN PATIENTS WITH RECENTLY SYMPTOMATIC VERSUS ASYMPTOMATIC CAROTID STENOSIS: RESULTS FROM THE HAEMOSTASIS IN CAROTID STENOSIS (HEIST) STUDY

S Murphy ¹, ST Lim ¹, C Coughlan ¹, J Kinsella ², S Tierney ³, B Egan ³, TM Feeley ³, S Murphy ¹, R Walsh ¹, D Collins ⁴, T Coughlan ⁴, D O’Neill ⁴, J Harbison ⁵, P Madhavan ⁶, SM O’Neill ⁶, M Colgan ⁶, D Cox ⁷, N Moran ⁷, G Hamilton ⁸, D McCabe ¹

Abstract

Background

The mechanisms responsible for the disparity in stroke risk between asymptomatic and symptomatic carotid stenosis remain unclear.

Methods

We performed a prospective, observational study to compare full blood count parameters and platelet activation in asymptomatic versus symptomatic moderate (≥50–69%) or severe (≥70–99%) carotid stenosis patients. Whole blood flow cytometry quantified platelet surface activation marker expression (CD62P and CD63) and leucocyte-platelet complexes. Multiple linear regression analysis examined the influence of relevant independent variables on observed differences between groups.

Results

Data from 34 asymptomatic patients were compared with those from 43 symptomatic patients in the ‘early phase’ (≤4 weeks) and 37 of these patients in the ‘late phase’ (≥3 months) after TIA/ischaemic stroke. Mean platelet count was higher in early (216 x 10⁹/L) and late symptomatic (219 x 10⁹/L) than asymptomatic patients (194 x 10⁹/L; P ≤ 0.044). Mean % lymphocyte-platelet complexes was higher in early symptomatic (2.79 vs. 2.16%; P < 0.001), and median % neutrophil-platelet complexes was higher in late symptomatic than asymptomatic patients (2.98 vs. 2.52%; P = 0.02). There were no differences in expression of other platelet activation markers between groups. Mean platelet count (P ≤ 0.047) and lymphocyte-platelet complexes (P = 0.026) remained higher in symptomatic patients after controlling for differences in age, hyperlipidaemia and smoking status between groups.

Conclusions

There is an ongoing stimulus to increased platelet production, secretion or reduced clearance, and enhanced acute and chronic platelet activation after TIA/ischaemic stroke in symptomatic vs. asymptomatic moderate-severe carotid stenosis patients. Platelet biomarkers have the potential to aid risk-stratification in asymptomatic and symptomatic carotid stenosis.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EVALUATION OF PERICYTE CONTRACTILE STATE IN RESPONSE TO VASOACTIVE SUBSTANCES AND ISCHAEMIA IN VITRO

A Neuhaus ¹, Y Couch ¹, B Sutherland ¹, A Buchan ¹

Abstract

Background

Pericytes are vascular mural cells overlying capillaries. They regulate cerebral blood flow through control of capillary diameter (Fig. 1A) and pericyte constriction in stroke has been implicated in the no-reflow phenomenon. Therefore, pharmacologically altering pericyte tone could improve tissue reperfusion after stroke. Here, we demonstrate a novel method for evaluating cultured pericyte contractility in response to vasoactive substances and chemical ischaemia.

Methods

Human brain microvascular pericytes (ScienCell) were cultured on the iCelligence platform (ACEA Biosciences), which records changes in electrical impedance as an indicator of surface coverage and, by extension, contractile state (Fig. 1B,C) and proliferation (Fig. 1D) of the cells. Vasoactive substances tested included endothelin-1, adenosine and sodium nitroprusside (SNP). Ischaemia was induced through inhibition of glycolysis (sodium iodoacetate) and mitochondrial respiration (antimycin A).

graphic file with name 10.1177_2396987316642909-fig116.jpg

Results

Pericytes exhibited a dose-dependent acute contraction in response to endothelin-1. This was prevented by the ET_A antagonist BQ-123, but not the ET_B antagonist BQ-788. Similarly, endothelin-1 increased pericyte proliferation through ET_A-mediated signalling. Conversely, adenosine and SNP evoked relaxation in the pericytes. Chemical ischaemia led to a rapid decrease in impedance that preceded cell death, demonstrating constriction as previously described in acute brain slices.

Conclusions

The iCelligence electrical impedance assay is suitable for high-throughput evaluation of pericyte responses, including both contraction and relaxation, and provides an excellent platform for investigating vasoactive and vasculoprotective drugs in vitro.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

INTRA-ARTERIAL COLD INFUSIONS FOR NEUROPROTECTION IN EXPERIMENTAL ACUTE ISCHAEMIC STROKE

Y Wang ¹, Y Xueyu ¹, F Härtig ¹, U Ziemann ¹, S Poli ¹

Abstract

Background

Hypothermia provides powerful neuroprotection in experimental acute ischaemic stroke (AIS), but so far side effects (e.g. shivering) and low cooling rates of available (whole-body) cooling methods limit translation into clinical practice. Due to a significantly smaller target volume, selective brain cooling may allow for higher brain-cooling rates with only minor body core temperature reductions. “Highjacking” the brain-supplying blood flow, intra-arterial cold infusions (IACI) could be a promising strategy for rapid induction of brain hypothermia and easily performed during endovascular intervention.

Methods

We applied IACI (4°C) in a filament middle cerebral artery occlusion rat model through the internal carotid artery via a specifically designed infusion port allowing for continuous pre- and post-reperfusion brain cooling. IACI were compared to intra-arterial warm infusions (IAWI, 37°C), intravenous cold infusions (IVCI, 4°C) and controls.

Results

Moderate hypothermia (32–33°C) of the ischaemic hemisphere was achieved within 42 seconds at an IACI rate of 2 mL/min and maintained for 17 minutes at 0.7 mL/min. Compared to IAWI and whole-body cooling with IVCI, IACI conveyed more effective neuroprotection (smaller infarct size) and had no significant impact on blood gases, respiratory rate, blood pressure and body core temperature. Ischaemic brain tissue of IACI-animals featured inhibition of ROS production, apoptotic cell death and neuro-inflammation. No bleeding complications were observed.

Conclusions

Our data suggests that IACI may be an effective and safe neuroprotective strategy in AIS. Further experimental studies in larger animals are needed to investigate the possibility of translation of IACI into clinical practice.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

SHORT-TERM SODIUM CHLORIDE-RICH DIET INCREASES INFARCT VOLUMES IN A MOUSE MODEL OF ACUTE ISCHEMIC STROKE

A Schmidt ¹, C Massoth ¹, JK Strecker ¹, K Diederich ¹, J Minnerup ¹

Abstract

Background

The inflammatory response is considered as important therapeutic target following ischemic stroke. Sodium chloride promotes pro-infammatory T-cell and macrophage polarization and aggravates CNS autoimmunity, even after short-term sodium chloride-rich diet. However, in spite of an immense translational relevance, the effects of sodium chloride in acute ischemic stroke are unknown. We therefore aimed to investigate the effects of sodium chloride-rich diet in a mouse model of middle cerebral artery occlusion (MCAO).

Methods

Thirty-six adult C57BL/6 mice received either either sodium chloride-rich diet with 4% sodium chloride content (ssniff, Germany) and tap water containing 1% sodium chloride ad libitum or standard diet and tap water ad libitum. Seven days after the initiation of sodium chloride-rich diet, all animals underwent 60 minutes of MCAO. A neuroscore was employed to assess the functional outcomes. Effects on blood pressure and body weight were monitored. Infarct volumes were determined three days after MCAO. The inflammatory response shall be characterized by flow cytometry and immunohistochemical analyses.

Results

Infarct volumes were significantly increased after sodium chloride-rich diet (67.22 mm³± 4.85 mm³ vs. 53.57 mm³± 4.01 mm³, p < 0.05, t test). Neuroscores, blood pressure and body weight were not significantly affected. Flow cytometry analyses and immunohistochemical analyses to characterize the postischemic inflammatory response are ongoing.

Conclusions

Increased sodium chloride-delivery results in increased infarct volumes in acute ischemic stroke. The underlying pathophysiological mechanisms shall be identified in future experiments.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EFFECT OF INTRAARTERIAL ADMINISTRATION OF MODIFIED PROUROKINASE ON INFARCT VOLUME AND RECANALIZATION RATE IN EXPERIMENTAL THROMBOEMBOLIC STROKE

N Shamalov ¹, M Kustova ¹, A Tolmachev ¹, I Gubsky ¹, A Belogurov ², R Bibelashvili ², E Delver ²

Abstract

Background

The purpose of our study was to assess the effect of intra-arterial (IA) infusion of prourokinase modified (m-pro-UK) in its growth factor-like domain in a rat model of thromboembolic stroke.

Methods

Male Wistar rats were embolized by intracarotid injection to the middle cerebral artery (MCA) of autologous fibrin-rich blood clots followed 2 hours later IA infusion of saline (group 1, n = 12) or 50.000 U m-pro-UK (group 2, n = 12). MR examination was performed before, in 1 and 24 hours after operation at 7 T system and included DWI with calculation of apparent diffusion coefficient (ADC), T2WI and 3D-TOF angiography. The hemispheric lesion volume (HLV) in mm3 was calculated on ADC. Lesion growth (in comparison to MRI in 1 hour after occlusion, %) at 24 hours was calculated. The recanalization rate was assessed on 3D-TOF angiograms.

Results

Preembolic ADC maps did not exhibit asymmetries between the 2 hemispheres. One hour after embolism, the HLVs in which ADC declined did not differ between groups (89.4 ± 48.6 mm³ and 101.8 ± 54.3 mm³ in group 1 and 2, respectively; p = ns). In 24 hours after MCA occlusion the more significantly lesion growth in group 1 was observed (by 26.8 ± 38.6 %) in comparison with 7.9 ± 12.6% in group 2 (p<0.05). Full or nearly full recanalization of MCA was observed in 9 rats in group 2 (none in group 1, p<0.01).

Conclusions

IA infusion of m-pro-UK led to recanalization of MCA and stabilized the lesion size in thromboembolic stroke in rats.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CHARACTERIZATION OF SIMVASTATIN ENCAPSULATION INTO LIPOSOMAL DELIVERY SYSTEM TO TREAT EXPERIMENTAL ISCHEMIC STROKE IN RATS

A Simats ¹, M Campos-Martorell ¹, M Cano-Sarabia ², M Hernández-Guillamon ¹, A Rosell ¹, D Maspoch ^2,³, J Montaner ^1,⁴

Abstract

Background

Although the beneficial effects of statins on stroke have been demonstrated both in experimental studies and clinical trials, the aim of this study is to characterize a new liposomal delivery system that encapsulates simvastatin to improve its delivery into the brain.

Methods

In order to select the liposome lipid composition with the highest capacity to reach the brain, male Wistar rats were submitted to sham or transitory middle cerebral arterial occlusion (MCAOt) surgery and treated (i.v.) with fluorescent-labeled liposomes with different net surface charges. Ninety minutes after the administration, fluorescent liposomes were evaluated ex-vivo in the brain, blood, liver, lung, spleen and kidneys using the Xenogen IVIS® Spectrum imaging system. Furthermore, simvastatin levels in brain homogenates from sham or MCAOt rats, treated with either free or encapsulated simvastatin, were detected through ultra high protein liquid chromatography (UHPLC) at 2 or 4 hours after receiving the treatment.

Results

Neutral and negatively-charged liposomes reached the brain and accumulated specifically in the infarcted area. Moreover, neutral liposomes exhibited higher bioavailability in plasma 4 hours after being administered. The detection of simvastatin by UHPLC confirmed its ability to cross the blood brain barrier (BBB), either when administered as a free drug or encapsulated into liposomes.

Conclusions

This study confirms that liposome charge is critical to promote its accumulation in the brain infarct after MCAOt. Furthermore, simvastatin can be delivered after being encapsulated. Thus, simvastatin encapsulation might be a promising strategy to ensure that the drug reaches the brain, while increasing its bioavailability and reducing possible side effects.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

TARGETING DISEASE MECHANISMS TO MODULATE SPONTANEOUS INTRACEREBRAL HAEMORRHAGE IN MICE

T Van Agtmael ¹, F Jones ¹, LS Murray ¹, KE Kadler ²

Abstract

Background

Haemorrhagic stroke accounts for 15% of adult stroke and there is no specific treatment. The basement membrane is an extracellular matrix structure that provides structural support to blood vessels. Collagen IV is a basement membrane component and mutations in the genes Col4a1 and Col4a2 (collagen IV alpha chain 1 and 2) cause familial forms of cerebrovascular disease including intracerebral haemorrhage (ICH). Importantly, common variants in COL4A2 are also associated with deep ICH in the general population. Mice with equivalent Col4a1 mutations are excellent models of the disease and develop spontaneous recurrent ICH associated with basement membrane defects and a cell stress, called endoplasmic reticulum (ER) stress. This ER-stress is associated with disease development and treating cells from patients with a chemical chaperone reduces ER-stress and the cellular phenotype. In this study we explore the efficacy of chemical chaperones in modulating adult ICH caused by Col4a1 mutations.

Methods

Compound administration occurred via modified diet. In vivo magnetic resonance imaging was used to assess ICH. Phenotypic analysis included histopathology and gross morphological examination. Western blotting for ER stress markers was used to measure ER stress.

Results

Lifelong chemical chaperone treatment from conception lowered ER stress levels in adult mice and, importantly, partially rescued intracerebral haemorrhage. Treatment during embryonic development also reduced the ICH-associated lethality of newborn pups. However, one month treatment of adult mice did not ameliorate the ICH.

Conclusions

Modulating ER-stress via chemical chaperones represent a potential therapeutic approach to prevent recurrent adult ICH due to collagen IV mutations.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PROGNOSTIC SIGNIFICANCE OF PLASMA MATRIX METALLOPROTEINASE-9 CONCENTRATIONS FOR SPONTANEOUS HEMORRHAGIC TRANSFORMATION IN CHINESE ACUTE ISCHEMIC STROKE

D Wang ¹

Abstract

Background

Controversy exists over the prognostic significance of plasma matrix metallopeptidase 9 (MMP-9) concentration for spontaneous hemorrhagic transformation (sHT) in acute ischemic stroke. We aimed to determine the association of MMP-9 concentration within 24 h of onset and subsequent sHT among Chinese ischemic stroke patients.

Methods

Ischaemic stroke patients admitted within 24 h of onset were recruited and plasma concentration of MMP-9 was determined by the Enzyme Linked Immunosorbent Assay (ELISA) and HT was diagnosed according to repeated brain CT/MRI. We drew the Receiver Operating Characteristic (ROC) curve to determine the critical value of MMP-9 concentration in predicting HT and further explored its predictive effect in Logistic regression.

Results

We enrolled 168 stroke patients and 40 health controls. HT occurred in 29 (17.3%) stroke patients. The plasma concentration of MMP-9 in HT group (median 244.3 ng/mL, interquartile range, IQR 190.6 to 431.4) was significantly higher than that in non-HT group (median 110.0 ng/mL, IQR 54.4 to 172.2) and in control group (median 63.3 ng/mL, IQR 37.9 to 84.9), respectively (both p values < 0.001). ROC analysis indicated 181.7 ng/mL was the critical value of MMP-9 concentration, of which the positive predictive value was 48% and the negative predictive value was 96%. Controlling for potential confounding factors, MMP-9 concentration > 181.7 ng/mL was an independent predictor for spontaneous HT (OR = 18.8, 95% Confidence Interval 6.0 to 58.5, p < 0.001).

Conclusions

Plasma MMP-9 concentration >181.7 ng/mL within 24 hours after ischaemic stroke is an independent prognostic factor for spontaneous HT.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

SNPS: STROKE ACENOCOUMAROL PHARMACOGENETIC STUDY

L Colàs-Campàs ¹, MV Monserrat ¹, S Cambray ¹, J Molina-Seguín ², I Benabdelhak ², C Marzo ³, J Sanahuja ², A Quílez ², C Gonzalez-Mingot ², MP Gil-Villar ², AB Vena ⁴, JL Royo ⁵, F Purroy ²

Abstract

Background

Among atrial fibrillation (AF) patients main treatment for stroke prevention is oral anticoagulant treatment, such as Acenocoumarol (AC). Genes involved in AC metabolism may suffer variations in a single nucleotide (SNP). These SNPs can affect AC target enzymes (VKORC1), enzymes responsible of AC degradation (CYP2C9) or enzymes responsible for vitamin K inactivation (CYP4F2).

Methods

We genotyped these SNPs in a cohort of patients with AF treated with AC who suffered a stroke (n = 36) and a matched cohort of long term anticoagulated (>2 years) AF patients without any vascular event (n = 44). DNA was extracted from blood, and genotyping was done by DNA sequencing. Data was analyzed with CLC Main WorkBench 7 and SPSS software.

Results

No differences were observed in the risk vascular profile and SNP frequency of both groups. However, diabetes mellitus and CYP4F2 rs2108622 polymorphism were significantly associated with early stroke. rs2108622 homozygous carrier patients presented an ischemic stroke significantly earlier than wild type genotype (600 vs 3000 days). Kaplan-Meyer curves showed that more than 60% of rs2108622 homozygous patients presented an ischemic stroke before 600 days of AC treatment. This early event was not due to under-anticoagulation treatment.

graphic file with name 10.1177_2396987316642909-fig117.jpg

Conclusions

Patients presenting rs2108622 polymorphism could be good candidates to be treated with new oral anticoagulants in order to prevent early ischemic stroke events.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PLASMA MIRNA AS BIOMARKERS FOR SMALL AND LARGE VOLUME SIZE INTRACEREBRAL HEMORRHAGE

I Iwuchukwu ¹, D Nguyen ², A Kohler ², N Mahale ², O Sulaiman ³

Abstract

Background

The expression patterns of miRNA are increasingly being studied in cerebrovascular diseases particularly as a biomarker. ICH volume varies amongst patients and influences clinical outcomes. We studied the difference in circulating plasma miRNA expression in patients with ICH stratified by volume (<30 ml and >30 ml).

Methods

Blood samples from eight patients with ICH; (<30 ml n = 4; >30 ml n = 4) were collected within 48 hrs of presentation. miRNAs were extracted from 200ul of plasma samples using RNeasy Plasma miRNA Mini Kit. The cDNA and real-time PCR were carried out using the miRCURY LNA Universal RT kit and Bio-Rad Sybr Green mastermix. Candidate miRNAs were selected from our initial screen of 752 miRNAs using the Exiqon platform: miR-204-5 p, miR-301 b miR-338-3p, miR-33a, miR-493-5p, miR-34b-3p, miR-34b-5p, miR-34c-5p, miR-9-5p, miR-9-3p, miR-19a-5p, miR-99a-3p, miR-126-5p, miR-135a-5p, miR-200a-5p, miR-301b, miR-219a-5p, miR-125b-5p, miR-486-3p, miR-122-5p, miR-92b-3p, miR-493-5p. Samples were run on an ABI 7500 fast PCR using a cycle threshold (Ct) of less than 34 as a cut-off for reliability.

Results

We identified miR-204-5p, miR-301b, miR-338-3p, miR-338-5p, miR-33a-5p, and miR-493-5p as potential biomarkers to distinguish low and high volume ICH. Only miR-338-3p was detected in both small and large volume ICH with a 7-fold reduction in large volume ICH. Expressions of miR-204-5p, miR-301b, miR-33a-5p, miR-338-5p, and miR-493-5p were detected in low volume but not in high volume ICH. Finally, miR-122-5p was found at moderate abundance across all samples.

Conclusions

Our study suggests decreased expressions of miRNAs in large volume ICH suggest a potential loss of miRNA-mediated gene repression and its targeted bioprocesses.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

GENETIC POLYMORPHISMS ASSOCIATED WITH SUBCLINICAL CAROTID ATHEROSCLEROSIS, INTRACRANIAL STENOSIS AND CEREBROVASCULAR RESISTANCE IN A POPULATION-BASED COHORT. RESULTS FROM THE BARCELONA-ASIA STUDY

E López-Cancio ¹, N Lamonja ², J López-Olóriz ², L Dorado ¹, G Pera ³, M Alzamora ³, P Torán ³, J Arenillas ⁴, A Dávalos ¹, M Mataro ², M Via ²

Abstract

Background

There is increasing interest in studying the molecular mechanisms involved in the development of vascular cerebral damage. We studied the association of some genetic polymorphisms previously related to symptomatic vascular disease with the presence of subclinical brain vascular disease at extra and intracranial locations

Methods

Barcelona-AsIA (Asymtomatic Intracranial Atherosclerosis) is a population-based study that included a random sample of Caucasian subjects older than 50 years without history of stroke or dementia. All patients underwent a cervical and transcranial color-coded doppler study. We evaluated asymptomatic large vessel atherosclerosis: carotid intima-media thickness (CIMT), presence of carotid plaques (CP) and presence of intracranial stenosis (IS). We measured pulsatility index (PI) in middle cerebral arteries as a marker of cerebrovascular resistance. We studied 17 polymorphisms in 15 genetic regions. Association analyses were adjusted by age, sex and traditional vascular risk factors (REGICOR score).

Results

ApolipoproteinE (ApoE)-rs429358 (n = 802) and methylenetetrahydrofolate reductase (MTHFR)-rs1801133 (n = 460) polymorphisms were independently associated with CIMT ≥ 0.9 mm (p = 0.045 and 0.001). When considering the different alleles of ApoE (ε2,ε3,ε4), there was a trend for ApoE- ε4 association with higher CIMT (p = 0.059). Monocyte chemoattractant protein-1(MCP-1)-rs1024611(n = 380) was independently associated with a higher cerebrovascular resistance (p = 0.024). None of the studied polymorphisms were significantly associated with presence of CP or IS.

Conclusions

We found a modest association of MTHFR with higher CIMT but not with carotid plaque. Interestingly, we found a modest novel association between polymorphism of chemokine MCP-1 and intracranial vascular resistance, a non-invasive marker of white matter disease and silent small vessel disease. These findings deserve future research

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

RELATIONSHIP BETWEEN TUMOR NECROSIS FACTOR-ALPHA (-308G/A, +488G/A, -857C/T AND -1031T/C) GENE POLYMORPHISMS AND RISK OF INTRACEREBRAL HEMORRHAGE IN NORTH INDIAN POPULATION: A CASE-CONTROL STUDY

S Misra ¹, P Kumar ¹, A Kumar ¹, R Sagar ¹, K Prasad ¹

Abstract

Background

Genetic factors may play a role in the susceptibility of Intracerebral hemorrhage (ICH). The present case-control study hypothesized that genetic polymorphisms in the Tumor Necrosis Factor- α (TNF-α) gene may affect the risk of ICH. We investigated the association of four single nucleotide polymorphisms (-308G/A, +488G/A, -857C/T and -1031T/C) within TNF-α gene promoter and their haplotypes with the risk of ICH in North Indian population.

Methods

Genotyping was determined by using SNaPshot method for 100 ICH patients and 100 age-sex-matched ICH free controls. Conditional logistic regression analysis with adjusting multiple demographic and risk factor variables was used to calculate the strength of association between TNF-α gene polymorphisms and risk of ICH. Haplotypes were reconstructed using PHASE 2.0 and patterns of Linkage disequilibrium (LD) analysis were done by using Haploview software.

Results

TNF-α +488G/A gene polymorphism was found to be independently associated with the risk of ICH under dominant [GG + GA vs. AA] (OR = 3.1; 95%CI 1.2 to 8.2; p = 0.001) and allelic [G vs. A] (OR = 2.2; 95%CI 1.2 to 4.2; p = 0.007) models. However, no significant association between -308G/A, -857C/T and -1031T/C gene polymorphisms and risk of ICH was observed. Haplotype analysis showed that 308A-488G-857C-1031T and 308G-488A-857T-1031T haplotypes were significantly associated with the increased risk of ICH. Strong LD was observed for +488G/A and -857C/T TNF-α polymorphisms (D’ = 0.72, r²= 0.01).

Conclusions

Our findings suggest that TNF-α +488G/A polymorphism may be an important risk factor for ICH, whereas -308G/A, -857C/T and -1031T/C gene polymorphisms may not be associated with the risk of ICH in North Indian population.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

IDENTIFICATION OF NOVEL INFLAMMATION-RELATED PLASMA BIOMARKERS BY PROTEOMIC ANALYSIS OF SEQUANTIAL SAMPLES IN ISCHEMIC STROKE

M Olsson ¹, T Stanne ¹, AC Lundell ², L Holmegaard ³, K Jood ³, J Christina ¹

Abstract

Background

Inflammation plays a role in ischemic stroke (IS) and post-stroke outcomes. We sought to identify novel inflammatory biomarkers related to IS and outcomes.

Methods

The study sample comprised participants from the Sahlgrenska Academy Study on IS (mean age 54 years at index stroke, 64% males), who took part in a 7-year follow-up (N = 202) and matched healthy controls (N = 202). Outcome was assessed at 3 months and 7 years by the modified Rankin scale (mRS). In patients, blood was drawn within 10 days of index stroke, at 3-month, and at 7-year follow-up. Controls were sampled once. The relative plasma levels of 92 inflammation-related proteins were analyzed using a novel targeted proteomics chip based on proximity extension assay technology. Multivariate discriminant analysis (OPLS-DA) was used to examine whether IS patients and controls could be separated based on these proteins.

Results

After filtering for proteins with high detection levels, 65 proteins remained. OPLS-DA demonstrated a separation between IS patients, at all three time points, and controls (goodness of fit (R²) and predictive ability (Q²) of models >0.65). The inflammation-related proteins that displayed the strongest contribution to this separation were CXCL5, Matrix Metalloproteinase-1, and Oncostatin-M. Plasma levels of these three proteins were significantly higher in cases at all three time points compared to controls (p < 0.001 throughout). In contrast, OPLS-DA poorly separated patients with good versus bad outcome (mRS 0–1 vs 2–6).

Conclusions

We identified novel inflammatory biomarkers that discriminated between IS patients and controls. We will now seek replication and investigate stroke subtypes in a larger sample.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

WARFARIN LOADING DOSE GUIDED BY PHARMACOGENETICS IS EFFECTIVE AND SAFE IN CARDIOEMBOLIC STROKE PATIENTS

T Růžičková ¹, M Šrámek ¹, Z Lacinová ², H Magerová ¹, I Šarbochová ¹, V Maťoška ², A Tomek ¹

Abstract

Background

Warfarin treatment is commonly started with a fixed loading dose, which could be associated with an increased bleeding risk in sensitive patients. Individual maintenance dose can be estimated based on pharmacogenetic algorithm. Starting treatment with estimated dose implies longer time to reach therapeutic range.

Methods

Prospective monocentric randomized trial. Our aim was to evaluate safety and efficacy of initiating warfarin treatment by a loading dose guided with pharmacogenetics compared to initaiting treatment by maintenance dose. Primary endpoint was time in the therapeutic range (TTR) in the first 10 days of treatment. Secondary endpoints were time to the first INR in therapeutic range (2.0–3.0) and occurrence of serious adverse events (INR > 4, major bleeding, thromboembolic events, death). Consenting cardioembolic stroke patients were genotyped for CYP2C9 and VKORC1 polymorphisms and maintenance warfarin dose was estimated. Patients were randomized into two groups. Loading dose group (LDG) patients received double the estimated dose in the first two days of treatment, maintenance dose group (MDG) patients received estimated dose directly from day 1. Patients were followed up for 90 days. International normalized ratio (INR) was measured on days 0–10,15,20,30 and 90.

Results

88 patients were analysed (41 LDG, 47 MDG). TTR was significantly higher in the LDG (0.50 vs. 0.38, p = 0.012). Time to the first INR in range was shorter in LDG (5.24 vs. 7.3 days). There were no significant differences in INR above range and serious adverse events.

Conclusions

Warfarin loading dose guided by pharmacogenetics improved the efficacy of warfarin initiation without increasing the risk of adverse events.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PROFILING OF CIRCULATING MIRNAS AFTER HUMAN ISCHEMIC STROKE IDENTIFIES DIFFERENTIALLY EXPRESSED MIR-125A-5P, MIR-125B-5P AND MIR-143-3P

S Tiedt ¹, M Prestel ¹, V Kautzky ¹, B Northoff ², R Malik ¹, M Klein ³, K Krohn ⁴, D Teupser ², LM Holdt ², M Dichgans ¹

Abstract

Background

Currently, there are no blood biomarkers supporting the diagnosis of cerebral ischemia in clinical practice. Circulating miRNAs have been shown to be dysregulated after stroke.

Methods

We sequenced small RNAs isolated from platelet-poor plasma from a discovery cohort of 20 ischemic stroke patients (symptom onset to hospital arrival: 3.9 ± 3.6 hours) and 20 matched healthy controls. An independent cohort for qRT-PCR validation comprised 40 ischemic stroke patients and 40 matched healthy controls.

Results

Sequencing identified 32 differentially expressed miRNAs. Validation by qRT-PCR revealed three miRNAs, which were upregulated in stroke patients vs controls: miR-125a-5p (1.80 ± 0.16-fold, mean ± SEM; p = 1.5 x 10^-6), miR-125b-5p (2.54 ± 0.36-fold; p = 5.6 x 10^-6) and miR-143-3p (4.77 ± 0.70-fold; p = 7.8 x 10^-9). Longitudinal analysis up to 90 days after stroke showed two distinct patterns: while miR-143-3p and miR-125a-5p quickly dropped to normal levels beginning from day 2, miR-125b-5p remained elevated until day 90. Upon admission, patients with ischemic stroke from the discovery cohort (n = 20) showed significantly higher expression levels of miR-143-3p and miR-125b-5p than patients with TIA (n = 18) (miR-143-3p: 6145 [3564 – 13376] versus 1781 [1068 – 3201] copies / µl plasma (median [interquartile range]), p = 0.0015; miR-125b-5p: 581 [456 – 1136] versus 308 [202 – 470] copies / µl plasma, p = 0.0012).

Conclusions

In conclusion, this study identifies a set of miRNAs, which are upregulated in the hyperacute phase of ischemic stroke. These miRNAs hold potential as acute and long-term biomarkers and might further be functionally relevant.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

MUTATIONS IN THE ABCC6 GENE ARE ASSOCIATED WITH AN INCREASED RISK FOR ISCHEMIC STROKE

E De Vilder ¹, S Cardoen ², MJ Hosen ³, P Coucke ¹, D Hemelsoet ², O Vanakker ¹

Abstract

Background

Ischemic stroke (IS) results from a complex interplay between environmental and genetic risk factors. Because of the increased IS incidence in pseudoxanthoma elasticum (PXE) – an autosomal recessive connective tissue disease with skin, eye and cardiovascular (CV) symptoms due to ABCC6 mutations – and the higher CV risk in carriers of one ABCC6 mutation, ABCC6 was hypothesized to be a candidate risk factor for IS.

Methods

Sanger sequencing of the coding region of ABCC6.

Results

In a three-generation family, we established segregation of a known ABCC6 mutation (p.Arg1314Gln) in 18 individuals with IS and/or CV disease at young age. Two additional family members were identified as having PXE, due to co-inheritance of a second ABCC6 mutation.

In an independent cohort of 424 IS patients, we identified 18 carriers of one ABCC6 mutation compared to 2 carriers in controls. None showed clinical features of PXE. Carriers were heterogeneous in age, familial history and stroke type. The calculated Odds Ratio was 5.4975 (p = 0.023; 95% CI 1.2-23.8). No interaction with other CV risk factors was noted.

Conclusions

The perfect segregation of an ABCC6 mutation in affected members of a multi-generation family with cerebro- and cardiovascular disease suggests heterozygous ABCC6 mutations to be a significant risk factor for IS. This was confirmed by a high incidence of ABCC6 mutations in cryptogenic IS patients compared to controls. As demonstrated by the diagnosis of two PXE patients in our first family, identification of ABCC6 mutation carriers has important implications for genetic counseling and follow-up of these families.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

MECHANICAL THROMBECTOMY AND STENTING IN ACUTE CAROTID ARTERY OCCLUSION

L Albert ¹, C Sánchez-Vizcaino Buendía ¹, E Carreón Guarnizo ¹, JB Escribano Soriano ¹, B García-Villalba Navaridas ², G Parrilla Reverter ², AM Morales Ortiz ¹, A Moreno Díeguez ³

Abstract

Background

Acute carotid artery occlusion (ACAO) has a high mortality rate. Early recanalization is the keystone for a favorable clinical outcome. Intravenous fibrinolysis is sometimes insufficient to achieve a good recanalization. Endovascular mechanical thrombectomy has emerged as a successful treatment; however, sometimes additional permanent stent placement associated with early antiplatelet treatment is necessary for a complete recanalization.

The aim of this study was to analyze the safety and efficacy of stenting in the internal carotid artery (ICA) in ACAO, and describe the demographic characteristics of patients who underwent thrombectomy.

Methods

145 patients with ACAO were treated with mechanical thrombectomy. Fifty-one of them (35%) needed additional stenting in the ICA. We compared demographic characteristics between the group treated with stent (G1) and those treated with thrombectomy alone (G2). We also compared recanalization, cerebral haemorrhage, extravasation, clinical outcome and death.

Results

Patients in G1 were younger (64 years [56–75]) compared to G2 (71 years [64–78], p = 0,045). There was higher proportion of male patients in G1 (76,4% vs 41,4%, p < 0,001). Atrial fibrillation was more frequent in G2 (44,0% vs.15,6%, p < 0,001). We found no differences regarding clinical outcome or recanalization score. In-hospital death was 26,9% in G2 compared to 17,0% in G1 (p = 0,138). Haemorrhage and extravasation rates were 29,0% and 43,0% in the G2, whereas 35,2% and 39,2% in G1 (p = 0,277 and p = 0,397 respectively).

Conclusions

We found that stenting and early treatment with antiplatelet drugs do not increase haemorrhage, extravasation or death. In our study, stenting in the ACAO is more used in male and younger patients.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

SAFETY AND EFFICACY OF PRIMARY MECHANICAL THROMBECTOMY COMPARED TO CONVENTIONAL TREATMENT IN PATIENTS WITH INTRACRANIAL LARGE VESSEL OCCLUSIONS

M Alonso de Leciñana Cases ^1,², P Martínez Sánchez ¹, A García-Pastor ³, MM Kawiorski ¹, P Calleja ⁴, BE Sanz-Cuesta ¹, F Díaz-Otero ³, B Marín ⁵, F Sierra-Hidalgo ^6,⁷, G Ruiz-Ares ¹, E Fandiño ⁵, E Díez-Tejedor ¹, B Fuentes ¹

Abstract

Background

Benefits of primary mechanical thrombectomy (MT) in patients not treated with intravenous tPA (IVT) have not been established. We compare safety and efficacy of primary MT, using stent retrievers, with standard IVT or combined IVT + MT, for patients with acute ischemic stroke.

Methods

Prospective, observational, multi-centered study (FUN-TPA: ClinicalTrials.gov; NCT02164357) including stroke patients with large intracranial arterial occlusion. Treatment was initiated within 4.5 hours from symptom onset. Primary MT was applied when there were contraindications for IVT and combined IVT + MT after IVT failure. Baseline characteristics, occurrence and timing of recanalization were recorded. Outcome measures were symptomatic intracranial hemorrhage (SICH), mRS score, and mortality at 90 days.

Results

Included were 132 patients, median baseline NIHSS 17 (IQR: 12; 20), treated with primary MT (16%) IVT (43%), or IVT + MT (40 %). Recanalization rate after MT was 82 %, vs 35%, after IVT (p < 0.001) and vs 91 % after IVT + MT (p = 0.29), median delay of 261 minutes (215; 330) vs 227 (180; 277) and 325 (280; 390) respectively (p = 0.0001). Complications of endovascular procedures did not differ between groups. There were no SICH after primary MT, 4% after IVT and 6% after IVT + MT. Independency at three months (mRS 0–2) was 45%, 61% and 68%, and mortality 14%, 11% and 4%. The tendency to better outcomes among patients receiving IVT + MT compared with primary MT was not statistically significant.

Conclusions

MT is equally safe if administered primarily or after standard treatment with IVT. It should be offered aiming prompt recanalization if there are contraindications for IVT.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

IMPROVING THE QUALITY OF CARE IN ACUTE ISCHEMIC STROKE PATIENTS, HOSPITALIZED IN THE UNIVERSITY HOSPITAL "SAINT MARINA“- VARNA

S Andonova ¹, E Kalevska ², D Georgieva-Hristova ²

Abstract

Background

Aim: The aim is to develope a model for management, monitoring and quality control of medical activities in patients with acute stroke.

Methods

The present prospective study is carried out in the period 2009–2013 and includes 5353 patients with acute ischaemic stroke hospitalised in the newly established stroke unit at UMHAT- St. Marina. The effect of the management intervention was assessed with the following quality indicators: period from onset of AISН to hospitalisation; % hospitalized up to the 3rd hour; % head CT; % with early rehab; % inhospital deaths; moratlity up to the 3rd month; neurological status at 24th hour, 7th day, at dehospitalization and on the 3rd month, assessed with the modified Rankin scale as well as NIHSS at the 24th hour and 7th day. The quality indicators from our hospital were compared with that of patients registered in SITS.

Results

Owing to the efforts of different institutions and the support of the management team of UMHAT Saint Marina, the care for AIS patients from Varna city/region at our clinic has been organized on the principles of multidisciplinary approach, team work and a full coordination between separate units engaged in this activity. As a result of the continuous organisational meetings and staff training, the number the AIS patients treated with thrombolysis has increased.

Conclusions

Based on the analysis of the data from the papers and the five-year research, we offer the introduction of Quality Indicators on a national Bulgarian level, related to the optimization of acute stroke management.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ICTUS3R THE ITALIAN STROKE-APP

M Baldereschi ¹, A Di Carlo ¹, B Piccardi ², D Inzitari ²

Abstract

Background

Any strategy to reduce stroke burden involves crucial inputs from individuals (risk reduction, rapid recognition and response to symptoms onset) which imply a certain level of stroke knowledge. We developed a user-friendly, free-of-cost application in italian, available at www.ictus3r.it, to contribute filling the gaps in stroke knowledge. Here we report on the development and usage of this application

Methods

The application was developed in collaboration with communication experts, stroke leaders and web producers.ICTUS3R was pilot tested in terms of number and distribution of downloads. Data on usage were anonymously collected during 15 months following release (October 29, 2014).

Results

ICTUS3R was designed to include comprehensive stroke information primarly accessed via a scrollable index. Three major sections were dedicated to stroke symptoms recognition, reaction, and prevention. Other sections included stroke information and calculation of personal stroke-risk according to the Framingham-Stroke-Risk-Score. The application was downloaded a total of 38500 times, the age-group mostly interested was 25–34 years (33,5%) but also the 12% of the downloads were from people 55 and over. More than 1700 downloads were done in US.Visitors picked in relation to national newspaper articles or national television broadcasting where ICTUS3R had been mentioned and described.

Conclusions

ICTUS3R for smartphone, tablet, and PC is a well-received application for dissemination of stroke information. Application widespread and download are strongly correlated with specific mass-media promotional events

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ACUTE ENDOVASCULAR TREATMENT DELIVERY TO ISCHEMIC STROKE PATIENTS THROUGH A TELESTROKE NETWORK

J Barlinn ¹, J Gerber ², K Barlinn ¹, LP Pallesen ¹, T Siepmann ¹, C Wojciechowski ¹, V Puetz ¹, R von Kummer ², H Reichmann ¹, J Linn ², U Bodechtel ¹

Abstract

Background

We aimed to explore whether a large hub-and-spoke telestroke network is capable of endovascular treatment (EVT) delivery to acute ischemic stroke patients.

Methods

Data derived from consecutive patients with intracranial large vessel occlusion who underwent EVT from 01/2010 to 12/2014 at our tertiary stroke center. We compared baseline characteristics, onset-to-treatment times, symptomatic intracranial hemorrhage (sICH), in-hospital mortality, reperfusion (mTICI 2b/3) and favorable functional outcome (defined by modified Rankin scale ≤2) at discharge between patients transferred from spoke hospitals and those directly admitted to our tertiary stroke center.

Results

We studied 151 patients who underwent emergent EVT for anterior circulation occlusive stroke: median age 70 years (IQR, 62–75); 55% men; median NIHSS score 15 (12–20). Forty-eight (31.8%) patients were transferred after teleconsultation and 103 (68.2%) were primarily admitted to our emergency department. Transferred patients were younger (p = 0.020), received more frequently intravenous tPA (p = 0.015), had prolonged time from stroke onset to start of EVT (p < 0.0001), tended to have lower rates of sICH (4.2% vs. 11.7%; p = 0.227) and mortality (8.3% vs. 22.6%; p = 0.041) than those patients directly admitted to our stroke center. The rate of mTICI 2b/3 reperfusion was comparable in both groups (56.2% vs. 61.2%; p = 0.567). Likewise, telestroke patients achieved similar rate of favorable functional outcome as directly admitted patients (18.8% vs. 13.7%; p = 0.470).

Conclusions

Telestroke networks may enable equitable delivery of endovascular treatment to selected ischemic stroke patients irrespective of their being transferred from remote hospitals or admitted directly.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

“IN SEARCH OF LOST TIME: DRIP-AND-SHIP OR SHIP-AND-DRIP?” EXPERIENCE OF TELESTROKE IN FRANCHE-COMTE

L Bonnet ¹, E Pomero ², E Medeiros de Bustos ¹, F Vuillier ¹, B Bouamra ¹, A Biondi ², T Moulin ¹

Abstract

Background

The recent introduction of thrombectomy in the management of cerebral infarctions (CIs) involves a secondary transfer of patients who received intravenous thrombolysis (IVT) via telemedicine. There are currently two different models of care pathways: immediate transfer of all suspected strokes to the thrombectomy centre or IVT for identified CIs at spokes via telemedicine followed by a secondary transfer.

Methods

Patients were prospectively selected from the Stroke Registry of Franche-Comte which includes a telestroke service (8 spoke hospitals and 1 hub with interventional neuroradiology). All acute infarctions treated in January–September 2015 with thrombectomy were included.

Results

Twenty-six patients were included (11 women; mean age: 65; age range: 25–85). Eleven patients (mean NIHSS: 18) received a secondary transfer from a spoke (9 IVTs, mean onset-to-needle time: 2 h 40) and 15 patients (mean NIHSS: 18.6) were initially treated at the hub (11 IVTs, mean onset-to-needle time: 3 h). Thrombectomy was initiated on average 3 h 50 from symptom onset for hub patients in comparison with 5 h for spoke patients. The proportion of poor outcome (Rankin 5–6) at 3 months was similar, 27% for hub and 36% for spoke (p > 0.5) respectively. The proportion of symptomatic haemorrhagic transformations and recanalization rates were similar for both.

Conclusions

Telemedicine for acute CIs shortens time delays for IVT and lengthens time delays for thrombectomy due to secondary transport with no difference in benefits and risks. Telestroke seems to improve patient selection and suitability.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

BLOOD BIOMARKERS FOR THE EARLY DIAGNOSIS OF STROKE. THE STROKE-CHIP STUDY

A Bustamante ¹, S Pich ², E López-Cancio ³, A Penalba ¹, D Giralt ¹, C Ferrer-Costa ², T Gasull ⁴, M Millán ³, M Rubiera ⁵, P Cardona ⁶, M Terceño ⁷, M Garces ⁸, J Casanova ⁹, R Marés ⁹, JJ Baiges ⁸, J Serena ⁷, F Rubio ⁶, E Salas ², A Dávalos ⁴, J Montaner ¹

Abstract

Background

An early biochemical diagnosis of stroke could result in better patient selection and safer and faster use of reperfusion therapies. We aimed to develop a blood-based diagnostic tool to differentiate between real strokes and stroke-mimics and between ischemic and haemorrhagic stroke.

Methods

The Stroke-Chip was a prospective, observational study, conducted at 6 Hospitals in Catalonia. Patients with suspected stroke were enrolled at Emergency Departments. Blood samples were obtained within the first six hours after symptom onset. A 21-biomarker panel was selected among our previous results and the literature, being measured by ELISA. Biomarkers were dichotomized by the best discriminative cut-off. Predictive models for stroke vs. stroke-mimics and ischemic vs. haemorrhagic stroke were developed by combining biomarkers and clinical variables in logistic regression models. Accuracy was evaluated with ROC curves.

Results

From August-2012 to December-2013, 1,332 patients were included (71% ischemic, 15% mimics, 14% haemorrhagic). For stroke vs. mimics comparison, only clínical variables but not biomarkers emerged in the logístic regression models. However, for ischemic vs. haemorrhagic comparison, IL-6 > 3.66 pg/mL (OR = 1.67 (1.01–2.75), p = 0.045), NT-proBNP < 4.9 pg/mL (2.19 (1.4—3.46), p = 0.001) and endostatin < 4.67 pg/mL (OR = 1.89 (1.1–2.24), p = 0.020), together with age, sex, blood pressure, stroke severity, atrial fibrillation and hypertension were included. Predictive accuracies for both indications were 80.9% (stroke vs. mimics) and 80.8% (ischemic vs. haemorrhagic).

Conclusions

Large multicenter trials on acute stroke diagnostic biomarkers are feasible. The obtained results are far from the requested accuracy for this indication. Additional discovery of new biomarkers and improvement on laboratory techniques seem necessary for achieving a molecular diagnosis of stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ANALYSIS OF STROKE MANAGEMENT AND THE SUBSEQUENT ACTIVATION OF THE STROKE CODE ON THE PREHOSPITALARY ENVIRONMENT

A Caballero ¹, A Palomino ², D Jimenez ², I Escudero ², JM Villadiego ¹, J Borja ³

Abstract

Background

Approximately 40% of healthcare resources are directed to the aging population, which will represent 20% of the Spanish population in 2020. The call to the emergency healthcare system is the first stage in the stroke survival chain. The alert should be made just after detecting any of the stroke suggesting symptoms.

The best results are obtained in patients treated within the first 90–120 minutes A third factor is the performance of the teleoperator, both in recognizing the reason for the call and the correct implementation of the plan in question.

This study analyzes multiple variables in order to improve our prehospitalary performance.

Objectives

To evaluate the implantation of new Triage guidelines.

To assess the prevalence of stroke in Andalucia.

To assess the total time spent on the out-of-hospital environment.

Methods

The study was carried out in 2014. A total of 4634 patients suffered a Stroke and were attended by Andalucia’s Emergency teams. However, only 2907 of them were correctly detected by the call center.

The variables were: Age, Gender, Location, the activation of the stroke code, the type of ambulance and the total time spent.

Results

Average time spent per patient: 49 minutes

Conclusions

1. The implantation of the Triage Guidelines is inefficient

2. A quality indicator should be created regarding status delivered by ambulances

3. The creation of new establishments would be advisable, to prevent secondary transfers

VARIABLES	RESULTS
MEDIAN AGE	74 MEN	81 WOMEN
SEXO	2213 MEN	2361 WOMEN
ACTIVATE CODICE ICTUS	1073
ALERT SINCE TELEPHONE	271
SECONDARY TRANSPORT INTER HOSPITAL	187 CASES

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Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CLINICAL COURSE AND TREATMENT OF PATIENTS WITH ACUTE ISCHEMIC STROKE AND TIA WITH INTRACRANIAL NONOCCLUSIVE THROMBUS ON COMPUTED TOMOGRAPHY ANGIOGRAPHY

A Cruz Culebras ¹, R Vera Lechuga ¹, A De Felipe-Mimbrera ¹, MC Matute-Lozano ¹, J Masjuan ¹

Abstract

Background

To determine the clinical course and treatment options performed in patients with acute ischemic stroke (AIS) and TIA who present with intracranial nonocclusive thrombus (NOT) on CTA imaging

Methods

Prospective data (2012–2015) of patients with AIS or TIA in our Comprehensive Stroke Centre who have CTA performed during the acute period and a NOT. Intracranial stenosis and wall calcifications were excluded. We analyse baseline characteristics, treatment options based on time since the onset of symptoms and outcome data in every therapeutic option

Results

31 patients (74% male, mean age 66+/-17 years, median NIHSS 4, range 0–18) were analysed. Three patients presented as a TIA (9.6%), 12 patients were treated with intravenous thrombolysis (38%), 11 received double antiplatelet therapy in the acute period (35%), 3 underwent endovascular procedures (9.6%), 4 received aspirin only (12.9%) and one patient received apixaban in the first 24 h. Median time onset-CTA was 206 min (range 45–1020 min). 20 patients (64.5%) had a NOT in the MCA, 6 patients on the PCA (19,3%), 4 patients had thrombus on the BA (13%) and one patient had a NOT in the Anterior Superior Cerebellar Artery (3,2%). Three patients had a clinical deterioration in the first 24 h (19.3%). 29 patients (93.5%) were functionally independent at three months (mRS 0–2) and 2 of them (6.4%) had a moderate disability (mRS 3–4). No mortality was registered

Conclusions

Patients with intracranial NOT seem to have a good clinical outcome. However clinicians should be aware of clinical deterioration in a small proportion of cases.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

SERUM NEUROFILAMENTS LIGHT CHAIN IN ACUTE ISCHEMIC STROKE, TIA, AND HEALTHY CONTROLS - A PROSPECTIVE COHORT STUDY

GM De Marchis ¹, M Katan ², C Barro ³, C Traenka ¹, D Seiffge ¹, H Lisa ¹, H Gensicke ¹, D Giulio ⁴, N Peters ¹, M Arnold ⁵, S Engelter ¹, P Lyrer ¹, J Kuhle ³, L Bonati ¹

Abstract

Background

To explore the diagnostic accuracy for acute cerebral ischemia and kinetics of serum neurofilament light chain levels (sNfL) in patients with acute ischemic stroke (AIS), TIA, and healthy controls.

Methods

Prospective cohort study, which included patients with AIS or TIA admitted within 24 h from symptom onset. sNfL were determined upon admission in all patients, and on the day following admission in a subgroup. Among the patients with MR-DWI on admission, we built 3 groups based on the acute lesion volume on DWI: (1) small lesions of <10 cm³, (2) medium sized lesions of 10–100 cm³, and (3) large lesions with a volume of >100 cm³.

Results

We included 731 patients with stroke (68%), 187 with TIA (17%) and 165 healthy controls (15%). Median sNfL levels were higher in patients with AIS, than TIA or controls (17 pg/ml | 13 pg/ml | 2 pg/ml [p < 0.01]). Among the patients with MR-DWI on admission (n = 654), increasing median sNfL-levels were associated with increasing DWI-lesion sizes (OR 1.69, 95%-CI 1.30–2.21, p < 0.01). On the day following admission, sNfL were measured in 132 patients, in which, compared to the admission day, median sNfL increased from 13 pg/ml to 20 pg/ml (p < 0.01 for matched pairs).

Conclusions

sNfL were highest in AIS, intermediate in TIA, and lowest in healthy controls. Being higher in patients with larger DWI-lesion sizes, sNfL may serve as surrogate marker for acute cerebral ischemia. The increasing sNfL levels across the first 24 hours of hospitalization may indicate a delayed NfL-release from the infarcted brain into the blood stream.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EFFICACY AND SAFETY OF ENDOVASCULAR TREATMENT FOR ACUTE STROKE SECONDARY TO CERVICAL INTERNAL CAROTID ARTERY OCCLUSION

S Fernández Menéndez ¹, D Larrosa ¹, E Murias ², P Vega ², E Morales ², A Pérez álvarez ¹, L Benavente ¹, S Calleja ¹

Abstract

Background

Ischemic stroke caused by acute cervical internal carotid artery (cICA) occlusion is associated with high rates of morbidity and mortality. Intravenous thrombolysis treatment has a low rate of recanalization (10%) and poor clinical outcome (80–90%). Endovascular treatment has been recently approved for acute ischemic stroke management. However, data on efficacy for cICA occlusion treatment are lacking.

Methods

We analyzed recanalization rates, clinical outcomes at 3 months and risk factors associated with poor clinical outcome to determine the efficacy and safety of endovascular treatment for ischemic stroke secondary to cICA occlusion attended at our institution for the last 4 years. TICI grades 2b-3 were considered succesful angiographic outcome. Prognosis was determined according to mRS, considering good prognosis 0–2.

Results

We identified 50 patients, 36 (72%) were men, with a mean age of 68.16 ± 9.15 years. Median NIHSS was 15 [12.75–19.00]. Succesful recanalization occurred in 92% of patients. At 3 months 42% of patients had good prognosis. History of coronary artery disease, diabetes, high blood glucose levels at admission and chronic ischemic signs on brain CT were associated with poor prognosis in the univariate analysis. On multivariate analysis, glucose levels showed a tendency. Mortality occurred in 10 patients (20%) and symptomatic intracranial hemorrhage in 7 (14%).

Conclusions

Endovascular therapy for acute ischemic stroke secondary to cICA occlusion results in high rates of recanalization and good functional prognosis at 3 months with a good safety profile. Glucose levels at admission could be an independent risk factor associated with poor clinical outcome.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ACCESSIBILITY TO MECHANICAL RECANALIZATION AFTER TRANSFER FROM A HIGH VOLUME PRIMARY STROKE CENTER TO A DISTANT COMPREHENSIVE STROKE CENTER: A THREE YEARS PROSPECTIVE REGISTRY ANALYSIS

D Sablot ¹, N Gaillard ¹, P Smadja ², JM Bonnec ³, S Jurici ¹, F Coll ³, JL Bertrand ², A Laverdure ³, V Costalat ⁴, C Arquizan ⁵, A Bonafe ⁴

Abstract

Background

We evaluated a transfer procedure strategy for selected acute ischemic stroke patients (AIS) in the intent of Mechanical Thrombectomy (MT) to a 156 km distant comprehensive stroke center (DCSC) from a high volume primary stroke center (PSC) in Perpignan, France

Methods

During a 3-years period, we included AIS in PSC within 6 hours from onset of symptoms eligible to intravenous thrombolysis (IVT) and/or MT with the Solitaire stent retriever. Eligible AIS had confirmed proximal arterial occlusion and absence of a large infarct on MRI (DWI ASPECTs ≥ 5). We analysed transfer, futile transfer, MT, reperfusion (TICI score > =2b-3) rates and main relevant times measures

Results

Among 2701 IS patients, 385 were eligible to IVT (347 cases) and/or MT (211 cases, 55%) after brain imaging (370 MRI, 96%). Among MT eligible patients, transfer rate was 56% (n = 119/211), futile transfer rate 56% (n = 67/119), MT rate 25% (n = 52/211) and overall reperfusion rate with MT 18% (n = 38/211). No unexpected complications was recorded during transfer. Relevant median times were in minutes (Interquartile range (IQR)): IVT start to DCSC door: 130 (107–169), PSC to DCSC door: 95 (79–118), IVT start to MT-puncture: 191 (174–218), symptoms to MT-puncture time: 354 (294–401), symptoms to reperfusion: 417 minutes (362–486)

Conclusions

transfer procedure between PSC and a 156 km DCSC was safe but associated with loss of chance for AIS with large artery occlusion, by offering to a minority a delayed reperfusion. These results can be translated to high volume PSC (>100 IVT/year) and closest DCSC beyond 150 Km (or >1 hour) distant

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

IMPACT OF DECISION DELAY AND FIRST MEDICAL CONTACT ON PREHOSPITAL DELAY

R García Ruiz ¹, J Silva Fernández ², R García Ruiz ³, M Recio Bermejo ¹, Á Mateu Mateu ¹, A González Manero ¹, E Botia Paniagua ¹, MDC Blanco Valero ⁴, J Abellán Alemán ⁵, C González Pereira ⁶

Abstract

Background

Despite several advances in pre-hospital and in-hospital workflow, time is still the main limitation for thrombolysis, as improvements in patient awareness are few. We report an analysis of the impact of decision delay (DD) and first medical contact (FMC) on prehospital delay (PD).

Methods

An observational study was conducted on a sample of consecutive stroke patients diagnosed by a neurologist in our Emergency Department between 15^th November 2013 and 14^th April 2014. Subarachnoidal haemorrage and in-hospital stroke patients were excluded. Descriptive and bivariate analyses were performed.

Results

138 patients were recruited (see sample characteristics in Figure 1). The shorter the decision delay, the higher the probability of arriving the hospital in the first 3 h. Delays of less than 15’, 30’ and 60’ were associated to a probability of arriving the hospital in the first 3 h of 96,6, 87,5 and 63% respectively, meanwhile delays longer than 15’, 30’ and 60’ showed a probability of 44, 28 and 9% (p < 0,001). Contacting the 112 Emergency Services was strongly associated with DD < 60' and PD < 180' (p < 0,01)(table 1).

graphic file with name 10.1177_2396987316642909-fig118.jpg

Conclusions

DD and FMC are the most important factors for PD. Calling the extrahospital emergency services was associated to both shorter DD and PD, and independently each other. Immediately contacting the EES should be the main message in future awareness campaigns.

Table 1.

Patients (%) with DD < 60' and PD < 180' in each subgroup.

FMC	DD < 60'	PD < 180'
112 Emergency Services	90,91%	95,45%
Primary Care Emergency Setting	58,49%	50,94%
Hospital Emergency Department	33,33%	25,00%
Primary Care Physician	29,41%	5,88%

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Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PREDICTORS FOR EARLY NEUROLOGICAL DETERIORATION AFTER ISCHEMIC STROKE

BH Helleberg ^1,², H Ellekjær ^1,², HK Bø ³, KA Kvistad ³, B Indredavik ^1,²

Abstract

Background

Early neurological deterioration (END) after acute ischemic stroke (AIS) is associated with poor outcome. Several factors have been associated with END, but the reported predictors vary between studies. The aim of this study was to identify predictors of END.

Methods

AIS patients admitted to our stroke unit were included prospectively. Relevant baseline demographics, medical history, current medical treatment, clinical features and NIHSS and SSS (Scandinavian Stroke Scale) were recorded. Blood samples were obtained. Cerebral CT/MR, carotid imaging and monitoring were performed. From initial ischemic changes, ASPECTS and clinical-ASPECTS-mismatch were assessed. END was defined as significant change in key SSS items at 72 hours. Factors associated with END in univariate analyses or plausible were used in binary logistic regression analyses.

Results

END occurred in 51 of 368 included patients (13.9%). In univariate analysis, END was associated with increasing age, stroke severity (NIHSS, SSS), mean arterial pressure and potassium level, a history of cardiac interventions, atrial fibrillation, intracranial stenosis/occlusion, and clinical/ASPECTS-mismatch, while hypertension and ACE/ARB-treatment were less frequent with END. Adjusted ORs (95% CI) for END were: Clinical-ASPECTS-mismatch 3.6 (1.6–8.0); more severe strokes 1.18 (1.10–1.27, per five points decreasing SSS score); blood glucose, 1.20 (1.03–1.39, per mmol/L); D-dimer 1.10 (1.01–1.19, per mg/L); and potassium 3.3 (1.3–8.1, per mmol/L) levels; ACE/Angiotensin receptor blocker treatment before admission 0.32 (0.13–0.75); and thrombolytic treatment 0.31 (0.11–0.87).

Conclusions

Our study identified several predictors for END which may be detected shortly after admission to a stroke unit, and thus identify patients at risk of END.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CAROTID ENDARTERECTOMY AND ENDOVASCULAR THERAPY OF ACUTE INTERNAL CAROTID ARTERY OCCLUSION

R Herzig ¹, M Roubec ², D Skoloudik ², M Kuliha ², D Sanak ³, P Sevcik ⁴, D Vaclavik ⁵, A Tomek ⁶, A Krajina ⁷, V Prochazka ⁸, M Kocher ⁹, F Slauf ¹⁰, T Hrbac ¹¹, P Bachleda ¹², D Krajickova ¹, J Waishaupt ¹, E Vitkova ¹, K Blejcharova ¹, J Zapletalova ¹³, M Valis ¹

Abstract

Background

In the treatment of acute internal carotid artery occlusion (ICAo), intravenous thrombolysis (IVT) has only limited effectiveness, endovascular treatment (EVT) becomes a preferred method of choice and carotid endarterectomy (CEA) represents an alternative treatment method. Nevertheless, only limited data are available regarding the comparison of their safety and efficacy. The aim was to evaluate safety and efficacy of CEA and EVT including bridging therapy in the treatment of acute ICAo with/without intracranial occlusion.

Methods

In the retrospective study, the set consisted of 179 acute ischemic stroke patients (114 males; mean age 64.0 ± 11.0 years) with radiologically confirmed ICAo. Following data were collected: baseline characteristics, risk factors, pre-event treatment with antithrombotics, treatment with statins, neurologic deficit, time to therapy, recanalization rate (with successful recanalization defined as Thrombolysis in Cerebral Infarction score 2–3), post-treatment imaging findings. 90-day clinical outcome was assessed using modified Rankin scale with good outcome defined as 0–2 points.

Results

Good 90-day clinical outcome was achieved more frequently in patients without vs. with intracranial occlusion (57.5% vs. 32.1%; p = 0.001) and in patients with vs. without achieved recanalization (44.6% vs. 24.1%; p = 0.042). Other differences found between the particular treatment groups (CEA, EVT, IVT + EVT) were not statistically significant: successful recanalization in 89.7%, 81.4% and 77.3%, resp., and good 90-day clinical outcome in 50.0%, 36.0% and 41.4%, resp. (p > 0.05 in all cases).

Conclusions

Data from the national multicenter registry showed that both CEA and EVT (including bridging therapy) represent safe and effective recanalization methods of acute ICAo.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ENDOVASCULAR TREATMENT FOR BASILAR ARTERY THROMBOSIS: A COMPARISON OF OUTCOMES WITH ANTERIOR CIRCULATION OCCLUSIONS.

M Kawiorski ¹, M Alonso de Leciñana ¹, A Cruz-Culebras ², Á Ximénez-Carrillo ³, A Gil-Núñez ⁴, B Fuentes ¹, J Masjuan ², J Vivancos ³, A García-Pastor ⁴, A Fernandez-Prieto ⁵, A De Felipe-Mimbrera ², MC Matute-Lozano ², G Zapata-Wainberg ⁶, F Diaz-Otero ⁴, R Frutos ⁵, JC Mendez ⁷, E Barcena-Ruiz ⁶, E Fandiño ⁷, JL Caniego ⁶, E Diez-Tejedor ¹

Abstract

Background

Basilar artery occlusions (BAO) have been excluded from recent clinical trials of mechanical thrombectomy (MT). We evaluated the efficacy and safety of MT in BAO comparing with anterior territory occlusions (ATO).

Methods

It is multicenter prospective registry 2012–2015 from the Northeast Madrid Stroke Network. Baseline characteristics, procedure times, procedural complications, mRS at 3 months, symptomatic intracranial haemorrhage (sICH), mortality were registered.

Results

Of 475 patients, 59 (12%) had BAO. Basal NIHSS was 13 (IQR 7; 24) in BAO vs. 18 (IQR 13; 21) in ATO p = 0.116. Prior intravenous thrombolysis (IVT) was performed in 24 (41%) patients with BAO and 229 (56%) with ATO p = 0.026. The rate of recanalization after IVT was 25% for BAO vs 6% for ATO p = 0.005, and after TEV 71% vs 83% p = 0.007. Duration of procedures was 103 min (SD 77) for BAO and 72 min (SD 46) for ATO p = 0.0003 and delay until recanalization from symptoms onset 505 min (SD 332) vs. 351 min (SD 146) p = 0.00001. sICH was 2% in BAO vs 5% in ATO, p = 0.217, rate of independence (mRS 0–2) 41% vs 50%, p = 0.345 and mortality 30% in BAO vs 16% in ATO p = 0.021. Main cause of death was stroke due to lack of recanalization (92 %) in BAO vs 52% in ATO.

Conclusions

MT appears to be more laborious in BAO than in ATO with lower recanalization rate. However safety and rate of independence after MT is similar in both groups. Earlier and higher recanalization rate is needed in BAO patients to warrant better outcomes.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

FACTORS ASSOCIATED WITH OUTCOMES IN ANTERIOR CIRCULATION STROKE WITH MILD SYMPTOMS WITHIN 4.5 HOURS OF ONSET

DH Kim ¹, HW Nah ¹, HS Park ², JH Choi ², SW Kim ³, SM Jun ⁴, JT Huh ², JK Cha ¹

Abstract

Background

Many patients with initially mild ischemic stroke have poor outcomes. We sought to assess factors associated with outcomes in anterior circulation stroke patients with minor symptoms within 4.5 hours after onset.

Methods

We identified consecutive patients with anterior circulation infarction who had initial NIHSS scores ≤5 between September 2013 and August 2015. We included patients who underwent diffusion-weighted imaging and MR angiography within 4.5 hours of symptom onset. Patients without evidence of acute ischemic stroke on initial or follow-up diffusion-weighted imaging were excluded. We analyzed baseline characteristics, infarction patterns on diffusion-weighted imaging and tissue plasminogen activator use. The primary outcome measurement was excellent clinical outcome, defined as a modified Rankin Scale score of 0 to 1 at 90 days from stroke onset. Logistic regression was used to determine the independent predictors of excellent outcomes.

Results

Among 126 patients included in this study, 34 (27%) had poor outcomes at 90 days. In multivariable-adjusted analysis, poor outcomes were associated with no thrombolytic therapy (OR, 5.7; 95% CI, 1.7–19.9; P = 0.006), higher NIHSS score (OR, 2.3; 95% CI, 1.5–3.4; P < 0.001), infarction in deep middle cerebral artery territory (OR, 6.2; 95% CI, 2.2–18.8; P = 0.01) and no pre-stroke antithrombotic agents use (OR, 3.4; 95% CI, 1.0–11.7; P = 0.047).

Conclusions

Thrombolytic therapy and pre-stroke antithrombotic agent use were independently associated with excellent outcome in acute anterior circulation infarction with mild symptoms. Infarction in deep middle cerebral artery territory could be considered as a predictor of poor outcome.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PNEUMONIA COMPLICATING STROKE: A UK WIDE SURVEY OF EXISTING PRACTICES IN DIAGNOSIS AND MANAGEMENT

A Kishore ^1,², S Mateen ^1,², C Smith ^1,², P Tyrrell ^1,²

Abstract

Background

Pneumonia is a serious post-stroke complication associated with mortality and increased healthcare costs. It is often difficult to diagnose and a recent systematic review suggested considerable variability in the diagnostic approach. The aim of this study was to identify current practice in the diagnosis and management of pneumonia complicating stroke in the United Kingdom (UK).

Methods

An online survey, which included clinical vignettes of acute stroke in-patients, was distributed through the British Association of Stroke Physicians (BASP).

Results

63 clinicians responded to the online survey (57% stroke physicians, 8% neurologists, 35% other). Varying terminologies such as community acquired pneumonia, aspiration pneumonia or stroke associated pneumonia were used when a diagnosis of pneumonia was made but this was dependant on time interval since admission with stroke. The majority chose abnormal respiratory examination (68%), positive CXR (62%) and tachypnoea/dyspnoea (57%) as mandatory criteria when diagnosing pneumonia; blood (87%) or sputum culture (84%), purulent cough (68%) and leucopoenia (86%) were perceived least as mandatory. The majority considered antibiotic therapy (99%) for duration of 5 days (55%) or 7 days (59%) with aminopenicillins/lactamase inhibitors (58%) or piperacillin/tazobactam (33%) following diagnosis, but choice of antibiotic depended on the type of pneumonia diagnosed.

Conclusions

There is substantial variation in the terminology and diagnostic parameters used, with abnormal respiratory examination and chest x-ray findings perceived to be mandatory in the majority of the respondents. This highlights the importance of standardised terminology and diagnostic criteria when making a diagnosis of pneumonia complicating stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

DIFFERENCES IN PERIPROCEDURAL TIME MANAGEMENT OF MECHANICAL THROMBECTOMIES PERFORMED WITHIN AND OUTSIDE WORKING-HOURS. IS THERE A "WEEKEND EFFECT“?

C Krogias ¹, R Weber ², G Reimann ³, R Hoepner ¹, K Berger ⁴, F Brassel ⁵, M Kitzrow ⁶, M Nolden-Koch ⁷, W Weber ⁸, C Weimar ⁹, E Busch ¹⁰, J Eyding ¹¹

Abstract

Background

In the sense of the proclaimed “time-is-brain”-concept, rapid processes are essential for an effective acute stroke therapy. Previous studies have inconsistently shown, that weekend admission is significantly associated with a delayed „door-to-needle (DTN)”-time in patients receiving iv thrombolysis. As mechanical thrombectomy (MTE) requires even more human and structural resources, we sought to determine the impact of admission times on periprocedural time management and clinical outcome in stroke patients undergoing MTE.

Methods

The „Neurovascular Net Ruhr (NNR) “consists of a total of 27 certified Stroke Units, nine of them have the ability to perform interventional reperfusion therapies. Since August 2012 a NNR-wide admission concept is established. During an implementation period of 14 months, the detailed periprocedural times and clinical outcomes of the performed MTE were documented prospectively.

Results

Periprocedural times of 512 acute stroke patients (mean age = 71yrs, female = 49.5%) having received MTE were analyzed. 206 interventions were performed within and 306 outside the working-hours (workdays 8–16 clock). Median „door-to-groin (DTG)“-time of the patients having admitted outside the working-hours showed a significant delay of 20 min (106 ± 71 min vs. 86 ± 58 min; p < 0.001). „Door-to-CT“-times showed no difference (20 ± 24 min vs. 21 ± 30 min). A significant correlation between the individual “DTG”-times and clinical outcome (NIHSS-at-admission minus NIHSS-at-discharge) was detected (Spearman-Rho corr. = −0.16; p < 0.001).

Conclusions

The periprocedural time management of mechanical thrombectomies being performed outside working-hours needs to be optimized. About 60% of acute stroke patients are affected by this “outside-working-hours”-effect.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PITTSBURG RESPONSE TO ENDOVASCULAR THERAPY (PRE) SCORE FOR PATIENT SELECTION FOR ENDOVASCULAR THERAPY FOR LARGE VESSEL OCCLUSION STROKES

P Maly ¹, H Parobkova ², M Mala ³, M Tinkova ¹

Abstract

Background

The Pittsburg Response to Endovascular therapy (PRE) score is a validated tool that may facilitate patient selection for endovascular therapy (EVT) in anterior circulation large vessel occlusions. The aim of our study was to assess the PRE score in subgroup of patients with modified Rankin scale (mRS) 6.

Methods

We retrospectively studied one hundert thirty nine patients with acute anterior stroke included in our stroke registry between January 2009 and Dezember 2015. The median National Institutes of Health Stroke Scale (NIHSS) score at admission was 13.6 (range 2–31). The PRE score (age -years + 2 x NIHSS – 10 x Alberta Stroke Program Early CT Score (ASPECTS) > 50 identifies patients where EVT is very likely to be futile in preventing disability.

Results

Twenty three patients (23/139) died within two to nine days after succesful recanalisation. Sixteen patients (16/23) were exluded from analysis due to 1/ long time interval between CT procedure and onset of angiography (median 144 minut, range 110–180 minut) in nine patients 2/ vessel perforation in one patient 3/ dead because of imunodeficiency and sepsis in one patient 4/ hyperperfusion syndrome in two patients. Only seven patients were included in final analysis, four of them (57.2%) had PRE-score > 52 (52–58) and three of them (42.8%) between 33–39.

Conclusions

The PRE score is a validated tool that can minimize futile recanalisation procedures. The limitation of our study is a small sample size, nevetheless our experiences are in complete agreement with this scoring system.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

USEFULNESS OF BLOOD PRESSURE VARIABILITY (BPV) PARAMETERS IN PREDICTING EARLY OUTCOME IN ACUTE STROKE: PRELIMINARY RESULTS OF A PROSPECTIVE OBSERVATIONAL STUDY

L Manning ¹, P Rothwell ², J Potter ³, T Robinson ¹

Abstract

Background

How best to measure BPV in acute stroke and which parameter is most useful in predicting outcome is unknown. We sought to address these issues in a prospective observational study.

Methods

Acute stroke patients (<24 hours onset) underwent the following: 6 casual-cuff BP measures (<30 minutes); 20 minutes beat-to-beat BP; 24 hours ambulatory BP monitoring (ABPM). Systolic, diastolic, PP, and MAP variability was calculated as standard deviation (SD), coefficient of variation (CV), average real variability (ARV), and variation independent of the mean (VIM). Primary outcome was death or major disability at one month (mRS > 2). Associations between BPV parameters and outcome were assessed with logistic regression models. Predictive performance was assessed using receiver operating characteristic (ROC) curves.

Results

One-month outcome data were available for 70 participants. Mean age was 72. No associations were found between any ABPM-derived BPV parameter and outcome. Several significant associations were found with beat-to-beat and casual cuff MAP variability parameters (but not systolic, diastolic or PP parameters) and outcome. Predictive ability of parameters is shown in the Table.

Conclusions

Beat-to-beat and causal cuff MAP variability in the acute stroke period may predict outcome but ABPM derived BPV does not. ABPM may be less useful than other BP measurement techniques in capturing acute stroke BPV

Table.

Predictive ability for 30-day death or disability of single variable logistic models

Measure	Proportion of explained variance (R²)	Area under ROC curve
Cuff SD-MAP	0.11	0.64
Cuff CV-MAP	0.10	0.62
Cuff VIM-MAP	0.09	0.63
Cuff ARV-MAP	0.09	0.64
Beat-to-beat SD-MAP	0.05	0.62
Beat-to-beat VIM-MAP	0.04	0.66

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Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

FEASIBILITY OF THE IMPLEMENTATION OF A NEW COLLABORATION PROTOCOL BETWEEN PRIMARY STROKE CENTER AND COMPREHENSIVE STROKE CENTER IN BELGIUM

P Paindeville ¹, M Gille ², A Peeters ¹, MP Rutgers ²

Abstract

Background

Thrombectomy is performed in case of acute ischemic stroke (AIS) with proximal arterial occlusion in comprehensive stroke centers (CSC). Patients with AIS first admitted in primary stroke centers (PSC) should be transferred with short delay to the nearest CSC. The aim of our study is to determine the feasibility of the implementation of a new protocol for transferring these patients.

Methods

Single-center retrospective open study between September 29, 2014 and October 15, 2015. We analyzed the population of patients and the clinical outcome with mRS at 3 months for patients who benefited from thrombectomy.

Results

254 patients were admitted of which 135 (53 %) with AIS. 29 patients received IVT (21.5 % of AIS patients) and 8 patients (6 % of AIS patients) were transferred for a potential thrombectomy. 6 of the 8 patients underwent an attempt of thrombectomy. Among patients treated by thrombectomy, one died after 3 days due to malignant stroke, whereas the other 5 patients all significantly recovered. One patient stayed dependent after 3 months. Four patients had a 3-months mRS ≤ 2 (67 %).

Conclusions

The implementation of this new protocol is achievable but requires specific management and good collaboration between neurologists (from the PSC and the CSC), radiologists, E.R. physicians and interventional radiologists. Our study included too few patients to be statistically significant. Those results should motivate others PSC to develop their collaboration with CSC. Larger trials are requested to compare the clinical outcome between patients transferred and patients first admitted in CSC.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

IDENTIFYING ACUTE STROKE PATIENTS CANDIDATE TO ENDOVASCULAR TREATMENT IN THE FIELD USING THE RACE SCALE

N Pérez de la Ossa ¹, S Abilleira ², A Ribera ³, D Carrera ⁴, M Gorchs ⁵, M Querol ⁵, X Jiménez ⁶, M Ribó ⁷, P Cardona ⁸, X Urra ⁹, A Rodríguez-Campello ¹⁰, A Dávalos ¹¹

Abstract

Background

Limited access to endovascular treatment (EVT) brings to light the need for prehospital tools to identify candidate patients, allowing their timely transfer to an endovascular-capable center. We aim to evaluate the capacity of the RACE scale to identify patients treated with EVT.

Methods

After an online educational program for Emergency Medical Services (EMS) professionals, use of the RACE scale was started up for prehospital assessment of acute stroke patients. We linked prospective EMS data of stroke code activations to data from the SONIIA registry, a government-mandated, externally monitored registry of stroke patients treated with reperfusion therapies in Catalonia, from January to September 2015. The accuracy of the RACE scale to identify EVT patients was determined with ROC, sensitivity and specificity analyses. We compared access to EVT in areas directly covered by endovascular centers to areas drip-and-ship areas.

Results

The RACE scale was registered in 1524 patients from a total of 2540 EMS stroke code activations; 113 (7.4%) were treated with EVT. The RACE scale was effective in identifying EVT patients (c-statistic 0.70, IC95% 0.65–0.74). The best cut-off point was established as RACE ≥ 5, with a sensitivity 0.76 and specificity 0.56 for detecting EVT patients. Overall, 12% of patients with RACE ≥ 5 received EVT compared to 3% of those with RACE < 5. Proportion of patients RACE ≥ 5 treated with EVT was 17% in areas covered by endovascular center but decreased to 8% in drip-and-ship areas.

Conclusions

The RACE scale is a prehospital tool useful to select patients with a high probability of requiring EVT.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

HYPERACUTE STROKE SIMULATION TRAINING IN A MULTIDISCIPLINARY TEAM

A Pitt Ford ¹, B Edge ¹, S Hervey ¹, T Chatten ², K Kay ³, I Kane ¹

Abstract

Background

Increasingly stroke thrombolysis is managed by specialist stroke teams meaning loss of experience and training for generalists who run calls out-of-hours. Confidence levels are low and there is need to practice in a safe environment as a multidisciplinary team. Multidisciplinary stroke simulation training is not widely available. We ran a pilot half day multidisciplinary simulation course in April 2015 and built this course based on the feedback.

Methods

Aims

Opportunity to learn as a multidisciplinary team

Increase confidence of staff attending stroke calls out-of-hours

Increase confidence in carrying out NIHSS

Fulfil feedback from pilot course

Method

Simulation day for 12 candidates open to nurses and health care assistants working on stroke wards, emergency department doctors and nurses, and junior medical doctors. The course included pre-course reading and NIHSS training. The day involved teaching on stroke thrombolysis and complications, NIHSS supervised practice, demonstration case and simulated cases for candidates working together. A tweetorial followed 48 hours later for candidates to raise further questions.

Results

Candidate feedback

Conclusions

Overall candidates found the multidisciplinary stroke thrombolysis simulation course useful. It increased both confidence levels and understanding around stroke thrombolysis for the whole team. The tweetorial was useful after time to reflect to raise further questions.

	Average pre-course (10 responses)*	Average post-course (11 responses)*	Improvement
Confidence in assessing patients with acute stroke	4.8	8.1	3.3
Confidence in using NIHSS	4.6	7.6	3
Good understanding of stroke thrombolysis	6.7	8.9	2.2
Good understanding of risks and benefits of stroke thrombolysis	6.6	8.7	2.1
Course was helpful		9.9
* 0 strongly disagree, 10 strongly agree.

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Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ASSOCIATION BETWEEN HOSPITAL ADMISSION AND 30-DAY OUTCOMES IN UNITED STATES VETERANS WITH AN EMERGENCY DEPARTMENT DIAGNOSIS OF TRANSIENT ISCHEMIC ATTACK (TIA)

M Reeves ¹, LJ Myers ², E Cheng ³, P Michael ⁴, W Linda ², B Dawn ²

Abstract

Background: It is unclear whether TIA patients admitted to the hospital from the emergency department (ED) are at lower risk of vascular events compared to those discharged from the ED. We identified the associations between hospital admission and 30-day outcomes among Veterans with TIA diagnosis in the ED.

Methods: We assembled a retrospective cohort of 3487 Veterans who had an ED-based diagnosis of TIA at Veterans Administration (VA) medical centers in 2011. A combination of VA and Medicare administrative data were used to identify 30-day outcomes (all-cause mortality, all-cause readmissions, vascular events, and ischemic stroke). Multivariable GEE logistic regression analysis was used to examine associations between hospital admission (versus discharge) and 30-day outcomes.

Results: Sixty-seven percent of TIA patients were admitted. After adjustment hospital admission was associated with significantly lower odds of ischemic stroke (adjusted odds ratio [aOR] = 0.58, 95%CI 0.37–0.92) but marginally significantly higher odds of mortality (aOR = 2.14, 95%CI 0.90–5.08) and readmissions (aOR = 1.24 95%CI 0.96–1.60), and lower odds of vascular events (aOR = 0.76, 95%CI 0.57–1.01) (Table).

graphic file with name 10.1177_2396987316642909-img24.jpg

Conclusions: In this representative cohort of Veterans with TIA, hospital admission was associated with a trend towards increased mortality and readmissions but lower risks of vascular events and stroke. Further exploration of the inter-relationships between specific care processes, patient-level risk (clinical status, comorbidity), and outcomes are required to improve our understanding of TIA admission decision-making.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

STROKE CODE AND EMERGENCY PHYSICIANS: EVALUATING THEIR KNOWLEDGE ABOUT ACUTE STROKE MANAGEMENT AT DIFFERENT CARE LEVELS

M Rico Santos ¹, C García-Cabo ¹, B Castaño ², P Oliva Nacarino ¹

Abstract

Background

Twenty percent of Stroke Codes (SC) are activated in the emergency department. As part of the chain of care, emergency physicians face a challenge when selecting patients for SC. Since the implementation of interventional therapies, protocols have become more complex, making the decision process significantly more difficult. Our aim was to evaluate the knowledge that emergency physicians have about the stroke code protocol at different hospitals in our region.

Methods

A 13-question survey was delivered at the emergency department of three different hospitals in Asturias, in the north of Spain. Hospitals A (administer thrombectomy and thrombolytic therapies), B (thrombolytic treatment at disposal; referral for thrombectomy) and C (transfers patients for both treatments depending on the indicated therapy; hospital A for thrombectomy and hospital B for thrombolysis)

Results

Forty-nine doctors answered the survey (18 in A, 23 in B and 9 in C). Physicians in A were more likely to disregard unknown onset stroke and continue with the protocol. Doctors y C had a better knowledge of the indication criteria for thrombectomy vs. thrombolysis alone. Seventy-five percent did not consider anticoagulation exclusion criteria for recanalization therapies. Fifty-five percent would not treat blood pressure levels of 200/120 mmHg. At least 50% of respondents explored visual disturbances, hypoesthesia and agnostic symptoms with insecurity.

Conclusions

Errors during neurological examination and insufficient knowledge about the inclusion criteria might be a source of failure in SC. Capacities while selecting patients for the protocol are conditioned for the place of work, which could cause undertreatment in a number of cases.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PERCEPTION AND INTERPRETATION OF STROKE SYMPTOMS AMONG PATIENTS

M Rico ¹, T Temprano ², I Casado ², P Oliva Nacarino ¹, DM Solar ²

Abstract

Background

Patients and their families are the first step in the chain of care in acute stroke, so general knowledge about the disease in the population is important. Our aim was to analyse the level of recognition of stroke symptoms among ischemic stroke patients.

Methods

52 consecutive patients admitted to a second level hospital with ischemic stroke were included. A personal interview during the first 48 hours after admission was performed, regarding recognition of symptoms, their actions about them and possible determining factors.

Results

60% of patients claimed to know the term “ictus” (stroke in Spanish) as a brain related disease; 17% did not understand the specific term but they did recognize alternative denominations; 20% of the sample had no knowledge about stroke. However, only 17% related their presenting symptoms as stroke. Nonetheless, 55% of patients consulted within the first 5 hours after clinical onset. Neither vascular risk factors or level of education were identified as determining factors in the knowledge of stroke. However, age below 70-years-old was associated with a better identification of the disease.

Conclusions

Knowledge of the disease in general population is important in stroke, even more now than ever due to recent advances in acute management. Community educational strategies should insist in the recognition of symptoms and the need for immediate assistance.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

INTRAVENOUS TISSUE PLASMINOGEN ACTIVATOR (tPA) ADMINISTRATION IN ELDERLY POPULATION IS FACILITATED BY A TELESTROKE SERVICE

S Sanchez ¹, M DePrince ¹, M Vibbert ¹, J Urtecho ¹, MK Athar ¹, B Bar ¹, D Tzeng ², L Sheehan ², C Pineda ², R Bell ², S Tjoumakaris ¹, P Jabbour ¹, R Rosenwasser ¹, F Rincon ¹

Abstract

Background

The objective of this study was to test the hypothesis that elderly stroke patients would have lower rates of intravenous (i.v.) tPA administration.

Methods

Cross-sectional study using prospective collected patient data maintained via our Telestroke Network between 2013–2015. Exposure of interest was age divided into >80 years or younger. Outcome of interest was recommendation for i.v. tPA administration (tPA-A). We used logistic regression to determine predictors of tPA-A and calculated odds ratios (OR) and 95% confidence intervals (CI). Finally, using reported rates and standard errors (SE) for i.v. tPA-A in the United States, we calculated the difference in tPA-A rates using the Z-score-test. Significance was set at p < 0.05.

Results

We selected 1317/2793 records. Mean age 67 ± 16 years, 57% (743/1317) were women, and median (Md) NIHSS was 4 (Interquartile Range [IQR] 8). The rate of tPA-A was 20% (267/1317). The elderly group had higher NIHSS (Md 6, IQR 13 vs. Md 4 IQR 7, p < .0001) and more women (66% vs. 52%, p < .0001) than the younger group. Adjusted for year and physician, the only predictor of tPA-A was NIHSS > 7 (OR 8.7, 95%CI 6.1–12.7, p < .0001). Compared to reported tPA-A rates in the nation, our tPA-A rate exceeded the one from the literature (3% vs. 20%, z = 2.83, SE = 0.04, p = .005).

Conclusions

Our data suggest that in our Telestroke system, rates of tPA-A in the elderly were not different than younger stroke patients. In a Telestroke system, the rates of tPA administration exceed those reported by the literature.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE RACE-DIRECT (RAPID ARTERIAL OCCLUSION EVALUATION FOR DIRECT TO ENDOVASCULAR TREATMENT CENTER TRANSFER): A PROPOSAL FOR PREHOSPITAL EVALUATION OF ACUTE STROKE

J Rodriguez-Pardo ¹, B Fuentes ¹, M Alonso de Leciñana ¹, Á Ximénez-Carrillo ², G Zapata-Wainberg ², FJ Barriga ³, L Castillo ³, J Carneado ⁴, J Díaz-Guzmán ⁵, J Egido-Herrero ⁶, A De Felipe-Mimbrera ⁷, JC Fernández-Ferro ⁸, A García-Pastor ⁹, A Gil-Núñez ⁹, C Gómez-Escalonilla ⁶, M Guillán ⁸, J Masjuán-Vallejo ⁷, MÁ Ortega-Casarrubios ⁵, J Vivancos-Mora ², E Díez-Tejedor ¹

Abstract

Background

Several studies have shown better outcome and lower mortality in patients with large vessel occlusion undergoing Endovascular Treatment (ET) with stent retrievers versus medical treatment alone. However, ET requires a wide variety of specialized care, provided by Comprehensive Stroke Centers (CSC). It remains unclear whether selected patients with acute stroke should be directly transferred to the nearest CSC in order to avoid delay in ET. Clinical scales such as RACE have been developed recently to predict large vessel occlusion, but were unable to rule out hemorrhagic stroke and their predictive value for ET was low. We propose new criteria to identify eligible patients for ET with higher accuracy.

Methods

RACE-DIRECT criteria were defined based on a retrospective cohort of 317 patients admitted at the Stroke Unit of a CSC for over a year. Age, sex, RACE scale score and blood pressure (BP) were registered for analysis. Cut-off points with the highest association with ET were thereafter evaluated in a prospective cohort of 153 patients from 9 stroke centers comprising the Madrid Stroke Network.

Results

Patients meeting RACE score > =5, Systolic BP <190 mmHg and Age < =80 showed a significantly higher probability of undergoing ET (OR 33 [IC 95% 12–93]). This association was confirmed in the prospective cohort with 68% Sensitivity, 84% Specificity, 42% Positive and 94% Negative Predictive Values for ET, ruling out 83% hemorrhagic strokes. 78% of secondly transferred patients met RACE-DIRECT criteria.

Conclusions

RACE-DIRECT criteria can be useful to identify patients suitable for ET and develop a direct-to-CSC transfer system.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

REMOTE COLLABORATION AND AUTOMATED IMAGE ANALYSIS FOR STROKE PATIENT MANAGEMENT

R Sales Barros ^1,², J Borst ³, H de Bliek ⁴, S Kleynenberg ⁵, C Majoie ³, S Delgado Olabarriaga ², H Marquering ^1,³

Abstract

Background

Stroke care requires the assessment of various types of medical data (e.g. vital signs, patient history, medication, image data, etc.). Optimal diagnosis and treatment selection requires participation of various experts and processing of patient data. Currently, medical staff needs physical meetings or telephone contact, which may causes delays in the patient treatment. Also, advances in imaging technologies results in large amount of image data, which requires extensive computational power for fast processing.

Methods

Cloud-based technologies were used to enable patient image data processing and collaboration in a scalable, fast, and cost-effective way. HTML5 was used for easy accessibility on smartphones, tablets, and desktop computers.

Results

The developed prototype has the following functionalities:

• multi-user interactions – users can visualizeeach other’s interactions in real time;

• quantitative analysis of stroke images – built-inhigh performance algorithms for hemorrhage segmentation, skull stripping, infarct segmentation, CTP processing;

• legacy applications – existing desktopapplications have been virtualized and integrated;

• automated decision support – notifications aredelivered based on approved medical protocols and real-time data collected fromthe patient;

• multiple cloud providers – different modules canbe hosted in different cloud providers allowing for migration to more costeffective infrastructures when needed.

graphic file with name 10.1177_2396987316642909-fig119.jpg

Graphical user interface of the hemorrhage segmentation module on a smartphone.

Conclusions

The prototype validation showed great benefit for remote collaboration and patient image analysis in acute management of stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

OPTIMIZED MANAGEMENT OF PATIENTS WITH ACUTE STROKE IMPROVES OUTCOME

K Schregel ¹, I Tsogkas ¹, D Behme ¹, I Maier ², M Knauth ¹, A Karch ³, J Hinz ⁴, J Liman ², MN Psychogios ¹

Abstract

Background

Early restoration of blood flow in patients with acute ischemic stroke is crucial for a good clinical outcome. We introduced an interdisciplinary standard operating procedure (SOP; fig. 1) and frequent meetings between neurologists, neuroradiologists and anesthesiologists in order to streamline the door to treatment process in our hospital. A shift towards better clinical outcome is expected.

graphic file with name 10.1177_2396987316642909-fig120.jpg

Methods

Data were extracted from a prospectively documented university hospital stroke database. 315 patients were divided into a) 242 patients treated with mechanical thrombectomy prior to the new SOP from 2007 until 2013 and b) 73 patients treated with mechanical thrombectomy after implementation of the new SOP from 2014 to date.

Results

After implementation of the SOP, time from admission to groin puncture was dramatically reduced from 120 to 65 minutes (p < 0.001). Time from puncture to restoration of blood flow also decreased significantly (p = 0.005). The use of stentrievers had no significant influence on time reduction. Finally, the outcome of patients was significantly better after work flow-optimization as measured with the modified Rankin Scale (mRS; p = 0.038).

Conclusions

Optimization of workflow and interdisciplinary teamwork significantly improved the outcome of patients with acute ischemic stroke due to a dramatic reduction of in-hospital examination, transportation, imaging and treatment times.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CLINICAL FLUCTUATIONS DURING FIRST FEW DAYS OF ACUTE ISCHEMIC STROKE ARE COMMONLY RELATED TO NEUROVASCULAR UNCOUPLING

V Sharma ¹, R Rathakrishnan ¹, A Kulkarni ¹, P Seow ¹, E Ting ¹, L Wong ¹, P Paliwal ¹, B Chan ¹, HL Teoh ¹

Abstract

Background

Neurological fluctuations are frequently seen during first few days in thrombolysed acute ischemic stroke (AIS) patients. Underlying mechanisms for these fluctuations often remain unclear. Cerebral homeostatic balance is regulated by autoregulation and neurovascular coupling (NVC). We hypothesized that neurovascular uncoupling in AIS contributes to the neurological fluctuations.

Methods

In this ongoing prospective study, thrombolyzed AIS patients were recruited within 12-hours of symptom-onset. Serial CT perfusion (CTP) imaging (within 12-hours, at 24 and 72-hours) were performed. Serial Quantitative EEG (QEEG) were performed, close to CTP. Alpha band (8–15 Hz) power was determined for each hemisphere using 10-seconds epochs. Neurological status was monitored with serial NIH stroke scale (NIHSS) scores. Neurovascular uncoupling was defined as mismatch among CTP, QEEG and clinical findings. Data were analysed independently by investigators blinded to clinical findings.

Results

A total of 32 patients (19 male, median age 68-years (range 56–86) were included. Median NIHSS score was 8-points (range 1–24). NIHSS fluctuations by 4 or more points (deterioration followed by improvement or deterioration following improvement in absence of re-occlusion) was noted in 13 (40%) cases. Increasing cerebral edema (2 cases) and regional hyperperfusion (4 cases) were seen on serial CTP. Remaining 7 cases showed serially improved CTP. QEEG showed significantly increased inter-hemispheric alpha band power ratio (unaffected/affected hemisphere ratio more than 1.5), independent of CTP results, suggestive of neurovascular uncoupling as the underlying mechanism for early neurological fluctuations.

Conclusions

Neurovascular uncoupling is relatively frequent during first few days of AIS. Multi-modal monitoring is useful in identifying patients for appropriate therapeutic decision making.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

A DIAGNOSTIC CHALLENGE: A STROKE OR A MIMIC? A PROSPECTIVE OBSERVATIONAL STUDY OF PATIENTS PRESENTING WITH SUSPECTED ACUTE STROKE IN A UK HOSPITAL

KM Sharobeem ¹, F Awad ¹, J Wilkinson ¹

Abstract

Background

The clinical presentation of stroke varies with some patients presenting with atypical symptoms, but it is also common to mistake other diagnoses for strokes (mimics). Accurate diagnosis is of paramount importance particularly in the thrombolysis era. Alternatively, several treatable conditions might be missed either acutely or chronically when patients are wrongly “labelled” as a stroke.

Methods

We conducted an observational prospective study collecting data from 447 consecutive patients presented to Sandwell Hospital with suspected acute stroke over three month period. Detailed medical history and clinical examination including NIHSS were assessed by the stroke team led by a stroke consultant. Diagnoses on admission and before discharge were analysed.

Results

Among patients who were triaged as suspected stroke, a diagnosis of acute stroke was made in 163 patients while a diagnosis of a mimic was made in 284 patients (figure 1). The stroke mimics were alerted via the emergency department (74%), ambulance crews (22%), hospital wards (3%), and the regional eye hospital (1%).

graphic file with name 10.1177_2396987316642909-fig121.jpg

Conclusions

The majority of stroke alerts at our hospital were mimics which is higher than the 25–35% documented in previous studies. The diagnosis of stroke remains a clinical one based on the history and clinical assessment; tests would only give limited support. This has been highlighted through our training programmes to staff members involved in the hyper-acute management of stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

NETWORK FOR CLINICAL STROKE TRIALS (NECST): A NEW JAPANESE RESEARCH NETWORK

K Toyoda ¹, H Yamamoto ², M Koga ³, M Sasaki ⁴, T Hamasaki ², M Fukuda-Doi ², K Minematsu ¹

Abstract

Background

Contribution of Japanese stroke researchers to multinational investigator-initiated trials is poor. Lack of necessary personnel and infrastructure may be a leading cause of the poor contribution.

Methods

To overcome such barriers, the Japan Agency for Medical Research and Development and the National Cerebral and Cardiovascular Center (NCVC) formed the research network for serving as the infrastructure and pipeline for multicenter clinical stroke studies, just as the NIH and core institutes of the NIH StrokeNet have done.

Results

The NCVC works as a national coordinating center having core functions, such as a central coordination office, data management center, and central pharmacy. A few advanced and established institutes including Iwate Medical University form central imaging laboratories. We have been seeking 50 to 100 participating stroke institutes based on the collaborators in our recent multicenter projects including the SAMURAI, THAWS, and ATACH-II. We assist the participating institutes in improving their human resources for trial support, strengthening the functions of their ethics committees, and joining a new nationwide registry for acute stroke patients. The recent ATACH-II was a touchstone that investigator-initiated trials among the US and Asian countries were realizable, though showing some conflicts caused by differences in medical systems (mainly insurance systems) and regulatory rules among nations. Solidarity of Asian multinational researcher networks may be necessary for Asian-specific cerebrovascular disorders, including intracranial atherosclerosis and intracerebral hemorrhage.

Conclusions

The NeCST will be a key for scientific and economical success in investigator-initiated trials for next generation stroke researchers as the acronym itself indicates.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE EFFECT OF EMERGENCY AMBULANCE SERVICE VERSUS PRIMARY CARE DOCTOR AS FIRST MEDICAL CONTACT ON SYMPTOM ONSET-TO-DOOR TIME IN ACUTE ISCHAEMIC STROKE

B Tunnage ¹, V Feigin ², R Krishnamurthi ², S Taylor ³, A Swain ⁴

Abstract

Background

In ischaemic stroke, the benefits of reperfusion therapy are strongly time-dependent. Pre-hospital delays are a major factor limiting treatment eligibility.

Methods

This population-based study is set in Auckland, New Zealand. Emergency ambulance service (EAS) records for patients transported to hospital by ambulance are used to compare referral by EAS to referral by primary care doctor in ischaemic stroke. Onset-to-door (O2D) time and total EAS contact duration are established for both referral routes and the association between referral route and administration of a thrombolytic agent is examined.

Results

1,046 ischaemic stroke events were identified over a one-year period. An O2D time could be determined for 61% (n = 638) of events. A Mann-Whitney Test revealed a significant (p < 0.001) difference in the O2D time when referral was by EAS (median = 134 minutes, n = 528) compared to a doctor (median = 1,145 minutes, n = 110). The duration of the EAS contact time was equivalent for both referral routes (EAS median = 48 minutes; doctor median = 49.5 minutes), (p = 0.09 using the Mann-Whitney Test). Results suggest that a patient’s odds of receiving thrombolytic therapy were reduced when a doctor was the first medical contact (AOR = 0.17; 95%CI = 0.02, 0.66; p = 0.004, Fisher's Exact test).

Conclusions

These provisional findings suggest that in cases of acute ischaemic stroke, arrival at hospital is more expeditious when the EAS is the first medical contact. O2D delay in referrals by primary care doctors were not attributable to EAS factors. The benefit of reduced delay by direct EAS referral may translate to improved rates of thrombolysis.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

STROKE HOTLINE SYSTEM INCREASED THE NUMBER OF PATIENTS TREATED WITH IV RT-PA

T Urabe ¹, M Watanabe ¹, M Nobukazu ¹, S Yoshiaki ¹, S Hideki ¹, N Senshu ², Y Yukimasa ², T Hiroshi ³

Abstract

Background

Prehospital delivery system plays a crucial role for intrahospital treatment in patients with acute ischemic stroke. Especially, it reflects to thrombolysis by intravenous recombinant tissue plasminogen activator (IV rt-PA) for eligible patients who can be treated within a 4.5-hour window. Our hospital implemented a citywide prehospital stroke hotline system in cooperation with 2 regional fire departments which deriver acute stroke patients.

Methods

From April 2013, we implemented a stroke hotline system between our neurological stroke center and the 2 regional fire departments in Urayasu-city and Ichikawa-city, Chiba, Japan. We explored the detail of transporting emergency patients and processing times, and compared consecutive patients with stroke transporting to our critical care center after the implementation of stroke hotline system.

Results

After the implementation of stroke hotline system, the examination time in emergency ward was significantly reduced compared with before stroke hotline system (37 ± 16 min versus 27 ± 7 min, p = 0.03). We get an effective outcome of a 4-fold increase in patients who were treated with IV rt-PA. The door-to-needle time for IV rt-PA treated patients had a decrease tendency.

Conclusions

The prehospital stroke hotline system led to improving IV rt-PA treatment for patients with acute ischemic stroke. However, the improvement of intrahospital system are needed to achieve an increase of eligible patients with IV rt-PA treatment.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

STROKE PATIENTS' LONG-TERM FUNCTIONAL INDEPENDENCE INCREASES MARKEDLY AFTER THE IMPLEMENTATION OF A 24-HOUR ENDOVASCULAR SERVICE IN A TERTIARY STROKE CENTER

M Usero ¹, AI Calleja ¹, S Pérez-Fernandez ², E Cortijo ¹, J Ortega ², M de Lera ¹, P García-Bermejo ¹, J Reyes ¹, PL Muñoz ¹, MJ Gutierrez ², M Martínez-Galdámez ², JF Arenillas ¹

Abstract

Background

On April 2015our Hospital Board approved the implementation of a 24-hour endovascular service (ES). We aimed to evaluate the impact of this ES on acute ischemic stroke (AIS) patients’ long-term functional outcome.

Methods

Consecutive AIS patients receiving reperfusion therapies in our stroke center were prospectively included in a brain-reperfusion database. For this analysis, we selected patients with anterior circulation AIS and a baseline NIHSS ≥ 6. We compared long-term outcome, assessed with the modified Rankin scale (mRS) at day 90, between the pre-ES and post-ES eras. Functional independence was defined as a mRS 0–2.

Results

From January 2008 to December 2015, 849 AIS patients received reperfusion therapies, 93 after the 24-hour ES started.Of them, 708 had NIHSS ≥ 6 and were included in this work(mean age 73, 53% men, median baseline NIHSS 14). The study group comprised 627 patients in the pre-ES group and 81 in the post-ES era. The use of endovascular treatment among all reperfusion therapies increased from 3% in the pre-ES era to 68% after ES start (p < 0.0001). The probability of long-term functional independence increased by 16 points after ES was implemented (51% vs. 67%, p = 0.03). Unadjusted logistic regression showed an association between ES period and good long-term outcome (OR 2, [1.03–3.8], p = 0.03), that was no longer significant after adjustment by NIHSS, age and baseline ASPECTS.

Conclusions

The probability of long-term functional independence increased markedly after the implementation of a 24-hour ES, which allowed a dramatic increase in the use of endovascular reperfusion therapy in AIS patients.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

GLUCOSE METABOLISM AND COGNITIVE OUTCOME AFTER ISCHEMIC STROKE - RESULTS FROM THE MUNICH STROKE COHORT

V Zietemann ¹, FA Wollenweber ¹, A Bayer-Karpinska ¹, GJ Biessels ², M Dichgans ¹

Abstract

Background

The relationship between glucose metabolism and stroke outcome is complex. We examined whether there is a linear or non-linear relationship between glucose measures in the acute phase of stroke and post-stroke cognition, and whether altered glucose metabolism at different time intervals is associated with cognitive outcome.

Methods

664 consecutively recruited patients with acute ischemic stroke and without pre-stroke dementia were included in this prospective observational study. Blood samples were taken at admission and fasting on the first morning after stroke. Duration of diabetes was assessed by interview. Cognitive outcome was assessed by the Telephone Interview for Cognitive Status (TICS) 3 months post-stroke. Dose-response analyses were used to investigate non-linearity. Regression analyses were stratified by diabetes status and adjusted for relevant confounders.

Results

Cognitive status was testable in 422 patients (81 with diabetes). There was a non-linear relationship between both admission and fasting glucose levels and cognitive outcome. Lower glucose values were significantly associated with lower TICS scores 3 months post-stroke in patients without diabetes with a similar trend in diabetic patients. There was an inverse association between duration of diabetes and TICS scores (linear regression: −0.10 [95%CI: −0.17 to −0.02] per year increase of diabetes duration) whereas HbA1c was not related to cognitive outcome. Results were supported by sensitivity analyses accounting for attrition.

Conclusions

Glucose levels in the acute phase of stroke are associated with cognitive outcome but the relationship is non-linear. Long-term abnormalities in glucose metabolism are also related to poor outcome, but this is not the case for shorter term abnormalities.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ASPECTS SCORE IN BASELINE AND PERFUSION CT IN PATIENTS TREATED WITH THROMBECTOMY: HOW ARE THEY RELATED TO EACH OTHER AND WITH PATIENTS' OUTCOMES?

C Aguirre ¹, L Pérez-Carbonell ¹, S Trillo ¹, S Bashir-Viturro ¹, G Zapata-Wainberg ¹, Á Ximénez-Carrillo ¹, G Reig ¹, JL Caniego ², E Bárcena ², J Vivancos ¹

Abstract

Background

We aimed to evaluate the correlation between ASPECTS score applied to non-contrast CT(ASPECTS-CT) and to cerebral blood volume maps of CT perfusion(ASPECTS-CBV) and the correlation of both scores with the outcome of patients with acute ischemic stroke treated with thrombectomy. Both ASPECTS scores were also correlated with infarct volume within 24 hours.

Methods

Retrospective study of consecutive patients with acute ischemic stroke in middle cerebral artery territory treated with successful thrombectomy in our hospital. ASPECTS scores and infarct volume were assigned by radiologists. Clinical outcome was measured using the modified Rankin scale (mRs) at 3 months.

Results

67 patients were analyzed. 41 women (61,2%). Average age: 66,38 years (range: 38–82). Median ASPECTS-CT: 8 (IQ range:3), and ASPECTS-CBV: 8 (IQ range:2). Median infarct volume within 24 hours: 24,64 cc. Median mRs at 3 months: 1 (IQ range:3). We found a strong direct correlation between both ASPECTS scores (rho: 0.82, p < 0.01). Among both ASPECTS scores and outcome an inverse correlation was obtained: ASPECTS-CT: rho −0.33 (p < 0.01), ASPECTS-CBV: rho −0.43 (p < 0.001). Among both ASPECTS scores and infarct volume within 24 hours, an inverse correlation was also found, stronger for ASPECTS-CBV (rho − 0.54 vs − 0.46, p < 0.01).

Conclusions

In our sample there is a good correlation between ASPECTS score in baseline CT and CT perfusion, although we found that the correlation in terms of patients' outcome and infarct volume is stronger using ASPECTS-CBV. Therefore, we consider it a very useful tool for acute ischemic stroke management.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

INTER-RATER VARIABILITY FOR EVALUATION OF ASPECT SCORE BETWEEN A NEUROLOGIST AND NEURORADIOLOGIST IN ACUTE STROKE PATIENTS

M Bar ¹, J Kral ¹, T Jonszta ², V Marcian ¹, H Tomaskova ³

Abstract

Background

Mechanical thrombectomy is a highly effective treatment of stroke if carried out in carefully selected patients. Main indication criteria for mechanical thrombectomy are acute arterial occlusion and ASPECT score more than 6 points. Un-enhanced CT and computed tomography angiography is therefore strongly recommended in management of acute stroke. The purpose of our study was to assess the inter-rater agreement of the diagnosis of ASPECT score between a neuroradiologist and neurologist.

Methods

CT images of 75 acute-stroke patients were evaluated for acute ischemic changes by an experienced interventional neuroradiologist and a general neurologist. Both of them had passed ASPECT web training cases. The neuroradiologist and the neurologist were blinded to clinical findings and to each other´s findings.

Results

75 patients were enrolled into the study. CT images were available for all 75 patients (34 females; mean age ± SD, 72 ± 14 years). The agreement between the neuroradiologist and the neurologist in evaluation of Aspect score was almost perfect; 97,2%, kappa (k) = 0,944; 95% CI (0,83–1,00).

Conclusions

Inter-rater agreement of evaluation of early acute CT ischemic changes in stroke patients between the neurologist and the neuroradiologist was almost perfect. Our results show that the ability of a trained general neurologist to evaluate ASPECT score could improve management of the acute stroke and mechanical thrombectomy care. It would support the faster activation of the thrombectomy team, leading to shorter door-to-needle times and better outcomes.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

WHO'S WHO OF HYPOPERFUSION: PREDICTORS OF PERFUSION CT FINDINGS IN HYPERACUTE STROKE

O Bill ¹, N Inácio ², D Lambrou ¹, P Michel ¹

Abstract

Background

Perfusion CT (CTP) may improve the performance of non-contrast CT (NCCT) in detection of acute ischemic stroke (AIS). However, little is known on the profile of patient that are more likely to benefit of this technique. We aim to describe predictors of focal hypoperfusion in AIS patients.

Methods

From the ASTRAL (Acute STroke Registry and Analysis of Lausanne) registry, all patients with an AIS and CT-based imaging within 24 hours were included. Patients with a good quality CTP were extracted. Preceding demographic, clinical, biological, radiological, and follow-up data were collected. Significant predictors of focal hypoperfusion were identified to go on to fit a multivariate analysis.

Results

Of 2216 patients with good quality CTP, 750 (33.8%) had an acute ischemic lesion on NCCT, and 1624 (73.3%) had a focal hypoperfusion on CTP. After analyzing 43 acute stroke covariates, onset to door time, aphasia on initial examination, as well as sensory impairement, neglect, visual field defect, Brainstem signs, or impaired consciousness, cardioembolic stroke mechanism, early ischemic changes on NCCT, and presence of significant arterial pathology were associated with a positive CTP. The sensitivity of CTP with regards to an infarction on follow-up imaging was 92.3% (with 95% CI 89.9%-94.3%), while specificity was 38.3% (with 95% CI 35.4%-41.3%)

Conclusions

Sensitivity of CTP for subsequent infarct is high, and specificity moderate, thus, adding CTP to acute CT-based imaging may improve early recognition of stroke and its localization, it’s relation to arterial pathology, and it’s etiology, therefore improve hyperacute as well as chronic stroke management.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ADMISSION CT-PERFUSION MAY OVERESTIMATE INITIAL INFARCT CORE. THE GHOST CORE CONCEPT

S Boned ¹, A Tomasello ², M Padroni ³, P Coscojuela ², J Cabero ², M Rubiera ¹, D Rodriguez-Luna ¹, J Pagola ¹, M Muchada ¹, JM Juega ¹, N Rodriguez ¹, E Sanjuan ¹, M Sanchis ¹, C Molina ¹, M Ribó ¹

Abstract

Background

Identifying infarct core is essential in order to establish the amount of salvageable tissue and indicate reperfusion therapies. CT perfusion (CTP) can be useful to identify the mismatch between infarct core and hypoperfused brain. Infarct core is established on CTP as the severely hypoperfused areas, however the correlation between hypoperfusion and infarct core may be time dependent and not always true as it is not a direct tissue damage indicator. We aim to characterize those cases in which admission core lesion on CTP does not reflect an infarct on follow-up imaging

Methods

We studied patients ICA/MCA occlusion who underwent CTP admission but received endovascular thrombectomy based on initial non-contrast CT ASPECTS ≥ 7. Admission infarct core was measured on initial CBV-CTP and final infarct on follow-up imaging. We defined ghost infarct core(GIC): initial core-final infarct > 10 cc. Time from symptom onset to CTP was recorded. Recanalization (TICI2b3) was assessed after thrombectomy.

Results

79 patients were studied: ICA/MCA occlusion 21/58, median NIHSS 17(11–20), mean time from symptoms-CTP: 218 ± 143 minutes. Recanalization rate: 77%. Mean CBV infarct core was 44 ± 59 cc, and mean final infarct volume was 38 ± 70 cc. 38% presented GIC > 10 cc and 29% GIC > 20 cc. GIC > 10 cc was associated with recanalization (TICI2b3:44Vs17%;p = 0.034), admission glicemia (<185 mg/dl:42%Vs0%;p = 0.028) and time-CTP (<185 minutes:51%Vs > 185:26%;p = 0.033). An adjusted logistic regression model pointed time from symptom-CTP < 185 minutes as the only predictor of GIC > 10 cc (OR:2.89;95%CI:1.04–8.09).

Conclusions

CT perfusion may overestimate final infarct core especially in the early window from symptom onset. Selecting patients for reperfusion therapies based on the CTP mismatch concept may deny treatment to patients who may still benefit from reperfusion.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

SUSCEPTIBILITY WEIGHTED IMAGING IDENTIFIES TISSUE AT RISK OF INFARCTION IN ACUTE ANTERIOR CIRCULATION STROKE

B Cheng ¹, N Schroeder ², ND Forkert ³, A Kemmling ⁴, J Fiehler ⁵, C Gerloff ², G Thomalla ²

Abstract

Background

Susceptibility weighted imaging (SWI) in magnetic resonance imaging (MRI) in acute stroke has shown potential as a surrogate marker of impaired hemodynamics and indicator of tissue at risk of infarction.

Methods

We investigated the value of visually rated asymmetrical hypointense cerebral veins (HV) on SWI to identify tissue at risk of infarction in acute anterior circulation stroke with onset <24 hours. Tissue-at-risk was volumetrically quantified on perfusion MRI using a delay threshold of T_max > 6 seconds. Status of the extra- and intracranial arteries was assessed by ultrasound and MRI-angiography.

Results

We included 35 patients (12 women; median age 67 years, IQR 61–77; median NIHSS at admission 10, IQR 6–20). Asymmetrically HV were detected in the stroke hemisphere in 25 patients (71%) with an interrater agreement (kappa-value) of 0.64. Twelve patients displayed occlusion of the middle cerebral artery, whereas occlusion of the extracranial internal carotid artery (ICA) was detected in 6 patients. The volume of tissue-at-risk of infarction tended to be larger in patients with asymmetrical HV as compared to patients showing symmetrical HV (mean volume 38.9 ml, SD 52.9 ml vs. 4.1 ml; SD 10.8 ml; p = 0.08). After excluding patients with extracranial ICA occlusions, the difference between groups was significant (42.9 ml; SD 50.3 ml vs. 4.2 ml, SD 5.9 ml; p = 0.02).

Conclusions

Visual analysis of HV in SWI identifies tissue at risk in patients with anterior circulation stroke. Extracranial ICA occlusions leading to prominent HV even in the absence of tissue at risk has to be considered as a confounding factor.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

SINGLE-PHASE VERSUS MULTIPHASE CTA IN CLOT/S DETECTION IN MIDDLE CEREBRAL ARTERY - COMPARISON OF BOTH METHODS

P Cimflova ^1,², O Volny ^1,³, P Kadlecova ¹, BK Menon ⁴, R Mikulík ^1,³

Abstract

Background

CT angiography (CTA) is recommended as standard of stroke imaging. We investigated accuracy and precision of standard single-phase CTA as compared to novel technique – multi-phase CTA in intracranial clot/s detection in the territory of middle cerebral artery (MCA).

Methods

Forty patients (20 single-phase and 20 multiphase CTA) were selected by consensus of experienced radiologist and neurologist. Acute occlusions of MidM1 MCA (n = 3), M2 and M3 (n = 12) and no occlusion (n = 5) were involved. Studies were assessed by 10 radiologists and 10 neurologists blinded to all clinical information (7 less-experienced with <100 CTAs and 3 more-experienced>100 CTAs evaluated). Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated. Detection of proximal clot and distal clot/s was compared with the consensus by using kappa.

Results

Sensitivity, specificity, PPV and NPV of single-phase CTA as compared to multiphase CTA for clot presence were: 88% (95% confidence interval/CI = 83–91%), 75% (65–83%), 91% (87–94%), 67% (57–76%) versus 90% (85–93%), 81% (71–88%), 94% (90–96%), 70% (60–78%). For distal clots, sensitivity, specificity, PPV and NPV of single-phase CTA as compared to multiphase CTA: 41% (95% CI = 29–53%), 77% (70–83%), 37% (26–49%), 80% (73–86%) versus 65% (57–74%), 78% (69–84%), 76% (67–84%), 67% (58–75%). Agreement for single-phase CTA was kappa 0.60 (0.51–0.69) and for multiphase CTA kappa 0.68 (0.60–0.76). For distal clots, agreement for single-phase CTA was kappa 0.17 (0.04–0.30) and for multiphase CTA 0.50 (0.36–0.60).

Conclusions

Distal clots in the MCA territory were detected more accurately and reliably with multiphase CTA as compared to single-phase CTA.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

OPTIMAL CT PERFUSION ISCHEMIC CORE THRESHOLDS FROM PATIENTS WITH CTP-TO-TICI 2B/3 REPERFUSION WITHIN 60 MINUTES

CD D'Esterre ¹, M Boesen ², K Khan ³, P Pordeli ⁴, S Hwan Ahn ⁵, M Njam ⁴, E Fainardi ⁶, M Rubiera ⁷, MD Hill ⁸, J Mandzia ⁹, AM Demchuk ¹⁰, T Sajobi ¹¹, TY Lee ¹², N Forkert ³, M Goyal ³, BK Menon ¹³

Abstract

Background

Perfusion thresholds for ischemic core (infarcted brain even if reperfused early) have yet to be determined in the setting of very fast and quality endovascular therapy. We determine CT perfusion (CTP) thresholds for ischemic core in patients with optimal endovascular treatment (reperfusion <60 minutes from CTP and TICI 2b/3 quality – current best possible care).

Methods

401 AIS patients from the Prove-IT database with occlusion on CT Angiography (CTA) were acutely imaged with CTP (<6 hrs from onset; GE Healthcare). Non-contrast CT and MR-diffusion weighted imaging (DWI) between 24–48 hours were used to delineate follow-up infarction. Reperfusion was assessed on the last run of DSA with TICI-scoring. The predictive performance of Tmax, cerebral blood flow (CBF) and cerebral blood volume (CBV) derived from delay-insensitive CTP post-processing. Receiver Operator Characteristic (ROC) curves using voxel-level histograms were used to derive gray and white matter (GM, WM) optimal thresholds associated with follow-up infarction for each patient individually (patient-level). Accuracy was assessed using the area under the ROC curve (AUC).

Results

19 patients were included in the study. Mean ± stdev time from onset-to-CTP was 138 ± 59 mins, and CTP to reperfusion was 45 ± 12 mins. Patient-level mean ± stdev optimal thresholds for CBF[mlċmin^-1ċ(100 g)^-1], Tmax(seconds) and CBV[mlċ(100 g)^-1] were: GM = 6.6 ± 1.8 (AUC = 0.81), 20.2 ± 3.6 (AUC = 0.84), and 4.2 ± 0.9(AUC = 0.59) and WM = 5.3 ± 1.5(AUC = 0.79), 19.7 ± 3.1(AUC = 0.81), and 2.9 ± 1.0(AUC = 0.62).

Conclusions

CTP-Tmax and CBF parameters are similar for prediction of ischemic core in patients with quality reperfusion <60 mins from CTP. Increased CBV can still go on to infarct, even with the fastest reperfusion currently possible, and should therefore not be used to define tissue status in AIS.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

MULTI-PHASE CTA AND CT PERFUSION HAVE EQUAL PREDICTIVE ACCURACIES FOR FOLLOW-UP INFARCTION REGIONALLY

CD D'Esterre ¹, A Trivedi ², K Khan ¹, P Pordeli ², S Hwan Ahn ³, M Njam ¹, E Fainardi ⁴, M Rubiera ⁵, J Mandzia ⁶, A Khaw ⁷, MD Hill ⁸, AM Demchuk ⁹, T Sajobi ¹⁰, N Forkert ¹¹, M Goyal ¹¹, TY Lee ¹², BK Menon ⁸

Abstract

Background

Triaging patients to endovascular therapy with advanced CT is now a mainstay. Slow processing time and technical/standardization issues hamper the use of CT Perfusion (CTP) in the acute ischemic stroke (AIS) setting. Multi-phase CTA (mCTA) may be a more practical and quicker alternative. We sought to determine the predictive performance of mCTA constructs and CTP parameters, respectively, for follow-up infarction after adjusting for variations across brain regions.

Methods

mCTA and CTP was performed <12 hrs from ictus in 77 AIS patients with MCA-M1 occlusions. Regional analysis was performed within M2-M6 ASPECTS-regions. Figure 1 depicts mCTA scoring paradigm. CTP-CBF, CBV, MTT, IRF-T0, and Tmax values were determined regionally. 24-hour MR-DWI or NCCT was used for final infarction. Logistic mixed-effects regression with c-statistic calculation was used to model the relationship between each set of imaging constructs and final infarction.

Results

graphic file with name 10.1177_2396987316642909-fig122.jpg

There was a negligible difference in the predictive accuracy of mCTA constructs and CTP parameters to discriminate 24 hr tissue infarction (84.59% and 83.04%, respectively). Extent was the most important mCTA construct that had the largest discriminatory power among the mCTA constructs, while CTP-Tmax had the largest discriminatory power.

Conclusions

mCTA assessments, even within small brain regions can help determine tissue fate and is as good as CTP. mCTA may be a more practical modality to obtain similar prognostic information for radiological and clinical outcomes in AIS.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PREDICTION OF SPACE OCCUPYING BRAIN EDEMA IN HYPERACUTE MIDDLE CEREBRAL ARTERY ISCHEMIC STROKE USING CEREBRAL PERFUSION COMPUTED TOMOGRAPHY

M de Lera ¹, AI Calleja ¹, E Cortijo ¹, S Pérez ², R Alcaide ¹, L Blanco ¹, J Reyes ¹, A Portela ³, P Muñoz ¹, O Valladolid ⁴, C Rodríguez-Arias ⁴, JF Arenillas ¹

Abstract

Background

We aimed to evaluate the capacity of cerebral perfusion computed tomography (PCT) to predict the development of brain edema (BE) with midline deviation (MLD), in severe middle cerebral artery (MCA) ischemic stroke.

Methods

We studied hyperacute (<6 h) MCA ischemic stroke patients with baseline NIHSS ≥ 15, who underwent plain CT and PCT upon admission. Extent of early signs of ischemia was assessed with the ASPECTS scale on plain CT. Blind automatic post-processing of CTP source-images was done with Olea Perfscape 2.0 software. Relative Cerebral Blood Flow <31% and T max >6 s were the predefined thresholds to calculate the extent of infarct core and hypoperfused brain tissue, respectively. Brain edema was evaluated on a control CT scan performed 3–5 days after stroke onset. Presence of BE + MLD was considered the principal outcome variable. Logistic regression models were performed to identify clinical and imaging predictors of BE + MLD.

Results

Forty-six patients were included (59% men, mean-age 72, median NIHSS = 20). Univariate analysis identified glycaemia, platelet count, baseline ASPECTS, and PCT-assessed infarct core and hypoperfused tissue volume as associated with BE + MLD. Both infarct core and hypoperfused tissue volume predicted the development of BE + MLD when an adjusted logistic regression model was applied. Areas under the receiver operator curves (AUC) to predict BE + MLD were AUC 0.79 (p = 0.008) for infarct core volume and AUC 0.72 (p = 0.03) for hypoperfused tissue volume.

Conclusions

Hyperacute PCT parameters infarct core and hypoperfused tissue volume may allow the prediction of space occupying BE in severe MCA ischemic stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

READOUT SEGMENTED ECHO PLANAR DIFFUSION-WEIGHTED IMAGING IMPROVES IMAGE DISTORTION AT THE COST OF INFARCT DISCRIMINATION IN ACUTE STROKE

E Edmond ¹, G Harston ², R Frost ³, F Sheerin ⁴, P Jezzard ³, J Kennedy ²

Abstract

Background

Diffusion weighted imaging (DWI), using echo-planar (EPI) readout, is the preferred MRI technique for defining infarction in acute stroke. EPI is limited by distortions from field inhomogeneity; readout-segmented EPI (rsEPI) mitigates this. We compared the performance of standard single-shot EPI (ssEPI) and simultaneous multi-slice accelerated rsEPI DWI in acute stroke.

Methods

12 patients underwent 3T MRI at presentation and 1 week. Protocols included T1, T2FLAIR, DWI, ssEPI, rsEPI and calculated ADC (apparent diffusion coefficient). EPI spatial resolution and acquisition time were matched (b = 1000s/mm², 1.5*1.5*1.5 mm, 3 min 20 sec, 5 readout segments [rsEPI] and 3 averages [ssEPI]). Final infarction was defined using 1 week T2FLAIR registered to DWI.

Results

Readout segmentation reduced EPI distortions (Figure-1C). Final infarct ADC values were similar between ssEPI and rsEPI (mean ± SD: 502.7 ± 174.3 versus 501.2 ± 201.7, p = 0.47). ADC lesion segmentation generated similar overlap coefficients compared to final infarct, and similar contrast-to-noise ratios (0.98 versus 0.81, p = 0.27). Area under the receiver operating curve analysis, for predicting infarction using ADC, was greatest for ssEPI (0.88 versus 0.80, Figure-1A). Optimal ADC thresholds were the same (620*10^-6mm/s, Figure-1B).

graphic file with name 10.1177_2396987316642909-fig123.jpg

Conclusions

rsEPI reduces distortion compared to ssEPI, while generating comparable ADC values and thresholds. The trend towards lower contrast resulted in poorer infarct discrimination using rsEPI. Readout segmentation is appealing for defining infarction in regions with EPI distortions, at the cost of infarct discrimination elsewhere.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

OBSERVER RELIABILITY OF CT PERFUSION SCANS

S El Tawil ¹, G Mair ², X Huang ¹, E sakka ², J Palmer ², I Ford ³, L Kalra ⁴, K Muir ⁵, J Wardlaw ²

Abstract

Background

CT perfusion (CTP) provides potentially valuable information to guide treatment decisions in acute stroke. Assessment of inter-observer reliability of CTP has, however, been limited to small, mostly single centre studies. We performed a large, internet- based study to assess observer reliability of CTP interpretation in acute stroke.

Methods

We selected 24 cases from the IST-3, ATTEST and POSH studies to illustrate various perfusion abnormalities. Observers were presented with non-contrast CT, maps of cerebral blood volume (CBV), cerebral blood flow (CBF), mean transit time (MTT), delay time (DT) and thresholded “penumbra” maps (dichotomised into penumbra and core), together with a short clinical vignette. A structured questionnaire asked observers to comment on presence of perfusion deficit, its extent compared to ischemic changes on NCCT, and on whether CTP supported a decision to give or withhold thrombolytic therapy. We assessed observer agreement with Krippendorff's-alpha (K-alpha).

Results

Fifty seven observers commented on one to 24 scans (median = 10). Inter-observer agreement was substantial for presence of an abnormality on perfusion sequences (k alpha values CBV = 0.73, CBF = 0.64, MTT = 0.77, DT = 0.78 and PM = 0.8). There was fair agreement for mismatch between perfusion and NCCT (k alpha values CBV = 0.21, CBF = 0.26, MTT = 0.39 DT = 0.38 and PM = 0.39). There was only slight agreement on treatment decisions. (k alpha = 0.2).

Conclusions

Despite substantial agreement between observers on presence of perfusion abnormalities, there was less agreement on the degree of “mismatch”, and only slight agreement on treatment decisions.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

DELAYED PHASE BLOOD POOL ASSESSMENT OF MULTIPHASE-CTA PREDICTS STROKE INJURY BEFORE ENDOVASCULAR THERAPY

A Famuyide ¹, CD D'Esterre ², M Hafeez ³, E Qazi ¹, M Njam ³, K Khan ³, B Menon ³, P Barber ³

Abstract

Background

Multiphase CT-Angiography (mCTA) provides dynamic microvascular ‘blood pool’ assessment during ischemia. We hypothesized that any delay of contrast enhancement after multi-phase CT angiography demonstrates the tissue at risk for final infarction, and therefore can assist in decision making for endovascular treatment.

Methods

Stroke patients with severe stroke and intracranial MCA occlusion were treated with endovascular therapy. There reperfusion status was determined by post treatment DSA 90 minutes of admission CT: no reperfusion TICI 0; successful reperfusion TICI 2b/3 ASPECT scores were calculated on admission NCCT and multiphase CTA two ways: 1) Delayed parenchymal filling (mCTA-delay) defined by any hypodense ASPECTS region, 2) Poor or non-existent parenchymal filling (mCTA-severe) defined by clearly well delineated hypodense ASPECT region. mCTA scores were compared to admission NCCT-ASPECTS. Sensitivity-specificity values were obtained by comparing all baseline CT ASPECTS values with follow-up CT/MRI-ASPECTS

Results

Fifty-nine patients were analyzed (32/59 = TICI-0, 27/59 = TICI-2b/3). Mean (range) specificities and sensitivities for prediction of final infarct volume by ASPECTS regions.are shown (Table 1).

graphic file with name 10.1177_2396987316642909-fig125.jpg

Conclusions

CT blood pool analysis is highly sensitive and specific for identifying ischemic brain tissue independent of acute reperfusion. CTA blood assessment is easy to apply and provides superior information about ischemic brain tissue in all ASPECTS regions than NCCT.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ISOLATED PUNCTUATE HIPPOCAMPAL INFARCTION AND TRANSIENT GLOBAL AMNESIA ARE INDISTINGUISHABLE BY MEANS OF MRI

A Förster ¹, H Wenz ¹, M Al-Zghloul ¹, HU Kerl ¹, C Groden ¹, E Neumaier-Probst ¹

Abstract

Background

Isolated punctuate hippocampal infarction (HI) might be a differential diagnosis of transient global amnesia (TGA). We evaluated the frequency of isolated punctuate HI and compared associated clinical symptoms and MRI findings to those observed in TGA.

Methods

From an MRI report database (2002–2015), we identified 222 patients with acute HI. Of these, 10 (4.5%) patients had isolated punctuate HI, were analyzed with regard to clinical presentation and MRI findings (lesion distribution and size on DWI, and relative ADC values) and compared to 12 TGA patients with typical hippocampal lesion on DWI.

Results

Isolated punctuate HI and TGA associated DWI lesions did not differ significantly, neither regarding the affected hemisphere (p = 0.10), size (p = 0.16), nor relative ADC values (p = 0.82). Furthermore, the distribution of lesions in the hippocampal head, body, and tail was similar (p = 0.40) in isolated punctuate HI (red) and Disorientation (p < 0.001) and memory deficits (p < 0.001) were much more common in TGA patients in comparison to patients with isolated punctuate HI. The latter in turn demonstrated significantly more often dysphasia/aphasia (p = 0.04) and nausea (p = 0.02) in comparison to TGA patients.

graphic file with name 10.1177_2396987316642909-fig124.jpg

Conclusions

Differentiation of isolated punctuate HI and TGA based on neuroimaging findings only is not possible. Consequently, hippocampal DWI lesions should not be used as an alternative criterion to the traditionally used clinical criteria in TGA.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

SUSCEPTIBILITY VESSEL SIGN ON T2*-WEIGHTED GRADIENT ECHO IMAGING IN PERFORATING ARTERY OCCLUSION IN LACUNAR INFARCTION

A Förster ¹, H Wenz ¹, M Al-Zghloul ¹, C Groden ¹

Abstract

Background

In stroke due to large vessel occlusion thrombotic material can be demonstrated directly by a hypointense signal on T2*-weighted gradient echo images (GRE). In the present study we evaluated the value of GRE for the detection of perforating artery occlusion in lacunar infarction (LI).

Methods

From a MRI database with 111 LI patients who underwent MRI within 24 hours after symptom onset we identified all patients with persistent hypoperfusion corresponding to the LI on DWI and analyzed these with special emphasis on GRE findings.

Results

Overall, 58 (52.3%) patients (median age 69.5 years, 46.6% male) were included in the analysis. On DWI, LI was found in the basal ganglia (17.2%), internal capsule (25.9%), corona radiata (19.0%), thalamus (32.8%), and brainstem (5.2%). Susceptibility vessel sign (SVS) could be detected in 11/58 (19%) patients (for an example see Figure 1). Patients with SVS had larger ischemic lesions on DWI (p = 0.045) whereas the size of the corresponding perfusion deficits did not differ significantly (p = 0.5). Anatomical localization did not differ significantly (p = 0.8) between patients with and without SVS.

graphic file with name 10.1177_2396987316642909-fig160.jpg

Conclusions

Susceptibility vessel sign on GRE may be used for detection of acute perforating artery occlusion in LI. However, this should be confirmed in larger studies using susceptibility-weighted imaging (SWI) which has higher sensitivity for the detection of intraluminal thrombus.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ASSESSMENT OF THROMBUS LENGTH IN ACUTE ISCHEMIC STROKE BY POST-CONTRAST MR ANGIOGRAPHY

R Ganeshan ¹, A Nave ¹, J Scheitz ¹, K Schindlbeck ², G Häusler ¹, C Nolte ¹, K Villringer ¹, J Fiebach ¹

Abstract

Background

In acute ischemic stroke, post-contrast MRA enables visualization of vessel segments distal to an intraarterial thrombus. We hypothesize that postcontrast MRA allows assessment of clot length.

Methods

Twenty-seven patients with MRI-confirmed ischemic stroke and intracranial artery occlusion admitted to our hospital within 24 hours from onset of symptoms were prospectively evaluated. Post-contrast MRA was added to a standard stroke MRI protocol. Thrombus lengths´ were measured on thick slab maximum intensity projection images. Clinical outcome was assessed by modified Rankin Scale (mRS).

Results

Post-contrast MRA enabled precise depiction of proximal and distal terminus of the thrombus at different vessel sites in 25 patients (83.3%, Figure 1 and 2), whereas in two patients (6.6%) post contrast MRA presented a partial occlusion. Median thrombus length in patients with complete occlusion was 9.9 mm (IQR 3.3–14.7). In patients with poor outcome, defined as mRS 3–6, median thrombus length (11.3 mm, IQR 7.3–17.2) was significantly longer (p = 0.006) than in those with good outcome, definded as mRS 0–2 (3.3 mm, IQR 1.8–8.0).

graphic file with name 10.1177_2396987316642909-fig157.jpg

graphic file with name 10.1177_2396987316642909-fig126.jpg

Conclusions

Postcontrast MRA demonstrates intraarterial thrombus length at different vessel occlusion sites. Longer thrombus length is associated with poor clinical outcome.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

MRI SCOUT IMAGES CAN DETECT THE ACUTE INTRACEREBRAL HEMORRHAGE ON CT

T Hayashi ¹, J Aoki ¹, K Suzuki ¹, Y Sakamoto ¹, A Abe ¹, S Suda ¹, K Kimura ¹

Abstract

Background

The disadvantage of magnetic resonance imaging (MRI) as the first-line test for stroke is to take a long scanning time, which may be critical for severe patients, especially those with intracerebral hemorrhage (ICH). MRI scout images, preliminary images obtained prior to a study, can screen rapidly the whole brain. If the MRI scout images have a high diagnostic accuracy for ICH on computed tomography (CT), we can stop to obtain additional MRI sequences, providing shortening the scan time and increasing the safety of MRI test.

Methods

Between September 2014 and July 2015, consecutively acute ICH patients who were taken both MRI scout and CT images in the hyperacute setting were studied. ICH on MRI scout images was defined as space–occupying lesions. Two neurologists assessed the scout images retrospectively.

Results

Seventy-six ICH patients (median age; 67.0 ± 12.8 [51 men and 25 women]) were enrolled. Among them, 71 (93.4%) patients were diagnosed as having ICH by MRI scout images (positive group) and 5 (6.6%) patients were not (negative group). The amount of bleeding was 21.2 ± 34.1 ml in the positive group and 1.1 ± 1.7 ml in the negative group (p = 0.001). Cutoff value of bleeding volume calculated from the receiver operating characteristic curve was 1.0 ml. Regarding the ICH lesion, 4 (57.1%) of the 7 pontine hemorrhage could be detected by MRI scout images, while 67 (97.1%) of the 69 other hemorrhages could be diagnosed (p = 0.001).

Conclusions

We can diagnose more than 90% of ICH using MRI scout images.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

INTRACRANIAL CAROTID ARTERY CALCIFICATION IS RELATED TO REVASCULARIZATION AND CLINICAL OUTCOME IN ACUTE STROKE PATIENTS TREATED WITH MECHANICAL THROMBECTOMY

M Hernández-Pérez ¹, D Bos ², L Dorado ¹, K Pellikaan ³, M Vernooij ², E López-Cancio ¹, N Perez de la Ossa ¹, M Gomis ¹, C Castaño ¹, J Munuera ⁴, J Puig ⁵, M Millán ¹, A Davalos ¹

Abstract

Background

Our purpose was to investigate the impact of intracranial carotid artery calcification (ICAC) on arterial revascularization, clinical outcome and mortality in acute stroke patients treated with mechanical thrombectomy.

Methods

A total of 194 patients admitted to our Stroke Unit between 2009 and 2015 that underwent mechanical thrombectomy for an anterior circulation occlusion were included. We semiautomatically quantified ICAC using the non-enhanced CT-scan made prior to thrombectomy. Demographical data, stroke severity and follow-up information were recorded. Complete arterial revascularization was defined as a TICI ≥2b on the final angiographic run. Good functional outcome was defined as a modified Rankin score ≤2 at 90 days. We assessed the association of ICAC volume and arterial revascularization, functional outcome, and mortality using logistic regression models, adjusting for age, stroke severity, time of ischemia and other relevant covariables.

Results

ICAC was present in 164 (84.5%) patients, with a median volume of 240.52 mm³ [interquartile range: 31.26–893.88]. Volume of ICAC correlated with age (r 0.482, p < 0.001) and it was associated with female gender (p = 0.031), diabetes (p = 0.023), hypertension (p = 0.002) and atrial fibrillation (p < 0.001). Larger ICAC volumes were independently associated with lack of complete revascularization (adjusted OR, 0.762; 95%CI, 0.61 to 0.94) and poor functional outcome (adjusted OR, 1.284; 95%CI, 1.06 to 1.55). Moreover, we found a non-significant trend of increased 90-day mortality (adjusted OR, 1.33; 95%CI, 0.97 to 1.83).

Conclusions

ICAC volume is an important marker of poor arterial revascularization and functional outcome in acute ischemic stroke patients treated with mechanical thrombectomy

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CORRELATION BETWEEN CLINICAL OUTCOMES AND BASELINE CT AND CT ANGIOGRAPHY FINDINGS IN THE SWIFT PRIME TRIAL

A Jadhav ¹, HC Diener ², B Menon ³, B Baxter ⁴, A Bonafe ⁵, T Jovin ¹, E Levy ⁶, V Pereira ⁷, R Jahan ⁸, J Saver ⁹, D Yavagal ¹⁰, M Goyal ³

Abstract

Background

To determine the effect of baseline computed tomographic and angiography (CT/A) on clinical outcome in the SWIFT prime trial to identify patients who would benefit from endovascular stroke therapy.

Methods

The primary clinical end point was 90-day dichotomized modified Rankin Scale (mRS) score. Subgroup and classification and regression tree analysis (CART) analysis was performed on baseline CT ASPECTS, site of occlusion, length of clot, quality of collateral circulation and onset to treatment time.

Results

Of 185 patients with baseline ASPECTS of 6–10, smaller baseline infarct (ASPECTS 8–10) was associated with better outcome (mRS 0–2) in patients treated with IV t-PA followed by thrombectomy versus IV t-PA alone (66% vs 41%, RR 1.62) compared to patients with larger baseline infarct (ASPECTS 6–7) (42% vs 21%, RR 1.98). Outcome stratification by occlusion location revealed benefit with thrombectomy across all groups (ICA, proximal-M1, middle-M1, distal-M1). Improved outcomes after thrombectomy occurred in patients with clot length of >= 8 mm (71% vs 43%, RR 1.67). Outcomes stratified by collateral status revealed benefit with thrombectomy across all groups: none-fair collaterals (33% vs 0%), good collaterals (58% vs 44%, RR 1.31) and excellent collaterals (82% vs 28%, RR 2.95). Using a 3-level CART analysis, optimal outcomes were observed in patients treated with favorable baseline ASPECTS, complete/near-complete recanalization (TICI2b/3) and early treatment (mean mRS 1.35 versus 3.73).

Conclusions

While benefit was seen with endovascular therapy across multiple subgroups, the greatest response was observed in patients with small baseline core infarct, excellent collaterals, early treatment as well as longer clot length.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EARLY DIAGNOSIS OF AORTIC ARCH ATHEROMATOSIS WITH CTA IN THE HIPERACUTE PHASE OF THE STROKE

J Juega Mariño ¹, J Pagola ¹, C Parra-Fariñas ², M Rubiera ¹, M Ribo ¹, S Boned ¹, R noelia ¹, M Muchada ¹, E San Juan ¹, E Montiel ¹, M Sanchis ¹, D Rodriguez-Luna ¹, A Flores ¹, L Sero ¹, H Cuellar ², P coscojuela ², A Tomasello ², J alvarez sabin ¹, CA Molina ¹

Abstract

Background

Computed tomography angiography (CTA) is a common diagnosis technique in the acute phase of the stroke. We aimed to assess aortic plaque location and morphology with CTA in the hiperacute phase of the stroke.

Methods

We prospectively performed CTA that include ascending part and left ICA ostium (proximal location) and beyond left ICA ostium and descending aortic arch (distal part) in patients within 8 hours from symptoms onset. Plaques at least 4 mm thickness or irregular ulcerations were defined as Complex aortic plaques (CAA). In order to grade the instability of the plaque, we described the plaque composition (calcic, fibrolipid or mixed).

Results

From 152 patients. CAA was detected in 30% (46/152). CAA was detected in 28.6% (20/70) of cryptogenic stroke. CAA patients were older compared with non-CAA (78 y vs 69 y) p = 0.002). We observed higher percentage of diabetic patients (28.3% vs 13.3%) (p = 0.028). We found no differences in neuroimaging pattern, baseline NIHSSS, grade of recanalization or occlusion location. The location of CAA was more prevalent in distal arch (60%) vs proximal (40%). The ostiums of the supra-aortic branches were affected in 28% (42 /150) fulfilling CAA criteria in 60% vs 14% (p < 0.01). According to Plaque Composition up to 34 % were fibrolipidic plaques, most of them ulcerated distal plaques comparing with no ulcerated ones (33.3% vs 6.5%) (p 0.017)

Conclusions

CTA was a useful technique to diagnose and classify CCA in the hiperacute phase of the stroke.

The prevalence of CAA in the ostium of supraaortic branches was remarkable.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

VESSEL RECANALIZATION AND RECOVERY OF RESTING BOLD SIGNAL DELAY IN ACUTE ISCHEMIC STROKE

AA Khalil ^1,², K Villringer ¹, A Rocco ³, JB Fiebach ¹, A Villringer ⁴

Abstract

Background

Blood-oxygen-level dependent (BOLD) signal fluctuations provide information about cerebral perfusion. We assessed the evolution of BOLD fluctuation delay in relation to vessel status in acute stroke.

Methods

Ten patients with supratentorial stroke and vessel occlusion received resting-state functional MRI (rsfMRI), MR angiography (MRA), and diffusion weighted imaging (DWI) scans within 24 hours of symptom onset (D0) and the following day (D1). BOLD signal delay between each voxel and the whole brain reference was computed using time shift analysis of the rsfMRI data. BOLD delay lesions were automatically segmented from the resulting maps and their volumes were calculated.

Results

Four patients recanalized (MCA = 2, PCA = 2) and six (ACA = 1, MCA = 5) had persistent vessel occlusion. Table 1 shows their BOLD delay volumes. Figures 1 and 2 show examples of patients with recanalization and persistent occlusion, respectively.

graphic file with name 10.1177_2396987316642909-img25.jpg

graphic file with name 10.1177_2396987316642909-fig128.jpg

graphic file with name 10.1177_2396987316642909-fig129.jpg

Conclusions

These preliminary results show that BOLD delay lesions recover following vessel recanalization and support the use of BOLD delay maps for non-invasively monitoring hemodynamic changes in acute stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

TWO SIMPLE AND RAPID METHODS BASED ON MAXIMUM DIAMETER ACCURATELY ESTIMATE LARGE LESION VOLUMES IN ACUTE STROKE

A Kufner ¹, J Fiebach ¹, C Nolte ¹, B Siegerink ¹, J Stief ¹

Abstract

Background

Assessment of lesion volume infarcted tissue is often used in stroke trials to select patients most likely to benefit from thrombolysis. Two methods have been proposed to rapidly estimate lesion size in the time-sensitive setting of acute stroke in which simple 2-diameter measurements are used. Here we compare 1) ABC/2 and 2) od-value cutoff methods in terms of their accuracy in predicting lesion size >70 mL and >100 mL.

Methods

Acute stroke patients screened for the AXIS2 trial were included for analysis; the maximum lesion diameter and the corresponding perpendicular diameter were measured on DWI obtained within 9 h of symptom onset. Estimation of infarct volume >70 mL and >100 mL based on the use of od-value cut-offs (2-axis measurement) and ABC/2 (3-axis measurement including slice thickness) was compared to volumetric assessments. C statistics were calculated.

Results

In 238 patients, the median baseline lesion volume was 26 mL (49 patients with lesion volume >70 ml and 37 patients with >100 ml). C statistics were 0.85 for od-value cut-off and 0.87 for ABC/2 calculation (difference 0.02, 95% Confidence interval [CI] −0.04 to −0.02). Refer to Table below. Conclusions: While ABC/2 and od-value perform similar in estimating lesion size in terms of C statistic and accuracy, ABC/2 tends to overestimate lesion size, resulting in lower specificity.

	Sensitivity (CI)	Specificity (CI)	Accuracy (CI)	PPV (CI)	NPV (CI)	Percent Overestimation (CI)
Od-Value 32 (>70 mL)	87.8 (75.2–95.4)	93.1 (88.5–96.3)	92.0 (0.88–0.95)	76.8 (63.6–87.0)	96.7 (93.0–98.8)	5.5 (2.57–8.35)
ABC/2 (>70 mL)	93.9 (83.1–98.7)	85.7 (79.9–90.4)	87.4 (0.83–0.92)	63.0 (50.9–74.0)	98.2 (94.8–99.6)	11.3 (0.07–15.3)
Od-Value 42 (>100 mL)	70.3 (53.0–84.1)	97.0 (93.6–98.9)	92.9 (0.90–96)	81.3 (63.6–92.8)	94.7 (90.6–97.3)	2.5 (0.01–0.04)
ABC/2 (>100 mL)	94.6 (81.6–99.3)	93.0 (88.6–96.1)	93.3 (0.90-.97)	71.4 (56.7–83.4)	98.9 (96.2–99.9)	5.9 (0.03–0.09)

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Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

VESSEL DAMAGE AND BLOOD-CEREBROSPINAL FLUID BARRIER DISRUPTION AFTER ACUTE ISCHEMIC STROKE: PREDICTORS AND CLINICAL RELEVANCE

A Renú ¹, C Laredo ¹, A López-Rueda ¹, R Tudela ², X Urra ¹, L Lull ¹, S Rudilosso ¹, L Oleaga ¹, Á Chamorro ¹, S Amaro ¹

Abstract

Background

The objective was to evaluate the predictors and prognostic significance of vessel damage and blood-cerebrospinal-fluid-barrier disruption (BCSFB-d) after acute stroke.

Methods

A prospective cohort of acute stroke patients with proximal intracranial occlusions at baseline (<6 h from onset) was analyzed. Vessel damage was defined as gadolinium vessel-wall enhancement (GVE), and BCSFB-d as gadolinium sulcal extravasation or subarachnoid hemorrhage (across >10 slices) accordingly in pre- and post-contrast FLAIR sequences of 24-hour follow-up contrast-enhanced MRI. Clinical outcome was evaluated with the modified-Rankin Scale at day 90 (mRS-90d).

Results

Ninety-five patients (median NIHSS = 14) were analyzed, 34 treated with alteplase alone and 47 with trombectomy (23 of them treated with alteplase prior to thrombectomy). A total of 29 (31%) patients had GVE, and 35 (37%) had BCSFB-d. GVE was associated to higher NIHSS at baseline, more proximal occlusions and higher rate of thombectomy use. In thrombectomy-treated patients (47/95), GVE was associated to pre-thrombectomy alteplase use (64% vs 32%, p = 0.028) and to more device passes [median (IQR) 1 (1–3) versus 2 (2–6), p = 0.013]. Overall, GVE was significantly associated to BCSFB-d (p = 0.001), and BCSFB-d predicted worse mRS-90d (adjusted-OR = 2.59, 95%CI = 1.15–5–85, p = 0.02) in ordinal regression models adjusted for potential confounders (including baseline NIHSS, age, thrombectomy use and recanalization).

Conclusions

Vessel damage and BCFSB-d are frequent and clinically relevant findings after ischemic stroke. Both direct vessel damage and BCSFB-d may be exacerbated with the use of alteplase prior to thrombectomy and with repeated device passes. These findings support the potential role of vasculoprotective therapies and call for an improvement of thrombectomy devices.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

A SIMPLE ROI BASED METHOD FOR DWI- AND FLAIR-BASED PREDICTION OF THE THROMBOLYSIS TIME WINDOW IN ACUTE STROKE

VI Madai ¹, MA Mutke ¹, CN Wood ¹, I Galinovic ¹, GS Revankar ¹, S Zweynert ¹, O Zaro Weber ², W Moeller-Hartmann ³, F von Samson-Himmelstjerna ⁴, WD Heiss ², M Ebinger ¹, JB Fiebach ¹, J Sobesky ¹

Abstract

Background

Patients with unknown time-from-stroke-onset are excluded from thrombolysis. Relative signal intensities (rSI) of DWI- and FLAIR-MRI are investigated to estimate eligibility for thrombolysis, but show heterogeneous results. We hypothesized that the method to calculate rSIs might influence the performance of these biomarkers and compared different methods to calculate rSIs.

Methods

Patients from two centers with acute stroke (onset <12 hours) were included in a retrospective analysis. The DWI-lesion and the contralateral region (CR) used for the calculation of rSIs were delineated and overlaid on FLAIR-maps. Lesion delineation was performed i) as a 2D-ROI (largest lesion-extent) or ii) as a 3D-VOI (whole lesion). The CR was defined a) by automated mirroring of the ROI or VOI, b) by a contralateral white-matter-VOI or c) by a hemispheric 2D-ROI on the height of the semioval centre. Each patient received 8 values for each MR sequence (4 lesion-ROI based and 4 lesion-VOI based values). By a receiver-operating-characteristic(ROC)-curve analysis the best performance was calculated based on the area-under-the-curve (AUC).

Results

82 patients were included. For DWI, the AUCs ranged from 0.77 to 0.85. The simple 2D-ROI-method (lesion-ROI, contralateral ROI) performed best (0.85). For FLAIR, the AUC-range was larger (0.66 – 0.84), but again the 2D-ROI-method performed best (0.84). For both, DWI and FLAIR, lesion-VOI based methods were not superior to lesion-ROI based methods (AUC 0.66–0.79).

Conclusions

For DWI- and FLAIR-based allocation to the thrombolysis time-window, a simple 2D-ROI based approach was not inferior to complex volumetric techniques. This supports fast decision making in clinical stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

VISUAL SCORING VERSUS COMPUTATIONAL VOLUME MEASURES OF PERFUSION DEFECTS IN ACUTE ISCHAEMIC STROKE

G Mair ¹, T Carpenter ¹, G Cohen ¹, R Lindley ², P Sandercock ³, J Wardlaw ¹

Abstract

Background

Perfusion imaging is used increasingly to assess ischaemic stroke. The Third International Stroke Trial (IST-3) was a large multicentre randomised-controlled trial testing intravenous rt-PA for ischaemic stroke; selected centres collected perfusion imaging.

Methods

All IST-3 patients with baseline CT/MR perfusion are included. We assessed perfusion defects on cerebral blood flow (CBF), cerebral blood volume (CBV), mean transit time (MTT) and time to maximum flow (Tmax) perfusion maps both visually with ASPECTS and by a semi-automated computer algorithm that used six predefined thresholds to determine volume. We tested for univariate associations between ASPECTS and computationally measured volumes, and between ASPECTS/computational volumes and age, stroke to scan time, baseline NIHSS. We performed ordinal regression analyses (adjusted for age, NIHSS, stroke to scan time, treatment allocation) to identify associations between ASPECTS and 6-month functional outcome.

Results

Amongst 121 patients with baseline perfusion imaging, median (interquartile): age 81(73–86) years; NIHSS 11(6–18); stroke to scan time 169(117–240) minutes; 64(53%) male, 57(47%) treated with rt-PA. ASPECTS did not correlate with computational perfusion volume for any perfusion map or threshold. ASPECTS CBF and CBV were significantly lower (larger defects) among patients scanned <3 versus 3–6 hours (p < 0.05). ASPECTS correlated significantly with NIHSS for all perfusion maps (p < 0.0001) but not age. Computational perfusion volumes were not associated with age, time to scan or NIHSS. ASPECTS independently predicted poor outcome for all perfusion maps (p < 0.01).

Conclusions

For assessing ischaemic stroke severity and predicting outcome, visual scoring of perfusion deficits is quick and may be superior to computational analysis regardless of threshold used.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

COLLATERAL PIAL CIRCULATION AND CEREBRAL EDEMA IN ACUTE STROKE

J Jesus-Ribeiro ¹, O Galego ², AI Martins ¹, J Sargento-Freitas ¹, M Baptista ², R Varela ¹, F Silva ¹, B Rodrigues ¹, C Machado ¹, G Cordeiro ¹, E Machado ², L Cunha ¹

Abstract

Background

Cerebral edema (CE) is frequent in patients with acute ischemic stroke (AIS) submitted to reperfusion therapy. No medical treatment has proven efficacy. Decompressive craniectomy has been shown to reduce mortality in selected patients. Although its pathophysiology is not entirely understood, several predictors of CE had been evaluated in the acute phase. Collateral pial circulation (CPC) has been associated with recanalization rates, infarction volume, and subsequent clinical outcomes. However, its potential impact in the development of cerebral edema is not definitely established.

Methods

We included consecutive patients with AIS and confirmed M1-MCA and/or distal ICA occlusion submitted to intravenous fibrinolysis and/or mechanical thrombectomy. Collateral circulation was evaluated in the acute-phase by angiography (Collateral Pial Score), CT-angiography (Retrograde filling of MCA) and/or transcranial color-coded Doppler (Flow diversion). CE was graded on the 24 h non-contrast CT (NCCT) scan, according to the classification proposed by Wardlaw. We performed an ordinal regression model for the effect of brain CPC on cerebral edema adjusting for the variables showing statistically significant univariate associations.

Results

Among the 88 patients included, 50% were male, mean age was 74 ± 12 years and mean admission NIHSS was 17( ± 6.8). Our results showed a significant association between cerebral edema and impaired CPC (OR: 0.23; 95%CI: 0.07–0.74; p = 0.013). Baseline ASPECTS (OR: 0.68; 95%CI: 0.49–0.95; p = 0.024) and parenchymal haemorrhagic transformation (OR: 14.73; 95%CI: 3.85–56.32; p < 0.0001) were also associated with cerebral edema.

Conclusions

Poor collateral pial circulation is independently associated with greater cerebral edema at 24 h in ischemic strokes submitted to reperfusion treatment.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ALBERTA STROKE PROGRAM EARLY CT SCORE (ASPECTS) AND IRREVERSIBLE INJURY TO THE CEREBRAL BRAIN PARENCHYMA - THE BEST EVALUATION METHOD

I Correia ¹, J Sargento-Freitas ¹, JJ Ribeiro ¹, AI Martins ¹, M Batista ², O Galego ², S Sintra ³, C Machado ¹, B Rodrigues ¹, G Santo ¹, F Silva ¹, L Cunha ¹

Abstract

Background

Alberta Stroke Program Early CT Score (ASPECTS) was developed to quantify early ischemic changes (EIC) in patients with acute ischemic stroke in the middle cerebral artery (MCA) territory on non-contrast CT (NCCT). Although classically EIC are defined as parenchymal hypoattenuation and/or isolated focal cortical swelling, some authors consider cortical swelling should not be quantified since it is inconsistently associated with definite infarct. Our objective was to evaluate the ability of two different methods of ASPECTS quantification to predict irreversible injury.

Methods

We included patients with acute ischemic stroke of the MCA territory submitted to intravenous fibrinolysis and complete recanalization within the first 6 hours (established by angio-CT and/or Transcranial color-coded Doppler). Initial NCCT scans were reviewed to quantify ASPECTS: ASPECTS-D considering areas of both parenchyma hypoattenuation and focal cortical swelling; ASPECTS-H considering only hypoattenuation. Final infarct was quantified on NCCT scan at 24 hours (ASPECTS-24). The lesion was considered reversible if the difference between ASPECTS-24 and initial ASPECTS (D or H) was positive.

Results

252 patients were included. Interobserver agreement was high for the evaluation of ASPECTS-D (κ = 0.9) and even higher for ASPECTS-H and ASPECTS-24 (κ = 0.95). The median values found were ASPECTS-D 9 (IQR 2) and ASPECTS-H 9 (IQR 3) (p < 0.001), ASPECTS-24 8 (IQR 3). There was a significant difference in lesion reversibility between then two methods of ASPECTS quantification: 20.4% of reversibility with ASPECTS-D vs. 5.95% with ASPECTS-H (p < 0.001).

Conclusions

Evaluation of ASPECTS on initial NCCT scan using only parenchymal hypoattenuation is more specific in the statement of irreversible lesions.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CEREBRAL AND CAROTID IMAGING OF HYPERACUTE CEREBRAL ISCHEMIA IN ACUTE TYPE A AORTIC DISSECTION

S Matsubara ¹, M Koga ², T Ohara ³, Y Tahara ⁴, M Higashi ⁵, Y Miyazaki ¹, K Kajimoto ⁶, N Tokuda ¹, K Nagatsuka ⁶, K Toyota ¹

Abstract

Background

There is little knowledge about cerebral and carotid imaging of acute ischemic stroke (AIS) or TIA in patients with acute Stanford type A aortic dissection (AAD).

Methods

Consecutive AIS/TIA patients with AAD and those without who were examined by CT or MRI within 4.5 h of onset were reviewed.

Results

24 AIS/TIA patients with AAD (15 women, 75 ± 11 y.o.), and 258 without AAD (104, 74 ± 12 y.o.) were studied. As compared to patients without AAD, AAD patients had infarcts more frequently in the right middle cerebral artery (MCA) territory (54.2% vs 28.3%, P = 0.018), and less frequently in the left MCA territory (8.3% vs 37.2%, P = 0.003). There was no difference of infarct location in the right anterior cerebral artery (ACA) (4.2% vs 1.6%), left ACA (0% vs 3.1%) territories, and in the posterior circulation (8.3% vs 16.3%). In MRA, AAD patients more frequently had poor visualization of the right internal carotid artery (ICA) (37.5% (6/16) vs 5.6% (14/249), P = 0.0004). There was no difference of deep or cortical infarcts, single or multiple infarcts, and monovascular or multivascular infarcts. In carotid ultrasonography, only AAD patients had an intimal flap of the common carotid artery (CCA) (70% (14/20), P < 0.0001). AAD patients more frequently had an intimal flap or occlusion of CCA (85.0% (17/20) vs 5.4%(14/258), P < 0.0001)

Conclusions

Right MCA territory infarcts and an abnormal finding in CCA or ICA were more common in AIS/TIA patients with AAD than those without. Early cerebral and carotid imaging is useful to identify AAD.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ADVANCED IMAGING-BASED VENOUS BIOMARKERS IN ACUTE ISCHEMIC STROKE PATIENTS

J Munuera ¹, J Puig ², M Hernández-Pérez ³, G Blasco ², J Daunis-i-Estadella ⁴, M Terceño ⁵, J Serena ⁵, Y Silva ⁵, C van Eendenburg ⁵, V Cuba ², G Carbo ², C Biarnes ², S Domenech ¹, M Wintermak ⁶, B Menon ⁷, A Davalos Errando ³, S Pedraza ²

Abstract

Background

Imaging-based venous biomarkers in acute ischemic stroke (AIS) could detect alterations in brain perfusion. We aimed (1) to correlate hypodense internal cerebral vein ratio (rHdV), hypointense veins on T2* (HVt), and asymmetrical venous drainage (AVd) with hypoperfusion of the ischemic territory, and (2) to assess possible relationships between these venous biomarkers and functional outcome.

Methods

We analyzed two patient groups with AIS of the anterior circulation within 12 hours from onset: (1) Patients treated with i.v. thrombolysis (CT group) who underwent perfusion CT and CT angiography and (2) candidates for mechanical thrombectomy (MR group), who underwent diffusion-weighted imaging, T2*, perfusion-weighted imaging and dynamic MR angiography. We analyzed baseline stroke severity, penumbra and infarct volume, arterial and recanalization (TIBI > 2) within 24 h with Transcranial Doppler ultrasound and mRS at 3 months, Penumbra on PCT was automatically calculated (MTT > 145% of the contralateral values plus CBV ≥ 2.0 mL/100g). Penumbra on MRI was defined as TMax6 on PWI-DWI volume.

Results

In the CT group (n = 123; 45 women; mean age = 78 y; baseline NIHSS = 18) rHdV correlated negatively with penumbra volume (r = −0.42), and rHdV ≥ 0.83 predicted good functional outcome (mRS 0–2) at 90 days (p < 0.001) and arterial recanalization (p = 0.005). In the MRI group (n = 25; 16 women; mean age = 65 y; baseline NIHSS = 17), 96% had HVt, and 52% had AVd in superficial sinuses. HVt was associated with greater median penumbra volume (74 ml versus 132 ml, p = 0.002).

Conclusions

Advanced imaging-based venous biomarkers are associated with increased hypoperfused tissue volume, worse recanalization rate, and poor functional outcome.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

REAL-LIFE EXPERIENCE WITH THE E-ASPECTS SOFTWARE IN A TERTIARY STROKE CENTER - REPORT ON THE FIRST 100 ACUTE ISCHEMIC STROKE CASES

S Nagel ¹, S Schönenberger ¹, J Pfaff ², C Gumbinger ¹, J Purrucker ¹, C Herweh ¹

Abstract

Background

e-ASPECTS is a CE-marked software which assesses ischemic damage on a non-contrast enhanced head CT (NECT) by applying the ASPECTS. It is intended to assist the physician in acute treatment decisions. We have been using e-ASPECTS in our routine clinical imaging pathway.

Methods

NECT DICOM images from a 64-slice CT scanner are pushed manually on demand to e-ASPECTS, installed on a local-server. Images are automatically analysed and the output is available via intranet based web interface and email alerts. Of the first consecutive 100 patients with suspected acute ischemic stroke, we descriptively assessed the performance of the software. In 86 cases a CT perfusion and/or angiography was available for comparison. In addition, a survey was performed amongst nine of our stroke physicians who have been regularly using e-ASPECTS.

Results

e-ASPECTS was able to process all NECT. Results were available within 2 minutes after push. Median e-ASPECTS was 9 (range 2–10) and in 43 patients a score of 10 was given. In 84 cases the software correctly identified the ischemic side or a score of 10 (no damage). In 94 patients the output guided or was in line with the clinical decision making. e-ASPECTS increased all physicians’ confidence when interpreting NECTs and 8 of 9 said that it helps them making treatment decisions faster and that they would like to continue using it.

Conclusions

e-ASPECTS is a valuable tool for the management of acute ischemic stroke patients and can give a standardised and unbiased assessment of NECTs to assist treatment decision making.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

QUANTITATIVE MEASUREMENT OF BLOOD BRAIN BARRIER PERMEABILITY ON CT PERFUSION MIGHT PREDICT HEMORRHAGIC TRANSFORMATION AFTER ACUTE ISCHEMIC STROKE

S Nannoni ¹, D Gadda ², B Piccardi ¹, V Palumbo ³, A Iaquinta ¹, G Pracucci ¹, S Mangiafico ⁴, D Inzitari ¹

Abstract

Background

Blood-brain-barrier (BBB) disruption is a key-phenomenon of tissue injury after reperfusion, which can be exacerbated by the revascularization treatments of acute phase. CT perfusion (CTP) may quantify BBB disruption, through the assessment of membrane permeability. Our study aimed to assess the diagnostic accuracy of CTP-derived BBB-permeability measurements in predicting hemorrhagic transformation (HT) in a cohort of ischemic stroke patients submitted to CTP.

Methods

We analyzed consecutive ischemic stroke patients evaluated by CTP between January 1 2012 and June 30 2015. Maps of surface permeability were obtained using the Patlak model. BBB-permeability was expressed in ml/100 gr/min. Radiologically significant HT was defined as the presence of hemorrhagic infarction type 2 or parenchymal hematoma type 1 or 2 according to ECASS III criteria on 24 h CT. A threshold of impaired permeability in the ischemic core corresponding to the best pair of sensitivity and specificity able to predict HT was identified using ROC curves.

Results

Of 31 patients evaluated by CTP, 5 were treated with systemic thrombolysis, 10 received endovascular thrombectomy, 7 underwent both treatment and 9 were not treated. Ten patients developed HT. ROC curve analysis showed that a value of permeability in the ischemic core ≥2.90 ml/100g/min has a sensitivity of 70% and a specificity of 76% in predicting a radiologically significant HT

Conclusions

Our preliminary data, to be confirmed from larger studies, suggests that CTP based measurement of a permeability threshold may help to predict the risk of HT, eventually allowing a better selection of candidates to different reperfusion treatments.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CAROTID PSEUDO-OCCLUSION ON DYNAMIC 4D-CTA IN ACUTE ISCHEMIC STROKE

F Ng ¹, P Choi ^1,², D Mineesh ³, A Gilligan ^1,^2,^4,⁵

Abstract

Background

Acute tandem occlusions of major intracranial vessels and extracranial Internal Carotid Artery (ICA) occlusion carry a poor prognosis and represent additional technical challenges for endovascular intervention. The flow-related imaging artefact of carotid pseudo-occlusion on conventional single-phase CT Angiography represents a false-positive finding that may significantly impact on clinical decision-making. We report the novel use of 4-Dimensional CTA (4D-CTA) as part of multi-modal hyperacute stroke imaging protocol in detecting carotid pseudo-occlusion.

Methods

Patients with 4D-CTA evidence of carotid pseudo-occlusion were identified from imaging records from a prospective departmental stroke database. Time resolved 4D-CTA images were reconstructed on Vitrea workstation (Toshiba Medical Systems) from whole brain CT Perfusion data.

Results

Eight patients (4 male, 4 female; mean age 78.9 year-old) were identified. Six out of eight patients presented with a NIHSS ≥18. All patients had left hemispheric strokes. Delayed antegrade contrast opacification of the intracranial ICA through the apparently occluded extracranial cervical segment was typically detected on 4D-CTA after the venous-filling phase once major intracranial venous sinuses were devoid of contrast at 20.5 to 47.4 seconds after the initial arterial phase (Figure 1).

Conclusions

4D-CTA is a convenient and non-invasive imaging modality that can be easily incorporated into existing hyperacute stroke imaging protocols to detect carotid pseudo-occlusion.

Figure 1. — Left ICA pseudo-occlusion (arrow) on 4D-CTA in arterial (a), venous, (b), post-venous phase (c&d).

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

IRREVERSIBLE ISCHEMIC LESION ASSESSMENT: TIME DEPENDENCY OF CBV_ASPECTS IMPROVEMENT OVER CT_ASPECTS

M Padroni ¹, S Boned Riera ², M Ribó ², M Muchada ², D Rodriguez-Luna ², P Coscojuela ³, A Tomasello ³, J Cabero ³, J Pagola ², N Rodriguez-Villatoro ², JM Juega ², E Sanjuan ², C Molina ²

Abstract

Background

ASPECTS is a useful score for assessing early ischemic signs in the anterior circulation on non-contrast CT. Cerebral blood volume (CBV) on CT perfusion defines the core lesion assumed to be irreversibly damaged. Whether CBV provides additional information over CT is unknown. We aim to explore the advantages of CBV_ASPECTS over CT_ASPECTS in the prediction of final infarct volume according to tme.

Methods

Consecutive patients with middle cerebral or internal carotid artery occlusion who underwent endovascular reperfusion treatment according to initial CT_ASPECTS ≥ 7 were studied. CBV_ASPECTS was assessed blindly later-on. Recanalization was defined as TICI 2b-3. Final infarct volumes were measured on follow-up imaging. We defined ASPECTS agreement(AA) as: CT_ASPECTS - CBV_ASPECTS ≤ 1.

Results

Sixty-five patients, mean age 67 ± 14, median NIHSS:16(10–20) were studied. Recanalization rate was 78.5%. Median CT_ASPECTS was 9(8–10), and CBV_ASPECTS 8(8–10). Mean time from symptom onset to CT was 219 ± 143 min.

Fifty patients(76.9%) showed AA. The ASPECTS difference was inversely correlated to the time from symptom onset to CT(r: −0.36, p < 0.01). A ROC curve defined 120 minutes as the best cut-off point after which the ASPECTS difference becomes ≤1. After 120 minutes, 89.5% patients showed AA(as compared with 37.5% <120 minutes, p < 0.01).

Globally, CBV_ASPECTS but not CT_ASPECTS correlated to the final infarct (r: −0,33, p < 0.01). However, if CT was done >2 hours after symptom onset CT_ASPECTS also correlated to final infarct (r: −0,39, p = 0,01).

Conclusions

In acute stroke CBV_ASPECTS correlates with final infarct volume. However, when CT is performed after 120 minutes from symptoms onset CBV_ASPECTS does not add relevant information to CT_ASPECTS.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CLINICAL PREDICTORS AND PROGNOSTIC IMPORTANCE OF CEREBRAL HYPOPERFUSION ON CTP IN PATIENTS WITH POSTERIOR CIRCULATION STROKE

LP Pallesen ¹, D Lambrou ², A Eskandari ³, J Barlinn ¹, K Barlinn ¹, V Puetz ¹, P Michel ³

Abstract

Background

There is only little data regarding CT perfusion (CTP) in patients with acute posterior circulation stroke. We aimed to determine clinical predictors of focal posterior cerebral hypoperfusion in baseline CTP and its association with clinical outcome at three and 12 months.

Methods

We included patients with posterior circulstion stroke from the Acute STroke Registry and Analysis of Lausanne (ASTRAL) who underwent CTP within 24 hours of stroke onset as part of acute stroke imaging protocol. Hypoperfusion was defined as an area of visually well demarcated mean-transit-time prolongation corresponding to a vascular territory on standard reconstruction CTP imaging maps. We assessed clinical and imaging baseline characteristics and functional outcome measured by the modified Rankin Scale (mRS) at three and 12 months.

Results

Of 3579 patients from the ASTRAL, 986 (28%) had a posterior circulation stroke of whom 439 (45%) had a good quality CTP at baseline. In multiple imputation analysis, loss of visual field (OR 9.07, 95%CI 4.35–18.94), reduced vigilance (OR 5.39 95%CI 2.45–11.89) and cardiac source of embolism (OR 4.00, 95%CI 1.54–10.36) emerged as clinical predictors of posterior hypoperfusion on baseline CTP; but not the overall NIHSS. Patients with focal hypoperfusion had a significant higher mRS at three (OR 1.41, 95%CI 1.23–1.63) and 12 months (OR 1.30, 95%CI 1.24–1.57) than those with normal CTP perfusion.

Conclusions

Neurological deficits and stroke mechanisms are associated with CTP hypoperfusion in posterior circulation stroke. Patients with hypoperfusion tend to have worse outcome compared to those without hypoperfusion

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CT PERFUSION BASED SELECTION OF ENDOVASCULARLY TREATED ACUTE ISCHEMIC STROKE PATIENTS - ARE THERE LESSONS TO BE LEARNED FROM THE PRE-EVIDENCE ERA?

MN Psychogios ¹, D Behme ¹, R Bshara ¹, I Tsogkas ¹, K Schregel ¹, M Ilko ², J Liman ², M Knauth ¹

Abstract

Background

Some of the latest groundbreaking trials suggest that using noncontrast cranial CT and CT-angiography are sufficient tools for patient selection within 6 h of symptom onset. Before endovascular stroke therapy became standard of care, patient selection was one of the most critical issues to avoid futile reperfusions. We report the outcomes of endovascularly treated stroke patients selected with a perfusion-based paradigm and discuss the implication in the current era of endovascular treatment.

Methods

After an interdisciplinary meeting in September 2012 we decided to base our treatment decisions regarding thrombectomy of stroke patients primarily on CT perfusion with a cerebral blood volume Alberta stroke program early CT scale (CBV-ASPECTS) of <6 being a strong indicator of futile recanalization. Our prospective neuro-interventional data base was screened for all patients with a M1 thrombosis treated from September 2012 to December 2014.

Results

Thirty-nine patients were identified. Median age was 69 years and the median admission NIHSS was 17. Successful reperfusion was observed in 74% of our patients and 56% had a favorable outcome at 90 days. Compared to previously published data from our database (2007–2011) we found a 2 point increase of median CBV-ASPECTS resulting in a significant increase of favorable outcomes.

Conclusions

CT perfusion used to be an important tool for patient selection in endovascular stroke therapy and although it has lost impact within the first 6 h we still use it to broaden the therapeutic time-window up to 12 hours.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CT PERFUSION (CTP) FINDINGS IN STROKE-MIMICS OF EPILEPTIC ORIGIN

S Quintas ¹, R López Ruiz ¹, M De Toledo ¹, MT Carreras ¹, A Gago-Veiga ¹, J Vivancos ¹

Abstract

Background

Acute onset of neurological symptoms raises the suspicion of stroke. However, epileptic neurologic symptoms are a well-known stroke-mimic, so that they are often evaluated for acute stroke in emergency departments and undergo a computed tomography. We evaluated possible differential CT perfusion (CTP) findings in these two entities.

Methods

We retrospectively studied 8 patients admitted on a stroke suspicion to the emergency department of our institution in the last year, finally diagnosed with epilepsy based on clinical and/or electroencephalographic criteria.

Results

N = 8 (female 50%, mean 67years). 3 had right hemisphere syndrome, 2 left hemisphere syndrome, 3 isolated aphasia. Mean time to imaging study (when onset was known): 2 hours. CT perfusion was normal in three patients, three showed a delayed/increased mean transit time (MTT), one had an increased cerebral blood volume (CBV) and the other a decreased CBV and decreased cerebral blood flow (CBF). 30-minute-electroencephalogram was performed 31,5 hours from clinical onset: one was normal, four showed ictal activity and an asymmetric hemispheric slowing was detected in three. No patient underwent thrombolysis: four had an unknown onset, one associated a generalized tonic-clonic seizure, two had fluctuating symptoms and one was asymptomatic on admission.

Conclusions

Imaging studies showing multilobar and cortical territories abnormalities respecting basal ganglia and with no vascular occlusion do not support a stroke diagnosis and should raise an epileptic suspicion. Therefore, CTP could be a fast, available and useful tool in many emergency departments for the differential diagnosis of acute neurologic deficits with an epileptic origin that are evaluated for stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

MALIGNANT PROFILE IN ACUTE ISCHEMIC STROKE PATIENTS WITH FAVORABLE ASPECTS: PREDICTORS AND PROGNOSTIC RELEVANCE.

A Renú ¹, C Laredo ¹, S Rudilosso ¹, L Llull ¹, V Obach ¹, X Urra ¹, L San Román ¹, J Blasco ¹, J Macho ¹, S Amaro ¹, Á Chamorro ¹

Abstract

Background

To evaluate the variables associated with the presence of malignant profile (MP) defined by CT-perfusion (CTP) in patients with acute ischemic stroke and favorable ASPECTS score in plain CT.

Methods

We evaluated a cohort of 244 consecutive patients imaged within 6 hours from onset of acute stroke secondary to Middle Cerebral Artery (MCA)-M1 occlusions [63 treated with systemic rtPA, 162 with endovascular therapy (ET) and 19 without reperfusion treatment]. Additional inclusion criteria were a favorable ASPECTS score (≥6) in admission plain-CT and the availability of a concurrent CTP. MP was defined as a CTP-predicted non-viable tissue volume higher than 70 ml (perfusion-threshold: relative Cerebral Blood Flow ≤30% of normal brain). Collateral status was qualified by using the Tan-score (poor collaterals, score 0–1).

Results

A MP was observed in 17% (41/244) patients. In multivariate analyses, MP was predicted by lower ASPECTS score (≤8) (OR = 9.25; 95%CI = 3.14–27.22, p < 0.001), high glucose at admission (per IQR, OR = 1.78, 95%CI = 1.17–2.70, p = 0.007) and poor collaterals (OR = 8.63, 95%CI = 3.29–22–65, p < 0.001). Overall, MP was associated with poor outcome at 3 months (Rankin > 2, OR = 5.74, 95%CI = 2.16–15.21, p < 0.001), although this relationship was not longer significant in the subgroup of patients treated with ET (OR = 3.08, 95%CI = 0.80–11.83, p = 0.101).

Conclusions

In patients with MCA-M1 occlusions, a favorable ASPECTS score (≥6) does not rule out the presence of a MP, especially in those with worse ASPECTS score, high glucose and poor collaterals. Acute ET may modify the association of MP with poor outcome. The clinical impact of MP should be evaluated in clinical trials of ET.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CONTRIBUTION OF LEPTOMENINGEAL COLLATERAL BLOOD SUPPLY IN PATIENTS WITH M1 OCCLUSION DETERMINED BY USING A NOVEL CT PERFUSION ANALYSIS

D Robben ¹, A Wouters ², A Bivard ³, S Sunaert ⁴, V Thijs ⁵, G Wilms ⁴, R Lemmens ², F Maes ¹, P Suetens ¹

Abstract

Background

Collateral flow is a predictor of outcome in acute stroke patients receiving reperfusion therapy. The relative importance of different collateral pathways is difficult to gauge with current techniques. We developed a novel CTP analysis to infer perfusion territories and quantified the leptomeningeal collateral circulation.

Methods

CTP was performed in 11 stroke patients with acute proximal middle cerebral artery (M1) occlusion. The hypo-perfused region was determined as the region for which bolus arrival was at least 3 s delayed compared to the contralateral side. In-house developed CTP analysis inferred the perfusion territories of the anterior, middle and posterior cerebral artery (ACA, MCA, PCA) by tracking the contrast bolus based on its arrival time. The relative contribution of collateral ACA and PCA supply was assessed by the overlap of the hypo-perfused region with their territories.

Results

The average hypo-perfused volume was 130(+-32)ml. The ACA perfused 47%(+-11) or 60(+-16)ml of this volume while the PCA fed 31%(+-20) or 44(+-30)ml. The proportion of collateral flow provided by the ACA was larger than that by the PCA(p = 0.04). Two representative cases are shown. The contralateral side has territories in concordance with literature.

graphic file with name 10.1177_2396987316642909-fig131.jpg

Conclusions

Using CTP we could determine and quantify the distribution of the leptomeningeal collateral flow in patients with M1 occlusions. In future work, these maps will be combined with arrival time metrics to grade the collateral cerebral perfusion.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

AREAS OF CONTRAST EXTRAVASATION AFTER MECHANICAL THROMBECTOMY CAN EXCEED INITIAL DWI LESION

T Schneider ¹, T Mahraun ¹, J Schröder ², A Frölich ¹, P Hölter ³, M Wagner ⁴, J Darcourt ⁵, A Bonafe ⁶, J Fiehler ¹, S Siemonsen ¹, JH Buhk ¹

Abstract

Background

The presence of intraparenchymal hyper-attenuated (IPH) foci on flat-panel CT (FP-CT), representing areas of transient contrast extravasation or more persistent contrast enhancement, is a common phenomenon after endovascular thrombectomy in stroke patients. It is generally presumed that IPH manifest within the ischemic core due to breakdown of the blood-brain barrier, but prior studies that investigate a mutual relationship are scarce.

Methods

This retrospective multi-center study included 21 acute stroke patients in whom diffusion-weighted imaging (DWI) was performed prior to FP-CT following mechanical thrombectomy. After co-registration of DWI and FP-CT, volumetry of IPH foci was conducted and overlapping areas of IPH and DWI were quantified

Results

Three different patterns on IPH on FP-CT were observed: a) IPH corresponding to the DWI-lesion, b) IPH exceeding the DWI-lesion, or c) distinct location of IPH. No differences regarding to initial NIHSS, fluoroscopy time, time from symptom onset to FP-CT, TICI grade, and 24 h follow-up CT (presence/absence of IPH) were seen. There was no positive relationship between the size of IPH and the fluoroscopy time.

Conclusions

IPH locations are mainly but not exclusively restricted to the ischemic core on initial MRI. This may be attributed to a progression of infarction and/or distal propagation of emboli over time.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

A COMPARISON OF VISUAL AND AUTOMATED APPROACHES TO ALBERTA STROKE PROGRAM EARLY COMPUTED TOMOGRAPHIC SCORE RATING USING DIFFERENT THRESHOLDS ON DIFFUSION-WEIGHTED IMAGING

J Schroeder ¹, B Cheng ¹, M Ebinger ², M Köhrmann ³, O Wu ⁴, DW Kang ⁵, DS Liebeskind ⁶, A Kemmling ⁷, T Tourdias ⁸, OC Singer ⁹, S Christensen ¹⁰, B Campbell ¹⁰, M Luby ¹¹, S Warach ¹², J Fiehler ¹³, J Fiebach ², C Gerloff ¹, G Thomalla ¹

Abstract

Background

Assessment of ischemic stroke lesions on CT or MRI using Alberta Stroke Program Early Computed Tomographic Score (ASPECTS) is widely used to guide acute stroke treatment. However, it has never been defined how many voxels on diffusion-weighted imaging (DWI) need to be affected to label an ASPECTS region ischemic. We aimed to assess the effect of different volume thresholds on ASPECTS values on DWI and compare automated analysis with visual rating.

Methods

We analyzed the overlap of individual stroke lesions of 315 patients from the previously published PRE-FLAIR study with a probabilistic ASPECTS template derived from 221 CT images. We then used different overlap thresholds (1%, 5%, and 10% of voxels in each ASPECTS region) to compute the ASPECTS value for each patient and compared the results to the visual reading by an experienced stroke neurologist.

Results

By visual rating, median ASPECTS was 9 (IQR 2), 84 patients had an ASPECTS value ≤7. In contrast, by use of 1%-, 5%-, and 10%-thresholds, median ASPECTS was 7 (IQR 4), 10 (IQR 2), and 10 (IQR 0); 163 patients, 59 patients, and 4 patients showed an ASPECTS ≤7, respectively. Agreement between automated assessment and visual rating was low (1%: κ = 0,046; 5%: κ = 0,015; 10% κ = −0,047).

Conclusions

Automated assessment of DWI-ASPECTS based on lesion overlap shows varying results, depending on the threshold applied. Agreement between automated and the usually used visual scoring is low. Too sensitive (i.e. lower) thresholds may result in unjustified exclusion of patients from therapy or clinical trials.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EARLY REVERSAL OF ADC VOLUME IS AN IMAGING BIOMARKER OF EARLY NEUROLOGIC IMPROVEMENT

A Simpkins ¹, E Kim ², R Leigh ¹

Abstract

Background

Percent early reperfusion (PER) correlates with response to therapy. Final infarct volume (FIV), defined as diffusion volume at 24 hours, has also been proposed as a surrogate for response to therapy. It is known that early change in stroke size (ECS) can occur resulting in decreased stroke volume after early reperfusion. We compared the accuracy of ECS, FIV, and PER in predicting response to therapy.

Methods

Acute stroke patients enrolled 2013–2014 with serial MRI scans (pre-treatment baseline, 2 hours post, and 24 hours post) who received IV tPA were included. Some patients also underwent endovascular therapy. ECS (using ADC < 600) and PER (using TTP < 4 seconds) were calculated from the baseline and 2 hour MRI scans. FIV was calculated from the DWI at 24 hours. Early neurologic improvement (ENI) was defined as ≥4 point decrease in NIHSS within 24 hours and the SITS-MOST definition of sICH was used. Logistic regression models and nonparametric area under the curves (AUC) were used.

Results

58 patients were included in the analysis. Only ECS was significantly associated with ENI (p = 0.045). ECS performed the best in predicting ENI (AUC = 0.70), followed by PER (AUC = 0.61), and then FIV (AUC = 0.55). ECS trended in association with lack of sICH (p = 0.054). ECS was also the best predictor for absence of sICH (AUC = 0.74) with PER (AUC = 0.57) FIV (AUC = 0.58) performing similarly.

Conclusions

In our study, ECS showed the highest predictive accuracy for response to therapy while FIV performed the worst.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

COMPARISON OF SIMPLE CBF GRADES BASED ON CT PERFUSION WITH MULTIPHASE CT ANGIOGRAPHY

Y Tanno ¹, T Mori ², T Iwata ², S Kasakura ², K Yoshioka ²

Abstract

Background

The aim of this study is to compare CBF grades based on CT perfusion (CTp) with types based on multiphase CTA (mCTA).

Methods

Included were acute stroke patients 1) who were admitted within 12 hours of onset and underwent CT angiography showing complete occlusion of the M1 segment of the middle cerebral artery (MCA), or all M2 segments of the MCA. CBF grade was calculated by using bilateral time-density curves (TDCs) of CTp. TDCs were generated on region of interests set at symmetrical positions of the bilateral MCA territories. According to the time to peak (TP) and the peak value (PV) comparing the affected side (a) with the contralateral side (c), CBF grade 1 was defined as TPa-TPc (TTP delay) >=2second(sec) and PVa/PVc (PV%) < 0.25, grade 2 as TTP delay > =2 sec and 0.25 < =PV% < 0.75, grade 3 as TTP delay < 2 sec or PV% < =0.75. In addition, poor, moderate or good collateral (pC, mC or gC) was defined according to the ESCAPE trial method.

Results

Thirty-nine patients were analyzed. In pC, mC and gC, there were 1, 20 and 18 patients. The one patient of pC had CBF grade 1, the 20 patients of mC were classified to grade1 in one, grade 2 in 15 (75%) and grade 3 in 4 patients, the 18 patients of gC to grade 2 in 2 and grade 3 in 16 patients (88%).

Conclusions

Our results indicate that pC is probably regarded as our CBF grade 1, mC as grade 2 and gC as grade 3.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

MIGRAINE AURA OR STROKE: THE T2* CORTICAL VEINS SIGN

A Viguier ¹, JF Albucher ¹, L Calviere ¹, N Raposo ¹, JM Olivot ¹, F Bonneville ², N Fabre ¹

Abstract

Background

Distinguishing migrainous manifestations from stroke onset or TIA is sometimes difficult. In patients with migraine aura, dedicated stroke MR imaging is supposed to be normal although recently perfusion abnormalities have been described. The aim of this study was to investigate the yield of T2* in this situation.

Methods

Among 3480 consecutive patients hospitalized in our stroke emergency unit from May 2014 to December 2015, we retrospectively identified 63 patients (40 females; mean age, 31+/-10 years) with final diagnosis of migraine aura who underwent 3T MR imaging at admission.

Results

Median delay from symptoms onset to MRI was 285 min [183–497]. Abnormal asymmetric visibility of dilated cortical veins on T2* was present in 20 (32 %) of patients. This sign was lateralized according to the clinical symptoms. Posterior areas were always involved without territorial systematization (see image). Bilateral involvement was seen in 2/20 and extension to the whole hemisphere in 5/20. Prevalence of these T2* cortical veins changes was much higher among patients scanned during or within 2 hours after symptoms resolution than among those scanned later (75% vs 16%; p < 0.0001).

graphic file with name 10.1177_2396987316642909-fig132.jpg

Conclusions

Evidence of dilated cortical draining veins on T2* may be a diagnostic sign of acute migraine aura.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PREDICTION OF STROKE ONSET BEFORE vs AFTER 4.5H IS IMPROVED BY RELATIVE FLAIR AND PERFUSION IMAGING COMPARED TO THE VISUAL DWI/FLAIR MISMATCH

A Wouters ¹, P Dupont ², B Norrving ³, R Laage ⁴, GW Albers ⁵, V Thijs ⁶, R Lemmens ⁷

Abstract

Background

In patients with unknown time of stroke onset the DWI/FLAIR mismatch is a reasonable predictor of stroke onset before 4.5 hours. The accuracy of visual rating of this mismatch is moderate and therefore we aimed to optimize this prediction by using various clinical and imaging parameters in a multivariate model.

Methods

From the ‘AX200 for ischemic stroke trial’ 141 patients were included. Relative FLAIR signal intensity (rFLAIR) was calculated in a voxel-based manner in the region of non-reperfused core (DWI lesion with Tmax >6 s). Mean Tmax was calculated in the total region with Tmax >6 s. Mean rFLAIR, mean Tmax, lesion volume with Tmax >6 s, age, site of arterial stenosis, core-volume and location of infarct were, together with their interaction terms, analyzed by logistic regression to predict stroke onset time before or after 4.5 h. Differences in deviances were used to select the model with the highest accuracy.

Results

ROC-analysis revealed an AUC of 0.68 (95%CI 0.59–0.78) for the visual DWI/FLAIR mismatch, which resulted in correctly classifying 69% of patients with an onset time before or after 4.5 h. In the logistic regression with mean rFLAIR, age and mean Tmax as predictive variables the accuracy was significantly increased (p = 0.03) to 0.82 (95% CI 0.74–0.89). Using this model 77% of patients were correctly categorized in stroke onset before vs after 4.5 h.

Conclusions

Our results suggest that using rFLAIR and perfusion imaging improves prediction of time from symptom onset before vs after 4.5 h compared to visual DWI/FLAIR mismatch rating.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

SUBTLE FLAIR LESIONS IN ACUTE STROKE EXTEND BEYOND THE DIFFUSION LESION

A Wouters ¹, P Dupont ², B Norrving ³, R Laage ⁴, GW Albers ⁵, V Thijs ⁶, R Lemmens ⁷

Abstract

Background

Visual FLAIR abnormalities are typically absent in hypoperfused tissue that does not exhibit diffusion restriction. We analyzed whether subtle, quantitative FLAIR abnormalities were present in areas of PWI/DWI mismatch and whether this FLAIR increase correlated with the severity of hypoperfusion.

Methods

From the ‘AX200 for ischemic stroke trial’ 102 patients were included. The ischemic core (ADC < 620*10^6 mm2/s) and the region of hypoperfusion (Tmax > 6 s) were delineated. Mean FLAIR voxel-based values in the PWI/DWI mismatch were compared to the contralateral hemisphere. Additionally the relative FLAIR (rFLAIR) was obtained for every voxel in the PWI/DWI mismatch area. Linear regression was performed for these voxels with rFLAIR as the dependent variable and Tmax as explanatory variable to obtain a regression coefficient (b-value). The b-values of every patient were combined in meta-analysis. Age, size of perfusion deficit, size of DWI lesion and stroke onset time were included as possible moderators.

Results

There was a median increase of 4.8% (IQR 0.2–7.4%, p < 0.01) in FLAIR values in the PWI/DWI mismatch area compared to the contralateral hemisphere. Meta-analysis showed a relationship between rFLAIR changes and depth of hypoperfusion: b-value of 0.21 (95%CI 0.09–0.34, p < 0.01) (Figure1). There was no relationship between rFLAIR and the other moderators.

Conclusions

Subtle FLAIR changes are present in the PWI/DWI mismatch area, which correlate with the severity of hypoperfusion.

graphic file with name 10.1177_2396987316642909-fig133.jpg

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

RELATIONSHIP BETWEEN TIME DEPENDENCY OF DWI-ASPECTS AND CBF GRADE OF MR PERFUSION IN ACUTE STROKE PATIENTS WITH THE CAROTID ARTERY OCCLUSION

K Yoshioka ¹, T Mori ², T Iwata ², Y Tanno ², S Kasakura ², S Kuroda ²

Abstract

Background

It remains unclear how strongly perfusion findings are related to time dependency of MR-DW images(DWI).

Methods

Included in our retrospective analysis were acute ischemic stroke patients 1)admitted to our stroke center within 6 hours of the onset between Jan 2004 and May 2015, 2)underwent MRA, displaying complete occlusion of the affected carotid artery. We evaluated time from onset to MRI, DWI-ASPECTS(ACT) at arrival and CBF grade, which was calculated by using bilateral time-intensity curves(TICs) of MRperfusion. TICs were generated on region of interests set at symmetrical positions of the bilateral MCA territories. According to the time-to-peak(TP) and the peak-signal(PS) comparing the affected side(a) with the contralateral side(c), we regarded the affected-sided PSa divided by TPa as possible CBFa and the contralateral-sided PSc divided by TPc as possible CBFc. CBF grade1 was defined as CBFa divided by CBFc(CBF%) less than 0.2, grade2 as CBF% of 0.2 or more and CBF% less than 0.7 and grade3 as CBF% of 0.7 or more.

Results

68 patients were included. Median time from onset to MRI was 1.9, and median ACT was 7. Median ACT in grade1, 2, and 3 was 1, 5.5, and 9(p < 0.0001), respectively, and there was a statistical significant difference between any grade groups(p < 0.016). Patients with ACT of 6 or more were 1/11(0.9%) in grade1, 15/30(50%) in grade2, 26/27(96.3%) in grade3.

Conclusions

Ratios of patients with time from onset to MRI within 6 hours and ACT of 6 or more were very low in grade1, about 50% in grade2, about 96% in grade3.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

MULTIPHASE COMPUTED TOMOGRAPHY ANGIOGRAPHY INCREASES DETECTION OF INTRACRANIAL OCCLUSION IN ACUTE ISCHEMIC STROKE

AYX YU ¹, C Zerna ², Z Assis ³, JK Holodinsky ⁴, PA Randhawa ², M Najm ², M Goyal ⁵, BK Menon ⁶, AM Demchuk ⁵, SB Coutts ⁶, MD Hill ⁶

Abstract

Background

Neurologists play a critical role in the evaluation of patients with acute ischemic stroke, where rapid and accurate identification of an intracranial vascular occlusion is crucial. Our objective was to evaluate whether the use of multiphase CT angiography (CTA) improves interrater agreement for intracranial occlusion detection between stroke neurology trainees and an expert neuro-radiologist.

Methods

A neuro-radiologist and two stroke neurology fellows independently reviewed 100 prospectively collected single-phase and multiphase CTA scans from acute ischemic stroke patients with mild symptoms (National Institute of Stroke Scale score less than or equal to 5). The presence and location of vascular occlusion(s) were documented. Interrater agreement between single- and multiphase CTA was quantified using unweighted kappa statistics. We assessed for any occlusions, anterior versus posterior occlusions, and pial vessel asymmetry.

Results

Using multiphase CTA, the neuro-radiologist detected 53 anterior and 15 posterior circulation occlusions with a median reading time of two minutes per scan. Median reading time for the neurologists was three minutes per multiphase CTA scan. Interrater agreement was fair between the two neurologists and neuro-radiologist when using single-phase CTA (κ = 0.45 and 0.32). Agreement improved minimally when stratified by anterior versus posterior circulation. When using multiphase CTA, agreement was high for detection of occlusion or asymmetry of pial vessels in the anterior circulation (κ = 0.80 and 0.84).

Conclusions

Multiphase CTA improves diagnostic accuracy in minor ischemic stroke for detection of anterior circulation intracranial occlusion and may improve clinical management of acute ischemic stroke patients.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE PERFORMANCE OF TMAX IN ACUTE STROKE VALIDATED WITH NON-QUANTITATIVE PET

O Zaro Weber ^1,², W Moeller-Hartmann ³, WD Heiss ¹, J Sobesky ²

Abstract

Background

The accuracy of perfusion weighted (PW)-MRI based quantitative maps of Tmax remains a matter of debate. Since Tmax is used in several studies and recent major clinical trials (ECASS-4: ExTEND) we investigated the performance of Tmax in acute stroke with non-quantitative 15O-water-PET in a previously unpublished patient sample.

Methods

PW-MRI and CBF-PET was performed in acute stroke patients. The performance of Tmax to detect tissue at risk of infarction was compared to non-quantitative CBF-PET. In a receiver operating characteristic (ROC) analysis, the performance of Tmax maps was assessed using non-quantitative CBF-PET maps with respect to penumbral flow. The penumbral threshold was set as <70% of the unaffected hemisphere. The best PW-thresholds as well as its sensitivity and specificity were calculated.

Results

For 15 stroke patients (median time MRI to PET: 55 minutes; patients imaged within 12 hours after stroke) the best cut-off value for Tmax to identify penumbral flow was 5.9 seconds with a sensitivity and specificity of 85% and 89%.

Conclusions

If these data are compared with a previous validation of Tmax with quantitative CBF-PET in acute stroke we can further corroborate, in the biggest comparative patient sample so far, that among the commonly used PW maps, quantitative Tmax maps showed an excellent estimate of penumbral flow.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

INFARCT FATE IN SUBCORTICAL STROKE: A VOXEL-BASED ANALYSIS

R Adam ¹, M Duering ¹, M Achmüller ¹, B Gesierich ¹, M Dichgans ¹

Abstract

Background

Subcortical ischemic infarcts show diverse fates when assessed months after stroke. Recent MRI studies have demonstrated a variable frequency of cavitation, hyperintensity (T2/FLAIR), and disappearance but did not account for within-lesion-heterogeneity. We systematically determined the rates of infarct conversion into a cavity, hyperintense lesion, or seemingly normal tissue focusing on individual voxels.

Methods

We studied 141 consecutive patients with acute stroke recruited through an observational, prospective study (NCT01334749). MRI was done in the acute phase, at 6 and 36 months using the same 3 Tesla scanner and 3D-T1-weighted, 3D-FLAIR, and DWI sequences. Infarcts were segmented from baseline diffusion trace images. Images were co-registered and infarct voxels from baseline scans were classified into 3 categories based on their appearance on follow-up scans: voxels that turned into a cavitation, voxels that turned into a hyperintensity (FLAIR), and no lesion.

Results

Baseline scans showed a total of 59 subcortical ischemic infarcts in 45 patients. For the majority of infarct voxels there was no visible lesion on the corresponding scan at 6 (71% ± 3%) and 36 (73% ± 8%) months follow-ups and in five infarcts (8%) the initial lesion completely disappeared within 6 months. Thirty-nine (66%) infarcts displayed cavitation at 6 months but the proportion of voxels that turned into a cavitation was small (7% ± 2%).

Conclusions

Subcortical ischemic infarcts display considerable within-lesion-heterogeneity in infarct fate. The majority of infarct tissue visible on baseline diffusion scans resolves without visible abnormalities on follow-up scans. Considering within-infarct-heterogeneity may be critical for future studies on infarct mechanisms and clinical outcome.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CLINICAL AND IMAGING FEASIBILITY OF CEREBROVASCULAR REACTIVITY MEASUREMENT IN PATIENTS WITH MILD ISCHAEMIC STROKE

G Blair ¹, Y Shi ¹, M Thrippleton ¹, I Hamilton ¹, P Andrews ¹, F Doubal ¹, I Marshall ¹, J Wardlaw ¹

Abstract

Background

Cerebral small vessel disease (SVD) pathophysiology remains poorly understood. Impairment of cerebrovascular reactivity (CVR) may play a role but little data exists on CVR in at-risk brain tissues. Advanced MRI techniques combined with breathing carbon dioxide (CO₂) allow tissue specific measurement of CVR. We tested the feasibility of these techniques in patients with stroke and the ability to measure CVR in subcortical structures.

Methods

48 mild stroke patients breathed 6% CO₂ in air for two 3 minute spells during a BOLD MRI sequence on a 1.5T scanner. 16 regions of interest were manually drawn on T1 images before co-registration to the BOLD image. CVR was calculated using linear regression of the BOLD signal against end-tidal CO₂ (EtCO₂) and expressed as % BOLD signal change/mmHg change in EtCO2. Patients reported symptoms experienced during the scan and rated tolerability on a four point scale.

Results

44 patients completed the CVR scan (age 53–88). Three withdrew due to claustrophobia, one withdrew due to breathlessness. Overall tolerability was rated between very tolerable and tolerable. 10 patients reported no symptoms. 29 reported respiratory symptoms. Feasibility of extracting tissue-specific CVR data is shown (figure).

graphic file with name 10.1177_2396987316642909-fig134.jpg

Conclusions

We show that CVR measurement is feasible and well tolerated and that CVR can be measured in specific subcortical tissues making this technique useful for investigating microvascular function in SVD.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

GRAPH ANALYSIS OF THE MOTOR NETWORK AFTER PRIMARY MOTOR CORTEX STROKE: LONGITUDINAL CHANGES IN NODE STRENGTHS AND RECOVERY

E Dirren ¹, J Richiardi ², F Albert ¹, R Sztajzel ¹, A Kleinschmidt ¹, E Carrera ¹

Abstract

Background

Recently, brain graph analysis has been applied to stroke, assuming that restoration of network architecture would be a relevant surrogate of recovery. The present study sought to identify the clinical relevance of dynamic changes in the motor network organization, after stroke limited to the primary motor cortex (M1).

Methods

We included 5 patients (66 y(52–81)) admitted to the Geneva University Hospital for hand paresis following M1 strokes. Motor examination was performed with evaluation of handgrip and finger dexterity at three time-points (TP1:<10 days of stroke, TP2:at 3 weeks, TP3:at 3 months). On the same day, resting-state fMRI data were acquired. Correlations between predefined nodes of the motor network were used to build the graph adjacency matrix. The global strength of the motor network was defined as the sum of the strengths of its nodes.

Results

4 patients were scanned at TP1, 5 at TP2, one at TP3. Between TP1 and TP2, there was a moderate improvement in handgrip (23 kg ± 7 vs 25 kg ± 8; p = 0.208) and dexterity (2773s ± 418 vs 2141s ± 179; p = 0.210). A non-significant increase in strength of the motor network (0.0706 ± 0.0092 vs 0.0857 ± 0.0214; p = 0.371) was found. Finally, there was a positive correlation between changes in dexterity and in strength of the motor network (r = 0.855; p = 0.145).

Conclusions

Based on a limited number of patients, we have not yet been able to reveal significant correlations between changes in node strength in the motor network and motor function. Inclusions of additional patients and comparison with healthy subjects will be performed to determine the clinical relevance of network analysis after stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

INFLUENCE OF VASCULAR RISK FACTORS ON WHITE MATTER HYPERINTENSITY AND BRAIN TISSUE VOLUMES IN VERY ELDERLY PEOPLE

DA Dickie ¹, S Ritchie ², S Cox ², E Sakka ¹, N Royle ³, B Aribisala ¹, MC Valdés Hernández ¹, A Pattie ², J Corley ², J Starr ⁴, M Bastin ¹, I Deary ², J Wardlaw ¹

Abstract

Background

Hypertension in midlife is a major risk factor for white matter hyperintensities (WMH). Few studies have assessed vascular risk factors (VRF) and brain volumes in very elderly people. We assessed VRF, WMH, normal appearing grey and white matter and whole brain volumes in community-dwelling subjects aged ∼92 years.

Methods

In members of the Lothian Birth Cohort 1921, we performed brain MRI and quantified WMH, grey and white matter, and whole brain volumes using validated methods. We recorded history of hypertension, hyperlipidemia, diabetes, cardiovascular disease, smoking, measured blood pressure and glycated haemoglobin. We used linear regression to quantify variance in WMH, grey and white matter, and whole brain volumes attributable to VRF, adjusting for intracranial volume, age and gender.

Results

In 49 subjects (N = 23 male) aged 92.1 ± 0.34 years, combined VRF explained a small and non-significant proportion of variance in WMH (R-squared = 0.08, F = 1.37, P = 0.234) and whole brain (R-squared = 0.05, F = 1.21, P = 0.319) volumes, but significant proportions in grey (R-squared = 0.25, F = 3.7, P = 0.002) and white matter (R-squared = 0.18, F = 3.35, P = 0.004) volumes: greater VRF = smaller grey/white matter volumes. Previous versus never smoking (absolute standardised betas = 0.77–1.53) and current hyperlipidemia (absolute standardised betas = 0.49–1.07) were consistently stronger individual predictors for worsening volumes than hypertension (absolute standardised betas = 0.12–0.30).

Conclusions

Combined VRF were not significantly associated with whole brain and WMH volumes but were strongly associated with grey and white matter volumes in the tenth decade of life. Non-smoking and lipid lowering may have important effects on preserving normal-appearing grey and white matter volumes, thus possibly reducing dementia and stroke risk, in older age.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

NOVEL MR IMAGING TO UNDERSTAND CAROTID WEB PATHOPHYSIOLOGY: THE CARWEB STUDY

PV Eswaradass ¹, M Boesen ², R Frayne ³, B Menon ⁴

Abstract

Background

The carotid web is a shelf-like projection within the lumen of the carotid bulb. It can potentially cause recurrent strokes. We describe the first detailed MR imaging study of carotid webs and correlate these findings with pathophysiological constructs.

Methods

The CARWEB study is a prospective imaging based cohort study of patients with carotid webs identified using CTA. All patients undergo 3T MRI (with Phase Contrast (PC), cine FSE, cine PC and 3D CE MRA) of the neck to visualize the carotid web on MRI and study morphology, composition and pulsatility. Demographics, MR brain imaging and prospective data on recurrent stroke risk is also collected.

Results

The study has enrolled 5 patients since initiation (mean age 57.4 yrs, all female). Recurrent ischemic events were seen in 2/5 patients. Carotid web was visible on 3D CE MR in 5/5. CE MRA and FSE demonstrated slow blood flow distal to the carotid web along with blood pooling post-contrast on one side of the web in all 5 patients. Cardiac-phase resolved cineFSE demonstrated atypical pulsatility of the carotid wall near the web. Multi-contrast FSE demonstrated thickening of the carotid wall with no evidence of atherosclerosis.

Conclusions

From the ongoing CARWEB study, we identify carotid webs as a non-atherosclerotic process (likely FMD) easily identified on MR imaging. Carotid webs are associated with impaired regional wall pulsatility and stasis (blood pooling) around the web, resulting in increased stroke risk.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

IDENTIFICATION OF SYMPTOMATIC CAROTID ATHEROMA USING SODIUM FLUORIDE-POSITRON EMISSION TOMOGRAPHY

N Evans ¹, J Tarkin ², S Malani ¹, J Rudd ², E Warburton ¹

Abstract

Background

Microcalcification is a histopathological feature of atheroma at risk of rupture; so-called “vulnerable plaques.” Positron emission tomography (PET) using ¹⁸F-sodium fluoride (NaF) has been used to detect microcalcification in ex vivo histology, though use in vivo has been largely limited to coronary vessels. We investigated the utility of NaF-PET to identify symptomatic carotid artery atheroma in vivo in the setting of acute ischaemic stroke.

Methods

Symptomatic carotid artery stenosis of >50% was imaged using NaF-PET within 14 days of ipsilateral cerebral hemisphere infarct. Symptomatic carotid arteries were compared to the contralateral asymptomatic carotid artery. NaF dose was 125 MBq with 60 minute uptake on a GE Discovery 690 with 64 slice computed tomography. NaF uptake was measured using standardised uptake values for each participant’s single region of maximum uptake (SUVmax) and mean of the SUVmax for each slice across the stenosis (meanSUVmax). Symptomatic and asymptomatic artery readings were compared using paired t testing.

Results

14 carotid arteries were analysed (7 symptomatic, 7 asymptomatic). Mean SUVmax was significantly higher in symptomatic carotid arteries than asymptomatic arteries: 2.39 (SD 0.83) and 1.72 (SD 0.62) respectively (p = 0.045). Mean symptomatic artery meanSUVmax was 2.13 (SD 0.68), significantly higher than asymptomatic artery meanSUVmax of 1.53 (SD 0.51) (p = 0.03). Calcium scores did not differ between symptomatic and asymptomatic carotid arteries (p = 0.34).

Conclusions

We demonstrate that NaF-PET can non-invasively identify symptomatic carotid atheroma in vivo. This has important implications for understanding atherosclerosis pathophysiology, as well as potential clinical applications to identify and risk-stratify vulnerable carotid atheroma.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EVOLUTION OF CAROTID ARTERY ATHEROSCLEROTIC PLAQUE APPEARANCES ON MRI OVER TIME

L Fisch ¹, L Carlton Jones ², R Jäger ², MM Brown ¹

Abstract

Background

Magnetic resonance imaging (MRI) shows features of vulnerable plaque, but little is known about the long-term stability of these findings. We studied the evolution of carotid artery atherosclerotic plaque characteristics using MRI.

Methods

Patients with carotid atherosclerosis recruited into a trial of optimised medical therapy (OMT) alone versus revascularisation had MR plaque imaging (T1, T2, contrast-T1) at enrolment and after 2 years follow-up. All patients received OMT. Two observers analysed plaque characteristics on MRI in consecutive non-revascularised patients. Differences were resolved by consensus. Stenosis severity was categorised on contrast-enhanced MR angiography as <50%, 50–69% or 70–99%. Changes over time were compared using paired t-tests.

Results

15 carotids from 10 patients have been studied to date. At baseline, 4 patients had severe carotid stenosis (70–99%). All four of these plaques significantly increased in length over time (mean 8.8 mm at baseline vs. 27.0 mm at 2-years, p = 0.03). In stenosis of <70%, plaque length remained stable over 2 years (mean 18.0 mm vs. 15.3 mm, p = 0.23). Stenosis severity remained stable (n = 9) or decreased (n = 3) in the majority. There was no significant change in inflammatory features (mean score 1.42 vs. 1.00, p = 0.52). Haemorrhage was present in 15% of plaques at baseline and persisted in all patients.

Conclusions

Optimised medical therapy is sufficient to prevent progression of atherosclerotic plaque over two years in patients with less than 70% stenosis, but did not prevent stenosis greater than 70% from lengthening. Plaque length appears to be more sensitive measure of progression than other plaque features.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

COMBINATION OF AXIAL AND CORONAL DIFFUSION-WEIGHTED IMAGING FACILITATES THE DIAGNOSIS OF BRAINSTEM INFARCTION

P Felfeli ¹, H Wenz ¹, M Al-Zghloul ¹, C Groden ¹, A Förster ¹

Abstract

Background

Diffusion-weighted imaging (DWI) is a very sensitive technique for detection of small ischemic lesions in the human brain. However, in particular in the brainstem DWI may fail to demonstrate ischemic lesions. In the present study we sought to evaluate the value of combined axial and additional coronal DWI for the detection of brainstem infarction.

Methods

In 155 patients (mean age 67.5 ± 13.5 years, 95 (61.3%) males) with isolated brainstem infarction, MRI findings were analyzed, with emphasis on ischemic lesions on axial and coronal DWI.

Results

On DWI, we identified ischemic lesions in the mesencephalon in 31 (20%), pons in 115 (74.2%), and medulla oblongata in 12/20 (60.0%) patients. In 3 (1.9%) cases - all of these with medulla oblongata infarction - the ischemic lesion was detected only on coronal DWI (for an example see Figure 1). Overall, in 36 (22.6%) was more easily identified on coronal DWI in comparison to axial DWI. In these, the ischemic lesions were significantly smaller (0.06 (IQR 0.05–0.11) cm³ vs. 0.25 (IQR 0.13–0.47) cm³; p < 0.001) in comparison to those patients whose ischemic lesion was more easily (6 (3.9%)) or at least similarly well identified (114 (73.5%)) on axial DWI.

graphic file with name 10.1177_2396987316642909-fig135.jpg

Conclusions

Combination of axial and coronal DWI facilitates the diagnosis of brainstem infarction. Consequently, we suggest the inclusion of coronal DWI in standard stroke MRI protocols.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CLASSICAL HARM SIGN AND BEYOND: SURROGATES FOR POSTISCHAEMIC BLOOD-BRAIN-BARRIER DYSFUNCTION

M Griebe ¹, A Alonso ¹, P Eisele ¹, K Szabo ¹, A Gass ¹

Abstract

Background

The hyperintense acute reperfusion marker (HARM) on follow-up magnetic resonance imaging (MRI) 1–3 days after an MR contrast agent application has been shown to be a marker for blood-brain-barrier (BBB) dysfunction. We prospectively investigated patterns of BBB dysfunction as early as minutes after contrast agent application and haemorrhagic transformation (HT) in patients treated with systemic thrombolysis.

Methods

54 patients who had received rtPA treatment were imaged on a 3T MR-scanner (Siemens Skyra) including diffusion-weighted imaging (DWI), fluid-attenuated inversion recovery (FLAIR), MR-angiography, T2*-, T2- and T1-weighted imaging, contrast-enhanced perfusion-weighted imaging (PWI), followed by susceptibility-weighted imaging (SWI), T1w and FLAIR. Signs of BBB-dysfunction were analysed in contrast-enhanced T1w and FLAIR. HT was evaluated in T2* and SWI: haemorrhagic infarction, HI1 or HI2, parenchymal haemorrhage, PH.

Results

Different patterns of a BBB-dysfunction were noted: 1. sulcal hyperintensities in post-contrast FLAIR, considered as the classical HARM sign; registered both in direct proximity to the acute ischaemic lesion and in remote areas; 2. vascular hyperintensities in post-contrast FLAIR; 3. parenchymal hyperintensities in post-contrast FLAIR; 4. parenchymal hyperintensities in post-contrast T1w. HT was detectable in sixteen patients (nine HI1, seven HI2, no PH) and was associated with parenchymal signs of BBB disruption, but not with the HARM sign.

Conclusions

Damage to leptomeningeal and parenchymal vessels resulting in BBB dysfunction can be visualised in contrast-enhanced MR-imaging. BBB-lesions beyond the index lesions indicate an initially larger affected vascular territory. Thus, the HARM sign is pathophysiologically informative but in contrast to a parenchymal BBB disruption not a predictor of a haemorrhagic transformation.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

INTRACRANIAL ATHEROSCLEROSIS PLAQUE POST-CONTRAST ENHANCEMENT: HIGH-RESOLUTION MAGNETIC RESONANCE IMAGING STUDY COMPARING SYMPTOMATIC VS. ASYMPTOMATIC PLAQUES

M Hernández-Pérez ¹, E Martínez-Velasco ², J Munuera ³, M Rodríguez ⁴, A Calleja ², E López-Cancio ¹, E Cortijo ², S Franco ⁵, M Rubiera ⁶, C Vert ⁷, A Dávalos ¹, J Arenillas ²

Abstract

Background

CRYPTICAS-A project was designed to analyze the morphologic features of symptomatic vs. asymptomatic intracranial atherosclerotic plaques using high-resolution MRI (HR-MRI). In this study, we aimed to compare the prevalence and characteristics of post-contrast enhancement (PCE) between symptomatic and asymptomatic intracranial plaques.

Methods

Symptomatic intracranial atherosclerotic plaques were studied in consecutive patients with an ischemic stroke attributable to a symptomatic intracranial stenosis, who underwent 3Tesla HR-MRI within 15 days after stroke onset. Asymptomatic intracranial plaques were imaged in healthy subjects included in the BNM-Asymptomatic Intracranial Atherosclerosis Study. Imaging protocol included MR-Angiography and orthogonal sequences targeting the stenotic segment, including post-contrast sequences. Images were blind-processed using Osirix software. Plaque area was measured in T2 sequences, and PCE was assessed by visual inspection in T1 sequences and then calculated as the percentage increase in mean intraplaque signal intensity after gadolinium administration.

Results

Eleven symptomatic and 31 asymptomatic intracranial plaques were fully analysed. 91% symptomatic and 39% asymptomatic plaques showed PCE. Median signal intensity increase in plaques with PCE was similar in symptomatic and asymptomatic plaques. Significant correlations were found between plaque area and PCE intensity increase both in symptomatic (r = 0.67, p = 0.04) and asymptomatic (r = 0.75, p = 0.01) plaques.

graphic file with name 10.1177_2396987316642909-fig136.jpg

Conclusions

Prevalence of PCE is higher in symptomatic vs. asymptomatic intracranial atherosclerotic plaques. However, more than a third asymptomatic plaques show PCE, whose intensity appears to be associated with plaque size.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

VALIDATION OF A NOVEL, AUTOMATED PERFUSION LESION-DETECTION ALGORITHM IN ACUTE ISCHEMIC STROKE

JY Hu ¹, AA Khalil ^1,², R Ganeshan ¹, K Villringer ¹, A Villringer ³, JB Fiebach ¹

Abstract

Background

Manual delineation of perfusion lesions is a time-consuming and subjective process ill-suited for large research datasets. We developed a user-independent, automated algorithm that identifies potential perfusion lesions on bolus-tracking MRI data.

Methods

After subtracting cerebrospinal fluid (CSF) using an ADC-derived mask, the algorithm determines the vascular territories affected by the acute infarct(s) using a template. It then sorts potential perfusion lesions into high, medium, and low-likelihood masks based on their size and proximity to the infarcts. We tested the algorithm on time-to-maximum (Tmax) >6 s maps from 21 patients scanned within 24 hours of symptom onset. Perfusion lesions manually delineated on Tmax > 6 s maps by consensus of two experts were compared quantitatively with algorithm-generated high-likelihood masks, and with maps thresholded at 6 seconds without further processing.

Results

We found a strong, positive correlation between algorithm-generated and manually delineated perfusion lesion volumes (ρ = 0.87, p < 0.001) with the algorithm slightly underestimating perfusion lesions (bias = −1.15 ml, limits of agreement = −14.38–12.08 ml, p = 0.44). A strong correlation between manual and thresholded lesion volumes (ρ = 0.90, p < 0.001) was also observed but thresholding alone significantly overestimated lesion volumes (bias = +43.6 ml, limits of agreement = −4.57–91.67, p < 0.001). Median spatial concordance (Dice coefficient) between algorithm-generated and manual lesions was 0.6 (IQR 0.4–0.75).

Conclusions

Our algorithm showed excellent volumetric and spatial agreement with perfusion lesions identified by expert consensus. It greatly surpassed simply thresholding the perfusion maps and may be an efficient method for analyzing large datasets.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ELECTRIC PROPERTIES TOMOGRAPHY IN ISCHEMIC STROKE: RESULTS OF AN EX-VIVO PILOT STUDY

U Jensen-Kondering ¹, R Böhm ², L Shu ¹, U Katscher ³, O Jansen ¹

Abstract

Background

Electric Properties Tomography (EPT) is a sequence which delivers information on tissue electrical conductivity. It has been mostly used in human brain tumour imaging. Ischemic stroke is another promising application. The aim of this study was to optimise the sequence and demonstrate the feasibility of EPT in a rodent model of stroke.

Methods

Five culled Wistar rats from another stroke study were examined in a 3T scanner using a dedicated animal coil. Three of them had been subjected to MCAo. In addition to DWI, EPT was performed using a Steady-State Free-Precession (SSFP) sequence (TR/TE = 4.5/2.3 ms, measured voxel size = 0.6 × 0.6 × 1.2 mm³, flip angle = 38°, NEX = 4). From the transceive phase φ of these SSFP scans, conductivity σ was estimated by the equation σ = Δφ/(2μ₀ω) with Δ the Laplacian operator, μ₀ the magnetic permeability, and ω the Larmor frequency. Subsequently, a median filter was applied, which was locally restricted to voxels with comparable signal magnitude.

Results

Healthy grey and white matter showed markedly different conductivity. All animals subjected to MCAo exhibited an infarct as demonstrated on DWI. Conductivity within the infarcted region was 60–70% of the conductivity of healthy gray matter (Fig. 1).

graphic file with name 10.1177_2396987316642909-fig158.jpg

Conclusions

EPT is feasible in a rodent model of stroke. Infarcted tissue exhibited decreased conductivity. In-vivo experiments with an emphasis on penumbra imaging are planned.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CEREBRAL VEIN AND DURAL SINUS THROMBOSIS: AN EVALUATION OF 65 CASES

DC Jianu ¹, SN Jianu ², F Dan ¹, L Petrica ³, D Matcau ¹

Abstract

Background

Cerebral vein and dural sinus thrombosis (CVT) generally manifest in various non-specific clinical forms.

Aims To identify CVT risk factors, to describe the demographic, clinical, laboratory, and neuroimaging data, and to evaluate the treatment and outcome.

Methods

We analyzed 65 CVT consecutive patients (pts), that were examined at admission, at 90 days, and after twelve months, using the mRS scores.

Results

Mean age was 38.6 years (SD 7.7); 44 were women, 79.5% of them being fertile. The most frequent neurological syndrome was intracranial hypertension. CT showed direct signs of dural sinuses thrombosis in 11 pts, and venous cerebral infarcts in 25 cases. MRI/MRA/CTA identified thrombosis of SSS in 43 pts, lateral sinus in 26 cases, cavernous sinus in four pts, etc. Emissary vein thrombosis was identified in five cases; 15 out of 65 MRI had a normal prior CT. DSA revealed isolated cortical veins occlusion in 5 cases. Risk factors were identified in 46 pts (70.8%); congenital thrombophilia being the most common (22 cases). All pts received anticoagulant therapy. After 12 months from admission, functional outcome was good, with a mRS score ≤2 in 39 pts (60%), moderate/severe disability in 19 cases, the death rate being 10.8% (7 pts). Severity of CVST was found to be associated with presence of rapidly worsening symptoms (p = 0.001), and occlusion of 4 or more sinuses (p = 0.005).

Conclusions

CVT was common in women of fertile age. The outcome was favorable if the pts were promptly diagnosed and adequately treated.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

HIPPOCAMPAL HYPERINTENSITY ON DIFFUSION-WEIGHTED MRI: INDIVIDUAL SUSCEPTIBILITY TO TRANSIENT GLOBAL AMNESIA

HY Kim ¹

Abstract

Background

Dot-like hippocampal hyperintensities on diffusion-weighted MRI (DWI) have been reported as a pathognomonic imaging finding of transient global amnesia (TGA). However, we found that these are occasionally observed in some patients without clinical symptoms of TGA. Clinical and radiological investigations in these patients could extend our understanding of the pathomechanism of TGA.

Methods

We identified eight patients who did not show clinical symptoms of TGA despite the presence of pathognomonic hippocampal lesions (No-TGA group, n = 8). For the comparison group, twice the number of age- and sex-matched patients were selected from among patients who had been diagnosed with TGA on the basis of diagnostic criteria (TGA group, n = 16). We investigated clinical findings including vascular risk factors and preceding activities and radiological findings including hippocampal lesions, concomitant lesions, and white matter hyperintensities.

Results

No significant difference was found in vascular risk factors, years of education, or underlying cognitive function between the two groups. More than half of the patients in each group performed preceding Valsalva-associated activities. Multiple hippocampal lesions or concomitant lesions in the cingulate gyrus were found exclusively in the TGA group. No difference was found between the two groups in underlying severity of white matter hyperintensities.

Conclusions

Dot-like hippocampal hyperintensities could be observed without the typical symptoms of TGA. Valsalva maneuver-associated activities could produce asymptomatic hippocampal lesions. The symptoms of TGA may be presented on a spectrum from no symptoms to mild vegetative symptoms or to the typical symptoms of TGA, depending on individual susceptibility.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

IRON-MARKERS IN HEREDITARY CEREBRAL AMYLOID ANGIOPATHY ON 7T MR IMAGING

E Koemans ¹, E van Etten ¹, A van Opstal ², SM Labadie ², G Terwindt ¹, A Webb ², S Greenberg ³, M Wermer ¹, M van Buchem ², J van der Grond ², S Rooden ²

Abstract

Background

Hereditary Cerebral Hemorrhage with Amyloidosis Dutch-type (HCHWA-D) is a unique model to study early stages of Cerebral Amyloid Angiopathy (CAA). Iron is a marker of hemorrhage and is related to neurodegeneration. We investigated radiologic iron-markers in presymptomatic and symptomatic HCHWA-D-patients on 7-Tesla MRI.

Methods

Symptomatic mutation-carriers (n = 15) with previous intracerebral hemorrhage (ICH), presymptomatic mutation-carriers (n = 11), and controls (n = 26) were enrolled in the EDAN (Early Diagnosis in Amyloid Angiopathy Network) study. ICH, intragyral hemorrhaging, microbleeds, superficial siderosis, cortical inhomogeneity, hypointense foci, hypointensity and phase-shift difference of the basal ganglia and cortex were scored on T₂*-weighted images and compared between groups adjusted for age and sex.

Results

Symptomatic mutation-carriers had more often microbleeds (100%, controls19.2%;p < 0.001), cortical microbleeds (60%, controls3.8%;p < 0.001), superficial siderosis (86.7%, controls0.0%;p < 0.001), intragyral hemorrhaging (26.7%, controls0.0%;p < 0.001), increased phase-shift difference of the occipital cortex (p = 0.001), and hypointensity of the basal ganglia (20%, controls3.8%;p = 0.004). Presymptomatic mutation-carriers tended to have cortical microbleeds more often (18.2%, controls3.8%;p = 0.150), and increased occipital phase-shift difference (p = 0.085), but this was not statistically significant. A new marker, the striped cortex (figure), was found in symptomatic HCHWA-D-patients (40%, controls0%;p < 0.001).

Conclusions

Cortical microbleeds and increased occipital phase-shift difference may be early CAA markers. Other iron-markers, including superficial siderosis and the striped cortex, only appear in patients with a history of ICH and might be related to previous hemorrhages, neurodegeneration, or amyloid-accumulation.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

POST-STENOTIC CAROTID ARTERY COLLAPSE IS ASSOCIATED WITH TRANSIENT ISCHEMIC SYMPTOMS

SM Koskinen ¹, P Ijäs ², L Soinne ², K Nuotio ², HM Silvennoinen ³, L Valanne ³, PJ Lindsberg ²

Abstract

Background

Severe carotid stenosis (CS) with near-occlusion i.e. post-stenotic collapse of the distal internal carotid artery (ICA) based on conventional angiography has been associated with lower stroke risk. We adopted computed tomography angiography (CTA) in determining a discriminatory side-to-side difference in distal ICA luminal diameter (LD) to distinguish collapse, and investigated the association to symptom state.

Methods

From 493 consecutive CS patients endarterectomized (37 bilaterally) in our hospital, 471 had undergone pre-operative carotid CTAs. We rated the ipsilateral ICAs (bilaterally operated vessel-wise) as collapsed if the ICA LD side-to-side difference was ≥1.0 mm [Koskinen et al. Neuroradiology 2014;56(9):723–729]. Advanced contralateral ICA pathology was considered a cause for exclusion (e.g. occlusion or > 70% stenosis), leaving 304 vessels to be allocated into discrete index symptom states; asymptomatic, pure amaurosis fugax (pAFX), hemispheric transient ischemic attack (TIA), and stroke.

Results

Collapse was present in 38.8% of the vessels, and it tended to be more common in the symptomatic than the asymptomatic CS (41.2% vs. 28.8%). Of the 101 collapsed ICAs with symptomatic CS, 34 (33.7%) had caused a pAFX, 30 (29.7%) a hemispheric TIA, and 37 (36.6%) a stroke (Pearson χ² p = 0.011). Collapse was more common in CS associated with pAFX (57.6%) and hemispheric TIA (42.3%) as compared to stroke (33.6%, Fisher’s exact test p = 0.018).

Conclusions

ICA collapse occurs commonly in symptomatic and asymptomatic CS. Collapse was more prevalent in patients with TIA and pAFX but stroke was still the presenting symptom in 33.6%. Factors associated with stroke risk in patients with collapsed ICA deserve further study.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

VASCULAR IMAGING FEATURES AND PROGNOSTIC FACTORS FOR THE IMAGING OUTCOMES OF THE VERTEBROBASILAR ARTERIAL DISSECTION

J Lee ¹, MG Kim ¹, JI Gwon ¹

Abstract

Background

We aim to identify the vascular imaging features and imaging outcomes of the dissection in patients with vertebrobasilar arterial dissection and prognostic factors which influence improving the imaging outcomes.

Methods

We included consecutive patients diagnosed with vertebrobasilar arterial dissection on the baseline vascular images. Imaging findings on the baseline were obtained within 7 days after onset of the ischemic symptoms and/or headache, and follow-up vascular images were performed 6 months or 1 year. We compared the vascular imaging features and the degrees of recovery (complete or partial recovery) between baseline and follow-up vascular images.

Results

A total of 50 patients who underwent baseline and 6-month or a year vascular imaging were compared for these analyses. The most common site of a dissection was in the intracranial vertebral artery (V4 segment, 48%). The baseline vascular images identified an aneurysm in 42% and stenosis or occlusion in 74%. Follow-up images showed partial or complete improvement in 50% with a year. The odds ratios for complete or partial improvement on the follow-up vascular images were 0.20 ([0.06–0.73], p = 0.015) from the lesion in the distal vertebral artery (V3 or V4 segment) and 0.1 ([0.06 to 0.73], p = 0.044) from dyslipidemia by the multivariate analysis including age, gender, and lesion in the posterior inferior cerebellar artery.

Conclusions

The rate of complete or partial improvement was over 50% within a year after vertebrobasilar arterial dissection. Dyslipidemia and distal vertebral arterial dissection are poor prognostic factors for the recovery of the vascular lesion.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

DIFFERENT FEATURES OF VASCULAR IMAGES AND OUTCOMES OF ANTERIOR AND POSTERIOR CIRCULATION DISSECTIONS

J Lee ¹, MG Kim ¹, JI Gwon ¹

Abstract

Background

Vascular imaging features and risk factors are not well established according to the location of the cervicocerebral artery dissection. We aim to compare the imaging outcomes and prognostic factors between anterior and posterior circulation dissection.

Methods

Consecutive patients who presented with ischemic symptoms and/or headache and underwent brain vascular imaging within 7 days after the onset of the symptoms were enrolled. Demographic characteristics, putative risk factors, imaging findings were assessed between anterior circulation dissection (ACD) and posterior circulation dissection (PCD). The baseline and follow-up vascular images (6 months or 1 year after the onset of symptoms) were compared.

Results

A total of 117 patients (n = 32 with ACD and n = 85 with PCD) was eligible. Patients with PCD were older (OR = 1.5 by increasing 10 years old [1.02–2.03]) and had a dissection associated with exercise or neck manipulation more frequently (OR = 4.8 [1.2–18.1]) compared to patients with ACD. The complete reverse on the follow-up images at the 6 months or 1 year was identified in 9 patients with ACD and 11 patients with PCD (45% vs. 22%, p = 0.054). Neither anticoagulation nor antiplatelet demonstrated significant differences between the frequency of the complete reverse on the follow-up vascular images in patients with ACD and PCD (33% vs. 21%, p = 0.613 for anticoagulation; 44% vs. 23%, p = 0.087 for antiplatelet).

Conclusions

These results substantiate the difference in the risk factors and radiologic features according to the dissection site. There was no difference in efficacy of antiplatelet and anticoagulant drugs at complete reverse of the lesion after cervicocerebral artery dissection.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

MEASURES OF SIGNAL INTENSITIES ON TIME-OF-FLIGHT MAGNETIC RESONANCE ANGIOGRAPHY TO REFLECT HEMODYNAMIC SIGNIFICANCE OF INTRACRANIAL ARTERIAL STENOSIS

X Leng ¹, L Lan ¹, J Abrigo ², KS Wong ¹

Abstract

Background

Signal intensity ratio (SIR) of intracranial arterial stenosis (ICAS), evaluated as the ratio of distal to proximal signal intensities across ICAS on maximum intensity projections (MIP) of time-of-flight magnetic resonance angiography (TOF-MRA), could represent the hemodynamic significance of symptomatic ICAS. However, there was doubt that it might be more reasonable to measure the signal intensities on MRA source images in the evaluation of SIR.

Methods

The distal to proximal SIRs of symptomatic ICAS lesions were respectively evaluated on the MIPs of TOF-MRA showing the greatest degree of stenosis (SIR-MIP), and on the source images showing the cross-sections of the index artery (SIR-source), which were separately correlated with CT perfusion measures. Steiger's Z tests were used to test the differences between the correlations.

Results

Overall, 50 cases with symptomatic ICAS were analyzed. The SIRs of the ICAS lesions by the two methods were significantly, linearly correlated (Pearson correlation coefficient 0.671, p < 0.001), but significantly different in the mean absolute values (SIR-MIP 0.77 versus SIR-source 0.86; p < 0.001). The correlations between SIR-MIP or SIR-source and ipsilateral cerebral blood volume (p = 0.986 for Steiger's Z test), cerebral blood flow (p = 0.390), and mean transit time (p = 0.524), on CT perfusion, were not significantly different.

Conclusions

The two methods to assess SIR of ICAS on TOF-MRA might be similar in reflecting the hemodynamic significance of the lesion. Further studies comparing the prognostic values of SIR by the two methods in predicting stroke recurrence in relevant patients would further verify the clinical relevance of the two methods.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

FRACTIONAL FLOW IN MIDDLE CEREBRAL ARTERY STENOSIS BY COMPUTATIONAL FLUID DYNAMICS MODELING: THE INTER-OPERATOR REPRODUCIBILITY

X Leng ¹, L Lan ¹, HL Ip ¹, H Liu ¹, J Abrigo ², T Leung ¹, DS Liebeskind ³, KS Wong ¹

Abstract

Background

There have been preliminary studies using the computational fluid dynamics (CFD) modeling methods to assess the fractional flow (FF) in intracranial arterial stenosis. However, the inter-operator reproducibility of such assessment methods is unclear.

Methods

For each case with symptomatic middle cerebral artery (MCA) stenosis recruited to the current study, two operators independently conducted the following procedures to construct the CFD model and assess the fractional flow of the lesion, under a predefined, standardized protocol. Vessel geometry was extracted based on computed tomography angiography (CTA) source images. A mesh was generated and CFD model was computed accordingly, with assumptions of rigid vessel wall and blood as Newtonian fluid. FF of MCA stenosis was defined as the ratio of the pressures measured distal and proximal to the lesion on the CFD model. Inter-operator agreement was defined as an absolute difference in FF of ≤ 0.05 by the two operators.

Results

Among 16 cases, 14 were successfully processed by both operators, with the mean FFs of 0.90 ± 0.07, and 0.93 ± 0.04, respectively. Overall, inter-operator agreement was achieved in 12 (85.7%) cases, while the absolute differences in FF by the two operators in the other two cases were 0.10 and 0.18, respectively.

Conclusions

Assessment of fractional flow of MCA stenosis by CFD models may be reproducible in a majority of cases, with a predefined and standardized protocol in a single center. However, further efforts are needed to identify features of lesions that would cause disagreement between operators.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

TRACT- BASED SPATIAL STATISTICS OF DIFFUSION TENSOR IMAGING DETECTS EARLY WALLERIAN DEGENERATION IN BRAINSTEM CORTICOSPINAL TRACT ON 30-DAY AFTER PURE MOTER LACUNAR INFARCTION

Y Likitjaroen ¹, S Sittipong ¹, N Riablershirun ², S Lerdlum ³, K Panthumchinda ¹, N C Suwanwela ¹

Abstract

Background

Diffusion tensor imaging (DTI) can detect microstructural changes. Wallerian degeneration is a delayed structural change as a consequence of neural tissue damage. We used tract-based spatial statistics (TBSS) of DTI to demonstrate early change of microstructure in brainstem corticospinal tract early after infarction of posterior limb of the internal capsule.

Methods

Eleven patients with pure motor hemiparesis who have an acute infarction involving posterior limb of the internal capsule were recruited. The severity of motor weakness was determined by Fugl-Meyer assessment (FMA) and DTI was performed at 3-day, 7-day and 30-day. Diffusion images of each patient were flipped to create 2 image sets with lesion on the left and on the right. TBSS was performed to detect fractional anisotropy (FA) change along the corticospinal tract. Regions of interest (ROI) analysis was performed to revealed correlation between FA at 3-day and FMA at 30-day.

Results

TBSS reveals FA decrease in the corticospinal tract along midbrain, pons and medulla at 30-day (5,000 permutation, uncorrected P = 0.05). ROI study demonstrates a significant positive correlation between low FA in midbrain at 3-day and low FMA at 30-day (R = 0.902, p < 0.001)

graphic file with name 10.1177_2396987316642909-fig138.jpg

Conclusions

TBSS detects early Wallerian degeneration of corticospinal tract along brainstem as a consequence of ischemic stroke affecting posterior limb of the internal capsule. The early change of FA in the cerebral peduncle may potentially predict the clinical outcome.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

SURROGATE MR-MARKERS OF CEREBRAL AMYLOID AND HIPERTENSIVE ANGIOPATHIES IN PATIENTS WITH CARDIOEMBOLIC STROKE WHO START ORAL ANTICOAGULATION

J Martí-Fàbregas ¹, L Prats-Sánchez ¹, S Medrano ², E Merino ³, P Camps-Renom ¹, R Delgado-Mederos ¹, A Martínez-Domeño ¹, M Zedde ⁴, M Gómez-Choco ⁵, MJ Torres ⁶, N González-Nafría ⁷, J Krupinski ⁸, B Zandio ⁹, B Fuentes ¹⁰, AM De Arce ¹¹, Y Bravo ¹², M Hernández ¹³, D Cánovas ¹⁴, I Casado-Naranjo ¹⁵, I Gich ¹⁶

Abstract

Background

Magnetic Resonance Imaging (MR) can detectsurrogate markers of cerebral amyloid and/or hypertensive angiopathies. Thepresence of these angiopathies may increase the risk of intracranial hemorrhagein patients treated with oral anticoagulants (OA). We evaluated the presence ofthese surrogate markers in patients with cardioembolic stroke.

Methods

In a multicenter study we enrolled consecutivepatients with cardioembolic stroke (transient ischemic attack or braininfarct), who were older than 64 y, OA-naive, and without contraindications forMR. Written consent was obtained before MR. Two expert neuroradiologists evaluated:1) Microbleeds (MBs: presence, distribution and burden); 2) Cortical Superficialsiderosis (cSS); 3) Hemispheric white matter lesions (WML: presence, degreeassessed by the Fazekas' scale score).

Results

We studied 354 patients (mean age 77.8 ± 6.7 y, 46% were men). MBs weredetected in 72 (20.3%) patients. MB distribution in these 72 patients wascortical/subcortical in 37 (51%), deep in 25 (35%) or both in 10 (14%). MBburden ranged from 1 to 50. One MB was detected in 46%, and >1 MB in 54%. SSwas present in 19 (5.4%). WML were detected in 289 (81.6%) patients. Fazekas'score was 1 in 134 (37.9%), 2 in 91 (25.7%) and 3 in 64 (18.1%) patients.Fazekas' score = 3 was associated with greater MB burden (p = 0.02).

Conclusions

Surrogate markers of cerebral angiopathies arefrequent in patients with cardioembolic stroke, in the form of MBs (1 out 5),SS (1 out of 20) or WML (4 out of 5). This may have implications on the safetyof long-term oral anticoagulation.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

SUPERFICIAL SIDEROSIS IN PATIENTS WITHCARDIOEMBOLIC STROKE WHO START LONG-TERM ANTICOAGULATION: FREQUENCY ANDPREDICTORS

A Martínez-Domeño ¹, L Prats-Sánchez ¹, E Merino ², S Medrano ³, P Camps-Renom ¹, R Delgado-Mederos ¹, A Rodríguez-Campello ⁴, D Cocho ⁵, MM Freijo ⁶, A Calleja ⁷, J Sanahuja ⁸, L Llull ⁹, M Garcés ¹⁰, E Palomeras ¹¹, I Díaz-Maroto ¹², M Serrano ¹³, J Fernández ¹⁴, A Lago ¹⁵, I Gich ¹⁶, J Martí-Fàbregas ¹

Abstract

Background

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Cortical superficial siderosis (cSS) isconsidered a manifestation of cerebral amyloid angiopathy (CAA). It has beenassociated with an increased risk of future intracerebral hemorrhage (ICH), andthus the administration of oral anticoagulants (OA) may enhance this risk. We haveexamined the frequency and predictors of SS in patients who need long-term OA.

Methods

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We enrolled consecutive patients with cardioembolicstroke, who were OA-naive. cSS was defined as a gyriform low signal lesionon gradient-echo or susceptibility MR sequences, without a correspondinghyperintense signal on T1/FLAIR. cSS was classified as focal (≤3 sulci affected) ordisseminated (>3 sulci). We collected demographic and anthropometricvariables, traditional vascular risk factors, risk scores (CHADS₂VASC₂, HAS-BLED), type of stroke (TIA vs infarct), prior treatments (antiplatelet, statins), echocardiography data, blood analysis, MR-field strenght and othersurrogate markers of CAA (microbleeds, white-matter lesions).

Results

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We studied 354 patients (age 77.8 ± 6,7 y, 46% were men). cSS wasdetected in 19 (5.4%) patients, and was focal in 17 and disseminated in 2.Patients with cSS presented a higher frequency of previous ICH (p = 0.016) andadvanced liver disease (p = 0.026) but this was based in only 4 and 5 out of 354patients, respectively. No association was found with any other variable in thebivariate analyses.

Conclusions

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cSS can be detected in 1 out of 20 patientswith cardioembolic stroke who start long-term anticoagulation. cSS is neitherassociated with other markers of CAA nor with other commonly availablevariables. Follow-up of these patients will clarify whether they have anincreased risk of ICH.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

MAGNETIC RESONANCE IMAGING IN THE ACUTE PHASE OF STROKE: A STROKE UNIT EXPERIENCE IN UMBRIA

S Mastrocola ¹, R Condurso ¹, C Padiglioni ², C Marando ¹, S Cenciarelli ¹, E Gallinella ¹, LM Greco ¹, A Mattioni ¹, I Sicilia ¹, D Giannandrea ², T Mazzoli ², S Ricci ¹

Abstract

Background

Background and Purpose: computed tomography (CT) is extensively used in the clinical management of acute stroke, diffusion-weighted magnetic resonance imaging (DWI-MRI) is not routinely available in most hospitals and is reserved for selected cases. We investigated the use and usefulness of MRI in the work-up of acute phase of stroke, in a stroke unit of a small Italian hospital.

Methods

Method: we retrospectively identified 411 acute ischaemic stroke patients who were admitted to our Stroke Unit between 01/01/2012 and 01/01/2014; they underwent brain CT scan on admission and lately a second CT scan and/or MRI

Results

Results: MRI was not performed in 114 patients (28%): out of them 32 (8%) had exam contraindications and 82 (20%) had a second CT scan showing an evident recent infarction. Among 297 MRI, 84 (28%) had a negative DWI (58 LACS, 26 POCS/PACS, according to the OCPS classification) and 213 showed a definite recent ischaemic lesion (44 LACS, 169 POCS/PACS/TACS). The two groups (DWI+/-) did not differ significantly for age, sex and MRI timing; instead there was a significant difference (p < 0.001) for the clinical subtype representation (LACS vs no-LACS).

Conclusions

Conclusion: 8% of the patients could not perform magnetic resonance due to contraindications. According to literature and the recent systematic review of Wardlaw and collegues, MRI was negative in more than 25% of acute ischaemic strokes. MRI could be helpful to help diagnostic and therapeutic decisions in selected cases and a shared protocol on MRI application in the acute phase of ischaemic stroke would be valuable.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

INVESTIGATING THE EFFECT OF HIGH-DOSE ATORVASTATIN THERAPY ON ADVANCED ATHEROSCLEROSIS REGRESSION WITH EXTRACTION OF INSTANTANEOUS CHANGES IN THE ARTERIAL WALL USING B-MODE ULTRASOUND IMAGES

H Mehrad ¹, M Mokhtari-Dizaji ², H Ghanaati ³

Abstract

Background

Advanced carotid atherosclerosis with severe stenosis (>70%) is a major clinical risk factor for ischemic stroke and its related death. The aim of this study was to generate an experimental rabbit carotid model of advanced atherosclerosis and the subsequent investigating the effect of high-dose atorvastatin therapy on atherosclerosis regression with extraction of instantaneous changes in the arterial wall using B-mode ultrasound images in this model.

Methods

Briefly, New Zealand white rabbits underwent primary perivascular cold injury at the right common carotid artery followed by a 1.5% cholesterol-rich diet injury for eight weeks. Then treatment group underwent high-dose atorvastatin therapy (5 mg/kg/day). For automatic measurement of the mean wall thickness and the percentage of luminal cross-sectional area of stenosis from longitudinal B-mode ultrasound images, two algorithms, i.e., maximum gradient and dynamic programming were composed and implemented. Reference points and cost function were based on dynamic programming and maximum gradient, respectively.

Results

Quantitative and morphometric analysis of the mean wall thickness and the percentage of luminal cross-sectional area of stenosis in the treatment group showed a significant correlation between the computer-assisted B-mode ultrasound image analysis and the histological measurements at each time point (R = 0.869 and R = 0.893, p > 0.05, respectively).

Conclusions

It is concluded that the new automatic method enables accurate and repeated evaluation of regression of advanced atherosclerosis in this animal model. Also, the results obtained in this study indicate that short-term administration of high- dose atorvastatin can cause to destroy the advanced soft plaque microvessels and reduce the lesion macrophages-derived foam cells.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ADDED VALUE OF 3 VS. 1.5 TESLA BRAIN MAGNETIC RESONANCE IMAGING IN A TRANSIENT ISCHEMIC ATTACK OUTPATIENT CLINIC

OD Ortega Hernandez ¹, A CALLEJA SANZ ¹, M RODRIGUEZ VELASCO ², L BAUTISTA GARCIA ¹, E CORTIJO GARCIA ¹, P GARCIA BERMEJO ¹, L LOPEZ MESONERO ¹, M USERO RUIZ ¹, M DE LERA ALFONSO ¹, J REYES MUÑOZ ¹, P LUIS MUÑOZ ¹, JF ARENILLAS LARA ¹

Abstract

Background

We aimed to compare the capacity of 3 Tesla (T) vs. 1.5T Magnetic Resonance Imaging (MRI) to detect acute ischemic lesions (AIL) in Transient Ischemic Attack (TIA) patients.

Methods

Consecutive patients with TIA seen by neurologists at the emergency room were referred to our TIA outpatient clinic once urgent diagnostic workup excluded symptomatic stenosis and cardiac source of emboli. Brain MRI was conducted within next 15-days. From 2011 to 2013, MRIs were performed in a 1.5T machine solely, and after 2013, some patients underwent 3T MRI. Clinical variables such as TIA-duration, symptoms, and ABCD2-score were recorded prospectively. The presence of AIL on DWI sequence was assessed blindly.

Results

A total of 249 patients were included (mean-age was 69.7 yrs, 130 were male, median ABCD2-score = 3), 193 (77%) patients underwent 1.5T MRI and 56 across 3T. Both groups were comparable regarding relevant baseline variables, including ABCD2 score, duration of symptoms, and time to MRI. The prevalence of AIL on DWI was similar in both groups; 43 (23%) in the 1.5T MRI vs. 13 (23%) with 3T. TIA duration >1 hr was associated with the presence of AIL in both groups. However, whereas DWI lesion detection was not influenced by ABCD2 score in the 1.5T group, it increased with ABCD2 score in the 3T group, reaching 57% if ABCD2 > 5 (p = 0.02).

Conclusions

Overall, 3T MRI did not detect more AIL on DWI in our TIA patients. However, 3T might be more sensitive in very-high risk TIA. These findings need to be confirmed in larger series.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE CIRCLE OF WILLIS ANOMALY IN PATIENTS WITH CAROTID ARTERY DISEASE; ITS RELATIONSHIP WITH STROKE

E Ozaydin Goksu ¹, P Koc ², E Kucukseymen ³, A Unal ⁴, F Genç ³, E Sarionder Gencer ³, A Yaman ³

Abstract

Background

The circle of Willis is an important collateral system that maintains perfusion to the stenotic area from contrlateral carotid and basillary artery to the region of reduced brain persion.

The aim of the present study was to assess the circle of willis anomaly in patients with carotid artery disease and its relationship with stroke

Methods

We analysed the patients who presented to our outpatient stroke clinic with unilateral symptomatic or asymptomatic carotid artery disease who had CTA imaging performed between January 2013 and June 2015. Demographic properties, carotid artery stenosis and the anomaly of circle fo willis was recorded.

Results

A total of 175 patients participated in this study. Mean age of the study population was 66.7 ± 9.2 /years. There were 121 (69%) males and 54 (31%) females. While 29.7% of the patiens did not have anomaly in the circle of Willis, 70.3% had anomaly. The most observed comorbid condition was HT in both groups. The number of patients with symptomatic and asymptomatic caroitd artery disease 83 (47.4%) and 92 (52.6%) respectively. The anomaly in the circle of the willis was detected in 63 (68.7%) patients with asymptomatic and in 60 (72.3%) patients with symptomatic carotid artery disease. The anomaly in the circle of willis was no statistically significant difference in patients with symptomatic or asymptomatic carotid artery disease(p = 0.58).

Conclusions

We did not detect a difference in patients with symptomatic and asymptomatic carotid artery disease in terms of the anomaly of circle of willis.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ASYMPTOMATIC INTRACRANIAL ATHEROSCLEROSIS IS ASSOCIATED WITH DECREASED BONE MARROW ACTIVITY

KY Park ¹, JM Kim ², JW Seok ³, ES Lee ³

Abstract

Background

Atherosclerosis is a dynamic process including mobilization of inflammatory cell from the hematopoietic organs. Recent studies suggest that the activity of the hematopeietic organs is increased after acute myocardial infarction. However, studies investigating hematopoietic organ in patients with cerebral atherosclerosis are rare. We investigated bone marrow activity among patients with asymptomatic cerebral atherosclerosis.

Methods

Between January1, 2011 and December 31, 2014, the subjects who participated in health screening program and had both brain CT angiography and whole body ¹⁸F-flurodeoxyglucose (FDG) positron emission tomography (PET) were included in this study. Intracranial cerebral artery atherosclerosis was diagnosed using CT angiography, and bone marrow activity was measured using FDG PET from the 4^th and 5^th lumbar vertebral bodies.

Results

We identified 20 (14 male and 6 female) patients. Mean age was 61 (standard deviation, 14) years. Seven of them had cerebral atherosclerosis on CT angiography. The representative whole body FDG PET scan showed that the subjects with cerebral atherosclerosis had decreased bone marrow activity and significantly lower mean standardized uptake values from the 4th (1.96 ± 0.52 versus 1.51 ± 0.38, p = 0.011) and 5th vertebra (1.80 ± 0.57 versus 1.46 ± 0.21, p = 0.015) compared to the results of patients without cerebral atherosclerosis. The FDG uptake of the spleen (0.88 ± 0.17 versus 0.82 ± 0.17, p = 0.35) was not different between the two groups.

Conclusions

This is the first study showing that asymptomatic intracranial cerebral artery atherosclerosis is associated with decreased bone marrow activity measured in the lumbar vertebra. Further studies are warranted to evaluate pathophysiological links between intracranial atherosclerosis and bone marrow activity.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ASSESSING THE RELATIVE IMPORTANCE OF INDIVIDUAL ASPECTS REGIONS TO MCA TERRITORY INFARCT VOLUME

T Phan ¹

Abstract

Background

The successes of recent clot extraction reperfusion therapy trials underpin the usefulness of Alberta Stroke Program Early CT Score (ASPECTS) to assess ischemic tissue. The Alberta Stroke Program Early CT Score (ASPECTS) is a widely-used, validated method which assesses involvement of 10 selected regions of the middle cerebral artery (MCA) territory (7 cortical and 3 subcortical regions). To understand the internal structure of the ASPECTS template better, the infarct volume corresponding to each region was estimated.

Methods

The individual ASPECTS regions were rated on subacute CT images (day 5-day 10) of nineteen patients with MCA territory stroke. Infarct volume was determined from manual segmentation of infarcts on CT images. The infarcts volume were normalized to the total MCA infarct volume. The contribution individual ASPECTS regions was assessed by Shapley value regression (finding the proportional contribution of each ASPECTS region to variance/R2). The confidence interval was estimated by bootstrapping the data 1000 times.

Results

The 10 ASPECTS regions contributes to 86.11% of the variance (R2) of the model. Figure 1 shows that the striatocapsular region (caudate, lentiform and internal capsule) made up 44.4% of the variance. By contrast M1, M5 and M6 individual contributed less than 4% of the variance of the MCA territory.

graphic file with name 10.1177_2396987316642909-fig139.jpg

Conclusions

the ASPECTS regions are weighted unequally with some M cortical regions contribute less weighting to the MCA territory compared to the striatocapsular region. These findings may be used to develop a scoring system to aid patient selection for reperfusion therapy.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

DIFFERENTIAL CONTRIBUTION OF EACH CORTICOFUGAL TRACT TO DISABILITY AND MOTOR DEFICIT IN SUBCORTICAL STROKE: HIERARCHICAL PARTITION ANALYSIS

T Phan ¹, H Ma ¹, J Ly ¹, B Clissold ¹, J Chen ², R Beare ², V Srikanth ¹

Abstract

Background

Motor outcome following subcortical stroke may depend on integrity of the descending motor corticofugal tracts (primary motor cortex (M1), premotor area (PMdv) and supplementary motor area (SMA)). The aim of this study is to assess the independent contribution of corticofugal tracts to disability and motor deficit in patients with subcortical stroke.

Methods

Patients with subcortical infarcts on MR imaging admitted to our institution (2009–2011) were included. Stroke deficit were classified according to the National Institute of Health Stroke Scale (NIHSS) at 90 days. The infarcts were manually segmented, registered into standard space. In normal subjects (n = 16), the corticofugal tracts were delineated using diffusion tractography and registered to standard space. Due to potential collinearity (relatedness) among the corticofugal tracts, the independent contributions of each corticofugal tract to disability were assessed by hierarchical partition of the goodness of fit of the models.

Results

There were 57 patients (57% male) with mean age 64.3 ± 14.4 year-old. The variance inflation factors/VIF were 1.1 for age, 8.5 for M1, 27.1 for SMA and 45.9 for PMvd (VIF > 10 suggest the presence of collinearity). The generalised R2 for the disability model was 0.52, motor arm and leg deficit were 0.33. The analysis showed that M1 tract had greater independent effect on motor arm deficit (Figure 1) and disability. Age had greater independent effect on motor leg deficit.

graphic file with name 10.1177_2396987316642909-fig140.jpg

Conclusions

The hierarchical partition analysis revealed differential effect of corticofugal tracts on disability and motor deficit. M1 tract involvement has greater role in motor arm deficit than motor leg deficit.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

FAZEKAS SCORE ON COMPUTED TOMOGRAPHY IN STROKE PATIENTS: INTER AND INTRA RELIABILITY

S Rudilosso ¹, L San Román ², J Blasco ², M Hernández-Pérez ³, X Urra ¹

Abstract

Background

White matter changes (WMC) are a common finding in stroke patients. Many visual rating scores for WMC are available, however some of the most used ones such as the Fazekas score, that evaluates both periventricular (PV) and deep white matter (DWM) areas, are based only on magnetic resonance imaging (MRI), while the fastest and most available technique in the evaluation of acute stroke is computed tomography (CT). We evaluated the feasibility of grading the Fazekas score on non-enhanced CT in a cohort of 157 consecutive acute stroke patients with a follow-up MRI study.

Methods

Two expert readers independently evaluated the CT scans blinded to MRI images. The Fazekas scores on CT were also dichotomized into low (0–1) and high (2–3) grade of WMC. The Fazekas scores on MRI were evaluated by a reader blinded to CT scans.

Results

The Fazekas scores on CT scans by the two readers showed fair and slight agreement for PV and DWM areas (kappa, 0.47 and 0.36 respectively), whereas intraobserver reliability was substantial for both areas (0.67 and 0.64 respectively). Interobserver reliability for dichotomized scores was good for PV areas and fair for DWM areas (0.71 and 0.49 respectively). Sensitivity and specificity for high grade WMC on CT scans compared with MRI were 67% and 91% for PV areas, whereas for DWM areas were 86% and 89%, respectively.

Conclusions

Despite its limitations Fazekas score on CT is a useful tool to address high grade WMC in both PV and DWM areas in the assessment of acute stroke patients.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

MAGNETIC RESONANCE IMAGING IN ACUTE ISCHEMIA: PERCENTAGE VOLUME CHANGE PER HOUR OF INFARCT GROWTH IS INDEPENDENT OF APPARENT DIFFUSION COEFFICIENT THRESHOLDS

RG Sah ¹, S Khan ¹, ND Forkert ², M Hafeez ¹, A Tsang ², S Tariq ¹, CD D’Esterre ³, E Santos ⁴, PA Barber ¹

Abstract

Background

Heterogeneity in diffusion weighted imaging (DWI) Intensity thresholds and Apparent diffusion coefficient (ADC) thresholds to delineate infarction is widespread. Therefore, a standardized metric to measure follow-up lesions post endovascular therapy is needed, especially when radiological measures are used as a primary outcome in clinical trials. We sought to determine a standardized infarct delineation method.

Methods

35 ischemic stroke patients were imaged (3T) within 4 h (baseline) and at 24 h (follow-up) of endovascular treatment. Baseline and follow-up infarct volumes were segmented using ADC thresholds of 550, 600, 630 and 650 × 10⁻⁶mm²/s, while DWI lesions were segmented based on relative thresholds of 1.28, 1.64, 1.96, 2.57 and 2.7 Standard deviations (SD) of contralateral hemisphere intensity. Both time points were used to calculate the relative (%) volumetric change/hour.

Results

Recanalization was confirmed (1.24 ± 0.06 hr) in the acute period. Treatment was provided with tPA in 27/35 or endovascular therapy in15/35 or both in 9/35. Ischemic lesions were identified in 27/35 patients on ADC and 29/35 on DWI intensity. There was no significant difference (p < 0.05) in %change/hr for ADC, while DWI showed significance (p < 0.05) for 1.28; 1.64 and 1.96 compared with 2.57 and 2.7 (Table1)

Conclusions

Infarct volumes vary considerably for both absolute ADC and DWI thresholds; however, relative % change/hr was independent of ADC threshold used and could therefore be used as a standardized primary outcome metric.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ASSESSMENT OF THE INFARCT GROWTH USING MR DIFFUSION-WEIGHTED AND QUANTITATIVE R2 IMAGING

RG Sah ¹, S Khan ², ND Forkert ³, M Hafeez ¹, S Tariq ¹, A Tsang ³, CD D’Esterre ³, PA Barber ¹

Abstract

Background

In acute ischemia, diffusion-weighted Imaging (DWI) is considered the preeminent examination to demonstrate restricted water motion (cytotoxic edema). However, measurement of free-water with quantitative R2 (qR2) relaxometry is generally ignored.

Hypothesis: Application of qR2 and DWI will better characterize the heterogeneity of infarct growth.

Methods

40 ischemic stroke patients (age; 72 ± 17) were imaged within 4 h (baseline) and at 24 h. Apparent diffusion coefficient (ADC) and qR2 maps were calculated from DWI and multi-echo T2. Volumetric segmentation of qR2 lesions were performed using threshold −12.5% of mean contra-lateral side. ADC lesions were segmented using threshold of 630 × 10⁻⁶mm²/s. Overlap of qR2 and ADC segmented volumes was calculated using Dice coefficient.

Results

Recanalization was confirmed in acute period (1.24 ± 0.06 hr). Treatment was provided with tPA in 20/40; endovascular therapy 6/40 or both 10/40 and antithrombotic in 4/40. Ischemic lesions were identified in 27/40 at baseline and 28/35 at 24 h based on ADC. QR2 lesions were observed in 22/32 at baseline and 23/30 at 24 h. QR2 and ADC volume overlap was 8.5% at baseline and 16.7% at 24 h. Percentage change in qR2 lesion was 173.8%, compared to ADC lesion growth of 88.2%. Lesion growth was more frequently demonstrated by qR2 than ADC (p < 0.05).

graphic file with name 10.1177_2396987316642909-fig142.jpg

graphic file with name 10.1177_2396987316642909-fig141.jpg

Conclusions

Acute ischemic lesion growth size was more frequently demonstrated by qR2 than by ADC. Acquisition of ADC alone underestimates severity of acute ischemia and infarct growth.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ADDED VALUE OF INTRACRANIAL VESSEL WALL IMAGING IN ISCHEMIC STROKE WORK-UP

J Schaafsma ¹, J Coutinho ², D Mikulis ², C Jaigobin ¹, D Mandell ²

Abstract

Background

High-resolution MR-imaging of the intracranial arterial wall is a promising technique for diagnosis of intracranial arteriopathies in patients with ischemic stroke. We aimed to evaluate the added value of vessel wall imaging (VWI) in the work-up of stroke patients.

Methods

We selected all patients with ischemic stroke who had intracranial VWI performed at our institute to evaluate possible intracranial arteriopathy. We reviewed clinical notes, laboratory results, results of cardiac work-up, conventional imaging, and VWI. We calculated the proportion of patients for whom VWI provided information beyond the standard stroke work-up in terms of change in suspected stroke etiology or narrowing of the differential diagnosis.

Results

177 patients with ischemic stroke, mean age 55 (IQ-range: 45–69), had VWI between 2006 and 2014. Currently, 121 cases were reviewed. Preliminary results show that VWI provided additional information in 69 patients (57%). In 22/121 patients (18%) the conclusion on stroke etiology was altered based on VWI and in 47/121 patients (39%) the differential diagnosis was further narrowed after VWI. Patients under the age of 45 benefited more often from VWI than older adults (RR 1.5; 95%CI: 1.1–1.8).

Conclusions

VWI provided additional information to the conventional stroke work-up in more than half of the patients suspected to have intracranial arteriopathy. Further investigation is needed to determine the proportion of patients for whom this added information altered therapy.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

OXYGEN-SENSITIVE MRI IN UNILATERAL CAROTID HIGH-GRADE OCCLUSIVE DISEASE: NO RELATIONSHIP BETWEEN SIGNAL ALTERATIONS IN QUANTITATIVE T2' MAPPING AND CEREBRAL BLOOD VOLUME WITHIN PERFUSION-RESTRICTED TISSUE

A Seiler ¹, R Deichmann ², W Pfeilschifter ¹, OC Singer ³, M Wagner ⁴

Abstract

Background

Quantitative T2' mapping (qT2') detects regional changes of the relation of oxygenated and deoxygenated hemoglobin (Hb) by using their different magnetic properties in gradient echo imaging. T2’ values have been shown to decrease significantly in regions with perfusion disturbances due to high-grade stenosis of brain-supplying arteries, probably due to an increased oxygen extraction fraction (OEF) for compensation of reduced perfusion pressure. Since elevations of cerebral blood volume (CBV) might have substantial influence on T2’ in these patients (accumulation of Hb) we evaluated the relationship between T2’ values and CBV in patients with unilateral high-grade large-artery stenosis.

Methods

16 patients (13 m, 3 f; mean age 53 y) with sonographic or MR angiographic proven unilateral symptomatic or asymtpomatic high-grade ICA or MCA stenosis/occlusion were included. MRI comprised perfusion-weighted imaging and motion corrected T2’ imaging. T2’ and CBV values were measured in areas with different degrees of perfusion delay and compared to values in corresponding contralateral areas of the healthy hemisphere.

Results

T2' values were significantly (p < 0.01) decreased in all perfusion-restricted compared to corresponding contralateral unaffected areas. Differences in T2’ values increased with the severity of the perfusion delay. However, no significant changes in cerebral CBV were detected within areas with significantly decreased T2’ values.

Conclusions

Decreased T2’ signal intensity in areas of restricted perfusion in patients with unilateral high-grade stenosis of the ICA or MCA is not only induced by changes of CBV but caused by increased OEF. T2’ mapping is suitable to detect altered oxygen consumption in chronic cerebrovascular disease.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

DECREASED THICKNESS OF CORTICAL STRUCTURES IN MINOR STROKE PATIENTS

MS Stringer ¹, O Varsou ¹, C Dinis Fernandes ¹, C Schwarzbauer ^1,², MJ Macleod ³

Abstract

Background

Accurate diagnosis of minor stroke and other similar ischaemic events plays a key role in preventing recurrence, however as symptoms tend to be transient they can pose considerable diagnostic challenges. Neuroimaging offers significant potential to unveil novel prognostic indicators and potential diagnostic biomarkers. In this study we compare the thickness of cortical structures in minor stroke patients to that of healthy controls.

Methods

High-resolution T₁-weighted magnetic resonance imaging scans were obtained as part of a diagnostic protocol from 22 patients with a final diagnosis of minor stroke (mean age: 54+/-14, 25–82) and 22 healthy controls with no known history of ischaemic events (mean age: 35+/-8, 21–47). Automatic cortical segmentation was carried out using Freesurfer before performing an ANCOVA, with age as a covariate, through SPSS 23.

Results

Significant differences (p < 0.05) were detected between the control and patient groups. In particular lower cortical thickness was detected in the right inferior parietal lobule (IPL) (F = 11.694, p = 0.001) and lateral occipital cortex (F = 6.474, p = 0.015) of the minor stroke group. Similarly reduced cortical thickness was observed in the left IPL (F = 4.234, p = 0.046), lateral occipital cortex (F = 10.544, p = 0.002), and pericalcarine gyrus (F = 4.233, p = 0.046).

Conclusions

Cortical thinning has previously been associated with ischaemic changes, with differences also being reported during the post-stroke recovery period. The IPL is associated with interpretation of a range of sensory information whereas the occipital cortex is involved with visual processing, which may relate to the symptoms experienced. Further work, preferably longitudinally, is required to explore the origin of these differences in minor stroke more fully.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PERFUSION IMAGING BY ARTERIAL SPIN LABELING IN SUBACUTE STROKE: FIRST EXPERIENCE WITH A CLINICALLY CERTIFIED SEQUENCE

T Thamm ¹, MA Mutke ¹, VI Madai ¹, S Zweynert ¹, E Siebert ², T Liebig ², J Sobesky ¹

Abstract

Background

Magnet resonance imaging (MRI) based perfusion imaging (PI) in stroke using gadolinium is restricted due to side effects. Arterial Spin Labeling (ASL) offers a non-invasive PI method but clinical experience is scarce. We describe a clinically certified 3D-GRASE ASL-sequence as part of a routine stroke imaging protocol.

Methods

Patients with subacute anterior circulation stroke and visible DWI lesion were included in a retrospective analysis. Stroke MRI (3 T or 1.5 T Siemens/Germany) included pulsed multi-TI-ASL with 3D-GRASE readout (acquisition time: 2 min). First, a visual qualitative analysis assessed a) image quality (good, medium, poor), b) perfusion abnormalities (hypo-, hyperperfusion, arterial transit delay artifact = ATDA). Second, the volumetric ratio of diffusion weighted imaging (DWI) lesion and perfusion lesion was calculated: ASLratio = volumeASL/volumeDWI.

Results

Of 59 patients screened, 23 were included (6 female, mean age 61 years, mean acute NIHSS: 3, mean onset-imaging: 60 hours). ASL image quality was good or medium in 91% (21/23). In 95% of the remaining patients (20/21), ASL showed perfusion alterations beyond structural imaging: In 10% (2/20) ATDA; in 45% (9/20) hypoperfusion (6/9 without major vessel occlusion); in 45% (9/20) hyperperfusion (3/9 patients imaged after endovascular treatment). Mean ASLratio was 15.1/21.4/3.4 for all patients/hypoperfusion/hyperperfusion.

Conclusions

We provide first data on a clinically certified ASL perfusion sequence in subacute stroke. A good diagnostic image quality in the clinical setting provided a detailed insight into post-stroke perfusion patterns. ASL imaging should be added to current stroke imaging protocols.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

NEUROANATOMICAL CORRELATES OF STROKE-ASSOCIATED INFECTION AND IMMUNODEPRESSION

X Urra ¹, C Laredo ¹, A Prats-Galino ², Y Zhao ¹, C Sorribes ¹, S Rudilosso ¹, A Renú ¹, L Llull ¹, S Amaro ¹, V Obach ¹, AM Planas ³, L Oleaga ⁴, Á Chamorro ¹

Abstract

Background

The neural control of systemic immunity is not well established. We studied the role of specific brain structures in stroke-induced immunodepression and stroke-associated infections (SAI), the most frequent complication after stroke.

Methods

In 101 ischemic stroke patients and 20 controls we studied the incidence of SAI, respiratory SAI, and dysphagia, and measured biomarkers reflecting immunodepression (hypercortisolemia, lymphocytopenia and monocyte deactivation). After segmenting the lesions we used voxel-based lesion-symptom mapping to study the associations between lesions involving different cortical regions and white matter tracts and the outcomes. Direct total volume control was used to rule out associations reflecting only the cerebrovascular anatomy.

Results

Lesion overlap maps were different for patients with (n = 22) and without SAI. The analysis after volume control substantially changed the cortical regions associated to each of the outcomes: SAI, respiratory SAI and lymphocytopenia were associated to lesions involving the superior and middle temporal gyri, and SAI and respiratory SAI were also associated to lesions of the orbitofrontal cortex. The greatest similarity in neuroanatomical correlates was found between dysphagia and respiratory SAI. Damage of the superior longitudinal fasciculus and the inferior fronto-occipital fasciculus, both of which connect the frontal cortex with the rest of the brain, was associated to all clinical outcomes. Laterality did not influence the risk of SAI and immunodepression.

Conclusions

Focal brain lesions are differentially linked to various complications of stroke. The superior and lateral temporal lobe and the prefrontal cortex are linked to immunodepression and SAI, and these associations are independent from the size of the ischemic lesion.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

IMAGING OF ATHEROSCLEROTIC CALCIFICATIONS: MRI VERSUS MDCTA. THE PLAQUE AT RISK STUDY (PARISK)

A van Dijk ¹, M van Hattem ², F Schreuder ³, A de Rotte ⁴, M Truijman ⁵, M Liem ⁶, T Zadi ², A van der Steen ⁷, M Daemen ⁸, R van Oostenbrugge ⁹, W Mess ¹⁰, J Kappelle ¹¹, P Koudstaal ¹², P Nederkoorn ⁶, J Hendrikse ⁴, E Kooi ¹³, A van der Lugt ²

Abstract

Background

For the detection of atherosclerotic calcifications, MRI is supposed to be inferior to MDCTA. However, MRI is increasingly used for plaque characterization due to its excellent soft-tissue contrast. We investigated the correlation between calcification volumes assessed at MDCTA and MRI.

Methods

We measured calcification volume (mm³) in the symptomatic carotid artery in 185 patients of the PARISK-study (Plaque-At-RISK; clinicaltrials.gov NCT01208025) with both a MDCTA and multi-sequence contrast-enhanced MRI. Sensitivity and specificity of MRI (MDCTA as gold standard) were assessed. We evaluated differences in calcification volume between MDCTA and MRI using a Wilcoxon signed-rank test. Possible reasons for discrepancies (>50 mm³) or mismatches in presence of calcifications were manually investigated.

Results

Prevalence of calcifications was 90% on MDCTA as well as MRI (n = 167). Sensitivity and specificity of MRI to detect calcifications were 93% and 39%. Calcification volume on MRI was significantly higher compared with MDCTA (39.1 vs. 24.3 mm³; p = 0.01; median difference −6.4 mm³ [minimum −154.6 mm³; maximum +279.4 mm³]). Possible reasons for large discrepancies or mismatches included incorrectly drawn contours, wrong interpretation of hypointensities or insufficient image quality (MRI) and/or 600 HU threshold, blooming effects and a larger scan range for MDCTA-detected calcifications.

Conclusions

MRI has good sensitivity and moderate specificity for the detection of plaque calcifications. MRI calcification volume was significantly higher than MDCTA volume and individual absolute differences can be substantial. Agreement between MDCTA and MRI can be improved by optimizing MRI evaluation, improving MRI image quality and the use of (semi-)automated tools.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

DIFFERENCES IN DISTRIBUTION OF CEREREBRAL MICROBLEEDS IN MULTIETHNIC (EASTERN AND WESTERN) POPULATIONS (DICOM): INTERNATIONAL COLLABORATIVE ANALYSIS OF POOLED DATA FROM OVER 13,000 PARTICIPANTS

Y Yakushiji ¹, A Charidimou ², D Wilson ², H Hara ¹, T Imaizumi ³, K Kohara ⁴, HM Kwon ⁵, LJ Launer ⁶, V Mok ⁷, JR Romero ⁸, V Srikanth ⁹, Y Takashima ¹⁰, Y Tsushima ¹¹, S Yamaguchi ¹², DJ Werring ²

Abstract

Background

The distribution of cerebral microbleeds (CMBs) is hypothesised to indicate different underlying small vessel disease (SVD): CMBs in deep regions share risk factors with hypertensive microangiopathy, whereas CMBs in strictly lobar regions are associated with cerebral amyloid angiopathy (CAA). We investigated whether CMBs distribution differs between stroke-free population-based cohorts of Eastern (Asia) and Western (Caucasian) ethnicities.

Methods

We searched PubMed between 1996 and 2014 using a combination of search terms: CMBs, healthy, or their appropriate synonyms/MeSH terms. CMBs distribution was classified as: strictly lobar; strictly deep or infratentorial (D/I); or mixed. Using CMB distribution or CAA diagnosis (possible or probable based on Boston criteria) as the dependent variable and ethnicity as the independent variable, multivariable logistic regression analyses was performed to compare the association of CMBs distributional patterns and CAA diagnosis between the ethnicities, adjusting for age, sex, hypertension, magnetic field strength, and echo time.

Results

In multivariable logistic regression analysis, including 13,578 individual data (mean age 67.8 years, 49% Western subjects) from 11 centers, a strictly lobar CMBs pattern was associated with Western ethnicity (OR 1.67, 95%CI 1.23–2.26), and a strictly D/I CMBs pattern was associated with Eastern ethnicity (OR 2.32, 95%CI 1.67–3.22). A mixed CMBs pattern showed no association with ethnicity. Both possible and probable CAA diagnosis were associated with Western ethnicity (OR 1.60, 95%CI 1.18–2.19; OR 2.17, 95% CI 1.11–4.24).

Conclusions

In stroke-free populations, Eastern and Western ethnicity are associated with different anatomical patterns of CMBs, suggesting that the spectrum of the predominant underlying SVD differs.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PRECEREBRAL STENOSIS INFLUENCE PULSATILITY INDEX VALUES IN ACUTE ISCHEMIC STROKES

O Bill ¹, G Toledo Sotomayor ², I Meyer ¹, P Michel ¹, T Moreira ³, J Niederhäuser ², L Hirt ¹

Abstract

Background

Transcranial doppler (TCD) is widely used on acute ischemic stroke (AIS) patients. Pulsatility index (PI) is a rheological TCD parameter used in clinical assessment of intracranial hypertension and vascular recanalization. We studied the influence of precerebral stenoses and other variables on middle cerebral artery (MCA) PI in anterior circulation AIS.

Methods

We conducted a retrospective analysis of ultrasound examinations on 2159 AIS at the CHUV (Lausanne University Hospital) from October 14, 2004, to December 31, 2014. We extracted degrees of stenosis and PI values on the main pre- and intracerebral vessels, and clinical characteristics from the ASTRAL registry. Carotid stenosis severity was divided into <50%, 50–70%, 70–90% and >90% according to established Doppler criteria. The variance of stenosis grade and MCA PI were analyzed first. Linear regression analyses were then performed adjusting for baseline differences using MCA PI as dependent variable. We retained as significance level at p < 0.05.

Results

Mean MCA PI was 0.87 in the 112 AIS with ≥90% stenosis, and 1.06 in 2047 AIS <90% ICA stenosis (p < 0.0001). In the multivariate analysis, age (Beta 0.38), pre-existing hypertension (Beta 0.06), and chronic alcohol consumption (beta 0.04) increase and carotid stenosis significantly decreases (Beta -0.09) MCA PI (r2: 0.15).

Conclusions

PI of the MCA is significantly reduced in patients with ipsilateral significant carotid stenosis, and increased in aged, hypertensive and alcohol-consuming patients, advising careful assessment of the PI in these patients for different indications, such as intracranial hypertension evaluation.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

TRANSESOPHAGEAL ECHOCARDIOGRAPHY FINDINGS IN PATIENTS WITH EMBOLIC STROKES OF UNDETERMINED SOURCE

K Ishizuka ¹, T Hoshino ², S Mizuno ¹, S Toi ¹, K Maruyama ¹, S Uchiyama ^1,^3,⁴, K Kitagawa ¹

Abstract

Background

Embolic stroke of undetermined source (ESUS) is a novel clinical entity for cryptogenic stroke. This study aimed to characterize the transesophageal Echocardiography (TEE) findings of ESUS, in comparison to other specific stroke subtypes.

Methods

We included 107 consecutive patients with acute ischemic stroke who underwent general work-up and TEE during hospitalization. ESUS was defined on the basis of the Cryptogenic Stroke/ESUS International Working Group criteria. Other etiologic subtypes were classified according to the TOAST classification.

Results

Among 107 patients (mean age, 58.3 years; male, 68.2%), 40, 31, 17, and 18 were classified as ESUS, cardioembolism (CE), large artery atherosclerosis (LAA), and other causes (e.g. arterial dissection, moyamoya disease, Trousseau syndrome, and antiphospholipid syndrome), respectively. There were significant intergroup differences in left atrial appendage flow velocity (ESUS, 52.8 + 15.8; CE, 33.7 ± 20.0; LAA, 68.7 ± 23.1; others, 56.5 ± 16.6 cm/s); it was the lowest in CE followed by ESUS. Patent foramen ovale was identified the most frequently in ESUS (ESUS, 25.0%; CE, 6.4%; LAA, 6.3%; others, 10.0%), and left atrial smoke-like echo was the second next to CE (ESUS, 5.0%; CE, 38.7%; LAA, 5.0%; others, 0). There were no significant intergroup differences in the prevalence of aortic complex plaque, aortic valve stenosis, atrial septal aneurysm, and mitral annular calcification.

Conclusions

In ESUS patients, TEE could give us additional information that were mainly related to paroxysmal atrial fibrillation or paradoxical embolism.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EVALUATION FOR THE INSTABILITY OF THE AORTIC PLAQUE USING CONTRAST-ENHANCED ULTRASONOGRAPHY

M Kouchi ¹

Abstract

Background

Presence of aortic plaque is considered a risk factor of ischemic stroke. Previously, plaque neovascularization is associated with plaque vulnerability and symptomatic disease. Contrast-enhanced ultrasonography (CEUS) is often used to the evaluation of intraplaque neovascularization in carotid artery plaque. However, there are few reports of the evaluation in aortic plaque. This study designed to evaluate the neovascularization of aortic plaque using CEUS.

Methods

Ten acute ischemic stroke patients were recruited, and we divided them into enhanced group or non-enhanced group, using Sonazoid^R CEUS. We also evaluated the characteristic of patients (age, gender, diabetes meritus, smoking), plaque lesions (max plaque thickness, mobile component, ulceration, density, CAM score [calcification, age, multiple ischemic strokes], and gray-scale medium [GSM]) and inflammatory laboratory data (high sensitivity CRP, IL-6).

Results

Six patients were observed the contrast lesion in aortic plaque. GSM (67.8 vs 100, p < 0.05) and high sensitivity CRP (12491 ng/ml vs 3165 ng/ml, p < 0.05) were significantly higher in enhanced group.

Conclusions

We could evaluate the intraplaqe neovascularization in aortic plaque. Sonazoid^R CEUS can be meaningful for the detection of the vulnerability and symptomatic disease in aortic plaque.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE LEICESTER CEREBRAL HAEMODYNAMICS DATABASE: NORMATIVE VALUES OF ACUTE ISCHAEMIC STROKE AND SUBTYPE

O Llwyd ^1,², RB Panerai ^1,², S Rahman ¹, NP Saeed ¹, A Salinet ¹, ER Atkins ¹, F Brodie ¹, TG Robinson ^1,²

Abstract

Background

Patients admitted to the Leicester Royal Infirmary with acute ischaemic stroke (AIS), have taken part in studies exploring cerebral haemodynamics and autoregulation index (ARI). The aim of the Leicester Database is to form a larger cohort of this population and report robust physiological parameters. It also allows further assessment on sub-groups such as influence of stroke subtype (cortical vs subcortical).

Methods

Data from baseline recordings (<72 hours of stroke onset) were extracted. These included beat-to-beat blood pressure (MABP, mm/Hg), electrocardiogram (HR, bpm), CO₂ (etCO₂, mmHg) and bilateral insonation of the middle cerebral arteries (CBFV, cm/s). Data for 120 patients were available and anonymised. Exclusion criteria consisted of: missing information (age, gender, OCSP classification), data quality, acceptable physiological parameters i.e. very low/high values. Mean values of physiological parameters and ARI (Tiecks’ model) were recalculated. Normality test (Kolmogorov–Smirnov) and mean differences were assessed using Student’s t-test (p < 0.05).

Results

Data (mean ± SD) from 69 patients (age 64 ± 14; 25 females) are reported. All parameters followed normal distribution; MABP (93 ± 17), HR (68 ± 10), etCO₂ (34.8 ± 3.7), Right CBFV (44.9 ± 15.52) and ARI (5.3 ± 1.9), Left CBFV (43.8 ± 16.8) and ARI (5.1 ± 1.8). Only MABP (87.7 ± 13.5 vs. 99.8 ± 19.6) between cortical/subcortical strokes respectively was significantly different. No differences were found between affected/unaffected hemispheres.

Conclusions

The database defines the cerebral haemodynamics of AIS patients and sub-groups. With supplementary analysis on age/gender warranted, this can be used for future references, sampling size calculations and other applications.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

USEFULNESS OF TRANSCRANIAL DUPLEX SONOGRAPHY FOR THE SELECTION OF PATIENTS FOR ACUTE ENDOVASCULAR TREATMENT

MÁ Martín Gómez ¹, AM Iglesias Mohedano ¹, A García Pastor ¹, P Sobrino García ¹, F Díaz Otero ¹, P Vázquez Alén ¹, M Vales Montero ¹, P Salgado Cámara ¹, P Simón Campo ¹, Y Fernández Bullido ¹, JA Villanueva Osorio ¹, A Gil-Núñez ¹

Abstract

Background

We aimed to determine the usefulness of transcranial duplex sonography (TDS) to detect arterial occlusions eligible for endovascular treatment (AOET) in acute stroke patients.

Methods

We evaluated consecutive patients with acute stroke eligible for endovascular treatment in our institution from January 2011 to December 2015. Vascular status was assessed using TDS and/or brain computed tomography angiography (CTA). We compared the results obtained from TDS, CTA and the combination of TDS + CTA. Digital substraction angiography (DSA) was considered as the gold standard for AOET detection. Door-to-groin puncture time was analyzed.

Results

141 patients were included, 74 patients were previously treated with intravenous thrombolysis. The vascular imaging method used for endovascular treatment selection was TDS in 28 patients (19.9%), CTA in 80 (56.7%) and both TDS + CTA in 32 patients (22.7%). Agreement in the detection of AOET between DSA and TDS, CTA and TDS + CTA was 89.7%, 93.4% and 84.2%, respectively. In the linear regression analysis, door-to-groin puncture time was significantly increased when both TDS and CTA were performed compared with the performance of only TDS or CTA (Beta: 0.438, p < 0.001).

Conclusions

TDS-DSA agreement for AOET detection is comparable to that obtained with CTA. Both techniques seem to be useful for selecting patients for endovascular treatment. The performance of both TDS + CTA does not improve the diagnostic agreement and delays door-to-groin puncture time, and therefore would not be justified.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

RELATIONSHIP BETWEEN EARLOBE CREASE AND HEMODYNAMIC DISTURBANCES IN SUPRA-AORTIC VESSELS AND INTRACEREBRAL CIRCULATION

L Martínez-Rodríguez ¹, C García-Cabo ¹, L Benavente ¹, P Martínez-Camblor ², M Rico ¹, P Suárez-Santos ¹, Á Pérez ¹, A García-Rua ¹, S Calleja ¹

Abstract

Background

The decrease of elastin and collagen within the media has been associated with aging and others vascular risk factors (VRF). It has been described as an important cause of changes in vessel wall compliance. This may explain the higher prevalence of ear lobe crease (ELC) in patients with VRF. The increase of arterial stiffness (AS) is associated with high cerebrovascular resistance and microvascular damage. Our aim was to demonstrate cerebral hemodynamic changes related to the presence of ELC.

Methods

Patients with ischemic stroke who were admitted in a Comprehensive Stroke Center during four months were included in an observational study. Carotid ultrasonography and transcranial Doppler (TCD) were performed in all of them. ELC presence and pulsatility index (PI) both in internal carotid artery (ICA) as in TCD were collected.

Results

Eighty five patients were included, 75,3% of them with ELC. ICA PI was increased in patients with unilateral ELC (p = 0,3) and the association was stronger and significative in bilateral ELC patients (p = 0,001). PI in TCD was also increased but a lower consistent relationship between ELC and PI was found (only statistical significance in AV, p = 0,02). Technical difficulties in PI measurement in posterior TCD may be a bias in these patients.

Conclusions

The ELC presence is linked to higher PI values intra and more clearly extracranially, so ELC may translate the increased AS and the underlying hemodynamic changes in the cerebral microcirculation related to stroke and therefore, a new reason for suggesting the ELC as a marker of cerebrovascular risk.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

OPTIC NERVE SHEATH ULTRASOUND IS RELATED TO NEUROLOGICAL OUTCOME AFTER TBI

C Monteiro Antunes Barreira ¹, LBM Alves ¹, KT Weber ¹, BP Rimoli ¹, AS Carvalho ¹, DM Vilela ¹, CSM Pileggi ¹, MC Braga ¹, RT Brisson ¹, DEB Peixoto ¹, TB Carnevalli ¹, LHS Stefano ¹, TEG Santos-Pontelli ¹, SC Mazin ¹, FA Dias ¹, MR Camilo ¹, OM Pontes-Neto ¹

Abstract

Background

Traumatic Brain Injury (TBI) is a major cause of morbi-mortality among adults, both in Brazil and worldwide. Sharp clinical monitoring after trauma leads to better long-term prognosis. Ultrasound of optic nerve sheath diameter (ONSD) is used to non-invasively estimate intracranial hypertension in neuro-critically ill patients. ONSD prognostic value has never been systematically studied in TBI patients. We aim to evaluate prognostic value of ONSD distension in moderate to severe TBI patients.

Methods

we evaluated consecutive moderate to severe TBI patients (GCS < 15; or intracranial traumatic lesion), aged between 18 and 80-years-old, admitted to a tertiary academic hospital in Brazil from February/2015 to July/2015. Glasgow Coma (GCS) and NOS-TBI scales defined neurological severity. ONSD standard methodology measurements were held by two investigators, blinded to initial TBI severity scores, using Toshiba Xario ™ USG machine. Univariate analysis and multivariate linear regression identified independent predictors of bad outcome at discharge (NOS-TBI > 30).

Results

70 patients were evaluated: 63 (90%) male, mean age of 37.5 (18–76) years, 32 (45%) with severe TBI; 29 (41%) TBI related to traffic accidents. Median GCS at admission was 10 [5–14] and median NOS-TBI score at discharge was 10.5 (IQR 4.35–31.25). On multivariate logistic regression, mean ONSD (OR: 1.8; 95%CI: 1.04–3.27; p: 0.34) was independently associated with discharge NOS-TBI score, after adjustment for the baseline GCS (OR: 0.83; 95%CI: 0.73–0.95; p: 0.010).

Conclusions

ONSD distension is independently associated with worse neurological severity at discharge in TBI patients. Further multicenter studies are needed to assess these findings.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CEREBROVASCULAR REACTIVITY ASSESSMENT USING BREATH HOLDING TEST AND ACETAZOLAMIDE INJECTION HIGHLY CORRELATE IN CAROTID ATHEROSCLEROTIC STENO-OCCLUSIVE DISEASE

N Nasr ¹, B Guidolin ¹, A Jaffre ¹, V Bezombes ¹, H Pillon ¹, V Larrue ¹

Abstract

Background

Two methods assessing cerebrovascular reactivity (CVR) are widely used in clinical settings: breath holding test (BHT) and acetazolamide injection (ACZ). The first aim of this study was to assess the correlation between BHT and ACZ in consecutive patients with carotid stenosis (>50%) or occlusion. The second aim was to assess the degree of stenosis beneath which ipsilateral CVR was normal.

Methods

Degree of stenosis was assessed using carotid Duplex and angioscanner or MRA. Patients were supine with TCD probe fixed using a probe holder. End tidal PCO2 was monitored using a capnometer. Arterial blood pressure (ABP) was continuously monitored using photo-plethysmography. BHT was performed prior to ACZ, at least twice, during 30 seconds. Performance of apnea and absence of Valsalva maneuver were verified. The highest increase of mean cerebral flow velocities (Vm;dVm) obtained was recorded (dVmBHT). Known value beneath which dVmBHT is considered pathological is 20%. ACZ at 13 mg/kg IV was administered. Vm was monitored for 30 minutes and highest dVm value was recorded (dVmACZ). Estimated value beneath which dVmACZ is considered as pathological is 25%.

Results

30 patients(median; IQR:70;65–80; M/F:26/4) were included. Median(IQR) degree of stenosis was 80(74–90). dVmBHT and dVmACZ correlated with degree of stenosis (Rho = −0.521; p = 0.003; Rho = −0.439; p = 0.015) and with each other (Rho = 0.585; p = 0.001). Below 80% degree of stenosis, there were no patients with pathological CVR

Conclusions

BHT and ACZ highly correlated in a context where capnometer and ABP continuous monitoring were used to check for BHT performance and absence of Valsalva maneuver. VRC in stenosis below 80% could be of no use in clinical setting.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ASYMPTOMATIC MICROEMBOLIC SIGNALS AT THE PATIENTS WITH CAROTID ATHEROSCLEROSIS AS THE PREDICTORS OF ACUTE ISCHEMIC CEREBROVASCULAR COMPLICATIONS

N Rybalko ¹, A Kuznetsov ¹, O Vinogradov ¹

Abstract

Background

Despite the subclinical character, asymptomatic carotid stenosis accounts for a substantial cerebral stroke burden. Transracial Doppler monitoring adjust to detect the signs of microembolisation from plaque surface - microembolic signals (MES).

We aimed to evaluate MES as an independent marker of subsequent ischemic stroke and in combination with other anamnestic and clinical features.

Methods

Material/Methods. One hundred and sixty patients with 50% and more carotid stenosis (by NASCET), assessed by ultrasound, with no sources of cardiogenic embolism were recruited. TCD recordings were taken from the ipsilateral middle cerebral artery all the patients during an hour at baseline, in 10 days, 6 months and 12 months.

Results

Results. Statistical communication between МES in cerebral arteries and embolic vascular cerebral complication (vascular death, stroke and TIA) was reported by using Chi-squared test

(p < 0,001). MES in clinical asymptomatic patients in conjunction with the age older 60 years, contralateral carotid stenosis, ultrasound plaque characteristic and the absence of antithrombotic therapy were factors determine the repeat development artery-to-artery embolism from the carotid plaque.

Conclusions

Сonclusions. The multivariate analysis and discriminant inequality reveal the patients group with high risk of subsequent ischemic cerebral events. This technique might be a useful risk predictor for identifying those patients who might benefit from intervention with carotid endarterectomy.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

POST STROKE COGNITIVE DECLINE IS LARGELY INDEPENDENT OF LONGITUDINAL CHANGES WITH THE CEREBRAL HEMODYNAMIC PARAMETERS

MS Suministrado ¹, E Wan Yee Shuang ², J Xu ³, B Chan ⁴, N Venketsubramanian ², R Seet ⁴, C Chen ², B Wong ⁵, VK Sharma ⁴, Y Dong ²

Abstract

Background: Background

Post-stroke vascular cognitive impairment (VCI) is highly prevalent (44%) with significant functional consequences. Despite the highly prevalent post-stroke VCI, biomarkers used at acute stroke phase to predict cognitive decline after stroke are not well established. It has been shown that baseline computed tomography (CT) scan of patients with stroke/TIA may be useful to predict significant cognitive impairment after index event. However, there is paucity of data related to post-stroke cognitive decline and changes in cerebral hemodynamic parameters. We explored the association between cerebral hemodynamic parameters on transcranial Doppler (TCD) and cognitive performance in a pilot study.

Methods: Methods

In this pilot substudy on TCD and neurocognition, 100 consecutive patients with ischemic stroke/transient ischemic attack (TIA) were recruited within 2 weeks following their index cerebrovascular event. At 3–6 months, 69 patients were followed up with both TCD and cognitive tests [Mini-Mental State examination (MMSE)/ Montreal Cognitive Assessment (MoCA)]. Basic demographics, clinical, cognitive information, vascular risk factors and neurological status were recorded.

Results: Results

Considerable proportion (13%) of patients showed cognitive decline and changes in the hemodynamic parameters over 3–6 months after an acute ischemic stroke. However, no significant relationship was observed between cognitive decline and longitudinal changes in cerebral hemodynamic parameters.

Conclusions

Conclusion: Although, cerebral hemodynamic parameters deteriorate in a considerable proportion of patients during first 3–6 months after a cerebrovascular ischemic event, cognitive decline appears to be an independent phenomenon.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ULTRASOUND DETECTED INDICES OF ATHEROSCLEROSIS IN CAROTID ARTERIES FOR THE PREDICTION OF STROKE: INTIMA-MEDIA THICKNESS VERSUS PLAQUE STENOSIS

T Tegos ¹, A Kiryttopoulos ¹, T Kalatha ¹, S Kouvavas ¹, P Nemtsas ¹, G Karafyles ¹, N Alexiou ¹, E Antoniadi ¹, K Notas ¹, A Petrakis ¹, A Valavanis ¹, C Xerras ¹, A Papadimitriou ¹, A Orologas ¹

Abstract

Background

Previous studies demonstrated that carotid atherosclerotic ultrasound findings are associated with stroke.

The aim of this study was to determine the relative value of intima-media thickness and plaque stenosis, both evaluated in carotid arteries, for the prediction of stroke.

Methods

Analysis involved imaging by duplex of carotid arteries of 2,355 patients (1,286 male, 1,069 female, mean age: 66.03 years), to evaluate the stenosis in carotid bifurcation and to assess the intima-media thickness (IMT) in common carotid arteries. Stroke (n = 491) was one of the reasons for referral to laboratory, as diagnosed on clinical and brain CT grounds. The presence of stroke per patient was noted, irrespective of side. In the process of analysis, the mean degree of stenosis and the mean IMT of the two sides per patient were calculated

Results

In the analysis of stenosis mean values, the median in symptomatic cases was 10%, whereas in the asymptomatic cases was 0% (p = 0.0001). In the analysis of IMT mean values, the median in symptomatic cases was 0.75 mm, whereas in asymptomatic cases was 0.7 mm (p = 0.0001). Receiver-Operating Characteristics (ROC) Curves failed to demonstrate the superiority of stenosis over IMT and vice versa for the prediction of stroke (p = 0.581).

Conclusions

Our results demonstrated that the degree of carotid atherosclerosis predicted cerebrovascular accident, taking into account stenosis and IMT. Neither of the two factors proved superior over the other.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

NEUROVASCULAR REACTIVITY IN PATIENTS WITH VASOVAGAL SYNCOPE

G Tekgol Uzuner ¹, N Uzuner ¹

Abstract

Background

The impaired cerebral reactivity was disclosed in patients with vasovagal syncope. However, the neurovascular reactivity was not investigated in the same population. Thus, we examined the neurovascular reactivity in patients with vasovagal syncope by transcranial Doppler (TCD) using complex visual stimulation.

Methods

Twenty patients with a diagnosis of vasovagal syncope and 20 healthy subjects were included the study within last 3 years. The second part of the posterior cerebral arteries were insonated simultaneously during visual stimulation procedure. Neurovascular reactivity was defined as a relative increase of the blood flow velocities during visual stimulation. The data of the 4 patients have excluded the study because of the insufficient TCD examination. The data of the remaining 16 patients (5 females, 11 males; mean age 41.4 ± 15.0 years) and 20 healthy subjects (8 females, 12 males; mean age 37.3 ± 14.2 years) were analyzed.

Results

Neurovascular reactivity in patients was 56.9% and 49.7% (right and left side, respectively), and 57.2% and 58.4% (right and left side, respectively) in control subjects. These findings were not significantly different (p > 0,05).

Conclusions

Our data suggest normal neurovascular reactivity in patients with vasovagal syncope. While impaired cerebral vascular reactivity was associated with the vasovagal syncope, neurovascular reactivity to visual stimulation has been well-preserved in these patients.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

DIAGNOSTIC ACUITY OF ULTRASOUND IN GIANT CELL ARTERITIS WITH ISOLATED HEADACHE PRESENTATION

L Vieira ¹, J Sargento-Freitas ^1,², F Silva ^1,², O Rebelo ³, MC Macário ¹, G Cordeiro ¹, L Cunha ¹

Abstract

Background

Headache is one of the most frequent symptoms of giant cell arteritis (GCA). However, recent evidence suggests that GCA may enclose different etiological mechanisms, with yet unknown associations with clinical presentation and complementary exams findings.

We aim to determine the influence of symptomatic manifestations of GCA on color Doppler ultrasound (CDU) diagnostic acuity.

Methods

Retrospective analysis of patients who underwent CDU for the suspicion of GCA. We assumed the clinical diagnosis of GCA, based on the American College of Rheumatology criteria, when patients fulfilled at least 3 of the following criteria: age over 50 years, elevated erythrocyte sedimentation rate, recent onset headache, visual symptoms or scalp tenderness. CDU was positive if halo sign was present, uni or bilaterally. We defined two groups of patients: those with headache as an isolated presentation of GCA and patients without isolated headaches. We assessed its impact over CDU diagnostic acuity.

Results

We included 134 patients, mean age of 71.84 (σ = 1.79) years. Clinical diagnosis of GCA was assumed on 40 patients (29.9%); 30 patients (22.4%) had headache as an isolated symptom. The diagnosis of GCA was assumed in 14 (46,7%) patients with isolated headache and in 46 (44,2%) of those without isolated headache.

Diagnostic acuity of CDU was different according to clinical presentation: 53,8% sensitivity; 94,1% specificity in patients with isolated headache and 74,1% sensitivity; 96.1% specificity in those without isolated headache (p = 0.034).

Conclusions

Distinct manifestations of GCA influence CDU diagnostic acuity, when compared with clinical criteria.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE DETECTION OF UNSTABLE CAROTID ARTERY PLAQUES USING ADVANCED ULTRASOUND METHODS

M Zamani ¹, M Skjelland ¹, K Ryeng Skagen ¹, D Russell ¹

Abstract

Background

Two new non-invasive ultrasound techniques have been developed which may improve the identification of unstable carotid plaques:

(i) Superb Microvascular Imaging (SMI, Toshiba Medical Systems Europe) can detect small low-flow vessels non-invasively, without the use of contrast agents, (ii) Shear Wave Elastography (SWE, Toshiba) uses acoustic radiation forces to generate shear wave propagation in tissue, enabling the assessment of tissue stiffness and indirectly plaque content.

Methods

30 consecutive symptomatic patients with high-grade carotid stenosis, scheduled for endarterectomy and 30 asymptomatic patients with high-grade carotid stenosis will participate. The study will assess the level of agreement between plaque characteristics such as intra-plaque neovascularization, lipids, hemorrhage and inflammation obtained using advanced SMI and SWE ultrasound examinations, computerized measurement of plaque echogenicity (grey scale median, GSM), carotid MRI with carotid coils and 18F-FDG-PET/CT. Findings will be compared to the histology of the plaques after endarterectomy in the symptomatic patients. Clinical and ultrasound assessments will be repeated in all patients at 6 months intervals during the following 2 years.

Results

The results of this on-going study will 1. Assess the accuracy of these new ultrasound methods for the assessment of carotid plaque instability 2. Enable a comparison between different methods used to assess plaque instability and 3. Determine which of these methods can best assess stroke risk in asymptomatic patients with high-grade carotid stenosis.

Conclusions

This study will hopefully improve the identification of unstable plaques non-invasively using advanced carotid ultrasound (SMI, SWE) and increase our knowledge regarding the unstable carotid artery plaque and stroke risk.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

BARRIERS AND FACILITATORS FOR HEALTH-RELATED BEHAVIOR CHANGE AFTER ISCHEMIC STROKE OR TIA

D Brouwer- Goossensen ¹, M Mastenbroek-de Jong ², E Taal ³, P Koudstaal ¹, L van Gemert-Pijnen ³, H den Hertog ⁴

Abstract

Background

Unhealthy lifestyle is common among patients with stroke or TIA. Hence, health-related behavior change may be an effective way to reduce stroke recurrence, but is often difficult to carry out successfully. We aimed to explore barriers and facilitators for health-related behavior change or sustaining healthy behavior.

Methods

We conducted a descriptive qualitative study with in-depth, semi-structured interviews. Interviews addressed barriers, facilitators, knowledge and support of health-related behavior change framed by the Protection Motivation Theory and Transtheoretical Model. Eighteen patients with recent TIA or ischemic stroke were interviewed. All interviews were transcribed and thematically analysed.

Results

All patients had some notion of what constitutes a healthy lifestyle, but seemed to lack a clear perception of their own health-related behavior. They also lacked sufficient knowledge of lifestyle risk factors for stroke. Almost all patients were in precontemplation stage. Low self- efficacy was the most important barrier in health-related behavior change, except for alcohol abuse. The most frequently cited facilitators were response efficacy and fear. Most patients already received support in changing their health-related behavior change, mainly by health professionals. They had a particular need for practical advice and guidelines for a healthy lifestyle. Most patients had a negative attitude towards technology based support.

Conclusions

This study suggests that patients with recent TIA or ischemic stroke do not have a proactive approach towards health-related behavior change. Increasing knowledge on lifestyle risk factors for stroke and improving self-efficacy may be important targets for lifestyle interventions after stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

MOOD AND ANXIETY SCORES IN PATIENTS READY OR 'NEAR READY' FOR DISCHARGE TO COMMUNITY THERAPY FORM THE HYPERACUTE STROKE UNIT

C Walters ¹, A Chandratheva ², G Christofi ², E Bretherton ¹, V Yeardley ¹, D Lally ¹, R Brealey ¹, H Warwick ¹, R Simister ²

Abstract

Background

Detailed assessment of mood and anxiety is challenging in the hyperacute setting. Mood disorders post-stroke are common with 1/3 developing post-stroke depression and 1/4 developing post-stroke anxiety. We aimed to assess this in a cohort of hyperacute stroke patients considered appropriate for early supported discharge (ESD).

Methods

Setting: A neurorehabilitation step-down unit at St Pancras Hospital, London, developed as part of a winter pressures project (January 26^th–May 27^th 2015) admitting medically stable patients deemed ready/‘near ready’ for ESD. We prospectively collected data on mood and anxiety using The Yale Anxiety Score, Depression Intensity Scale Circle (DISCS), Anxiety Scale Circle (ASC) and Open Q. Complexity was assessed using Patient categorization tool (PCAT). High scoring patients were referred for neuropsychological intervention. We evaluated whether higher anxiety scores were related to living alone.

Results

Of 76 patients 43(53%) male, mean age 73yrs (SD 16.7), 33(40%) age ≥80, 26(38%) scored ≥3 on the DISCS and ASC; On the Yale questionnaire 18 (24%) scored ‘Yes’; On Open Q 27(36%) scored ‘Yes’. Of those scoring ≥3 on DISCS, 6(60%) and ASC, 9(56%) were living alone. Average PCAT: 20.91 (SD 3.6). Average length of stay for patients deemed appropriate or ‘near ready’ for ESD was 8 days which was contributed to by health anxiety and mood-related issues. 7(9%) patients were referred for further neuropsychological intervention.

Conclusions

Anxiety and depression was present in approximately 40% of patients with ‘less severe’ strokes. These patients tended to live alone. Identifying these patients could help facilitate early community interventions.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

MEDICATION ADHERENCE POST-STROKE: DO THE BELIEFS OF STROKE NURSES REFLECT THE CHALLENGES FACED BY PATIENTS AND CARERS IN MANAGING MEDICATION AT HOME EARLY AFTER DISHARGE?

JME Gibson ¹, J Coupe ¹, CL Watkins ¹

Abstract

Background

Poor medication adherence post-stroke is common and may allow recurrence. This study compared stroke nurses’ beliefs about medication adherence with stroke survivors’ and carers’ experiences of managing medication early post-discharge.

Methods

We interviewed registered nurses from one UK stroke unit, and stroke survivors and carers <1 month post-discharge. We explored their beliefs, experiences, and strategies employed. Initial interpretation of interview content was verified with participants; analysis was undertaken iteratively. Interviews were audiotaped and transcribed. Thematic analysis was undertaken using NVivo software.

Results

Fifteen nurses, nine stroke survivors, and three carers participated.

Practical issues: both groups identified dexterity, co-ordination and mobility, reading labels, cognitive impairment, regime complexity, and lack of knowledge as problems.

Motivational issues: both groups identified the preventive nature of medications, concerns about side-effects, and the stigma of medication as problems. Nurses suggested that depression, or a fatalistic attitude, led to poor adherence.

Identification of risk: Nurses suggested that living alone, stroke severity, prior poor adherence, and cognitive impairment were risk factors.

Strategies to manage medication: Both groups suggested that multidisciplinary communication, carer involvement, and appropriate drug formulation were important. Nurses suggested that ‘teaching’ drug rounds, individualised assessment, regime simplification, and telephone follow-up were useful. Both groups identified that support was often sporadic, opportunistic and inconsistent.

Conclusions

There are some commonalities of understanding about the challenges of establishing a new medication routine post-stroke, but provision of support is inconsistent. Further work is needed to develop, validate and evaluate methods for assessment and management of post-stroke medication adherence.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

IMPROVING ORAL CARE IN ACUTE INPATIENT STROKE

T Green ¹, D Harwood ², O Fisher ³, S Chou ², S Jamieson ⁴

Abstract

Background

Hospitalized survivors of acute stroke experience numerous sources of stress that can adversely affect oral health; poor oral health may lead to stroke-associated pneumonia (SAP) which has been identified as a leading hospital-acquired infection following stroke, with 1:5 stroke survivors affected. SAP is associated with poorer rehabilitation outcomes and death and research indicates a possible link with patients’ oral health.

Methods

In a two-phased quality improvement project, current outcomes related to oral care post-stroke will first be assessed via a retrospective chart review. This will be followed by implementation of a QI rapid cycle process to implement and evaluate an enhanced oral care protocol. Methods: Using a Plan-Do-Study-Act quality improvement process, oral care processes and procedures at RBWH will be evaluated. Health record data will be reviewed to identify indicators that may be related to oral care after stroke. We will measure our local data on documented oral care and will extract age, gender, BMI, previous medical history including previous stroke or TIA, in-hospital care pathway, documented processes & provision of oral care from the heath record.

Results

Primary outcomes: hospital-acquired pneumonia, gingival bleeding, and dental referrals.

Secondary Outcomes: oral health, plaque, antibiotic use, length of stay, death, use of oral healthcare equipment and products, and documented oral healthcare plans.

Conclusions

Implications for Nursing Practice: This quality improvement project will provide evidence to support implementation of evidence based protocols for oral care for stroke unit and ICU patients using a QI cycle that includes ongoing assessment of the provision and processes of care.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

TRIAGE, TREATMENT AND TRANSFER (T3) INTERVENTION IN ACUTE STROKE CARE: IDENTIFYING A SET OF PRIORITY BARRIERS TO FACILITATE SUCCESSFUL IMPLEMENTATION

S Middleton ¹, L Craig ¹, L Churilov ², L Olenko ², S Dale ¹, C Martinez ¹, D Cadilhac ³

Abstract

Background

Understanding barriers that inhibit adoption of evidence-based stroke care processes has an integral role in implementation trials. Since not all barriers have equal importance, standardised methods for their prioritisation are needed.

Aim: To identify the major barriers to target as part of the implementation of an evidence-based triage, treatment and transfer intervention in Emergency Departments (ED) within an acute stroke care trial (T³ Trial).

Methods

A questionnaire listing each T³ trial intervention (n = 9) was completed by a convenience sample of Australian stroke opinion leaders. Participants produced two ranked lists: the first based on how influential the barrier is in preventing clinicians from adopting each T³ intervention; and the second based on how difficult the barrier is to overcome. Using simultaneous analysis of the two attributes, priority barriers were identified.

Results

Response rate 100% (n = 17). For each T³ intervention a set of priority barriers were identified. Patients presenting with resolving symptoms and no hospital protocol for rapid stroke care were priority barriers to overcome in relation to appropriate triage. Lack of leadership and delays in obtaining computed tomography (CT) scans were priority barriers to overcome for assessing eligibility for thrombolysis. Prolonged patient stay in ED and lack of fever protocols were priority barriers to overcome in relation to taking temperature on arrival to ED.

Conclusions

This standardised, efficient method for identifying and classifying the importance of barriers for implementation interventions is novel within a stroke trial. This could be used in future stroke implementation trials and ensure greater success.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

IMPLEMENTATION OF A NEW METHOD TO REGISTER FALLS IN HOSPITALIZED NEUROLOGICAL PATIENTS

L Muñoz-narbona ¹, C Casanovas ², M Castella ², M Lopez ², I Andres ³

Abstract

Background

About the 2–12% of patients suffers at least one fall during their hospitalization. It is the 5th leading cause of death in the elderly. Our aim is to improve compliance on recording fall risk of patients hospitalized in the neuroscience area through an implementation of a new method of registration in the medical records of the Catalan Institute of Health

Methods

After a training course aimed at nurses of the neuroscience department, a new method to register falls was implemented in May 2015. Falls were classified according to the degree of injury: 1. Fall without lesion, 2. Fall with mild lesion, 3. Fall with multiples mild lesion, 4. Moderate fall with traumatic lesion, 5. Serious fall with traumatic lesion, 6. Fall with transient loss of consciousness. When a fall is registered an automatic record is generated in the care plan and medical history warning the medical team. Variables registered were: demographic data, cause of admission and risk factors, falls during hospitalization and degree of injury

Results

From a total of 1612 admissions during a 7 month period, 18 patients fells (1.11%), 25 falls were recorded (1.55%), median age 67 years, a 38,8% of female, and a 61,2%male. The 100% of the falls were classified as falls without lesion. Factors related with falls were cognitive impairment (28%), mobility problems (83%) and incontinence (11%)

Conclusions

The implementation of the program facilitates the registration of falls in hospitalized patients. This tool helped nurses performed preventive actions for the patient and family

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

NURSING INTERVENTIONS FOR STROKE PATIENTS: AN INTEGRATIVE COORDINATION OF CARE PRIMARY CARE, HOSPITAL AND COMMUNITY SOCIAL SERVICES. EBRICTUS STUDY

ML Queralt-tomas ¹, MA Gonzalez-henares ¹, A Panisello-tafalla ¹, JL Clua-espuny ², R Ripolles-vicente ³, T Forcadell-arenas ¹, J Lucas-noll ¹

Abstract

Background

The ageing will double by 2050 as well the stroke incidence, its residual deficits and new needs for caregivers. The purpose of this study was to improve nursing care to provide continuity across the stroke-recovery trajectory and support for caregivers

Methods

It's a longitudinal prospective study of population-based cohort of cases of a first episode of stroke since 1/April/2006 to 30/June/2015 in primary care health area. We analyzed patient demographics, Barthel and Rankin score, and social services contact.

Results

1,404 cases (54.1% male); mean age 73.9 ± 12.5 years. 43.4% go directly home and need a home caregiver and 17.6% were referred to long-term care. The NHISS score was registered in 39.4%. It’s a predictor of functional outcome (p 0.022) and survival (p < 0.001). The Barthel score at postroke was recorded in only 24.6%. It was a predictor of long-term mortality (p < 0.001). The cases without functional records were concentrated in the cases with a Barthel ≤60 or whose mortality endpoint was 55.9%. At postroke the percentage of individuals with moderate or greater dependence at least triples (19.3%). Just few (<10%) used reference social services. We consider of special interest the standardization of hospital discharge reports to provide integrated post-acute care managed by nurse practitioners and social care service to get the simplification and standardization of the evaluation f dependence.

Conclusions

These results support the elaboration of integrative protocols which include multidisciplinary care to reduce the loss of welfare to dependent individuals and their families in the number of applications for benefits and services.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

TO TELL THE TRUTH OR WITHHOLD IT: STROKE TEAM MEMBERS REASONING oN UNEXPECTED SUDDEN DEATH FROM STROKE

Å Rejnö ¹

Abstract

Background

Ethical problems are especially evident in end of life. Since stroke is the second most common cause of death globally, and mortality in the acute phase is considerable, stroke team members are frequently confronted with such problems. Patients dying due to acute stroke often have reduced consciousness and thereby a limited ability to make decisions about their own care. Next of kin often act as proxies in these situations.

Methods

The aim of the study was to deepen the understanding of stroke team members reasoning about truth-telling and truthfulness when caring for patients dying from acute stroke. Four physicians, seven registered nurses and four enrolled nurses working at acute- and rehabilitative stroke units at two hospitals in Sweden participated. Interviews were analysed with combined deductive and inductive content analysis and resulted in two categories.

Results

The main findings were the team members’ dynamic movement between the categories “Truth above all” and “Hide truth to protect”. They honoured honesty high and held it as reason for always telling the truth without embellishing, with the argument of truth as common morality. Truth was also showed to be viewed as harmful. The team members stated they commonly could hide the truth or parts of it and argued that this could be beneficial and help to protect the next of kin.

Conclusions

The results indicate barriers for truth-telling like level of experience and will to shared decision making. Reflecting on truth-telling together in the stroke team can be valuable and promote ethically justified care, benefiting the patient.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

REVIEW OF THERAPEUTIC COMPLIANCE IN PATIENTS TREATED WITH ORAL ANTICOAGULATION VS NEW ORAL ANTICOAGULATION. CLINICAL EXPERIENCE

M Garcés-Redondo ¹, S Reverté-Villarroya ¹, P Esteve-Belloch ¹, G Martín-Ozaeta ¹, S Escalante-Arroyo ¹, J Zaragoza-Brunet ¹, C Matamoros-Obiol ¹, R Benet-Martí ¹, E Inglada-García ¹, N Bernado-Llambrich ¹, E Sanjuan ², R Güell-Baró ³, JJ Baiges-Octavio ¹

Abstract

Background

The use of oral anticoagulants has incremented progressively due to new indications for anticoagulation therapy (AT) and increasing age of the population. Lack of adherence is a problem in clinical practice with a prevalence of 50 % in chronic diseases. The aim of this study is to compare adherence to classic oral anticoagulation (C-OA) (acenocumarol) and with new oral anticoagulant therapy (N-AT) measured by Morisky-Green-Levine test.

Methods

A total of 25 subjects were enrolled. Data collected: age, sex, cardiovascular risk factors (CRF) (hypertension (HTA), diabetes mellitus (DM), dyslipidemia (DL), previous stroke (PS), smoking (SK), alcoholism (AH)), modified Rankin scale (mRs) score and adherence measured by Morisky-Green-Levine test (adherence and non-adherence) 3 months after indication of AT.

Results

People enrolled had a mean age of 67 years (SD: 14). 68% were men. They were classified in two groups: C-AO (N = 15) and N-AO (N = 10). Scores 3 months post-AT for C-AO vs N-AT; HTA 66,7% vs. 80%, DM 33,3 vs. 30%, DL 53,3% vs. 50%, PS 33,3% vs. 20%, SK 33,3% vs. 10%, AH 33,3% vs. 20%, mRs 1 ± 1 vs. 2 ± 1 and Morisky-Green-Levine test showed 20% C-AO vs. 60% N-AO of adherence. No statistical significance differences have been observed.

Conclusions

The population under new oral anticoagulant therapy was more HTA and more dependent. This group showed highest rate of adherence to treatment. We suspect that the increased to adherence to N-AO is due to more stable dosage and no need for periodic control. These are preliminary results so it is necessary to increase the sample size.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CT STROKE CODE DRAMATICALLY REDUCES DOOR-TO NEEDLE AND DOOR-TO GROIN TIMES FOR REPERFUSION THERAPY

E Sanjuan ¹, M Rubiera ¹, S Boned ¹, M Ribo ¹, M Muchada ¹, D Rodriguez-Luna ¹, J Pagola ¹, JM Juega ¹, N Rodriguez-Villatoro ¹, M Sanchis ¹, E Montiel ¹, KE Santana ¹, L Calleja ¹, P Giron ¹, MT Rodriguez Samaniego ¹, S Lucas ¹, CA Molina ¹

Abstract

Background

Shortening door-to-needle(DTN)time is one of the major goals of reperfusion therapy. Stroke Code (SC) pre-notification leading to a direct transfer from ambulance to CTsuit, bypassing ER, may dramatically reduce DNT. To ensure quality of care, the role of an expert stroke nurse(ESN) may also be essential. We aimed to assess the impact of SC and direct transfer to CT (CT-SC) on DTN and door-to-groin (DTG) time and to evaluate the role of an expert stroke nurse to ensure the quality of care.

Methods

Thirty-eightCT-SC patients were compared to 74contemporary SCpatients who underwent reperfusion treatment. Once CT-SC is activated and information provided is clear, neurologist and an ESN await the patient in the CTsuit. If SC is not activated, patient is unstable or information is incomplete/unclear, patient is first transferred to ER before CT (SCgroup). Our primary outcome was a DTNtime < 20 minuntes and DTG < 60 min, and secondary outcome: security(Symptomatic ICH and mortality)&feasibility(lack of incidents) of the CT-SC protocol.

Results

In CT-SCgroup mean DTN was 24 min and 19 patients(50%) were treated in <20 min vs 4(5.6%) in SCgroup mean52 min, p < 0.001. CS-CTprotocol significantly reduces DTG (n = 6;42.9%) compared to CSgroup(n = 2;9.1%), p < 0.001. Regarding security, no differences were found between CS-CTvsCSgroup in SICH(10.5%vs6.7%) nor death (7.9%vs10.8%). Regarding feasibility no major incidents were found in the stroke unit while ESN was attending a CS-CT. ESN mean time out of the stroke unit was 26+/-5 min, actions at CTsuit incuded: BP management(16%patients required antihypertensive treatment),glicemia control(insulin 13.4%),other iv medicacions(10%).

Conclusions

CT-SC protocol markedly reduces DTN and DTG times, and seems to be feasible and safe.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

IMPLEMENTATION OF A NEW INTERMITTENT PNEUMATIC COMPRESSION PROTOCOL IN A STROKE UNIT

K Santana Roman ¹, E Sanjuan ¹, M Rubiera ¹, C Molina ¹, N Rodriguez ¹, J Juega ¹, M Sanchis ¹, D Rodriguez ¹, S Boned ¹, J Pagola ¹, M Ribo ¹, M Muchada ¹, G Dalmases ¹, O Miñarro ¹, MT Rodriguez ¹

Abstract

Background

Intermittent pneumatic compression(IPC) has demonstrated to prevent deep venous thrombosis(DVT) and improve survival in acute stroke. However, early application of the IPC in the first hours after symptom onset may induce hemodynamic changes and modify outcomes.

We aimed to implement a new IPC protocol in our non-invasive stroke unit by applying IPC in the hyperacute stroke phase.

Methods

All acute stroke patients with high DVT risk and contraindication for pharmacological DVT prophylaxis received IPCtreatment. In ischemic stroke patients treated with reperfusion therapies, IPC protocol was planned for24hours; intracraneal hemorrhage(ICH) patients were treated with IPC during72hours.Nurses&patients were interviewed for satisfaction.

Results

From March-August2015, we enrolled 132patients: 56.4%male, mean age71+/-15 y.o.,ischemic strokes 79.2%.Time from admission to IPC application 102+/-375 min. Duration of treatment in ischemic patients was37+/-21hours while in ICH was 44+/-26hours. No patient presented DVT in the series. We observed 6deaths(4.5%) and 66patients(56.4%) presented other complications, none of them related to IPC.

Hemodynamic values during the IPC were: Ischemic stroke patients(n = 103) had a mean Systolic Blood Pressure(SBP)132.5+/-18.4 (Min:78, Max194)mmHg, 11patients(10.8%) had SBP > 180 mmHg. ICH stroke patients(n = 27) mean SBP136.5+/-10.6 (Min88, Max230)mmHg; 10 patients(37%) had SBP > 140 mmHg. Glycemia was out of range > 140 mg/dl in 30 patients(22.6%), mean127+/-23 (Min85, Max267)mg/dl.

Only at implementation phase nurses referred a relevant work burden with the new protocol compared to classical low-weighed-heparin DVT prophylaxis. After training, it only takes6 ± 1.5 min to apply IPC.

Only 3patients(2.3%) presented discomfort, 2of them with early IPC drop off.

Conclusions

IPC treatment is feasible, safe, and comfortable for stroke patients in the hyperacute phase. It increases work burden for nurses only at the implementation phase.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

LOW LEVEL OF STROKE CARE AWARENESS AMONG STROKE PATIENTS’ CAREGIVERS: AN IMPORTANT BUT NEGLECTED AREA OF STROKE CARE

N Sharma ¹, L Thapa ²

Abstract

Background

Stroke is one of the leading causes of mortality and morbidity worldwide. Stroke patients require long term care for better outcome. Most often family members are the back bone of the service provided to people affected by stroke. Stroke patients and their caregivers are known to have large gaps in stroke knowledge and have suboptimal personal health behaviors, thereby putting the patient at high risk for complications. Our study was designed to explore the stroke care awareness among stroke patients' caregivers.

Methods

Fifty stroke caregivers aged >18 years from neurology ward of College of Medical Sciences-Teaching Hospital were selected by non-probability purposive sampling from June 2012 to July 2012. Questionnaire focusing basic stroke care was prepared by researchers with the help of literature and a neurophysician. Validity and reliability of the tools were tested and data collected. Analysis of collected data was done using SPSS 16.0.

Results

The mean age of the respondents was 40 years (range: 20–80 years). Thirty-nine (78%) were either spouse or children. Thirty-eight (76%) caregivers were literate. Overall, 27 (54%) caregivers had low level of awareness regarding stroke care and mean knowledge score was 23.7.

Conclusions

Our report revealed the existence of low level of stroke care awareness amongst stroke caregivers in Nepal. Interventional education program oriented to address this important yet neglected area can improve the stroke care in countries like Nepal where recent advancement for stroke management is lacking.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

DEVELOPMENT AND FEASIBILITY OF AN ORAL HYGIENE COMPLEX INTERVENTION FOR STROKE UNIT CARE

C Smith ¹, M Horne ², G McCracken ³, D Young ⁴, I Clements ⁵, S Hulme ⁶, C Ardron ⁷, S Hamdy ⁸, A Vail ⁹, A Walls ¹⁰, P Tyrrell ⁶

Abstract

Background

Oral hygiene interventions might improve clinical outcomes after stroke but evidence-based practice is lacking. Our objective was to develop an oral hygiene complex intervention and evaluate it’s feasibility in a UK stroke centre.

Methods

We used a sequential mixed methods approach and developed an oral hygiene complex intervention comprising: (1) web-based education and “hands-on” practical training for stroke unit nursing staff; (2) a pragmatic oral hygiene protocol consisting of twice-daily powered (or manual if preferred) brushing with chlorhexidine gel (or non-foaming toothpaste) +/- denture care. We evaluated feasibility of (1) the staff education and training; and (2) the oral hygiene protocol in consenting inpatients with confirmed stroke, requiring assistance with at least 1 aspect of personal care.

Results

The staff education and training were feasible, acceptable and raised knowledge and awareness. Several barriers to completing the education and training were identified. The oral hygiene protocol was feasible and well-tolerated. 22% of eligible patients screened declined study participation. Twenty-nine patients (median age = 78 y; National Institutes of Health Stroke Scale score = 8.5; 73% dentate) were recruited at a median of 7 days from stroke onset. 97% of participants chose the default chlorhexidine-based protocol; the remainder the non-foaming toothpaste-based protocol. The mouth hygiene protocol was administered as prescribed on 95% of occasions, over a median duration of 28 days. There were no adverse events attributed to the oral hygiene protocol.

Conclusions

Our oral hygiene complex intervention was feasible in a UK stroke centre. Further studies to optimise patient selection, model health economics and explore efficacy are now required.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

INFLUENCE OF CIRCADIAN VARIATION IN ALTEPLASE-TREATED ISCHEMIC STROKE PATIENS ON PROGNOSIS

JN Alves ¹, C Machado ¹, JM Amorim ², J Araújo ¹, AF Santos ¹, S Varanda ¹, J Pinho ¹, C Ferreira ¹

Abstract

Background

A number of vascular diseases are believed to display a circadian variation and this may be mediated by several biological factors which are not completely understood. Our was to determine if prognosis is influenced by timing of stroke onset in a pool of patients treated with alteplase.

Methods

From the prospective registry of ischemic stroke patients treated with alteplase in Hospital de Braga between February 2007 and June 2015, we divided patients in 4 groups, according to stroke onset: G1 (00:01–6:00 h), G2 (6:01–12:00), G3 (12:01–18:00), G4 (18:01–24:00). Demographic, clinical and imagiological variables and 3-month prognosis were analyzed using SPSS.22®.

Results

Of the 593 patients included (56% female, median age 74 years, mean admission NIHSS 14, 35 underwent additional revascularization), 22 patients were included in G1, 203 in G2, 212 in G3 and 156 in G4. G1 patients were significantly younger, less frequently hypertensive, had more posterior circulation events and had a better prognosis at 3 months. G2 patients had a lower NIHSS score on admission and were more frequently independent at 3 months. G3 patients underwent additional revascularization less often and more frequently had a poor 3-month prognosis. G4 patients were treated more frequently with additional revascularization techniques. After adjusting for age, NIHSS, ASPECTS score, symptom-to-needle time and additional revascularization, only G2 was significantly associated with better prognosis (OR = 1.8, 95%CI = 1.07–3.08, p = 0,026).

Conclusions

Alteplase-treated ischemic stroke patients with clinical onset between 6:01 and 12:00 hours have a better functional outcome than patients with symptoms initiated at other periods of the day.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CEREBRAL WHITE MATTER PERFUSION AND SMALL VESSEL DISEASE IN PATIENTS WITH ACUTE ISCHEMIC STROKE. SUBGROUP ANALYSIS OF IST-3 TRIAL

F Arba ¹, G Mair ², T Carpenter ², E Sakka ², P Sandercock ², R Lindley ³, D Inzitari ¹, J Wardlaw ²

Abstract

Background

Small vessel disease (SVD) is associated with impaired cerebral perfusion. However, it is unknown whether perfusion worsens with severity of SVD. We investigated associations between CT features of SVD (leukoaraiosis, lacunes, brain atrophy) and perfusion parameters in patients with ischaemic stroke who underwent perfusion imaging in the IST-3 trial.

Methods

We rated SVD features on baseline plain scans using validated scales. We assessed white matter perfusion visually (hypoperfusion yes/no) in the unaffected hemisphere (representing

Background subcortical perfusion) with reference to the acutely hypoperfused (i.e. acute ischaemic) defect. We examined associations between SVD features (individually and summed) and hypoperfusion on time-based perfusion parameters using logistic regression, adjusting for age, sex, baseline NIHSS, hypertension, and diabetes.

Results

151 patients, median (IQR) age 81 (72–86) years, 79 (52%) males, received CT or MR perfusion imaging. Hypoperfusion varied with perfusion parameter, being most (63 patients, 57%) on mean transit time (MTT), least (19, 17%, patients) on Tmax. Leukoaraiosis and central atrophy were independently associated with hypoperfusion on both MTT (OR = 1.49; 95% CI = 1.09–2.04; OR = 2.29; 95% CI = 1.22–4.30 respectively) and arrival time fitted (ATF) (OR = 1.70; 95% CI = 1.23–2.35; OR = 2.19; 95% CI = 1.17–4.11 respectively), but only central atrophy with Tmax (OR = 3.72; 95% CI = 1.44–9.59). The SVD summed score was independently associated with hypoperfusion on MTT (p = 0.002), Tmax (p = 0.001), and ATF (p > 0.001).

Conclusions

Leukoaraiosis, central atrophy and particularly the SVD summed score are associated with hypoperfusion on time-based parameters. Our results provide validity to the SVD score concept, showing increasing severity of SVD is associated with worse cerebral perfusion.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PRIOR STATIN USE AND HIGH-RESOLUTION MR IMAGING CHARACTERISTICS OF INTRACRANIAL ATHEROSCLEROTIC PLAQUE: THE STAMINA-MRI STUDY

JW Chung ¹, J Hwang ¹, MJ Lee ¹, J Cha ², GM Kim ¹, CS Chung ¹, KH Lee ¹, OY Bang ¹

Abstract

Background

Although statin has been link to stabilization of systemic atherosclerosis, its impact on symptomatic intracranial atherosclerotic plaque remains to be explored. We hypothesized that premorbid statin use is associated with plaque characteristics of intracranial arteries and may lead to differential ischemic lesion patterns in acute intracranial atherosclerotic stroke patients (ICAS).

Methods

One hundred thirty-six patients with acute infarcts caused by ICAS underwent high-resolution MRI. Patients were categorized in to three groups based on their premorbid statin use; non-user, low-to-moderate dose user, and high-dose user according to the ACC/AHA 2013 cholesterol guidelines. Symptomatic intracranial artery was analyzed using high-resolution MRI for vascular morphology (stenosis degree, remodelling index, and wall index) and plaque activation (pattern and volume of enhancement). The ischemic brain lesions on DWI were measured in terms of their cortical distribution and volume.

Results

Among enrolled patients, 38 (27.9%) were taking statin prior to index stroke; 22 taking a lower-dose and 16 taking high-dose. Among high-resolution MRI parameters, stenosis degree, remodelling index, and wall index did not differ between the three groups. However, volume of plaque enhancement was significantly lower in statin users (non-user, 33.26 ± 40.72; a lower-dose user, 13.15 ± 17.53; high-dose user, 3.13 ± 5.26; P = 0.002). In terms of infarct pattern, premorbid statin use was associated with higher prevalence of non-embolic pattern stroke with decrease in large cortical infarcts (P = 0.012).

Conclusions

Premorbid statin usage is independently associated with reduced plaque vulnerability and decreased large cortical lesion patterns in patients with ICAS.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EFFECTS OF STROKE LOCALIZATION IN ARTERIAL PRESSURE MONITORING

C García-Cabo ¹, L Martínez ¹, L Benavente ¹, A García-Rua ¹, S Fernández ¹, Á Pérez ¹, P Suárez-Santos ¹, P Martínez-Camblor ², S Calleja ¹

Abstract

Background

Autonomic disfunction (AD) is common in patients with acute ischemic stroke(IS). AD might play a role in arterial blood pressure(ABP) variations as some studies showed a correlation between urinary catecholamines and ABP course in IS. The aim of this study was to demonstrate the differential effects of stroke localization (SL) on ABP variations.

Methods

All patients who were admitted in our Stroke Unit from September to November 2015 were included in the study. IS or haemorrhagic stroke (HS) were diagnosed according to neurological examination and Computer Tomography (CT) scan. To confirm SL and size, another CT or Magnetic resonance imaging was performed. Brain affected areas were divided according to Alberta Stroke Programme Early CT Score (ASPECTS) and Posterior Circulation-ASPECTS areas. All patients were followed by bedside continuous ABP monitoring. BP higher than 140/90 was defined as hypertension.

Results

One hundred fourteen patients were included. 78 (68%) of the patients suffered IS, 16 HS, 9 transient ischaemic attacks and 1 stroke mimic. No differences in ABP variations were found between HS and IS. Thalamus and cerebelum in PC-ASPECTS and M2 and M8 areas from ASPECTS were more frequently associated with higher systolic ABP values. Thalamus area was also strongly associated with higher diastolic ABP values.

Conclusions

Arterial hypertension occurs in approximately 80% of patients with acute stroke and is related to poor outcome. The pathophysiology is very complex and sometimes it was linked with insula involvement. Present study suggested that thalamus and other areas are also associated with ABP variations.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ROLE OF LIPOPROTEIN-ASSOCIATED PHOSPHOLIPASE A2 IN ISCHEMIC STROKE PATIENTS TREATED WITH TPA THROMBOLYSIS: THE MAGIC STUDY

AM Gori ¹, B Giusti ¹, B Piccardi ², P Nencini ², G Pracucci ², M Nesi ², V Palumbo ², A Sereni ¹, R Abbate ¹, D Inzitari ²

Abstract

Background

Lipoprotein-associated phospholipase A2 (Lp-PLA2), a member of phospholipase A2 proteins family, plays a key role in the metabolism of pro-inflammatory phospholipids and in the generation of pro-atherogenic metabolites which may affect vessel walls. Several studies have demonstrated that Lp-PLA2 is an independent risk marker for ischemic stroke (IS). However, scarce data exist in IS patients treated with tPA. We evaluated the role of Lp-PLA2 on adverse clinical outcomes in tPA-treated IS.

Methods

Blood was taken at baseline (B) and 24 hours after tPA from 327 patients (mean age 68 yrs, mean NIHSS 11). Lp-PLA2 activity levels were measured by immunoturbidimetry, and inflammatory markers by Bioplex assay. Baseline, post-thrombolysis and B/24 hrs post-tPA variations of Lp-PLA2 activity were analyzed according to SICH, death and 3-month mRs.

Results

Lp-PLA2 activity levels at B were significantly higher in males than in females [F = 172(140–199.5) nmoL/min/mL, M = 200(165–235) nmoL/min/mL, p < 0.001]. A slight, but significant correlation was found between B total cholesterol levels and Lp-PLA2 (r = 0.194, p = 0.002). B Lp-PLA2 activity levels were significantly higher in patients with mRS3–6 vs mRS0–2 [194 (161–232) vs 182 (145–220) nmoL/min/mL;p < 0.05], whereas neither post-tPA Lp-PLA2 activity nor B/24 hrs post-tPA variations of Lp-PLA2 activity differ in relation to mRS or other outcome measures. After adjustment for major outcome determinants, B Lp-PLA2 activity remain independently associated with mRS3–6 [OR(95%CI) = 1.37(1.07–1.76),p = 0.012 for every 50 nmol/min/mL increase].

Conclusions

Our data suggest that Lp-PLA2 may contribute to the pathophysiological mechanism of IS and poor outcomes after tPA, suggesting that a vascular inflammation may have a detrimental role in this clinical setting.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CEREBRAL VENOUS SINUS THROMBOSIS: INCIDENCE AND HYPERHOMOCYSTEINEMIA AS A RISK FACTOR IN JAPANESE PATIENTS

M Kuriyama ¹, T Himeno ², M Takemaru ², Y Shiga ², S Takeshima ², K Takamatsu ², Y Shimoe ²

Abstract

Background

Cerebral venous sinus thrombosis (CVT) occurs commonly in young female adults and is caused by various risk factors. Our aim was to determine the incidence, clinical characteristics, and risk factors of Japanese CVT patients.

Methods

We performed a retrospective study of CVT patients from January 2006 to June 2015. In the patients who had hyperhomocysteinemia, folate and vitamin levels were measured. To define the clinical characteristics in patients with hyperhomocysteinemia, we statistically compared them to those patients with normal levels of homocysteine.

Results

Twenty-five patients (aged 59.8 ± 18.6 years; 20 men and 5 women) were included. The incidence of CVT was 0.22% among all types of strokes or 0.30% of acute ischemic strokes, which was lower than previously reported. The patients were characterized by advanced age, low frequency of headaches, and few female patients, especially female patients using oral contraceptives. The predisposing conditions included a notably high incidence of hyperhomocysteinemia (56.3%). They also included deficiencies of folate, vitamin B12, vitamin B6, or combined deficiencies. Marked hyperhomocysteinemia over 100 nmol/ml was noted in combined deficiencies.

Conclusions

CVT in Japan commonly occurred in older males. The prevalence of hyperhomocysteinemia as a risk factor of CVT was high, and the main underlying disorders were folate and vitamin B12 or B6 deficiencies. This is clinically important, because these acquired risks can be corrected by supplementation therapy to prevent the recurrence of CVT.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CEREBRAL PERFUSION AND COGNITIVE FUNCTIONS IN PATIENTS AFTER CAROTID ENDARTERECTOMY FOR SYMPTOMATIC CAROTID STENOSIS

A Mushba ¹, O Vinogradov ², A Tsvetkova ², A Kuznetsov ²

Abstract

Background

25% of ischemic strokes are associated with atherosclerosis of extracranial and intracranial arteries. Carotid endarterectomy (CEA) is used for secondary prophylaxis of ischemic strokes in patients with symptomatic stenosis of internal carotid artery over 70%. Nevertheless, it is still unknown whether the removal of atherosclerotic plaque from internal carotid artery (ICA) improves perfusion of hemisphere and, as a consequence, cognitive function, or not.

Methods

30 patients with atherotrombotic type of ischemic stroke who undergone CEA were included in study. 22 (73.3%) of them were male and 8 (26.7%) were women; mean age of patients was 62.5 ± 1.3 years. Preoperatively and 10–14 days postoperatively patients were studied with cognitive impairment scales (MMSE, МоСа), cognitive evoked potentials (P-300), duplex scanning of brachiocephalic arteries, transcranial duplex scan, brain MRI and Single-photon emission computed tomography (SPECT)with 99mТс-HMPAO.

Results

Improvement of cerebral perfusion in affected hemisphere after CEA was demonstrated: SPECT showed increasing of perfusion in medial cerebral artery system from 87.3% to 92.1% (р < 0.05). Improvement of cerebral perfusion did not result to improvement of cognitive functions: mean MMSE score pre-op and post-op were 25.1 ± 0.5 and 25.9 ± 0.2, respectively (p > 0.05); МоСа score pre-op and post-op were 26.3 ± 0.4 and 26.7 ± 0.3, respectively (p > 0.05). Differences in neurofuncional data pre- and postoperatively were not statistically significant. Cognitive evoked potentials showed pre-op and post-op latency of P-300 399.7 ± 8.7 msec and 360.3 ± 9.6 мс msec, respectively (p > 0.05).

Conclusions

CEA for symptomatic stenosis of ICA improves cerebral perfusion in affected hemisphere but do not improve cognitive functions.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

MACROSCOPICAL AND HISTOLOGICAL ANALYSIS OF CEREBRAL THROMBI OF ACUTE STROKE PATIENTS: A NEW CLASSIFICATION?

V Quenardelle ¹, C CANNET ², I ZINCHENKO ¹, V LAUER ¹, S KREMER ³, JS RAUL ², A MICHEL ⁴, R POP ⁵, R BEAUJEUX ⁵, C GACHET ⁴, V WOLFF ¹

Abstract

Background

Mechanical thrombectomy in acute stroke allows retrieval of cerebral thrombi from the intracranial or cervical vessels. A few data are available in the literature about histopathologic composition of cerebral thrombi. The aim of our study was to determine the age and the composition of these thrombi.

Methods

Between January 2010 and March 2013, in Strasbourg University Hospital (HUS), we collected consecutively the thrombi extracted by mechanical thrombectomy. After an IRM with 3D-TOF-MRA, indication of mechanical thrombectomy associated or not with rt-PA treatment was retained by stroke team. Specimens were embedded in glutaraldehyde 2.5%. All thrombi were stained with hematoxylin and eosin, Martius Yellow / Scarlet red /Methyl Blue, Perls, and Picrosirius and analyzed by transmission electron microscopy.

Results

Thirty-two thrombi were classified based on their color and composition in red blood cell and fibrin. Macroscopically, we distinguished yellow thrombi (n = 2), beige thrombi (n = 10), brown thrombi (n = 12) and black thrombi (n = 8). We identified 14 red thrombi (43.75%), 3 white thrombi (9.25%), and 15 mixed thrombi (47%). A correlation between the color of the thrombi and its histological composition, and between the color and the age of the clot was demonstrated. Moreover, all thrombi were heterogeneous among them and within the clot and all were fresh (<36 h), independently to the recanalization delay.

Conclusions

This is the first work showing that macroscopical analysis could help us to determine age and thrombus composition. Further research is necessary to affine this classification, which could help to develop more therapeutical strategies at the early stage of ischemic stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

LOW O2 SATURATION AND WAKE AFTER SLEEP ONSET EPISODES ARE ASSOCIATED WITH POOR COGNITION IN ASYMPTOMATIC HYPERTENSIVE INDIVIDUALS

I Riba Llena ¹, J Álvarez-Sabín ², O Romero ³, E Santamarina ², G Sampol ³, O Maisterra ², Á Ferré ³, J Montaner ⁴, M Quintana ², P Delgado ¹

Abstract

Background

Cognitive impairment has been inconsistently associated with sleep disordered breathing and changes in sleep architecture. Our aims are to test whether respiratory parameters and sleep architecture are associated with cognitive performance and diagnosis.

Methods

This study was conducted within a cohort of hypertensive individuals without previous stroke or dementia. All participants underwent MRI to assess silent brain infarcts and white matter hyperintensities (WMH). Cognitive testing was carried out with a screening test (Dementia Rating Scale-2, DRS-2) and a complete neuropsychological battery when cognitive screening was failed. MCI was diagnosed according to previous criteria. Moreover, inhospital polysomnography including EEG, EOG and EMG was also performed.

Results

149 subjects participated with mean age 66.6(±6.6), 69.1% male and median apnea-hypoapnea index 21.3 (IQR = 10.0, 40.4). 23 subjects were diagnosed with MCI. Regarding respiratory parameters, lower Total DRS-2 score (β = −0.024; CI95% = −0.038, −0.010, p < 0.001) and lower memory score (β = −0.018; CI95% = −0.030, −0.006, p = 0.007) were associated with longer desaturation time (time with O₂ saturation<90%) after correcting for age, education, sex, vascular risk factors, body mass index and high grade WMH. However, respiratory parameters were not independently associated with cognitive diagnosis (MCI versus normal cognition or NC). Regarding sleep architecture, lower executive function was independently associated with higher wake after sleep onset episodes (β = −0.003, CI95% = −0.005, −0.001, p = 0.034). Besides, MCI participants had increased time in sleep phase I/II and decreased phase III compared to NC but these differences were not independent of other covariates.

Conclusions

Low O2 saturation and sleep architecture disturbances may contribute to cognitive deficits, particularly by affecting memory, executive and overall cognitive functions.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EARLY LEUKOCYTE COUNTS ARE PREDICTIVE FOR ACUTE ISCHEMIC STROKE OUTCOME

A Semerano ¹, D Strambo ², G Comi ², L Roveri ², M Bacigaluppi ¹

Abstract

Background

Leukocyte subtypes play both detrimental and protective different roles after acute ischemic stroke, both in the brain and in the periphery. They mediate complex interactions as contribution to ischemic injury, microvascular reperfusion impairment, development of post-stroke infections as well as plasticity and neuroprotection processes. We investigated the association between early leukocyte subtype counts and stroke outcome.

Methods

Retrospective analysis of 575 patients with acute ischemic stroke or TIA, admitted between 2009 and 2014 to our hospital within 4.5 h from symptom onset. Blood samples were collected within 48 h, and complete blood cell counts, CRP, glucose and fibrinogen were examined.

Results

graphic file with name 10.1177_2396987316642909-fig143.jpg

graphic file with name 10.1177_2396987316642909-img26.jpg

Neutrophil counts were positively associated with stroke severity (p < 0.001), worse 3-month functional outcome (p < 0.001) and larger stroke extent (TACI in OXFORD classification, p < 0.001; Figure1); lymphocyte and eosinophil counts were inversely correlated with stroke severity (p < 0.001) and the extent of ischemic lesion (p < 0.01 and < 0.001 respectively) and lower levels were found in patients with 3-month poor outcome (p < 0.001). Outcome associations were confirmed after adjustment for age, thrombolysis admnistration and baseline NIHSS (Table1). Neutrophil/lymphocyte ratio (NLR) was significantly associated with poor outcome, while eosinophil/leukocyte (EoLeuR) was a predictor of good outcome. Neutrophil count and NLR were directly whereas eosinophil count and EoLeuR were inversely associated with haemorrhagic transformation.

Conclusions

Leukocyte subtype counts and ratios (NLR and EoLeuR) constitute independent predictors of outcome and result associated with haemorrhagic complications, thus representing readily available biomarkers of the immune response to stroke. The investigation of the mechanisms that might underlie these effects could provide new therapeutical targets.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PREGNANOLONE GLUTAMATE TREATMENT IMPROVED FOCAL CEREBRAL ISCHEMIA OUTCOME IN IMMATURE MICE

G Tsenov ^1,², S Tambalo ³, S Fiorini ⁴, E Nicolato ¹, K Vales ², P Marzola ⁴, G Bertini ¹, P Fabene ¹

Abstract

Background

Ischemic stroke is a rare disease in children and newborns with a significant impact on morbidity and mortality. Moreover, ischemic injury in the immature brain is different from that in the adult. Our microdialysis study showed that ischemia-induced metabolic changes in 12-days-old (P12) animals are different in comparison with adults (P60). These extend insights of focal cerebral ischemia (FCI) outcome in neonates and necessity of age-related treatment. Experimental and clinical data suggested that neurosteroids concentration increased in the brain shortly before born and their possible therapeutic role is the subject of research. We hypothesized that treatment with the 3α5β-pregnanolone glutamate (PG) might prevent FCI outcome in immature brain.

Methods

The FCI was induced by the single infusion of the endothelin-1 (40 pmol) into the right dorsal hippocampus of P12 mice. A group of animals was treated with the PG (10 mg/kg, i.p.) 5 min after the ET-1. To determine ischemia-induced outcome and effect of treatment we performed MRI study 2 h, 6, 13 and 30 days after FCI.

Results

We found T2 signal intensity increase in the ipsilateral hippocampus of ischemic animals in all time points. However, post-treatment with the PG significantly reduce ischemia-induced changes in all post-ischemic intervals. Whereas there were no differences in the signal intensity 30d after FCI, blood perfusion was affected in the ipsilateral hippocampus in not-treated group.

Conclusions

Our results indicate that PG treatment can avert FCI outcome.

This study was supported by grant GACR No.14-20613S.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

MIGRAINE IS NOT ASSOCIATED WITH ENHANCED CEREBROVASCULAR ATHEROSCLEROSIS IN PATIENTS WITH ISCHAEMIC STROKE

H van Os ¹, I Mulder ¹, I van der Schaaf ², J Kappelle ³, B Velthuis ², A Broersen ⁴, M Ferrari ¹, W Schonewille ⁵, G Terwindt ¹, M Visser ⁶, A Algra ⁷, M van Walderveen ⁴, M Wermer ¹

Abstract

Background

Migraine, especially with aura, is a well-established risk factor for ischaemic stroke, but its connecting mechanisms are puzzling. We investigated the association between migraine and cerebrovascular atherosclerosis in patients with ischaemic stroke.

Methods

We retrieved data on patients with ischaemic stroke from the Dutch Acute Stroke Study. Non contrast CT and CT-angiography were performed within 9 hours of symptom onset. Migraine history was assessed with a migraine screener and confirmed by telephone interview based on ICHD-II criteria. We assessed atherosclerotic wall abnormalities in the intra- and extracranial anterior and posterior circulation and quantified intracranial internal carotid artery (ICA) calcifications. We calculated risk ratios (RR) with adjustments for possible confounders (aRR) with multivariable Poisson regression analysis.

Results

We included 652 patients, aged 18 to 99 years, of whom 49 had a history of migraine (26 with aura). Patients with migraine did not have more often atherosclerotic wall abnormalities in extracranial (65% versus 80%; aRR 0.91; 95%CI 0.75–1.10) or intracranial (54% versus 75%; aRR 0.85; 95%CI 0.66–1.09) vessels, and had lower ICA calcification volumes (highest volume vs. lowest tertile, aRR 0.69; 95%CI: 0.23–2.10) than patients without migraine. The atherosclerotic burden was similar in migraineurs with and without aura.

Conclusions

In patients with ischaemic stroke migraine is not associated with enhanced atherosclerosis in intra- and extracranial large vessels. These findings support the hypothesis that the biological mechanisms by which migraine results in ischaemic stroke are more related to microvascular changes than to large vessel atherosclerosis.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PROTECTIVE EFFECT OF PREGNANOLONE GLUTAMATE IN ENDOTHELIN-1 MODEL OF FOCAL CEREBRAL ISCHEMIA

K Vondráková ^1,², L Uttl ³, M Mikoska ⁴, K Syslova ⁴, P Kacer ⁴, K Vales ^3,⁵, G Tsenov ^3,⁶

Abstract

Background

Ischemic injury, although more common in older adults, also occurs in neonates and infants. Recently, ischemic injury in the immature brain is different from that in the adult and exhibits periods of heightened sensitivity depending on the developmental stage of the brain. Experimental and clinical reports showed, that in several neurological diseases a treatment with neurosteroids can be effective. Previously, we demonstrate that the 3α5β-pregnanolone glutamate (PG) can prevent neurodegeneration after focal cerebral ischemia (FCI) in immature brain.

Methods

FCI was induced by infusion of the endothelin-1 (ET-1, 40 pmol) into right dorsal hippocampus of 12-days-old rats (P12). Group of animals was intraperitoneally administrated with the PG (1 mg/kg) 5 min after the end of ET-1 injection. To evaluate ischemia induced outcome EEG and microdialysis study was performed during first 2 h after FCI and 24 hour after. Following evaluation of brain tissue were done using immunoblotting and immunohistochemistry techniques.

Results

We found, that PG treatment lead to impairment of ET-1 induced seizures. Likewise, PG reduced lactate acidosis, production of NO. and inflammatory reaction. However in all animals, except controls, we determine an increased expression of actin, tubulin, interleukin-1b and ETB receptors proteins. On the other hand, PG significantly reduce activation of microglia and neurodegeneration 24 h after FCI.

Conclusions

Our results indicate that PG treatment can avert FCI outcome in acute phase, however possible long-term effect should be determined by further research.

This study was supported by Grant Agency of the Czech Republic No.14-20613S and Charles University in Prague project No.165115

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

HIGH EXTENT OF INTRACRANIAL CAROTID ARTERY CALCIFICATION IS ASSOCIATED WITH DOWNSTREAM MICROEMBOLI IN STROKE PATIENTS

X Wu ¹, XY Chen ¹, YH Fan ², TWH Leung ¹, KS Wong ¹

Abstract

Background

Intracranial arterial calcification (ICAC) is frequently detected on head computer tomography (CT) and found to be associated with ischemic stroke by recent clinical studies. Based on a hospital-based study, we aimed to compare the occurrence of microembolic signals (MES) among stroke patients with different degrees of ICAC, which may indicate the potential mechanisms linking ICAC and ischemic stroke in intracranial atherosclerosis patients.

Methods

From 2005–2007 we consecutively recruited stroke patients with middle cerebral artery territory infarctions and good temporal window for MES monitoring. The degree of ICAC in the Circle of Willis and ipsilateral intracranial internal carotid artery (iICA) was evaluated on unenhanced head CT.

Results

Among 68 recruited patients, MES was detected in 26 patients (38.24%). The overall degree of ICAC in the Circle of Willis was similar between patients with and without MES. High extent of ipsilateral iICA calcification was found to be more prevalent in patients with MES than those without (50% vs 26.2%; P = 0.046). Logistic regression found that the extent of ipsilateral iICA calcification was an independent risk factor of MES (OR 3.134; 95% CI, 1.029–9.543; P = 0.044).

Conclusions

Based on our findings, high extent of ICAS indicates arterial vulnerable lesions, which may account for the occurrence of downstream microemboli in the corresponding artery.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

BILATERAL OR UNILATERAL “CHAMPAGNE BOTTLE NECK SIGN” ON CAROTID ULTRASONOGRAPHY AND BACKGROUND FACTORS

M Yasaka ¹, S Gotoh ¹, T Kuwashiro ¹, A Nakamura ¹, K Tokunaga ¹, G Takaguchi ¹, Y Okada ¹

Abstract

Background

"Champagne bottle neck sign" (CBNS), indicating great reduction of the diameter of proximal portion of the internal carotid artery above bulbus to be less than half that of the common carotid artery, is often seen bilaterally or unilaterally in patients with moyamoya disease and sometimes in those with atherosclerotic disease. We investigated whether

Background factors of patients with bilateral CBNS are different from those with unilateral CBNS.

Methods

Subjects were 26 patients with CBNS demonstrated by carotid ultrasonography, who received brain MRI and MRA due to past history of stroke. The CBNS was noted bilaterally in 13 patients (median 47 y.o., male 31%, bilateral group) and unilaterally in the other 13 (53 y.o., male 31%, unilateral group). We compared between the two groups incidence of atherosclerotic risk factors, carotid plaque on ultrasonography, and brain MRA findings that were characteristic of moyamoya disease or atherosclerosis.

Results

Frequency of hypertension (54% vs. 8.3%, p = 0.03), dyslipidemia (54% vs. 8.3%, p = 0.03), and plaque at the carotid arteries (54% vs. 7.7%, p = 0.03) was higher in the unilateral group than in the bilateral group significantly. MRA findings of moyamoya disease was more frequently seen in the bilateral group than in the unilateral group (100% vs. 46%, p < 0.01) and that of atherosclerotic disease was seen in 54% of the unilateral group but not in the bilateral group (p < 0.01).

Conclusions

It seems that bilateral CBNS is strongly related to moyamoya disease and the unilateral CBNS is not only to moyamoya disease but also to atherosclerosis.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

NOSOCOMIAL INFECTIONS AND THE NEED FOR ADVANCED IMAGING PREDICTED LONGER HOSPITAL STAY IN STROKE PATIENTS. A RETROSPECTIVE COHORT STUDY

A ALHABIB ¹, M Almekhlafi ¹

Abstract

Background

Billions are spent to compensate for stroke's economic burden worldwide yearly.The long hospital stay after a stroke contribute significantly to the direct cost of stroke care. We aimed to determine and analyze the influencing factors on the length of stay for hospitalized stroke patients in our center.

Methods

This retrospective study obtained data of all stroke patients who were admitted to King Abdulaziz University Hospital in Jeddah, Saudi Arabia between Jan 2010 to the end of 2014. All patients who were hospitalized for an acute stroke were included. Clinical, radiographic, and outcome data were collected. Data analysis was undertaken using descriptive statistics. Predictors of long hospital stay were explained using logistic regression model.

Results

548 patients were included. 19.5% of those patients were 50 years of age or younger. Females represented 42.1% of the cohort and 90% were treated for hypertension while 65.5% had diabetes. The mean length of stay in the hospital was 19.6 days (SD 31) while the median was 9.7 days (16). A long hospital stay was defined in those requiring admission exceeding the median duration of 9.7 days. Predictors of long hospital stay in our cohort included nosocomial infections (OR 2.6, CI₉₅ 1.5 to 4.5, p 0.001) and the need for MR imaging (OR 1.7, CI₉₅ 1.1 to 2.5, p 0.009).

Conclusions

Long hospital stay was noted in patients with hospital acquired infections and those requiring advanced imaging. Strict application of infection control measures and system changes to facilitate advanced imaging may help reduce hospital stay for stroke patients.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

OCCUPATIONAL THERAPY TASK-ORIENTED APPROACH TREATMENT PROTOCOL FOR UPPER EXTREMITY POSTSTROKE REHABILITATION

K Almhdawi ¹, V Mathiowetz ²

Abstract

Background

Occupational Therapy Task-Oriented approach (TO) seems an effective and client-centered post-stroke Upper Extremity (UE) treatment approach. However, TO clinical application is easier for therapists using clear protocol guidelines. We detailed TO clinical evaluation and treatment guidelines supported by flowcharts and videos.

Methods

This is the treatment protocol used in a randomized cross-over trial evaluating TO approach. 20 participants of 3 months or more post-stroke chronicity were recruited. Participants were capable of 10° active affected shoulder flexion and abduction and elbow flexion-extension. TO protocol incorporated standardized assessments and activity analysis evaluating individual's post-stroke life roles and occupational limitations in self-care, interests, and productivity. TO 6-week remedial and/or compensatory intervention aimed to improve occupational performance of individualized functional goals in 70% or more of therapy time. 30% or less of treatment time is spent on other components might improve motor performance such as motor, sensory, and cognitive abilities.

Results

Following TO, Canadian occupational performance measure performance and satisfaction were 2.83 and 3.46 units greater respectively (p < .001), Motor Activity Log amount of use and quality of use were 1.1 and 0.87 units greater (p < .001), Wolf Motor Function Test time was 8.35 second faster (p = .009). Using a 5-point scale, participants reported that TO was unique, customized, meaningful, challenging, and of better quality compared to other interventions.

graphic file with name 10.1177_2396987316642909-fig144.jpg

graphic file with name 10.1177_2396987316642909-fig145.jpg

Conclusions

TO appeared an effective UE poststroke rehabilitation approach inducing clinically meaningful functional improvements. TO clinical application is a feasible task when guided by relevant protocol flowcharts. More studies are needed to improve TO protocol.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

INTRODUCING AN EXERCISE PROFESSIONAL TO AN ACUTE STROKE UNIT ("IN-REACH") - A QUALITATIVE STUDY OF THE PATIENT EXPERIENCE

G Baer ¹, K Jagadamma ¹, A Hebson ², G Mead ³, K Foy ¹, L Haquin ¹, F Leiulsfrud ¹, C Meinich-Bache ¹, N Mohamamd Jamal ¹, O Shell ¹, W Cameron ⁴, A Redpath ⁴, P Halliday ⁵, L Egan ⁵, A Peters ⁶, H Macrae ⁷, A Chaudhary ⁷, L Irons ⁷, M Smith ⁴

Abstract

Background

This qualitative study explored participants’ experiences of an innovative 12 month pilot Exercise after Stroke (EAS) “In-Reach” Service which introduced a Stroke specialist exercise instructor into an acute stroke ward. The instructor offered advice on exercise and “taster” exercise sessions using gym equipment on the ward, with the aim to educate people with acute stroke about the benefits of exercise. Participants were referred to Edinburgh Leisure (EL) EAS service on discharge from hospital and were met and supported by the same In-Reach exercise instructor there.

Methods

A convenience sample consisting of 12 people with stroke (6 male, 6 female, age range 35 – 86) who had experienced EAS “In-Reach” and continued to exercise in the community gave consent to participate. Two focus groups were conducted in an EL facility by two researchers independent of the stroke team. Data were audiotaped, transcribed verbatim and analysed thematically. Field notes were used to enhance analysis.

Results

A wide range of benefits were reported by the participants with regard to EAS and being introduced to an exercise professional in hospital. The four emergent themes were: “knowledge and support”, “empowerment” “challenges” and “self-management”. In addition, participants identified the need for more informed, on-going support opportunities following hospital discharge.

Conclusions

The findings identified important positive physical and psychological benefits gained from the EAS In-Reach service that supported the transition from the acute ward to community based exercise. Regular exercise and confidence to be active may be important features in long-term recovery for people with stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE EFFECT OF ERROR AMPLIFICATION AND HAPTIC GUIDANCE ROBOTIC TRAININGS ON TIMING ACCURACY AMONG CHRONIC STROKE SURVIVORS: PRELIMINARY RESULTS

A Bouchard ¹, H Corriveau ¹, MH Milot ¹

Abstract

Background

During motor activities, longer reaction times can be observed post-stroke, hindering the performance of daily activities. Robotic training by haptic guidance (HG-guiding someone to make the appropriate movement) has improved timing accuracy among healthy seniors, whereas error amplification (EA-exaggerating movement error to maximize motor learning) has not. No study has directly compared HG and EA to improve timing accuracy among stroke survivors.

Methods

Fourteen chronic stroke survivors (66 ± 9 years; 42 ± 44 months since stroke) participated in this randomized crossover study. With their affected hand positioned in a one-degree of freedom robot, participants played a computerized pinball-like game. The goal was to hit targets by activating the robot with the correct timing. After a baseline phase, participants received EA or HG, where the robot increased (EA) or decreased (HG) their timing errors according to when they initiated their movements, followed by a retention phase. The differences in absolute timing errors at the baseline and retention phases following HG or EA were the main measures of change in performance.

Results

After HG, a worsening of timing accuracy was noted (11.3 ± 6.6 vs 15.5 ± 12 ms, p = 0.05), whereas EA caused no change in timing (10.7 ± 5.8 vs 11.1 ± 7.8 ms, p = 0.19).

Conclusions

HG worsened performance, possibly because participants relied too heavily on it while training, preventing motor learning. Guiding movement after stroke might not be the best strategy to improve timing, although more participants will be needed to confirm these results.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

HUB AND SPOKE NEUROREHABILITATION: AN ACUTE, COST EFFECTIVE, STEP DOWN MODEL TO IMPROVE PATIENT FLOW THROUGH THE STROKE PATHWAY

A Chandratheva ¹, G Christofi ¹, C Walters ², E Bretherton ², Y Vicky ², D Lally ², R Brealey ², B Tahtis ², H Warwick ², S Meechin ², V Stevenson ¹, S Daniels ¹, C Melody ¹, S Browning ¹, S Edwards ¹, R Macarimban-Ingelsant ¹, R Simister ¹

Abstract

Background

We sought to observe if a new step-down acute neurorehabilitation model, targeting medically stable patients ready or ‘nearly ready’ for early supported discharge (ESD) but for which capacity was lacking would improve patient flow through the hyperacute stroke unit (HASU).

Methods

Setting: Extended Oakwood (EO), 7-bedded neurorehabilitation (winter pressures) unit at St Pancras Hospital, London, January 26^th-May 27^th 2015. We undertook daily (weekday) face-face HASU reviews, accepting patients 7 days/week, using the Patient Categorization Tool (PCAT) and Rehabilitation Complexity Score (RCS). HASU bed days and outliers were compared to the equivalent 2014 period. Cost analysis was performed.

Results

We admitted 82/142 referred patients from 12 London boroughs. 43 (53%) male; 33 (40%) mean age 73yrs (SD 5yrs) and 33 (40%) ≥80yrs. Thirty percent were transferred Friday-Sunday. Average PCAT: 21.4 (SD 4.0); RCS: 9.83 (SD 3.2). 12 patients were ESD-ready on transfer; 70 required more detailed assessment, medical interventions, declined ESD or were non-stroke. Average LOS was 8 days. 3 patients required transfer to acute care. Total HASU bed days were 158 less than in 2014 (1770 vs 1928, p = 0.353). Outlier bed days were 263 less than 2014 (586 vs 323, p = 0.121). Cost saving of £2300/patient was made compared to an equivalent ASU admission.

Conclusions

‘Medically stable’ HASU patients assessed as appropriate for ESD may have ongoing therapy and medical needs, not evident from HASU assessment. This acute neurorehabilitation model is safe, cost effective, improves flow through HASU to the community whilst reducing HASU and outliers bed days.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE VALUE OF MEDICAL INTERVENTION WITHIN AN EARLY SUPPORTED DISCHARGE TEAM: A PROSPECTIVE COHORT STUDY

G Christofi ¹, A Chandratheva ¹, C Walters ², D Howell ¹, R Simister ¹

Abstract

Background

Complications after acute stroke are common. We aimed to determine medical intervention requirements in a cohort of patients from the hyperacute stroke unit (HASU) deemed fit for discharge for early supported discharge (ESD).

Methods

We prospectively collected data from 26th January-27th May 2015, from a consecutive patient cohort admitted to a 7-bedded step-down neurorehabilitation unit at St Pancras hospital, London, a winter pressures project. Patients were deemed medically fit and appropriate for discharge with ESD. We recorded all medical interventions and length of stay (LOS).

Results

Of 82 patients, 43(53%) male, mean age 73yrs (SD 16.7), 33(40%) age ≥80yrs, 57 (70%) required medical attention. Commonest interventions: (1) medication adjustment (n = 20; 35%) including optimizing secondary prevention, analgesia; (2) Counseling for health anxiety, smoking, alcohol, functional symptoms (n = 15, 26%); (3). Further diagnostics (imaging reviews, new diagnoses of vascular parkinsonism, vascular dementia, cord compression, brachial plexopathy, myasthenia gravis (n = 13, 23%); (4). Treating metabolic derangement (n = 11,19%); Other interventions: treating infection (n = 7,12%); liaising with specialties (n = 7,12%). Three (4%) were readmitted acutely, two with acute pneumonia; one with stroke extension. Five (6%) with functional symptoms were directed for neuropsychological intervention; 16 (20%) were non-strokes. Average LOS: 8 days, related to further therapy and medical interventions.

Conclusions

In a cohort of patients with ‘minor stroke’ or stroke mimics, assessed appropriate for discharge from acute care, 70% required further medical intervention; 4% required acute readmission. Patients discharged from HASU but not appropriate for ASU often have ongoing medical needs, potentially missed by the community ESD model.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ANALYSIS OF THE BARTHEL INDEX USING QUANTILE REGRESSION IN THE CHIMES STUDY

CF Lee ¹, N Venketasubramanian ², KSL Wong ³, C Chen ⁴; CHIMES Study Investigators⁵

Abstract

Background

Barthel Index (BI) is pseudo-continuous and often violates the normality assumption of linear regression. Quantile regression does not depend on such assumptions. We aimed to investigate the BI using quantile regression in the CHIMES Study, a randomized, double-blind, placebo-controlled trial of MLC601 in stroke of intermediate severity.

Methods

We analyzed 999 subjects (499 MLC601, 500 placebo) with month 3 BI. Multivariable linear, quantile (median, 5th, 10th 25th percentile), and logistic (dichotomized cutoffs 85, 90, 95) regression models were fitted to the BI, which was regressed to treatment allocation, age, sex, baseline NIHSS, time from stroke onset to first dose, and pre-stroke mRS.

Results

Baseline characteristics were similar between groups. Overall distribution of BI was heavily skewed to the left, with nearly half of subjects obtaining BI of 100 (a significant ceiling effect).

While the favorable treatment effect of MLC601 did not reach statistical significance in the linear regression and logistic regression models regardless of cutoff used, the median BI was significantly higher by 1.28 points (95%CI 0.04–2.51, p = 0.043) in the MLC601 group using quantile regression. The 10th percentile of BI was also significantly higher in the MLC601 group.

graphic file with name 10.1177_2396987316642909-img27.jpg

Conclusions

Quantile regression demonstrates the treatment effect of MLC601. It can be a reliable alternative for analyzing BI in stroke trials. Other percentiles of the distribution can be modeled depending on stroke severity.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

RELATIONSHIP BETWEEN THE MODIFIED RANKIN SCALE AND OTHER STROKE-RELATED MEASURES IN THE CHIMES STUDY

CF Lee ¹, N Venketasubramanian ², KSL Wong ³, C Chen ⁴; CHIMES Study Investigators⁵

Abstract

Background

The modified Rankin Scale (mRS) estimates a subject’s disability through a single item, making decomposition into more basic items unfeasible. We explored the relationship between mRS and the total score and individual items of other stroke-outcome measures, such as the NIHSS and Barthel Index (BI), to implicitly examine the factors that constitute the mRS.

Methods

We analyzed data from 910 patients (453 placebo, 457 MLC601) who completed month 3 assessments in the CHIMES Study, a double-blind, randomized, placebo-controlled trial of MLC601 in patients with ischemic stroke of intermediate severity. Ordinal logistic regression models were fitted to estimate mRS using the total score and individual items of NIHSS, BI and mini-mental status examination (MMSE).

Results

mRS was strongly associated with NIHSS and BI scores and most of their items (table). The NIHSS items associated with mRS coincided with 3 factors, namely left motor factor (right arm, right leg and dysarthria), right motor factor (left arm and left leg), and left cortex factor (commands and language). However, none of the items in the right cortex factor (gaze, visual field, sensory and extinction) was associated with mRS. The addition of MMSE score or items to the model did not improve performance.

graphic file with name 10.1177_2396987316642909-img28.jpg

Conclusions

The mRS is mainly constituted by left and right motor functions and left, but not right, cortical function.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

QUALITY OF LIFE OF STROKE SURVIVORS AND THEIR INFORMAL CAREGIVERS: A PROSPECTIVE STUDY

E Chuluunbaatar ¹, C Pu ², YJ Chou ³

Abstract

Background

Healthcare improvements have led to increased survival among stroke patients; however, the disability level remains high. These patients require assistance from caregivers, particularly in the first year after stroke. Longitudinal studies of quality of life (QoL) and the factors associated with QoL for both patients and caregivers are limited. Objectives of this study were to describe the changes in QoL and determine the factors associated with QoL for stroke patients and their informal caregivers in the first year after stroke.

Methods

Multi-centered prospective study was conducted in public hospitals in Mongolia. In this study, 155 first-time stroke patients and their 88 informal caregivers were followed up for 1 year. The WHOQOL-BREF questionnaire was used to assess QoL. The Barthel Index (BI) was administered to the patients at the baseline and after 1 year. A generalized estimating equation analysis was used to determine the factors associated with QoL.

Results

QoL of stroke patients in the domains of physical and environmental aspects improved significantly (p < 0.05) after 1 year; however, social relationship and psychological health declined, but these were not significant. Among caregivers, psychological health and social relationship domains improved significantly. Factors associated with low QoL among stroke patients were advancing age, male patients, being single and less improvements on BI score, and among caregivers were poor physical health and financial difficulties.

Conclusions

Efficient rehabilitation therapy for poststroke patients can improve their QoL. Disability training and financial support for caregivers of poststroke patients might be helpful.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CHANGES IN CAREGIVER BURDEN AMONG INFORMAL CAREGIVERS OF STROKE SURVIVORS: A LONGITUDINAL STUDY

E Chuluunbaatar ¹, C Pu ², YJ Chou ³

Abstract

Background

Informal caregivers are crucially important for stroke survivors for recovery after acute stage of stroke.

Objectives: To identify changes in caregiver burden among long-term informal caregivers of stroke in three domains: objective, subjective, and demand burden at acute stage and 1-year among caregivers of stroke survivors in Mongolia.

Methods

Prospective, longitudinal study was conducted in 9 secondary and tertiary public hospitals in Ulaanbaatar. Participants were 103 dyads of caregivers and first-time diagnosed stroke patients. Montgomery Caregiver Burden Scale was used to assess caregiver burden at baseline and 1-year after. Ordinal logistic regressions were conducted to determine the factors associated with changes in caregiver burden in one year.

Results

Spousal Caregivers had decreased objective (β = −2.113) and demand (β = −2.089) burden compared to other caregiver relatives, and child of care recipient also decreased in demand burden (β = −1.642) compared to other relatives. Subjective burden change was associated with caregiver’s education level and financial difficulty. Less than college educated caregivers had decreased in subjective burden (β = −1.135). Caregivers who had financial difficulties (β = 1.723) or sometimes faced financial difficulty (β = 1.158) were significantly increased in both subjective and demand burden. Caregivers who took care of less educated care recipients had decreased demand burden (β = −1.176).

Conclusions

Caregiver’s financial difficulty was the most consistent factor influencing higher caregiver burden for long-term caregivers of stroke survivors. Financial support for long-term informal caregivers of stroke could decrease their caregiving burden.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

WRIST WORN ACCELEROMETERS WITH VIBRATING-ALERT TO PROMPT EXERCISES AFTER STROKE (WAVES)

R Da Silva ¹, S Moore ¹, D Jamieson ², D Jackson ², M Balaam ², K Brittain ³, L Brkic ¹, T Ploetz ², H Rodgers ¹, L Shaw ¹, F van Wijck ⁴, C Price ¹

Abstract

Background

Recovery of arm function post-stroke is optimised through frequent repetition of functional movements. We explored the feasibility of using a wrist-worn tri-axial accelerometer with vibrating alert (the CueS wristband) to prompt impaired arm use when activity levels fell below a personalised threshold, thereby encouraging movement and discouraging learned non-use.

Methods

Adults ≤28 days post-stroke with new upper limb impairment completed a four week rehabilitation programme wearing a CueS wristband for 12hours per day. Patients and therapist reviewed twice weekly report of prompts and movement activity data (signal vector magnitude) to agree personalised prompt thresholds (median baseline activity + 5%, 15%, 25% or 50%) and maximum frequencies (every 1–4 hours).

Results

7 patients completed the programme (age 65 ± 4; males 4/ females 3; days post-stroke 13 ± 7; baseline Action Research Arm Test 31 ± 19; 4 week ARAT 42 ± 24)

Conclusions

Stroke patients increased upper limb activity following personalised prompts by the CueS wristband.

Patient	Median (IQR) number of prompts/day over 4 weeks	Overall mean activity (95%CI) 1 hour pre-prompt	Overall mean activity (95%CI) 1 hour post-prompt	% change in activity 1 hour post-prompt	p-value
1	1 (3)	985 (735–1235)	1162 (837–1487)	+18	0.21
2	4 (6)	1255 (1053–1457)	1547 (1331–1763)	+23	0.04
3	4 (5)	3213 (2430–3996)	3841 (3016–4666)	+20	0.18
4	5 (3)	5002 (4055–5949)	5618 (4684–6552)	+11	0.11
5	3 (6)	6455 (5395–7515)	8311 (7089–9533)	+22	0.01
6	1 (2)	514 (435–593)	617 (492–742)	+20	0.19
7	7 (4)	1725 (1473–1978)	2123 (1839–2408)	+23	0.01

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Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

MALNUTRITION IN STROKE PATIENTS INCREASES LENGTH OF STAY

L Dooley ¹, N Flanagan ², J Harbison ³, L Healy ²

Abstract

Background

There is ample evidence that malnutrition is associated with poor outcome in patients with stroke. We compared 2 validated nutrition screening tools, and the impact of malnutrition risk scores on length of stay (LOS).

Methods

Subjects with confirmed stroke were prospectively recruited for a 6 month period. They were screened on admission using the Malnutrition Screening Tool (MST) and the Malnutrition Universal Screening Tool (MUST). LOS was recorded

Results

Seventy three patients (58% male, mean age 70.7 ± 14.7 years) were recruited with almost 80% (n = 58) suffering an ischaemic stroke. MST identified 12 (16.4%) to be at risk of malnutrition, compared to 17 (23.3%) using MUST. MST and MUST both identified 9 (12%) patients, MUST identified an additional 8 patients, due to BMI < 18.5 kg/m2 (n = 2) and acute disease effect (n = 6). MST identified an additional 3 patients, as degree of unintentional weight loss was not quantified. LOS significantly increased with malnutrition risk (see table 1), presence and severity of dysphagia (p = 0.000), and age greater than 70 years old (p = 0.045).

Conclusions

A fifth of stroke patients were at risk of malnutrition on admission. Both MST and MUST were effective in identifying at risk patients with minor disagreement over specific patients. ‘At risk’ score in both scales impacts negatively on their LOS

Table 1.

Length of Stay according to Malnutrition Risk

Malnutrition Screening Tool Score	MST Median LOS (Range)	MUST Median LOS (Range)
0 (Not at Risk)	14.5 (1-159)	9 (1-147)
1	7 (6-103)	10 (4-159)
≥2 (At Risk)	55.5 (6-147)	59 (6-144)
P Value	0.012	0.000

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Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

OUTCOME MEASUREMENT IN STROKE UPPER LIMB REHABILITATION TRIALS: WHAT TOOLS ARE USED AND HOW OFTEN?

J Duncan Millar ¹, M Ali ¹, A Pollock ¹, F van Wijck ²

Abstract

Background

Improved Upper Limb (UL) rehabilitation is a stroke research priority. Randomised Controlled Trials (RCTs) use different assessment tools (AT), hindering inter-study comparisons and data aggregation for secondary analyses.

We aimed to describe the current use of AT in UL stroke rehabilitation RCTs, in the context of the International Classification of Functioning, Disability and Health (ICF).

Methods

RCTs of interventions for UL rehabilitation after adult stroke were collated from 43 systematic reviews based on a recent Cochrane overview. We extracted data on AT (type; reported purpose) and categorised these according to the ICF domains, using linking rules.

Results

After review, 243/736 RCTs met our eligibility criteria; 208 unique AT were reported across 243 trials and 120 (58%) AT were used only once.

Overall, 78/243 RCTs (32%) used the Fugl-Meyer UL section (FMA-UE); 23% (56/243) used Action Research Arm Test (ARAT) and 22% (53/243) used modified Ashworth Scale (mAS). FMA-UE and mAS (predominantly body function ATs) were used to assess body function in 87% and 94% of cases, respectively. ARAT (a predominantly activity/participation AT) was used to assess activity/participation in 21% and body function in 50% of cases.

Conclusions

Use of AT in stroke UL rehabilitation RCTs lacks standardisation, and there was some inconsistency between the reported purpose of AT use and its actual ICF domain of assessment. Consensus recommendations on core UL assessments would greatly enhance evidence synthesis, and secondary data analyses to inform clinical practice. Planned activities will standardise outcome measure use across UL stroke rehabilitation trials.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

RETURN TO WORK AFTER STROKE

MM Molleda Marzo ¹, C Figueroa Chacón ¹, E Ramirez Miraval ¹, V Calderon Padilla ¹, MJ Durà Mata ¹

Abstract

Background

Return to work and sustaining employment are considered key aspects of rehabilitation and recovery in younger stroke survivors. The aim of our study is to analyse return to work at 6 months post-stroke and to identify factors that contribute to return to work. Design: Observational cross-sectional study

Methods

83 patients between 18 and 60 years old were diagnosed of stroke, at a university hospital in Barcelona, Spain, between 2011 and 2012. Clinical, functional and employment status were analysed pre stroke and six months post stroke. Statistical analysis was performed using SPSS

Results

63.9% patients were employed before admission. 51.9% returned to work at 6 months post stroke. 7.1% required adaptations to the new job. Factors that showed a significant relationship between predictor and return to work: Employment Status before stroke(employed vs unemployed), type of job (white collar vs blue collar), NIHSS at hospital discharge, neurological deficit or impairments (vision loose, weakness, speech impairment and balance problems), and functionality (Barthel index and modified Rankin scale)at 6 months post stroke. Factors with no significant influence: age, gender, Barthel and, mRankin scale during hospitalization, type of stroke (ischaemic / hemorrhagic) and sensory impairment, Bladder and Bowel Dysfunction and being self employed or a paid employee

Conclusions

Almost half of patients in working age do not return to work after a stroke. Determinant factors are functional disability at 6 months post stroke, employment status before admission and type of job

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

INTRAVENOUS FLUID THERAPY IN THE ACUTE STROKE UNIT SETTING. DO WE MEET THE CHALLENGE?

NK Gadapa ¹, M Krommyda ¹, S Andole ¹

Abstract

Background

Intravenous fluid therapy to correct or prevent problems with the fluid homeostasis and/or electrolyte status is a very common clinical requirement in the early phase of a stroke. To review the clinical practice of administering intravenous fluid therapy and correcting electrolyte disturbances in the setting of an acute stroke unit

Methods

The fluid charts and medical case notes of 30 patients admitted to our acute stroke unit from December 2014 to February 2015 and receiving IV fluids were reviewed. The IV fluid therapy NICE audit tool format was used for this study.

Results

The age range of the patients was from 65 to 95 yrs old. The fluid and electrolyte needs had been assessed as part of every ward review in 97% of the patients, but only 77% of them had a clear IV fluid management plan. The type, rate and volume of fluid to be administered was included in the prescription, however a 24 hour re-assessment and monitoring plan occurred only in 80% and 83% of the patients accordingly.

Conclusions

Electrolyte imbalance is a frequent complication in the management of an acute stroke patient. To prescribe the optimal amount, composition and the best rate of IV fluids to be administered can be a difficult and complex task. Therefore, a clear IV fluid management plan based on careful assessment of the patient’s individual needs and clear documentation are required.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

VERY EARLY REHABILITATION IN SPEECH (VERSE) AFTER STROKE: TRIAL STATUS AND RECRUITMENT

E Godecke ¹, E Armstrong ¹, S Middleton ², T Rai ³, N Ciccone ¹, A Holland ⁴, A Whitworth ⁵, ML Rose ⁶, F Ellery ⁷, D Cadilhac ⁸, GJ Hankey ⁹, J Bernhardt ¹⁰

Abstract

Background

There is limited evidence to support very early intensive aphasia rehabilitation as a best-practice standard in stroke care. VERSE is a randomised, open-label, blinded endpoint evaluation trial designed to determine whether two different types of intensive aphasia therapy, provided for 20 sessions, beginning within 14 days of acute stroke, provides greater efficacy and cost-effectiveness than usual care.

Methods

246 participants with acute post-stroke aphasia who meet the selection criteria are required. Participants are stratified by aphasia severity and randomised to receive usual care (usual ward based aphasia therapy), usual care-plus (usual ward based therapy provided daily) or VERSE therapy (a prescribed aphasia therapy provided daily). The primary outcome is the Aphasia Quotient of the Western Aphasia Battery at three months. Secondary outcomes include resource use, quality-of-life and depression measures.

Results

14 sites are involved in the trial with 11 sites actively recruiting to date. 3206 people with confirmed stroke have been identified since July 2014. 784 patients had aphasia (24%) and 157 (20%) were trial eligible. Of those, 67 (42%) have been recruited (September 2015). The top two reasons for non-enrolment include: Out of area rehabilitation services (32%) and participant refusal (20%).

Conclusions

The post-stroke aphasia rate is lower than predicted. Our recruitment rate is higher than anticipated for this population. A new multi-site network has been built for this trial, which has slowed start up. When complete, this trial will provide Level 1 evidence to support clinical practice guidelines. Site recruitment is still open.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

MANAGING AFTERCARE IN STROKE (MAS) - RESULTS FROM A CROSS-SECTIONAL STUDY IN THE POST-REHABILITATIONAL PHASE OF STROKE CARE

B Hotter ¹, I Padberg ², A Liebenau ¹, P Knispel ³, S Zöllner ³, I Wellwood ², A Meisel ¹

Abstract

Background

Stroke survivors are often affected by long-term disabilities and complications. Long-term data after stroke and appropriate care models are scarce. In a three-step process we aim to develop a comprehensive stroke aftercare concept. First, we developed a systematic assessment describing individual needs and current care. Second, we will develop a practicable and comprehensive treatment model for aftercare. Finally, we will investigate this model for effectiveness and sustainability. Hereby, we present the results of the first phase (MAS-I) evaluating frequency and severity of complications and ongoing deficits in an observational, cross-sectional study.

Methods

We invited subjects of previous observational stroke studies (n = 559) to a late follow-up. Participating patients underwent a comprehensive interview and examination in the following domains: self-reported needs, spasticity, neuropathic pain, aphasia, neurocognitive deficits, depression, secondary prevention, social work, caregiver strain.

Results

We recruited 57 patients with a median mRS of 2 (IQR1–3) following 39.1 months (mean; ±13.5 SD) after stroke. Initial severity measured by NIHSS was 5.5 (median; IQR 2.75–12). Frequencies of remaining disabilities varied significantly (spasticity 25%, cognitive deficits 43%, depression 22%, neuropathic pain 8%, incompliance 14%, aphasia 5%). Whereas early therapy prescription (81% rehabilitation, 32% speech therapy, 58% physiotherapy, 5% neurocognitive training) was satisfactory, we observed a lack of ongoing treatment in all domains of care: need for medical reevaluation (30%), need for change in secondary prevention (18%), need for speech, neurocognitive or physiotherapy (47%), social work (33%).

Conclusions

Our data suggest an undersupply in aftercare warranting further longitudinal study to develop a comprehensive concept of stroke aftercare.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PATIENT CENTERED GOAL-SETTING IN A HOSPITAL-BASED OUTPATIENT STROKE REHABILITATION CENTER

D Rice ¹, A McIntyre ¹, M Mirkowski ¹, S Janzen ¹, R Viana ², E Britt ³, R Teasell ²

Abstract

Background

The benefits of goal-setting have been consistently demonstrated in the literature. Interestingly, patients’ perceptions of their progress do not always reflect true achievements during therapy, as measured by standardized outcome measures. This study aimed to determine the type of goals that stroke patients intend to achieve during outpatient hospital-based rehabilitation and whether they were able to accurately predict goal accomplishment with respect to objective and quantifiable outcome measures

Methods

Patients rated their ability to perform goals at admission and discharge from rehabilitation. Goals were sorted into recurrent themes and International Classification of Functioning, Disability and Health (ICF) categories. We compared patients’ satisfaction scores of goals on admission and discharge through paired t-tests and repeated measures ANOVA based on ICF category. Patients’ satisfaction with their goals at discharge was then compared to an outcome measure scores obtained by a therapist.

Results

A total of 286 stroke patients made at least one goal. Patient goals concentrated on themes of improving hand function, mobility and cognition as well as ICF levels of impairment and activity limitation, after further categorization. Compared to activity- and participation-based goals, patients with impairment-based goals perceived greater satisfaction of goals at admission and discharge. Most patients (72.9%) accurately perceived their progress during rehabilitation.

Conclusions

Within an outpatient stroke rehabilitation setting, patients set heterogeneous goals that were predominantly impairment-based. The findings from this study may help to inform clinical care structure to ensure that stroke outpatient rehabilitation is adequately designed to help patients achieve their goals.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

A KNOWLEDGE TRANSLATION INITIATIVE: EXAMINING THE SUSTAINABILITY OF CHANGE ON A STROKE REHABILITATION UNIT

S Janzen ¹, A McIntyre ¹, J Iruthayarajah ¹, J Vermeer ¹, E Britt ², R Teasell ³

Abstract

Background

Knowledge translation (KT) of research into clinical practice has been named a priority in stroke rehabilitation; however, it is imperative that the effectiveness and sustainability of KT initiatives are evaluated. The Rehabilitation Knowledge to Action Project (REKAP) identified areas where adherence to stroke guidelines on a rehabilitation unit were low. As a result, several KT initiatives were implemented. This study aimed to assess the extent to which these evidence-based care strategies were sustained over time after REKAP had finished.

Methods

A retrospective chart audit was conducted to examine current clinical practice at least one year after REKAP had ended. Patient charts were reviewed independently by two researchers. All information pertaining to depression, benzodiazepine use, bladder management, and hypertension management was extracted. T-test and chi-square tests were conducted, as appropriate, to compare REKAP end date data to the follow-up.

Results

Continued improvements were shown between study end and follow-up in the screening of depression (46% versus 56%), and prescription of benzodiazepines (26% to 12.5%). The number of patients with at least one unmonitored blood pressure day declined from 89% at baseline to 9% at the end of the study; however, the follow-up rate was found to be 13.6%. Adherence to bladder management initiatives were not sustained.

Conclusions

The REKAP project was shown to make sustained change in several critical areas of stroke care. There is a need to embed strategies for sustainability within all phases of the multifaceted, knowledge translation initiatives in order to make long-term changes to clinical practice.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

LARGER INFARCT VOLUMES PREDICT IN-HOSPITAL COMPLICATIONS AND LENGTH OF STAY AFTER ANTERIOR CIRCULATION LARGE VESSEL OCCLUSION (ACLVO) STROKE

R Jha ¹, C Streib ², A Jadhav ³, S Rangaraju ⁴, B Jankowitz ⁵, T Jovin ³

Abstract

Background

Post-stroke in-hospital complications(PSIHC) cause significant morbidity, particularly in large-vessel occlusions. Salvaging penumbra may be important not only to improve neurologic outcomes, but also to reduce systemic morbidities. We aimed to determine if increasing final infarct volumes(FIV) predict increased PSIHC.

Methods

All institutional acute ACLVO patients (6/2012–9/2014) without early withdrawal of care were included. FIV was calculated from CT/MRI. PSIHCs were obtained from billing data. Dependent variables included FIV and occlusion level. The relationship of these factors with outcomes [PSIHC, ICU-length-of-stay(ICULOS), Hospital Length of Stay(HLS)] was assessed through univariate and multivariate logistic regression controlling for age, baseline NIHSS, and hemorrhagic transformation.

Results

354 patients (median-age 69 [IQR 57–80], median-NIHSS 16 [IQR 13–21]) were included. Most PSIHCs were significantly associated with increasing FIV(Table-1). For example, increasing FIV by 10 cm³ results in 9.4% higher odds of acute respiratory failure and 19.5% increased odds of decompressive-hemicraniectomy. Progression from moderate to large core infarction was associated with increasing likelihood of most complications. HLS and ICULOS were strongly associated with FIV. M2-occlusion independently predicted decreased probability of respiratory complications and ICULOS despite controlling for FIV suggesting that stroke topology may be important in predicting complications.

graphic file with name 10.1177_2396987316642909-fig146.jpg

Conclusions

Patients with larger infarctions had more PSIHC and longer admissions. The relationship between topology and systemic complications warrants further investigation. Endovascular therapy limits infarct expansion and may decrease PSIHC in ACLVO stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

QUANTITATIVE MEASUREMENT OF PHYSICAL ACTIVITY AND SLEEP BEHAVIOUR LONGITUDINALLY AFTER STROKE

L Johnson ¹, S Kramer ¹, T Cumming ¹, J Bernhardt ¹

Abstract

Background

There is very little longitudinal evidence on changes in physical activity and sleep in the months after stroke. We aimed to quantify these variables within a week of stroke and at 3 months post-stroke.

Methods

This sub-study formed part of the larger ‘A Very Early Rehabilitation Trial’ (AVERT). Participants were patients with confirmed stroke recruited within 24 hours of symptom onset. SenseWear, a triple axis accelerometer attached to a band worn on the upper arm, was worn for ≤7 days in the acute hospital and for 7 days at 3 months post-stroke. Data from this device were used to calculate percentage of the waking day spent active (using a 1.5 METs threshold), energy expenditure, sleep time and sleep efficiency.

Results

Eighteen participants were assessed acutely, with 14 of these followed up at 3 months. Marked increases were seen between the acute stage and 3 months in percentage of the day active (median 4.6% to 18.1%; p < 0.001), daily energy expenditure (median 7123 to 9167 joules; p = 0.001), nightly sleep time (median 440 to 519 minutes; p = 0.04) and sleep efficiency (median 73.6% to 85.1%; p = 0.002).

Conclusions

This is the first study to longitudinally and objectively measure the physical activity and sleep behaviours of stroke survivors. We have shown stroke survivors are primarily inactive early after stroke, and even when accounting for time spent asleep, there remain long periods of the day when stroke survivors are inactive. These periods could be targeted for further physical activity and rehabilitation.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ASSESSING THE UPTAKE OF INTERMITTENT PNEUMATIC COMPRESSION (IPC) IN ACUTE STROKE FOLLOWING THE PUBLICATION OF THE CLOTS3 TRIAL

M Kavanagh ¹, P Tyrrell ², M James ³, G Cloud ⁴, B Bray ⁵, A Hoffman ¹, C Williams ⁶, L Paley ¹, E Vestesson ¹, A Rudd ⁵; On behalf of the SSNAP Collaboration⁷

Abstract

Background

CLOTS3, (May 2013), established IPC reduces the risk of deep vein thrombosis (DVT) in immobile stroke patients. It is estimated that 50% of stroke patients are eligible for IPC. We describe the uptake of IPC in stroke patients admitted to hospitals in England and Wales.

Methods

Data were extracted from the Sentinel Stroke National Audit Programme (SSNAP), the national register of stroke care. Data collection on IPC usage has been reported quarterly from 1 April 2014.

Results

12027/111986 (10.7%) adults with acute stroke discharged between April 2014 and September 2015 had IPC. Of these 3085 (15.8%) had IPC between July-September 2015, an increase from 2710 (13.7%) in April-June 2015 and 563 (3.7%) in April-June 2014. There is wide variation between hospitals; from 0% to 62% of patients with IPC applied. 77/208 (37%) hospitals did not use IPC. IPC is applied for a median of 7 days.

A higher percentage of patients with haemorrhage compared to ischemic had IPC (12% vs 7.6%,p < 0.001). IPC patients had suffered more severe strokes (median NIHSS 9 vs 4, p < 0.001) and were older (median 79 vs 77 years, p < 0.001).

graphic file with name 10.1177_2396987316642909-fig147.jpg

Conclusions

Despite the evidence base for IPC as an effective method of reducing DVT risk and possibly improving survival after stroke, uptake remains far lower than expected from primary research. This should be a priority area for quality improvement in stroke care.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

INCREASED ENERGY DEMANDS OF WALKING IN ACUTE STROKE

S Kramer ¹, L Johnson ¹, J Bernhardt ¹, T Cumming ¹

Abstract

Background

There is evidence that rehabilitation should start early after stroke and should include cardiorespiratory fitness training. The energy cost (EC) of physical activity early after stroke has implications for prescribing individualised exercise therapy, yet very little is known about it. We aimed to determine the difference in EC of walking between stroke survivors early post-stroke and healthy controls.

Methods

We recruited participants <2 weeks post-stroke and matched healthy controls. Participants performed 2 bouts of 6 minutes walking at a comfortable walking speed, separated by a 30-minute rest-period. EC of walking was assessed by measuring oxygen uptake in ml/kg/m over 6 minutes and during steady-state (final 3 minutes of each walking bout) using a portable metabolic system. Differences between groups were analysed using a t-test.

Results

We included 13 stroke survivors (mean age 75 ± 13 years; mean days post-stroke 4 ± 3) and 10 controls (mean age 73 ± 13 years). EC during the 6 minute walk was higher in stroke survivors (0.26 ± 0.12 ml/kg/m) compared to healthy controls (0.16 ± 0.02 ml/kg/m), with a significant mean difference of 0.10 ml/kg/m (95% CI 0.02–0.18). EC during steady-state was also higher in stroke (0.28 ± 0.12 ml/kg/m) compared to healthy controls (0.18 ± 0.03 ml/kg/m), with the same significant mean difference of 0.10 ml/kg/m (95% CI 0.02–0.18).

Conclusions

Acute stroke survivors use more energy while walking compared to healthy controls and also exhibited greater individual variability in EC than controls. Energy cost should be taken into account when setting individual exercise intensity goals early post-stroke and can help inform development of exercise prescription guidelines for stroke survivors.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ACUTE-PHASE FATIGUE PREDICTS INCREASED DEPENDENCE WITH ACTIVITIES OF DAILY LIVING AMONG PATIENTS WITH FIRST EVER STROKE - A LONGITUDINAL STUDY OVER 18 MONTHS

A Lerdal ^1,², CL Gay ^1,³

Abstract

Background

Fatigue during the acute phase following stroke has been shown to predict long-term physical health, specifically increased bodily pain and poorer self-rated general health. The aim of this analysis was to determine whether acute phase fatigue also predicts patients’ level of functioning with respect to activities of daily living (ADL) 18 months after first stroke.

Methods

Patients with first-ever stroke (n = 88) were recruited upon admission at two hospitals in Norway. Patients were assessed within 2 weeks following admission and at 18 months using the Barthel Index of Activities of Daily Living, Fatigue Severity Scale, and Beck Depression Inventory II. Pre-stroke fatigue was assessed retrospectively. The relationship between acute-phase fatigue and later ADL functioning was evaluated using multivariate regression analysis controlling for relevant covariates and acute-phase ADL functioning.

Results

Acute-phase fatigue was associated with ADL functioning at 18-month follow-up (p = .006), even when controlling for other predictors of ADL functioning, including age, gender, cohabitation status, body mass index, and acute-phase depressive symptoms and ADL function. Examining the reverse relationship, acute-phase ADL function was unrelated to fatigue 18 months after stroke. Pre-stroke fatigue was associated with acute-phase fatigue, but not with ADL function, either in the acute phase or at 18 months.

Conclusions

Our study indicates that acute-phase fatigue may be an independent risk factor for increased dependence with ADL 18 months after stroke. The finding indicates that effective treatments for post-stroke fatigue both in the acute-phase and later in the recovery period may contribute to better stroke rehabilitation.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE ASSOCIATIONS OF POST-STROKE FATIGUE AND DEPRESSION WITH HEALTH-RELATED QUALITY OF LIFE, MOBILITY AND CARDIORESPIRATORY FITNESS IN AN INDEPENDENTLY-AMBULANT, COMMUNITY-DWELLING COHORT: A PILOT STUDY

D Marsden ¹, A Dunn ², A Bawden ³, R Callister ², J Marquez ³, C Levi ¹, N Spratt ¹

Abstract

Background

Post-stroke fatigue (PSF) and depression are common after stroke. This study investigated the associations of PSF and depression with health-related quality of life (HRQoL), mobility and cardiorespiratory fitness.

Methods

We recruited 23 independently ambulant, community-dwelling stroke survivors within one year of stroke for a controlled trial of an exercise intervention. Participants were assessed at baseline and 12-weeks. PSF was assessed using the Fatigue Assessment Scale, depression using the Patient Health Questionnaire (PHQ-9) and HRQoL using the Stroke and Aphasia Quality of Life questionnaire (SAQoL-39). Mobility and peak oxygen consumption (VO_2peak) were assessed during the Six-Minute Walk Test (6MWT) and Shuttle Walk Test (SWT). A linear regression model with a random-effect for the individual was used to examine the associations. The model was adjusted for age and modified Rankin Scale scores.

Results

PSF was associated with depression (0.9 CI 0.6, 1.2, p < 0.001). Higher levels of PSF and depression were associated with lower HRQoL (PSF: −8.5 CI −11.3, −5.7, p < 0.001; depression: −5.8 CI −8.2, −3.4, p < 0.001), less distance walked in the 6MWT (PSF: −0.02 CI −0.04, −0.005, p < 0.01; depression: −0.02 CI −0.03, −0.005, p = 0.01), fewer shuttles completed (PSF: −0.1 CI −0.3, −0.02, p = 0.02; depression: −0.1 CI −2.2, −0.1, p = 0.001) and lower VO_2peak during the SWT (PSF: −0.5 CI −0.95, −0.1, p = 0.02; depression: −0.3 CI −2.2, −0.1, p = 0.048).

Conclusions

There are strong relationships between the physical and psychosocial aspects of post-stroke recovery, even for those with minimal mobility limitations. Further investigation into the causal relationships is required.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ASSESSMENT OF PHYSICAL FUNCTIONING AND MOOD AFTER MILD STROKE

CA McHutchison ¹, V Cvoro ¹, K Shuler ¹, S Makin ¹, M Dennis ¹, JM Wardlaw ¹

Abstract

Background

Disturbances in mood and physical functioning are common following stroke resulting in increased disability and dependence. These difficulties can be subtle in those with mild stroke but still impact significantly on the individual’s quality of life. Accurate measurement is important but it is unclear whether self-report measures are as reliable as objective measures.

Methods

Patients in the Mild Stroke Study were seen 3–4 years post mild-ischaemic stroke. Trained researchers assessed physical functioning using the Timed Get Up and Go (TUG) and the Nine Hole Peg Test (9-HPT); depression using the Beck’s Depression Inventory (BDI); and disability using the Modified Rankin Scale (mRS). Self-reported physical functioning, disability and mood was assessed using the Stroke Impact Scale (SIS).

Results

Objective and subjective measures were administered to 138 patients aged 38–93 (M = 68.26, SD = 11.02). Both the Mobility and Hand function domain scores of the SIS significantly predicted scores on the TUG (F(1,137) = 93.4, p < 0.001) and both the left and right handed 9-HPT (F(1,137) = 10.89, p = 0.001 and F(1,137) = 30.72, p < 0.001 receptively). Logistic regression showed that the Recovery score of the SIS was a significant predictor of mRS score (F(1,137) = 43.28, p < 0.001). Finally, depression measured using the BDI was also significantly predicted by the Emotion domain score of the SIS (F(1,138) = 58.22, p < 0.001).

Conclusions

The Stroke Impact Scale is a reliable measure of physical functioning, recovery and mood changes when compared to objective measures in mild stroke patients. Use of these measures can save time as they can easily be administered to large samples of patients.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CORRELATES OF DEPRESSIVE SYMPTOMS IN STROKE PATIENTS IN A HOME-BASED REHABILITATION SETTING

J Vermeer ¹, A McIntyre ¹, S Janzen ¹, D Rice ¹, D Ure ², R Teasell ¹

Abstract

Background

Community Stroke Rehabilitation Teams (CSRT) provide home-based rehabilitation for stroke patients in Ontario who otherwise might not have access to outpatient services. Since post stroke depression has been shown to affect rehabilitation progress, the objective of this study was to tTo review stroke patients who actively participated in the CSRT program to determine variables that correlate with depressive symptoms in this population.

Methods

A retrospective review was performed of patients who were provided rehabilitation by CSRT clinicians from January 1, 2009 until September 30, 2015. Demographic variables and disability study measure scores from the Functional Independence Measure (FIMTM), Bakas Caregiving Outcomes Scale (BCOS), and Reintegration to Normal Living Index (RNLI) were extracted and tested in relation to patients’ Patient Health Questionnaire (PHQ-9) scores.

Results

A total of 889 patients (53.2% male) with complete PHQ-2 and PHQ-9 assessments were included in the final analysis. On average, patients were 69.8 ± 13.0 years old (range, 22–98 years) and 83.6 ± 200.5 days post stroke (median = 53.0). Based on PHQ-9 scores, no or mild depressive symptoms were present in 797 patients (89.7%) whereas 92 (10.3%) were considered to have had moderate or severe depressive symptoms. Lower FIM™ admission scores and RNLI admission scores, higher BCOS total scores, and age were significantly associated with patients having moderate to severe depressive symptoms.

Conclusions

Given the impact that post-stroke depression has on rehabilitation, clinicians should take into consideration functional status, community reintegration, caregiver burden, and age when monitoring and treatment depression symptoms.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

QUANTIFICATION OF STROKE GAIT CHARACTERISTICS USING A SINGLE TRI-AXIAL ACCELEROMETER: FIRST STEPS TOWARDS COMPREHENSIVE, FREE-LIVING GAIT ASSESSMENT

S Moore ¹, A Hickey ², S Lord ², M Trenell ¹, A Godfrey ², L Rochester ²

Abstract

Background

Presently measurement of key gait characteristics post-stroke is undertaken in a laboratory, limiting assessment of ‘real world’ ambulation. The aim of this feasibility study is to determine if a tri-axial accelerometer can accurately measure and quantify key gait characteristics post-stroke, with a view to using this tool in the community to measure future intervention response.

Methods

Step count and gait characteristics were measured using a single tri-axial accelerometer attached to the lower back. Two gait algorithms quantified step count and 14 gait characteristics during a two minute continuous walk at preferred pace. Video analysis was used to test accuracy of step count.

Results

Fourteen gait characteristics were quantified in 12 participants (age 65 ± 13, time since stroke 55 ± 30 months) (Table 1). Excellent agreement was demonstrated between accelerometer step count measures versus video analysis (203 ± 32 vs 201 ± 34, ICC 0.933).

Conclusions

Accurate measurement of step count and quantification of 14 spatio-temporal gait characteristics was determined using a single tri-axial accelerometer. Further analysis of validity and reliability of the triaxial accelerometer will be undertaken from the full study cohort (n = 25) to further determine the accuracy of this promising method of gait measurement post-stroke.

Table 1.

Accelerometer quantification of gait characteristics

	Spatio-temporal characteristics (mean ± standard deviation)	Variability spatio-temporal characteristics (mean ± standard deviation)	Asymmetry spatio-temporal characteristics (mean ± standard deviation)
Step velocity (m/s)	1.096 ± 0.182	0.190 ± 0.094
Step length (m)	0.636 ± 0.141	0.105 ± 0.060	−0.010 ± 0.097
Step time (ms)	0.619 ± 0.101	0.094 ± 0.073	0.021 ± 0.107
Swing time (ms)	0.472 ± 0.097	0.098 ± 0.080	−0.015 ± 0.116
Stance time (ms)	0.755 ± 0.120	0.100 ± 0.080	0.018 ± 0.117

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Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

UNDERSTANDING THE FACILITATORS AND BARRIERS TO VOLUNTEER ENGAGEMENT IN STROKE REHABILITATION

M Nelson ¹

Abstract

Background

The increasing medical and social complexity of stroke patients has had a profound impact on the amount and extent of care rehabilitation clinicians are able to provide. Volunteers represent an underutilized human resource that could bridge the gap between patient needs and resource availability. While volunteers have historically played auxiliary roles in hospitals, there has been a move to leverage all hospital human resources (paid and unpaid) to meet stroke rehabilitation patients’ wide range of medical and psychosocial needs.

Methods

This project aimed to understand the role of volunteerism in improving patient outcomes and patient experience in stroke rehabilitation, specifically facilitators and barriers to volunteer engagement within the stroke rehabilitation team. A case study approach was utilized. 59 participants, including clinicians, hospital administrators and volunteers, participated in focus groups and interviews.

Results

There is strong clinical support for volunteer engagement in stroke rehabilitation, with a wide range of roles for volunteers. Three key elements are essential for optimal patient oriented volunteer programs (Right Program, Right Process, and Right Person). Clinicians identified significant risk-related barriers to volunteer engagement in inpatient stroke rehabilitation, most notably patient safety, confidentiality, and bargaining unit concerns.

Conclusions

Inpatient stroke rehabilitation patients place heavy demands on care providers who are working within resource constrained environments. Volunteerism represents a relatively untapped health human resource. However, to optimize volunteers’ contributions, organizational perceptions need to shift from volunteers as a ‘nice-to-have’, to seeing these team members as a Health Human Resource essential to core business of rehabilitation.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

STROKE REHABILITATION AND MULTIMORBIDITY: DO THE GUIDELINES PROVIDE ENOUGH GUIDANCE?

M Nelson ¹

Abstract

Background

Stroke care presents challenges for clinicians; most strokes occur in the context of other medical diagnoses, with patients having on average five other chronic diseases. There are challenges in applying guidelines developed for single diseases in the care of multimorbid patients; the high quality evidence on which guidelines are founded is largely based on RCTs where recruitment criteria typically exclude individuals with comorbid conditions.

Methods

This study sought to understand stroke rehabilitation clinicians’ familiarity and use of the best practice recommendations. Phase II was an appraisal of the Canadian Stroke Rehabilitation Best Practice Recommendations, to determine to what extent the recommendations provide guidance specific to multimorbidity. Twenty three clinicians from two inpatient stroke rehabilitation units participated in focus group sessions. 26 recommendations (plus eligibility and admission criteria) contained within the Stroke Rehabilitation Best Practice Recommendations were reviewed and charted.

Results

Participants reported seldom consulting the recommendations. The application of the recommendations in practice was deemed problematic due to a) perceived lack of guidance in the recommendations regarding comorbidities and multimorbidity, and b) queries regarding the applicability of the recommendations to “real life patients”. Comorbidities and stroke risk factors were mentioned in 9 recommendations; however no explicit clinical guidance was provided.

Conclusions

Clinicians’ concern regarding the best practice guidelines raises an important question in terms of guidelines’ impact on reducing practice variations: If a goal of practice guidelines is to reduce practice variation – does this not only increase variation?

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ASSESSING LONG TERM NEED AFTER STROKE USING THE GERMAN LANGUAGE VERSION OF THE UK STROKE SURVIVOR NEEDS SURVEY IN A BERLIN COHORT STUDY

I Padberg ¹, B Hotter ², A Liebenau ³, P Knispel ⁴, S Zöllner ⁵, S Wiedmann ⁶, P Heuschmann ⁶, CDA Wolfe ⁷, C McKevitt ⁷, A Meisel ⁸, I Wellwood ⁹

Abstract

Background

Assessment of self reported longer term medical and social needs after stroke is important; however few German language measures are available. We formally translated and tested a German language Version of the UK Stroke Survivor Needs Survey (McKevitt et al., 2011).

Methods

The original 40 item version was translated following the Medical Outcome Trust protocol. The Stroke Research (Patient and Carer) Group and research group members (including clinicians and social workers) in Berlin commented on face validity. The translation was pilot tested by social workers in a cohort of out-patient stroke survivors 2–5 years after stroke.

Results

Questions were practical (30 minutes duration) and easily understood. In the 57 patients (mean age 69 (range 42–86), 58% male), 44% did not report unmet clinical needs; the remainder reported a median of 1 unmet clinical need (range 1–8). In the proportion of patients reporting clinical needs, unmet clinical needs ranged from 9% (speaking difficulties) - 44% (pain). Furthermore 40% of the patients reported a wish for further stroke information, 28% reported moderate to marked changes related to work and 58% reported such changes in leisure time.

Conclusions

Preliminary results suggest self-reported unmet needs are common in stroke out-patients in Germany. In some aspects the results differed from UK (notably pain, speaking, reading and mobility), but sample size and methodology limit comparisons. The German translations can be used with permission from the original authors and can contribute to measurement, comparison and understanding of long term need after stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

REHABILITATION PROFILES OF OLDER ADULTS STROKE SURVIVORS ADMITTED TO INTERMEDIATE CARE UNITS: A MULTI-CENTER STUDY

LM Perez ¹, M Inzitari ¹, Q Terence ², J Montaner ³, R Gavaldà ⁴, E Duarte ⁵, L Coll-Planas ⁶, M Cerdà ⁷, S Santaeugenia ⁸, C Closa ⁹, M Gallofré ¹⁰

Abstract

Background

Intermediate care units provide rehabilitation programs to patients unable to return home directly from the acute hospital. We aim to identify possible rehabilitation profiles of older adult stroke survivors admitted to these units.

Methods

We performed a cohort study, enrolling stroke survivors over 65 years, admitted to 9 intermediate care units in Catalonia-Spain. To identify potential profiles, a k-means cluster analysis was performed. Age, caregiver presence, comorbidity, pre-stroke and post-stroke disability, and stroke severity were included in the analysis. Differences on functional improvement, relative functional gain, rehabilitation efficiency, length of hospital stay and new institutionalization were analyzed with ANOVA and ANCOVA models (adjusting for sex and previous institutionalization).

Results

Among 384 patients (79.1 ± 7.9 years, 50.8% women), we identified 3 clusters: a) Lower Impact with Caregiver (LIC), b) Moderate Impact without Caregiver (MIN), and c) Severe Impact with Caregiver (SIC). LIC and SIC showed differences on functional improvement (mean difference = 12.4, (95% CI:5.0–19.7), p < 0.001), Heineman (mean difference = 0.24, (95% CI:0.02–0.46), p = 0.03), rehabilitation efficiency (mean difference = 0.4, (95% CI:0.1–0.70), p = 0.004) and new institutionalization (LIC: 17.8%(N = 28) vs SIC: 34.6%(N = 36), p = 0.006). MIN and SIC differed only for functional improvement (mean difference = 8.7, (95% CI:0.3–17.0, p = 0.039)). No other statistically significant differences in the outcomes were found.

Conclusions

Our data suggest that post-stroke rehabilitation profiles could be identified and that pre-stroke disability, stroke severity and presence of a care-giver are relevant characteristics and should be systematically assessed.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CLINICAL FEATURES OF SUBJECTS UNDERGOING DRIVING TESTS POST STROKE: EXPLORATORY ANALYSIS USING MACHINE LEARNING METHODS

T Phan ¹, P Sagar ¹, J Talbot ¹, H Ma ¹, J Ly ¹, B Clissold ¹, S Singhal ¹, V Srikanth ¹

Abstract

Background

Returning to drive is an important aspect of resuming normal function after stroke. There is lack of information guiding decisions on returning to drive and only some ambulatory patients are referred for driving assessments after stroke. The aim of this study is to discover patterns which lead clinicians to request driving tests after stroke.

Methods

Medical records were searched for ambulatory patients presenting with a stroke at Monash Health (2010–2014). Those undergoing driving tests with an Occupational Therapist were included. We used non-negative matrix factorisation (NMF), an unsupervised machine learning method which extracts latent (hidden) patterns from observed clinical features. The matrix for NMF decomposition consists of rows of patient data and columns containing NIHSS sub-component and disability Rankin scores and demographic data.

Results

graphic file with name 10.1177_2396987316642909-fig148.jpg

There were 82 subjects, mean age of 62.7 ± 12.1 years, 74% male. Visual field deficit was present in 12%, visual extinction (neglect) in 15%, aphasia in 33%, and motor deficit in 74%. The heat-map in Figure 1 shows the top ranked patterns were: 1) demographic features (age and male sex); 2) cognitive features of right middle cerebral artery infarct (extinction, visual field deficit and sensory disturbance); 3) disability score, while the Rankin score, motor deficit and aphasia ranked the lowest.

Conclusions

Machine learning methods may assist in provide an understanding of hidden patterns underlying a clinicians’ decision to refer patients with stroke for driving tests.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

FEASIBILITY OF TRANSCUTANEOUS VAGAL NERVE STIMULATION IN RECOVERY OF UPPER LIMB WEAKNESS AFTER STROKE

J Redgrave ¹, T Oyekunle ², M Ebrahim ², N Snowdon ², A Ali ³, A Majid ⁴

Abstract

Background

Vagal nerve stimulation (VNS) may promote neuroplasticity by release of neurotransmitters from brain stem nuclei. In animal models of stroke, VNS enhances forelimb recovery when paired with purposeful movements. VNS can now be performed non-invasively in humans by stimulating the auricular branch. We assessed feasibility, safety and acceptability of this technique in humans post stroke.

Methods

We recruited participants with arm weakness (Upper limb Fugl-Meyer score 20–50) resulting from an ischaemic stroke 4 months-2 years previously. Participants received repetitive task training of the weak arm during 3 x weekly 1-hour sessions for 6 weeks. Throughout each session, electrical stimulation (0.1–0.4 mA, 25 Hz, pulse width 0.2 ms) was delivered to the concha of the participant’s ear. ECG monitoring was performed after each session and adverse events recorded. Qualitative interviews with participants were carried out to determine the acceptability of the treatment.

Results

9 eligible participants were screened of whom 5 agreed to take part. A total of 76 therapy sessions were completed (1 participant withdrew after the 4th session due to the time commitment). There were no significant ECG changes or adverse events. Side effects were minor and included tiredness (2 participants in 3 sessions) and skin irritation (1 participant in 6 sessions). On 3 occasions electrode placement proved difficult. However all participants said they would be prepared to be randomised to the treatment in a trial.

Conclusions

Transcutaneous VNS was well tolerated and clinical trials of the technique are likely to be feasible in this patient population.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

MOTOR DEFICITS AFTER STROKE ARISE PARTLY FROM LESION OVERLAP WITH ATTENTION-CONTROL NETWORKS

P Rinne ¹, M Hassan ¹, E Han ¹, E Hennessy ¹, A Waldman ¹, P Sharma ², D Soto ¹, R Leech ¹, P Malhotra ¹, P Bentley ¹

Abstract

Background

Executive or attention-control deficits are common after stroke, but are generally considered in terms of their cognitive consequences. Given that attention-control networks are implicated in motor-response selection and execution, we hypothesised that lesions to attention-control networks contribute to motor deficits after stroke.

Methods

92 hemiparetic stroke patients, with no cognitive deficits on standard tests, and 49 controls, underwent grip dexterity and strength tasks, with varying degrees of distraction. Lesion anatomy and resting-state fMRI were related to behavioural data.

Results

Across all tasks, performance was not only worse with the hemiplegic arm (unilateral component), but there were correlations between arms (bilateral component). The bilateral, but not unilateral, component correlated with attention-control (resistance to distraction). A dissociation occurred in that good performance strongly associated with good attention-control, whereas poor performance was associated with either impaired or intact attention-control - suggesting impaired attention-control causes impaired motor performance, rather than vice versa. Both the bilateral motor component, and attention-control, correlated selectively with lesion overlap of a predefined frontostriatalthalamic network; whereas unilateral motor impairment correlated with corticospinal tract lesions. Correspondingly, affected-arm performance correlated with integrity of attention-control and sensorimotor resting-state networks independently.

Conclusions

Our results indicate that stroke hemiplegia is not only a disorder of motor pathways, but also partially reflects a disorder of attention-control. This provides a rationale for attention-enhancement strategies forming part of rehabilitation after motor stroke. We have since developed a bedside, tablet-based gaming-device that can assess, and train, motor and attention-control impairments.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PLASMA MATRIX METALLOPROTEINASES IN STROKE PATIENTS DURING INTENSIVE REHABILITATION THERAPY

F Ma ¹, S Rodriguez ², X Buxó ², A Morancho ¹, I Riba-Llena ¹, A Carrera ², A Bustamante ¹, D Giralt ¹, J Montaner ¹, C Martinez ², I Bori ², A Rosell ¹

Abstract

Background

Despite advances in the acute management of stroke, rehabilitation therapies are the only approved treatments to improve neurological recovery in stroke survivors. We aimed to study plasma levels of matrix metalloproteinases (MMPs) as potential markers of recovery during intensive rehabilitation therapy (IRT) after stroke.

Methods

Prospective and descriptive follow-up study was designed for patients with first-ever ischemic strokes (n = 15) enrolled to IRT (≥3 hours per day/5 days per week) and healthy volunteers serving as non-ischemic controls (n = 15). The primary outcome was to measure plasma MMP3, MMP12 and MMP13 levels and evaluate potential associations with motor/functional scales using a battery of tests (NIHSS, RANKIN, BI, FMA, FAC, MRC, CAHAI and the 10 meter walk) before IRT therapy and at one- and three-month follow-up. The secondary outcome was to evaluate the use of these MMPs as biomarkers as predictors of patient’s outcome.

Results

MMP levels remained stable during the study period and were similar to those in controls. However, baseline MMP12 and MMP13 levels were strongly associated with stroke severity as measured by NIHSS score (p < 0.001 and p = 0.008, respectively) and were elevated in the patients with the most extensive infarcts (p = 0.009 and p = 0.058, respectively). Interestingly, plasma MMP3 was independent of baseline stroke characteristics but was found to be increased in patients with better motor/functional recovery and in patients with larger improvements during rehabilitation.

Conclusions

MMPS might act as biological markers of recovery during rehabilitation therapy related to injury and tissue remodeling. Future confirmatory investigations in multicenter studies are warranted by our data.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

FACTORS BEHIND SUCCESSFUL RETURN TO DRIVING POST STROKE

P Sagar ¹, J Talbot ², H Ma ², J Ly ², B Clissold ², S Singhal ², V Srikanth ², T Phan ²

Abstract

Background

Returning to drive motor vehicle is important aspect of resuming normal function after stroke. There is a lack of information guiding decision on returning to drive a motor vehicle after stroke. We aim to fill this gap by exploring relationships between a patient’s initial stroke severity score (National Institute of Health Stroke Score/NIHSS) and passing driving test.

Methods

Medical records at Monash Health were searched for patients presenting with a stroke between 2010–2014. The inclusion criteria were ambulatory patients undergoing driving test with an Occupational Therapist to assess suitability for returning to drive. The initial NIHSS of stroke severity and its sub-components were extracted from the medical records. Continuous data were analysed using unpaired t-test and categorical data were analysed using chi-square test.

Results

71 of 81 subjects successfully passed the on-road driving test. The cumulative number of subjects who pass the driving test taken is displayed in Figure1. There is increasing number of subjects who pass the driving test between 90 days and 1 year post-stroke. However, there was no statistical difference in age (62.6 ± 12.6, pass-group versus 64.8 ± 9.2, fail-group), stroke severity score (6.27 ± 2.63, pass-group versus 6.9 ± 5.04, fail-group), disability Rankin at 90 days, (1.3 ± 1.02, pass-group versus 1.6 ± 0.84, fail-group), aphasia (0.52 ± 0.89, pass-group versus 0 ± 0, in fail-group) and neglect (0.25 ± 0.60, pass-group versus 0.3 ± 0.67, fail-group).

Conclusions

Among ambulatory patients in the chronic phase of stroke, there were no distinguishing clinical features between the group who pass or fail the driving test. Time is the key factor behind successful return to driving.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THEORY-INFORMED DEVELOPMENT AND VALIDATION OF A GUIDE DESIGNED TO FACILITATE ADOPTION OF AN EVIDENCE-INFORMED APPROACH TO ADMINISTERING THE 10-METRE AND 6-MINUTE WALK TESTS POST-STROKE

N Salbach ^1,², L Kelloway ³, D Brooks ¹, M MacKay-Lyons ⁴, P Solomon ⁵, M Bayley ^6,⁷, A Mihailidis ⁸, JA Howe ^1,⁹, A McDonald ¹⁰

Abstract

Background

The objective was to develop a theory-informed guide to facilitate physiotherapists’ application of an evidence-informed approach to using the 10-metre walk test (10 mWT) and 6-minute walk test (6 MWT) post-stroke.

Methods

Following a systematic review, high-quality walk test protocols and normative values for interpreting test performance were selected. A clinical guide was developed, informed by an implementability framework for developing guidelines, self-efficacy theory, and barriers to walk test implementation. Academic and clinical reviewers rated guide features using a 5-point scale (1-poor, 2-fair, 3-average, 4-good, 5-excellent) and provided comments.

Results

The iWalk guide consists of eight modules: Introduction; Performing the Tests; Interpreting Test Performance; Educating and Setting Goals; Selecting Treatments; Evaluating Practice using Audit and Feedback; Putting it All Together with Case Scenarios; and iWalk Toolkit. Ten academic reviewers rated nine implementability domains, assigning 4-points to adaptability, and 5-points to usability, validity, applicability, communicability, relevance, resource implications, implementation, and evaluation, on average. Eighteen physiotherapists rated format, organization, readability, and content validity of the guide 5-points, and scored the feasibility of implementing the guide in acute, rehabilitation, and outpatient settings, 3, 4, and 5-points, respectively, on average. Revisions primarily related to validity (e.g., improving 6 MWT protocol, expanding references), applicability (e.g., expanding indications to include patients requiring assistance to walk, revising scenarios), resource implications (estimating cost to implement guide), and readability (rewording, using terms consistently, shortening the guide).

Conclusions

The iWalk guide is a valid and implementable guide to using the 10 mWT and 6 MWT post-stroke. The extent to which the guide can facilitate practice change requires investigation.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PROGNOSTIC FACTORS AND QUALITY INDICATORS OF EARLY REHABILITATION AFTER SEVERE STROKE

G Seidel ¹, L Eggers ², K Detmar ², U Debacher ³, R Töpper ⁴, A Majewski ⁵, K Klose ⁵, C Terborg ⁶, P Wohlmuth ⁷, E Zukunft ³

Abstract

Background

Analysis of process and outcome parameters in early stroke rehabilitation could improve patient outcome.

Methods

Analysis of the Asklepios Hamburg early stroke rehabilitation registry. All cases fulfilled the criteria of the German coding system for structural characteristic item OPS 8–552. Predefined quality indicators were analysed. We used descriptive statistics (median [1st quartile, 3rd quartile] and proportions, respectively) and regression models for outcome prediction of unsuccessful outcome. The latter was defined as less than 30 points in the early rehabilitation Barthel Index (FR-BI) at the end of the rehabilitation.

Results

From 7/2012 to 06/ 2015 complete records of 818 stroke patients (median age 72 years [61, 78], 44% female, hemorrhagic [27%] and ischemic [71%] stroke) were analyzed. The early rehabilitation Barthel Index (FR-BI) at admission was in 16.9% lower than -100 points, in 60.4% between -100 and 0 pts. and in 22.7% higher than 0 pts. The median length of stay was 34 [21, 48] days

Quality indicator and proportion of patients who meet the indicator are shown in table 1. Predictors for unsuccessful outcome (less than 30 points in the early rehabilitation Barthel Index (FR-BI) based on a multiple logistic regression model are displayed in table 2.

graphic file with name 10.1177_2396987316642909-img29.jpg

graphic file with name 10.1177_2396987316642909-img30.jpg

Conclusions

We found striking differences in the regression of various symptom complexes, which form the basis for further optimization of the treatment. Older age, neuropsychological deficits, female sex, atrial fibrillation, delirium, epileptic seizure, long-term care before stroke and pneumonia were significant associated with unsuccessful outcome.

Acknowledgment

The study is sponsored by Asklepios Kliniken Hamburg GmbH

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CLINICAL PREDICTORS OF MOTOR FUNCTION IN UPPER EXTREMITY ONE MONTH POST STROKE

J Snickars ¹, H Persson ², K Sunnerhagen ²

Abstract

Background

Recovery of upper extremity impairment after stroke primarily takes place in the first month. However, little is known about early prediction of motor function in the short perspective. The purpose of this study was to investigate factors that within three days post stroke may predict motor function in upper extremity at one month.

Methods

In total 104 patients (average 69 years, median NIHSS 7) with first ever stroke and impaired motor function in upper extremity, were consecutively recruited from a stroke unit. Motor function impairment in upper extremity was based on results of Fugl Meyer Assessment for Upper Extremity (FMA-UE) one month after stroke: severely (≤31p FMA-UE) and less severely (≥32p FMA-UE) impaired motor function. At three days post stroke, age, gender, hand dominance, type of stroke (ischemic or hemorrhage), stroke severity (NIHSS), grip strength (grip strength dynamometer), finger extension, shoulder abduction, physical activity, smoking and diabetes were investigated as plausible clinical predictors. Logistic regression was used to predict severely impaired motor function at one month.

Results

Three days post stroke, either a model including grip strength, stroke severity and gender (85.0%) or a model including finger extension and stroke severity (86.4%) had the best predictive ability for severely impaired motor function at one month.

Conclusions

A simple assessment of upper extremity three days post stroke had high predictive ability of severely impaired motor function at one month but need to be combined with stroke severity. Finger extension and grip strength had similar predictive ability, both superior to shoulder abduction.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ORAL FEEDING IN ACUTELY RUPTURED INTRACRANIAL ANEURYSM

H Takahata ^1,², Y Matsushima ¹, S Saeki ¹

Abstract

Background

Stroke is a major cause of dysphagia but little is known about dysphagia following a subarachnoid hemorrhage (SAH). The aim of this study is to reveal the true feeding status in individuals with acutely ruptured intracranial aneurysm.

Methods

A retrospective observational study was conducted in Nagasaki Medical Center between January 2005 and December 2008. One hundred and sixty five adults (age ≥ 20) with ruptured intracranial aneurysm who received surgical or endovascular treatment within 72 hours of onset were included. Fifteen people who deceased at 4 weeks follow-up were excluded from the analysis. Feeding status at 4 weeks was assessed using the functional oral intake scale (FOIS).

Results

Mean age was 74.5 +/- 13.1 years and 105 (70%) were female. Sixty-four people (42.7%) were on normal diet (FOIS 7) at 4 weeks follow-up, while 45 (30%) were dependent on tube-feeding (FOIS 1–3). A multivariate logistic regression analysis revealed severity of SAH (defined by the World Federation of Neurosurgical Societies grade) (OR 1.47, 95%CI 1.04–2.09, p = 0.031), hydrocephalus (OR 7.46, 95%CI 2.51–21.9, p < 0.001), and pneumonia (OR 5.20, 95%CI 1.64–16.5, p = 0.005) were predictors for tube-dependency at 4 weeks.

Conclusions

As many as 30% of SAH survivors need nutritional management longer than 4 weeks of onset. Further studies need to be done to clearly understand eating problems in acutely ruptured intracranial aneurysm.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ON-LINE TRAINING AND CONSULTING SUPPORT TO CAREGIVERS OF STROKE PATIENTS

H Temizer ¹

Abstract

Background

By determining the difficulties of at-home care that caregivers of stroke patients face regularly, a prospective experimental study, which uses pre-test and post-test control groups, has been conducted to evaluate the impact of training that increase the proper care giving and related stress control capacity, as well as the impact of telephone follow-ups on the perception of care giving and the level of care-giving knowledge.

Methods

The data space of the study was constituted by patients who are diagnosed with SVO at Neurology Clinic, GATA, Ankara, residing in the downtown of Ankara but were discharged to their homes after completion of treatment, having only at-home care from their relatives and their care givers. Experimental and control groups of 40 patients are formed by randomly dividing 80 individuals: Patients of first week are taken into the experimental group and arrivals of the second week are taken into the control group.

Results

Caregivers within the control and experimental groups were determined to be homogeneous in terms of defining features (p > 0.05).While knowledge pre-test scores of caregivers within the experimental group were 58.12 ± 14.30, at the end of the program their post-test scores increased to 91.1 ± 8.1. Pre-test scores (54.4 ± 14.1) and post-test scores (55.4 ± 13.8) of control group are found to be different only by 1 point.

Conclusions

The results of the study reveal that establishing a call center that provides professional training and consulting services to the caregivers of SVO patients at home-care has a positive impact on the care giving and reduces the difficulties of caregivers.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

LOW MOLECULAR WEIGHT HEPARIN (LMWH) FOR VENOUS THROMBOEMBOLISM (VTE) PREVENTION AFTER ACUTE ISCHAEMIC STROKE (IS) IN SOUTH YORKSHIRE

K Trevest ¹, M Obaid ¹, A Ali ¹, A AbdelHafiz ², R Maclean ³, G Pratt ¹

Abstract

Background

VTE is common post IS. The CLOTS3 trial found a 12% incidence amongst patients not on prophylaxis. Once a VTE has occurred, full dose anticoagulation is warranted. The risk of anticoagulation, both prophylactic and treatment dose, is that of haemorrhagic transformation of the IS. Current RCP guidelines do not recommend routine use of LMWH prophylaxis in acute IS despite the PREVAIL trial demonstrating safety and efficacy when used within the first 10 days.

Current practice within STH and TRFT is to prescribe LMWH from 48hours post IS until the patient is ambulant or discharged.

Methods

Retrospective case note analysis was performed on 247 consecutive patients admitted to STH and RFTH with IS. Baseline demographic data, stroke characteristics and use of LMWH was recorded. Outcome measures included symptomatic intracranial haemorrhage (SICH), extra cranial haemorrhage (ECH) and VTE.

Results

127 (51.4%) patients were identified that received LMWH VTE prophylaxis. Of those that received prophylaxis there were no cases of SICH or symptomatic VTE. There were five ECH cases all of whom were on concomitant oral anti-platelets (Three gastrointestinal (GI) bleeds, one epistaxis and one injection site bleed). One patient died as a result of the GI haemorrhage.

Conclusions

No patients developed SICH. The risk of severe ECH is low (2.4%) when compared to the risk of VTE development from trial data. In line with existing evidence our observations suggest LMWH is efficacious and safe in preventing VTE in stroke patients with reduced mobility, and thus randomised controlled trials are required to address this issue.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

NITRIC OXIDE-RELATED BRAIN DAMAGE IN ACUTE ISCHEMIC STROKE IN UZBEKISTAN

A Umarov ¹, A Prokhorova ¹

Abstract

Background

The aim of this trial was to analyze the relationship between NO metabolite (NO-m) concentrations in cerebrospinal fluid (CSF) and clinical and neuroimaging parameters of brain injury in patients with acute ischemic stroke.

Methods

We studied 102 patients and 24 control subjects who were included in a larger previous study conducted to analyze risk factors of progressing stroke. NO generation was calculated by quantifying nitrates and nitrites with a colorimetric assay in CSF samples obtained within the first 24 hours from symptoms onset. Early neurological deterioration was defined as a fall of one or more points in Canadian Stroke Scale score between admission and 48 hours after inclusion. Infarct volume was measured on days 4 to 7 with cranial CT.

Results

Median NO-m concentrations [quartiles] were 2.1 [1.0, 4.5] μmol/mL in patients and 1.0 [1.0, 1.0] μmol/mL in control subjects (P < 0.0001). In 45 patients with subsequent early neurological deterioration, NO-m levels in CSF were significantly higher than in those with stable stroke (4.0 [1.7, 7.8] versus in 1.6 [1.0, 2.5] μmol/mL, P < 0.0001). There was a moderate correlation between NO-m and infarct volume (coefficient 0.39, P < 0.001). NO-m concentrations > 5.0 μmol/mL were significantly associated with early neurological worsening (OR 5.7, 95% CI 1.2 to 27.4; P = 0.030) independent of other important factors related to progressing stroke, such as CSF glutamate levels.

Conclusions

Our clinical findings suggest an important role of NO generation in acute ischemic stroke. Increased NO-m in CSF are associated with a greater brain injury and early neurological deterioration.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

FEASIBILITY AND EFFICACY OF A MULTIDIMENSIONAL STRATEGY FOR PHYSICAL ACTIVITY PROMOTION IN ACUTE STROKE PATIENTS

JA Cruz ¹, X Urra ¹, A Alba ¹, I García-Bouyssou ¹, J Queralt ¹, S Rudilosso ¹, A Renú ¹, L Llull ¹, S Amaro ¹, V Obach ¹, Á Chamorro ¹

Abstract

Background

Guidelines recommend that stroke survivors engage in regular physical exercise, but repeated encouragement and verbal instructions to be physically active are not enough to increase physical activity. We describe the feasibility, safety and efficacy of a multidimensional approach to promote physical activity after ischemic stroke.

Methods

We compared outcomes in consecutive patients before and after implementing a physical activity promotion protocol. During hospitalization, we gave the patients information about the benefits of physical activity and they did an aerobic exercise using a cycle ergometer. The primary outcome measure was physical activity at 3 months using the International Physical Activity Questionnaire. Secondary outcomes were the feasibility of the exercise, sedestation time, functional outcome at 3 months and the knowledge on the topic of physical activity and stroke.

Results

A total of 93 patients were included (60 in the control and 33 in the active group). Pre-stroke activity was low. The 126 cycle ergometer sessions were well tolerated. At 3 months, post-stroke physical activity was greater (693 vs 462 MET-min/week; p = 0.039) and sedestation time lower (2100 vs 2520 min; p = 0.009) in the active group. Functional outcome was similar. The knowledge on the relevance of physical activity was high in both groups.

Conclusions

Despite a proper knowledge of the health benefits of exercise, physical activity is low in patients with stroke. Most of them are able to exercise using a cycle ergometer during inpatient care. A multidisciplinary approach combining early exercise and individualized information on the benefits of physical activity may increase physical activity after stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

DECREASING GENERAL SELF-EFFICACY ASSOCIATED WITH DEPRESSION DIAGNOSIS SIX MONTHS AFTER STROKE

M Volz ¹, M Joebges ², C Letsch ³, K Werheid ⁴

Abstract

Background

Depression is the most frequent mental disorder after stroke. However, our knowledge about the pathogenesis of post-stroke depression (PSD) remains fragmentary. As part of the Berlin PSD study, we investigated if PSD occurred more frequently in patients with decreasing self-efficacy and if early depressive symptoms influenced PSD risk when controlled for established risk factors: activities of daily living, stroke severity, pre-stroke depression and social support.

Methods

We assessed PSD 6 months post-stroke using DSM-IV criteria in a sample of 82 patients from our prospective, longitudinal rehabilitation center based study. We also measured perceived self-efficacy (General Self-Efficacy Scale, GSES), depressive symptoms (Geriatric Depression Scale, GDS) and well-known risk factors for PSD at baseline and 6 months later. Using χ2-test we assessed if PSD occurred more frequently in patients with decreasing GSES. Binary logistic regression investigated the influence of the aforementioned factors on the risk for PSD.

Results

PSD occurred more often in patients with decreasing GSES (χ2 (.1; 1, N = 82) = 3.37; p = .06) and was related to increasing depressiveness (r = -.42; p < .00). Patients with decreasing GSES reported higher baseline self-efficacy. Logistic regression showed the predictive value of GDS (OR = 1.43). GDS fully mediated the influence of pre-stroke mental disorders and social support.

Conclusion/Discussion

Decreasing self-efficacy is associated with PSD 6 months post-stroke, especially in patients with high baseline GSES. This effect may be explained by dissatisfaction following high expectations. Early depressive symptoms predicted PSD, underlining the importance of early screening and treatment.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE VALIDATION OF TWO RISK PREDICTION MODELS FOR REPEAT FALLS WITHIN THE FIRST YEAR AFTER STROKE

M Walsh ¹, R Galvin ², F Boland ³, D Williams ⁴, J Harbison ⁵, S Murphy ⁶, M Crowe ⁷, R Collins ⁸, D McCabe ⁹, F Horgan ¹

Abstract

Background

Several multivariable models have been derived in the literature to predict falls after stroke. These require external validation before facilitating decision-making. The aim of this study was to validate two models that predict repeat falls in the community within the first year post-stroke.

Methods

Stroke survivors were recruited consecutively from five hospitals and falls were recorded for 12 months. Potential fall predictors were assessed prior to discharge. These included inpatient falls and near-falls, hemi-neglect, cognition, arm function, mobility, balance, gait speed, falls-efficacy and mood. Two models were applied to the data. Model 1, incorporating inpatient fall-history and balance, measured the outcome at six months. Model 2, incorporating inpatient near-fall history and arm function, measured the outcome at twelve months. Area under the curve (AUC), sensitivity and specificity within the validation sample were calculated using STATA 13.1.

Results

128 participants (65% male, mean age 68.3 SD 13.1) were recruited. Data about fall status was available for 116 and 110 participants at 6 and 12 months respectively. There were 17 repeat fallers at 6 months, increasing to 28 by twelve months; an outcome incidence of 15% and 26% respectively. Model 1 achieved AUC of 0.55 (95% CI 0.46–0.65), sensitivity 14.8% and specificity 94.9%. Model 2 achieved AUC of 0.54 (95% CI 0.43–0.65), sensitivity 50.0% and specificity 57.5%.

Conclusions

Neither model achieved acceptable discrimination in the validation sample. Work is ongoing to recalibrate, revise and extend the models. The resulting prediction models will require both internal and external validation before their clinical impact can be evaluated.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

POST-STROKE DEPRESSION AND ANTIDEPRESSANT THERAPIES: DO THEY MATCH?

K Werheid ^1,², M Hackett ³

Abstract

Background

Post-stroke depression (PSD) occurs in one third of all stroke survivors, and strongly impacts recovery. While pharmacological and psychosocial therapies for depression in general are well established, specific evidence for PSD is scarce. The present paper investigates the use of antidepressant treatment in stroke patients in the first year after stroke, related to the presence of a depressive disorder.

Methods

In the context of the prospective longitudinal, rehabilitation center based Berlin PSD study, DSM-IV diagnosis of depression was obtained for 170 stroke patients by clinical interviews 6 and 12 months after stroke. DSM-IV diagnosis and self-reports of depressive symptoms (Geriatric Depression Scale; GDS) were assessed along with antidepressant interventions, including both medication and talking therapies.

Results

DSM-IV criteria of minor or major depression were fulfilled by 30% of the patients after 6 months, and by 25% after one year. Half of these patients were receiving any form of antidepressant therapy. Notably, 18% and 16% in the non-depressed subsample received antidepressant treatment, respecitively. Further examination of patients’ individual trajectories showed that most of them had neither previously fulfilled the clinical criteria of depression, nor shown specific patterns of depressive symptoms.

Conclusions

Relating antidepressant treatments over one year to repeated clinical assessment of depression revealed a complex picture. Applying general treatment guidelines for depression, our results would signify significant undertreatment of depressed stroke patients. Contrastingly, one in six stroke patients received antidepressant treatment without traceable indication. Both findings underline the need of further research on evidence-based treatments of PSD.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

NITRIC OXIDE DONORS (NITRATES), L-ARGININE, OR NITRIC OXIDE SYNTHASE INHIBITORS FOR ACUTE STROKE: A SYSTEMATIC REVIEW AND META-ANALYSIS

JP Appleton ¹, K Krishnan ¹, L Woodhouse ¹, PM Bath ¹

Abstract

Background

Nitric oxide is a crucial molecule in health and disease. Nitric oxide donors (nitrates) have several effects that are potentially beneficial in acute stroke including neuroprotection, haemodynamics and reperfusion. We aimed to assess the effects of nitric oxide donors, L-arginine, or nitric oxide synthase inhibitors in acute stroke by performing a systematic review and meta-analysis.

Methods

We searched the Cochrane Stroke Group Trials Register, MEDLINE, EMBASE, Science Citation Index and online trial databases for published and unpublished randomised controlled trials evaluating nitric oxide donors, L-arginine or nitric oxide synthase inhibitors in acute stroke. Primary outcome was death or dependency end of trial, defined as the modified Rankin Scale (mRS) >2.

Results

Five randomised controlled trials totalling 4197 patients of transdermal glyceryl trinitrate (GTN) were included. Overall, GTN lowered systolic and diastolic blood pressure by 7.23 mmHg (95% CI 5.86–8.59) and 3.33 mmHg (95% CI 2.46–4.2) respectively and increased heart rate by 2.02 beats per minute (95% CI 1.13–2.91) at first measurement post-treatment. GTN did not improve functional outcome end of trial or secondary outcomes. A subgroup of patients who received GTN within six hours of stroke onset had improved functional outcome end of trial (OR 0.64, 95% 0.41–1.01) in addition to improvements in disability (Barthel Index), quality of life (EuroQoL-5 dimensions, EuroQoL Visual Analogue Scale) and mood (Zung Depression Scale).

Conclusions

Transdermal GTN lowers blood pressure and is safe in acute stroke. The potential early treatment effect of GTN is being assessed in a large ongoing clinical trial.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EARLY LIFE RISK FACTORS FOR SUBCLINICAL CEREBROVASCULAR DISEASE IN LATER LIFE: A SYSTEMATIC REVIEW AND META-ANALYSIS

EV Backhouse ¹, CA McHutchison ¹, V Cvoro ¹, SD Shenkin ², JM Wardlaw ¹

Abstract

Background

Cerebrovascular disease (CVD) includes subclinical, ‘silent’ brain vascular changes detected using neuroimaging. Factors from childhood such as cognitive ability, socioeconomic status (SES) and education may increase risk. We meta-analysed all available evidence on early life factors and subclinical CVD on imaging in later life.

Methods

We searched MEDLINE, PsychINFO and EMBASE for studies examining childhood (premorbid) IQ, childhood SES, education and subclinical CVD. Two authors assessed all studies and extracted data. Overall inverse variance hazard ratios (HR), odds ratios (OR), mean difference, correlation and 95% confidence intervals (CI) were calculated using a random effects model.

Results

We identified 30 relevant studies, total 23,626 participants. Lower childhood IQ was associated with more white matter hyperintensities (WMH) (5 studies, n = 1512, r = -0.07, 95% CI −0.12, −0.02). One study (n = 243) reported significant correlations between lower childhood SES and increased deep (r = -0.181) and periventricular WMH (r = -0.146). After adjustment for vascular risk factors fewer years of education were associated with increases in several subclinical CVD markers (13 studies, n = 34328, OR = 1.08, 95% CI 1.03–1.12, P < .001), but there was no difference in mean years of education between those with and without CVD markers (7 studies, n = 6032, MD = 0.07, 95% CI −0.42, 0.28) or in mean WMH volume between those with high and low levels of education (4 studies, n = 4330, MD = 0.02, 95% CI −0.02, 0.07). Heterogeniety ranged from 0–75%.

Conclusions

Lower childhood IQ, SES and less education increase risk of subclinical CVD in later life. Further studies are required to confirm these findings and adjust for confounders.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ASSOCIATION BETWEEN TIME INTERVAL TO NON-INSTRUMENTAL DYSPHAGIA SCREENING AND DEVELOPMENT OF STROKE ASSOCIATED PNEUMONIA AFTER ACUTE STROKE - A SYSTEMATIC REVIEW

J Barker ¹, A Vail ², C Smith ³, P Tyrrell ³, A Kishore ³

Abstract

Background

Dysphagia is an independent predictor of stroke associated pneumonia (SAP) and mortality after acute stroke. In the UK, guidelines advocate bedside swallow screening within 4 hours of hospital admission in acute stroke, although supportive evidence for this recommendation is uncertain. We therefore aimed to determine whether time interval to dysphagia screening is associated with development of SAP.

Methods

A systematic literature review of multiple electronic databases was undertaken, in accordance with Cochrane guidance. Published studies of hospitalised adults with ischaemic and/or haemorrhagic stroke who underwent non-instrumental dysphagia screening, and reported frequency of SAP, were considered and independently screened for inclusion by two reviewers.

Results

A total of 13 studies were considered eligible for inclusion. The interval times to swallow screen varied from 4 hours to 72 hours with the water swallow screen (62%) the most commonly used method. The reported frequency of SAP (0%-32%) varied substantially, with the diagnostic approach reported in only 62% of studies. There was a trend towards a lower percentage of patients developing SAP with shorter interval time to dysphagia screening, but further quantitative analysis was limited by the heterogeneous nature of studies and methodology used.

Conclusions

Although limited by small studies and absence of randomised controlled trials, the review suggested a trend towards lower frequency of SAP when swallow screen was done early after acute stroke. Further research is required to standardise dysphagia screening methods and timing after acute stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

SINGLE TRANSIENT PRECEDING CEREBROVASCULAR EVENTS ARE MOST EFFECTIVE IN ISCHEMIC PRECONDITIONING IN HUMANS

P Correia ¹, I Meyer ¹, A Eskandari ¹, M Amiguet ², P Michel ¹

Abstract

Background

Preconditioning improves acute ischemic stroke (AIS) outcomes in animals and possibly in humans. We aimed to identify whether preceding ischemic events (PIE) at any time before an AIS can have a preconditioning effect on a subsequent AIS.

Methods

Using consecutive AIS from the single center ASTRAL registry, we determined demographics, risk factors, past medical history, PIE and stroke features potentially associated with initial stroke severity (admission NIHSS). We used a linear regression model to compare groups with and without different forms of PIE.

Results

Of 3501 consecutive AIS patients (43% females, median age 73 y), 996 (28.4%) had preceding PIEs (15.7% TIA, 12.9% ischemic stroke, 2.4% retinal ischemia, some with several PIEs) at a median delay of 180 days (IQR 5 – 1425). After multiple adjustments (see graph with linear Beta regression coefficients), NIHSS significantly decreased with PIEs (mean NIHSS 12.1 v/s 13.4 without PIE), with maximal benefit with single, transient PIE’s in the same territory as stroke (NIHSS 10.5). PIE effect was significant through the whole range of timings before the index AIS, with insignificant reduction in PIE benefit with temporal distance (0.01NIHSS/year).

graphic file with name 10.1177_2396987316642909-fig150.jpg

Conclusions

We found an independent association between decreasing AIS severity and PIE, in particular when preceding events were single and of short duration. These results suggest a possible ischemic preconditioning and give indications about the most favourable timing and number of PIE's in humans.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

SYSTEMATIC REVIEW AND STRATIFIED META-ANALYSIS OF THE EFFICACY OF BLOCKING HMGB1 SIGNALING IN ANIMAL MODELS OF STROKE

D Li ¹, M Liu ¹

Abstract

Background

Stroke is a devastating disease and has been lack of specific therapies. To assess whether there is any significant evidence, from relevant extracted data, to suggest that blocking high mobility group box-1 (HMGB1) signaling in animal models of stroke has any beneficial potential in ameliorating stroke outcome.

Methods

We performed a literature research up to October 2015 based on searches querying Ovid Medline, Ovid Embase, Biosis Preview, China National Knowledge Infrastructure, VIP Database for Chinese Technical Periodicals. We identified 41 studies that met our inclusion criteria. The data from these studies were used to evaluate the effect of blocking HMGB1 signaling in animal models of stroke according to methodological quality score, drug/gene knockout, the time, route, and dose of the drug administration, the number, species, sex and strain of the animal, subtype of stroke (intracerebral hemorrhage, subarachnoid hemorrhage or cerebral ischemia), injury induction method, comorbidity, the anesthetic and ventilation method used during the induction of injury, efficacy assessment methods (neurobehavioral test, brain water content or lesion volume) and time of assessment.

Results

The results showed that the anti-HMGB1 signaling treatments seem to improve infarct/hemorrhage volume, brain water content and neurobehavioral outcome in animal models of stroke.

Conclusions

Our findings of this meta-analysis demonstrate that blocking HMGB1 signaling in animal models of stroke has beneficial effect on ameliorating stroke outcome. As a corollary, it would be a promising therapeutic strategy to target HMGB1 signaling for treating stroke in the future.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE EFFECT OF HYPERTHERMIA ON OUTCOME IN ANIMAL MODELS OF ACUTE ISCHEMIC STROKE: A SYSTEMATIC REVIEW AND META-ANALYSIS

JC de Jonge ¹, J Wallet ¹, ES Sena ², MR Macleod ², HB Van der Worp ¹

Abstract

Background

High body temperatures in the first days after stroke are associated with a greater risk of a poor outcome. If this relation is causal, prevention of hyperthermia might improve outcome. Causality can most easily be tested in animal models. We therefore assessed the effects of hyperthermia on outcomes in animal models of ischaemic stroke and explored under which conditions prevention of hyperthermia was most effective.

Methods

We performed a systematic review and meta-analysis of data from animal experiments testing the effect of spontaneous or induced hyperthermia on outcome after focal cerebral ischaemia. Our primary outcome measure was infarct size. Normalized mean differences were combined using the random effects model and stratified meta-analysis was used to explore the impact of study characteristics.

Results

We included 19 publications, reporting on 49 comparisons involving 589 animals. Overall, the presence of hyperthermia increased infarct size by 48.0% (95% confidence interval, 33.9% to 62.2%) and worsened neurobehavioral outcomes by 41.1% (23.8%-58.4%). The effect on infarct size was higher with higher temperatures. Hyperthermia was most harmful in models of temporary focal cerebral ischaemia, with longer durations of hyperthermia, and when hyperthermia was present both before, during, and after induction of ischemia.

Conclusions

Hyperthermia substantially increased infarct size in animal models of ischaemic stroke, suggesting that the relation between fever and poor outcome observed in patients is at least in part causal. These data provide support to trials testing the effect of the prevention of fever with antipyretic drugs in patients with acute stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EFFECT OF CONSTITUTION-BASED DIET THERAPY FOR LIFESTYLE-RELATED DISEASES IN KOREA MEDICINE: A SYSTEMATIC REVIEW AND META-ANALYSIS

L Eui Ju ¹, S Shin ¹, J Yoo ¹, EY Kim ¹, L Yanhua ¹, K Hyun Jung ²

Abstract

Background

Clinical researches have been carried out to show the effectiveness of constitutional diet therapy (CDT) for lifestyle-related diseases (obesity, hypertension, diabetes, and hypercholesterolemia, etc.) This systematic review aimed at exploring the effect of CDT for any lifestyle-related disease in traditional Korean medicine (TKM), over the standard diet therapy (SDT), assessed by objective outcomes.

Methods

Electronic and manual search was carried out as of October 16, 2015 with no language restrictions. The database of MEDLINE, EMBASE, Cochrane Library, Chinese National Knowledge Infrastructure, Oriental Medicine Advanced Searching Integrated System, Research Information Sharing Service, National Digital Science Library, and Korean Medical Database were searched. Searching terms for diet therapy and constitution in TKM were combined. The clinical studies with CDT versus SDT were considered eligible. Two independent authors performed risk of bias assessment with the Newcastle-Ottawa Scale (NOS). Statistical analyses were also carried out with the Reviewer Manager Software.

Results

Six studies (242 patients) were included in the analysis (Fig. 1). Each study was appraised as yes in 4 to 6 items with NOS assessment. Meta-analysis showed CDT significantly decreased total cholesterol (mean difference of −17.62, 95% CI [-34.62, −0.63], p = 0.04, n = 103) (Fig. 2) and triglyceride (mean difference of −39.15, 95% CI [-73.83, −4.47], p = 0.03, n = 103) (Fig. 3) levels of non-stroke patients with lifestyle-related diseases. CDT did not address any significant effectiveness on any objective outcomes in the stroke patients group with lifestyle-related diseases.

Conclusions

CDT could be beneficial in improving total cholesterol or triglyceride for the non-stroke patients with lifestyle-related diseases.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CLINICAL PREDICTION MODELS FOR ISCHEMIC STROKE RECOVERY: A SYSTEMATIC REVIEW

M Fahey ¹, E Crayton ¹, AG Rudd ^1,², CDA Wolfe ^1,², A Douiri ^1,²

Abstract

Background

Clinical prognostic models (CPM) may be useful in clinical practice to support tailored and cost-effective approaches to the management of stroke survivors. We systematically reviewed the methodology and results of studies that have developed and validated prognostic model for mortality or recovery after stroke.

Methods

MEDLINE, EMBASE, CINHAL, Cochrane Database of Systematic Reviews were searched from inception to September 2015 for CPM. Reference lists and citations of included studies were searched. Models were appraised using CHARMS checklist and QUIPS risk of bias tool for prognostic research. The GRADE framework for prognostic research was used to assess the quality of the evidence. Studies were selected for inclusion, according to pre-specified criteria and critically appraised by two independent reviewers. This review was completed consistent with PRISMA guidelines.

Results

Eighty-seven relevant papers were identified describing 109 discernible CPM. These studies included at least 100 patients in whom at least three predictor variables were used in the developed CPM. Demographic (Age: n = 82, Sex: n = 30) and co-morbidity (Diabetes: n = 24, Atrial Fibrillation: n = 23) variables were the most common predictors of recovery and survival. Forty-nine CPMs were found but most had potentially serious deficiencies in internal validity. Although 83 have been adequately validated they have limited generalisability (hospital based). No model reported all items recommended by CHARMS.

Conclusions

The current evidence base does not support the use of existing stroke CPM in clinical practice. Better quality validated models with adequate accuracy are still needed to enable, comparisons of outcomes across treatments and high risk groups.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

A SYSTEMATIC REVIEW OF THE SCREENING METHODS FOR POST-STROKE VISUAL IMPAIRMENT

K Hanna ¹, F Rowe ¹, L Hepworth ¹

Abstract

Background

Post stroke visual impairments are wide ranging, affecting approximately 60% of stroke survivors.The aim is to therefore, provide a systemic review of the available screening methods for identifying post-stroke visual imapirments.

Methods

A systematic review of the literature was conducted including randomised controlled trials, controlled trials, cohort studies, observational studies and retrospective reviews. Subjects included adult participants (aged 18 years or over) diagnosed with a visual impairment as a direct cause of a stroke. We searched a wide variety of resources and a quality of evidence and risk of bias assessment was undertaken for each article.

Results

Twenty articles (n = 2398) were included in the review. The majority of tools screen for visual perception including visual neglect with few screening for visual acuity, visual field loss or ocular motility defects. Only two tools screened for all visual impairments however, they cannot accurately account for those with aphasia or communicative problems which is common following stroke. A further 11 articles were found which reported on individual vision screening tests in stroke populations.

Conclusions

There is currently no standardised visual screening tool which assesses all potential post-stroke visual impairments. The current tools screen for only a number of potential stroke-related impairments meaning many visual defects will be missed. Furthermore, many clinical tests used regularly to assess vision on stroke patients have not yet been reported on in the literature. Future research is required to develop a tool which encompasses all potential visual deficits to ensure all stroke survivors with visual impairment are accurately identified and managed.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

BARRIERS AND FACILITATORS ASSOCIATED WITH RETURN TO WORK AFTER STROKE: A QUALITATIVE META-SYNTHESIS

F Horgan ¹, C Brannigan ¹, R Galvin ², M Walsh ¹, C Loughnane ³, EJ Morrissey ³, C Macey ³, M Delargy ⁴

Abstract

Background

We conducted a systematic review to examine barriers to and facilitators of return to work after stroke from the perspective of people with stroke through the process of a qualitative meta-synthesis.

Methods

Studies that employed qualitative methods to explore the experiences of individuals with stroke around return to work after stroke were included. The methodological quality of the studies was assessed by two independent reviewers. Overarching themes, concepts and interpretations were extracted from each individual study, compared and meta-synthesised.

Results

Fifteen studies were included and the overall methodological quality of the studies; (i) the nature of the effects of stroke, (ii) the preparatory environment, (iii) personal coping strategies and internal challenges, and (iv) the meaning of work.

Conclusions

Return to work after stroke is a complex process which can be facilitated or impeded by organisational, social or personal factors, as well as accessibility to appropriate services.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CARDIAC MONITORING FOR DETECTION OF ATRIAL FIBRILLATION AFTER TIA: A SYSTEMATIC REVIEW AND META-ANALYSIS

E Korompoki ¹, A Del Giudice ¹, S Hillmann ², U Malzahn ³, DJ Gladstone ⁴, P Heuschmann ², R Veltkamp ¹

Abstract

Background

Diagnostic accuracy of atrial fibrillation detection by various cardiac monitoring methods has been studied in mixed stroke and TIA cohorts but not specifically in TIA patients. We conducted a systematic review and meta-analysis to determine the rate of newly diagnosed AF using different methods of ECG monitoring in TIA patients.

Methods

A comprehensive literature search was performed following a pre-specified protocol in accordance with the PRISMA statement. Prospective observational studies and randomized controlled trials were considered that included TIA patients who underwent cardiac monitoring for >12 hours. Primary outcome was frequency of detection of AF lasting at least 30 sec. Analyses of subgroups and of duration and type of monitoring were performed.

Results

17 studies enrolling 1163 patients were included. Overall, the pooled AF detection rate was 4% (95% CI: 2%-7%). Yield of monitoring was higher in selected (in terms of age, pre-screening for arrhythmias and cause of TIA) than in unselected cohorts (7% vs 3%). Pooled mean AF detection rates rose with duration of monitoring: 4% (24 hours), 5% (24 hours to7days) and 6% (>7 days), respectively. The yield of non-invasive monitoring was significantly lower than that of invasive monitoring (4% vs. 11%). Significant heterogeneity was observed among studies (I2 = 60.61%).

Conclusions

This first meta-analysis of AF detection in TIA patients suggests that the rate of AF detection is lower in TIA patients than previously reported for IS. Prospective studies are needed to determine the optimal diagnostic procedure for AF detection in TIA patients.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

TELEMEDICAL STRATEGIES FOR THE IMPROVEMENT OF SECONDARY PREVENTION IN PATIENTS WITH CEREBROVASCULAR EVENTS - A SYSTEMATIC REVIEW

P Kraft ¹, S Hillmann ², U Malzahn ², PU Heuschmann ²

Abstract

Background

Data from European countries consistently show that guideline-conform secondary prevention (SP) after stroke/transient ischemic attack (TIA) is being realized in only 50–80% of patients. Use of telemedicine to support long-term SP has been effective in other cardiovascular diseases. We reviewed current evidence for telemedical supported strategies to improve SP after stroke/TIA.

Methods

A systematic review was performed in accordance with the PRISMA statement searching MEDLINE, the Cochrane Central Register of Controlled Trials, and reference lists of articles published until December 4^th 2015. Randomized controlled trials (RCT) and observational studies were included if they analyzed the effect of a telemedical strategy for supporting SP after stroke/TIA compared to usual care and reported primary (behavior according to guidelines, e.g. medication adherence, healthy behavior) or surrogate outcomes (consequences of primary outcome, e.g. mortality, blood pressure lowering).

Results

The review included 13 of 103 identified studies involving 2577 patients (range 11 to 537). Telemedical support comprised telephone (predominantly by nurses), and web-based interventions. Outcomes were heterogeneous: medication adherence did not differ in one RCT (p = 0.089). Mortality was reported in one study and was significantly (p < 0.001) higher in patients non-participating in a web-based intervention. 7 studies assessed blood pressure at follow up, of those 4 reported a significant (p < 0.05) reduction. Furthermore, patients in the intervention group were physically more active compared to the control group (43.4% vs. 40.1%).

Conclusions

Telemedical supported SP in cerebrovascular diseases might be effective but larger trials with standardized interventions and outcome measures including clinical endpoints are needed.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

NEUROMUSCULAR ELECTRICAL STIMULATION (NMES) IN STROKE TO IMPROVE ACTIVITY: A SYSTEMATIC REVIEW

MGH Kristensen ¹, H Busk ¹, T Wienecke ¹

Abstract

Background

Despite intensive rehabilitation efforts, functional outcome of post-stroke limb disabilities is poor. Prior research indicate that NMES can contribute to the recovery of voluntary movement. In theory, NMES is an ideal rehabilitation device for paretic muscles due to its capability of initiating contractions independently. However, until today, the scientific evidence is unclear and therefore not implemented in clinical practice.

Objectives: To explore whether NMES improves functional motor ability or activities of daily living (ADL).

Methods

A MEDLINE search using the PubMed database for relevant articles published between its inception to November 2015. Selection criteria were randomized controlled trials with electrical surface stimulation applied to the motor point or muscle belly designed to improve functional motor ability or ADL in stroke survivors. The methodological quality was assessed using the PEDro scale.

Results

Of the 1724 references identified, fifteen trials (831 participants) were eligible for inclusion. We found no convincing effect of NMES’ ability to improve functional motor ability or ADL. The conclusion is affected by the heterogeneity in patient characteristics including time since stroke and disability level, in addition to the variability in stimulation settings and -duration.

Conclusions

At present, there are insufficient data to recommend implementation of NMES in rehabilitation after stroke. Further research is needed to identify the patients most adequate to benefit from the intervention and to determine whether the variability in stimulation settings can be minimized or should be personalized.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

A SYSTEMATIC REVIEW OF CLINICAL TRIALS OF BONE MARROW MONONUCLEAR CELL THERAPY FOR PATIENTS WITH ISCHEMIC STROKE

A Kumar ¹, M Prasad ², A Pandit ², V Jali ², S Misra ², P Kumar ², K Chakravarty ², A Gulati ²

Abstract

Background

Bone marrow mononuclear cell (BM-MNCs) therapy has emerged as a potential therapy for the treatment of stroke. We performed a systematic review of published studies using BM-MNCs therapy in patients with ischemic stroke (IS).

Methods

Literature was searched using MEDLINE, EMBASE, Trip Database and Cochrane library, clinicaltrial.gov to identify studies on BM-MNCs therapy in IS till May 2015. Data was extracted independently by two reviewers. STATA version 13 was used for carrying out meta-analysis. We included non-randomized open label, single arm, and comparative studies or randomized controlled trials (RCT) if BM-MNCs were used to treat patients with IS in any phase after the index stroke

Results

One randomized trial, one non-randomized comparative trial, and four single arm open label trials (total six studies) involving 191 subjects were included in the systematic review using proportional meta-analysis. The pooled proportion for favourable clinical outcome (modified Rankin Scale score <2) was 29% (95% CI 0.19 to 0.43) for 122 patietns exposed to BM-MNCs. For the total 69 control subjects (taken from two comparative trials), those who did not receive stem cells, had pooled proportion for favourable outcome (mRS < 2), 10% (95% CI 0.09 to 0.29). The pooled differences in the safety outcomes were not significant beteen both the groups.

Conclusions

Our systematic review suggests that BM-MNCs therapy is safe and feasible; however, its efficacy in the case of stroke patients is debatable. Well designed randomized controlled trials are necessary to provide more information on the efficacy of BM-MNCs transplantation in patients with IS.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EARLY VERSUS DELAYED MOBILISATION AFTER STROKE: A SYSTEMATIC REVIEW

P Langhorne ¹, J Bernhardt ², J Collier ², T EM Trialists ¹

Abstract

Background

Early mobilisation has been recommended in many acute stroke clinical guidelines and performed in some stroke units. We aim to determine the benefits and harms of early (within 48 hours of stroke) and increased out of bed mobilisation (EM), compared with more delayed mobilisation practices.

Methods

We searched MEDLINE, EMBASE, CINAHL, Cochrane Stroke Group trials register, international ongoing trials registers, reference lists of articles and performed citation searching up to 2015. Foreign language translations were sought. Two review authors assessed trial eligibility, quality and performed data extraction. The primary outcome was death or a poor outcome (dependency or institutionalisation) at follow up. We used fixed effect models to estimate odds ratios.

Results

We identified nine eligible RCTs, of which one is pending further information. Of the remaining eight trials (2618 participants) AVERT provided the most information (2104 participants). Complete 3 month outcome data were available for 2539 (97%) participants. Compared with delayed mobilisation, EM showed non-significant increases in the odds of death or dependency (odds ratio 1.10; 95% CI 0.94–1.29), death (1.27; 0.95–1.70) and decreased odds of having any complication (0.89; 0.73–1.08). There was substantial heterogeneity of intervention but the average time to first mobilisation was not significantly related to the odds of death or dependency, or death alone (test for subgroup differences P = 0.35 and 0.19 respectively).

Conclusions

EM was not associated with improved outcomes compared with delayed mobilisation. In view of the complexity of the intervention and the uncertainty around the effect estimates, more detailed analyses are warranted.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

DO THE BENEFICIAL EFFECTS OF GOOD COLLATERALS ON IMAGING AND CLINICAL OUTCOMES IN ENDOVASCULAR TREATMENT DEPEND ON THE ONSET-TO-TREATMENT INTERVAL?

X Leng ¹, H Fang ², KS Wong ¹, DS Liebeskind ³

Abstract

Background

Good pre-treatment collateral circulation has been found to be correlated with better reperfusion and functional outcome, in acute ischemic stroke under endovascular treatment. But it was unclear if such beneficial effects vary in studies with different onset-to-treatment (OTT) intervals.

Methods

Full-text articles reporting the effects of pre-treatment collateral status on reperfusion, and 3-month functional outcome, in endovascular treatment for anterior-circulation stroke, were retrieved from PubMed since 2000. Only those providing information on the mean OTT interval were included in the current meta-analysis. Random-effects models were used to estimate the risk ratios (RR), and subgroup analyses were performed for studies with a mean OTT of ≤ or >300 minutes.

Results

Overall, 9 studies with 665 patients were analyzed. The beneficial effects of good pre-treatment collateral status on reperfusion (9 studies; 663 patients), did not significantly differ between studies with a mean OTT of ≤ or >300 minutes (RRs: 1.11 versus 1.28; P = 0.57 and I²= 0% for between-subgroup heterogeneity). However, the beneficial effects of good pre-treatment collaterals on favorable functional outcomes at 3 months (6 studies; 284 patients), differed between the two subgroups (RRs: 29.79 versus 4.24; P = 0.05 and I²= 74.4%).

Conclusions

OTT intervals were not systemically reported in relevant studies. Thus, no definite conclusions could be drawn regarding of the study question at the current stage, due to the limited number of studies analyzed. Standardized reporting of endovascular studies in stroke is needed, for cross-sectional comparisons of results from future studies.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PUERARIN FOR ISCHAEMIC STROKE

B Liu ¹, Y Tan ², M Liu ¹

Abstract

Background

Puerarin, a form of herbal medicine, is widely used in the treatment of ischaemic stroke in China

Methods

We searched the Cochrane Stroke Group Trials Register (last searched August 2015), the Chinese Stroke Trials Register (last searched August 2015). In addition, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library August 2015), MEDLINE (1948 to August 2015), EMBASE (1980 to August 2015), AMED (the Allied and Complementary Medicine Database, 1985 to August 2015) and the China Biological Medicine Database (CBM-disc 1979 to August 2015).

Results

We included 20 RCTs with 1574 participants in the review. Time windows within which patients were randomised ranged from 4.5 hours to 10 days. Ishcmeic stroke was confirmed by CT or MRI in 18 trials. Meta-analysis of two trials with 164 participants showed that treatment with puerarin did not reduce death or dependency at final follow-up (RR 0.79, 95% CI 0.45 to 1.36; participants = 164; studies = 2). One trial included children with 83 participants reported mean value of BI (Barth Index) in puerarin group was below than that in control group. Meta-analysis of 16 trials with with 1305 participants showed that puerain improved neurological deficit at the end of follow up (RR 0.42, 95% CI 0.33 to 0.55; participants = 1305; studies = 16). None of the included trials reported serious adverse effects

Conclusions

There is not enough evidence to evaluate the effect of puerarin on survival or dependency in people with ischaemic stroke

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EFFICACY OF ENDOVASCULAR TREATMENT FOR ACUTE ISCHEMIC STROKE: A META-ANALYSIS

P Cerrone ¹, C Marini ¹

Abstract

Background

Systemic thrombolysis is considered the gold standard of acute stroke therapy but it may be unsuitable for many patients. Endovascular treatments may also play a relevant role in the treatment of acute ischemic stroke but available trials showed conflicting results. The aim of this meta-analysis was to evaluate the efficacy of endovascular treatment over standard therapy in acute ischemic stroke.

Methods

A thorough search of all trials was performed in medical literature databases, trial registers, congress abstracts and reference lists. The primary end-point was favorable outcome at 90 days at the modified Rankin Score. Secondary end-points were symptomatic intracerebral hemorrhage and recanalization rates. Data were extracted by papers and reports and analyzed with the Mantel-Haenszel method. A pre-planned sensitivity analysis was performed by excluding trials not performing imaging studies of cerebral vessels before randomization.

Results

11 trials fulfilling inclusion criteria, overall including 2792 participants, were identified. When compared with standard therapy, either including systemic thrombolysis or not, endovascular treatment significantly improved the outcome at 90 days (OR 1.76, 95% CI 1.24–2.50), though with significant heterogeneity. Sensitivity analysis, excluding trials randomizing patients without any evidence of occlusion of major cerebral vessels, confirmed the efficacy of endovascular treatment (OR 2.05 95% CI 1.38–3.03) in the absence of any heterogeneity. Analysis of secondary end-points proved safety of endovascular treatment.

Conclusions

Endovascular treatment for acute ischemic stroke is effective and safe when added to standard therapy, either including systemic thrombolysis or not.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

REHABILITATIVE BENEFITS OF HIPPOTHERAPY IN ADULTS WITH STROKE: A SYSTEMATIC REVIEW

J Marquez ¹, L Chambers ¹

Abstract

Background

Horseback riding therapy has been utilised to supplement conventional therapy in neurological conditions for many years with evidence supporting its use in paediatric patients, however evaluation of its merit in adult stroke patients is lacking.

Methods

We performed a systematic review with meta-analysis of controlled trials to collate the available evidence in adults with residual motor impairments as a result of stroke. The primary outcome was change in motor function or impairment as a result of hippotherapy or simulated hippotherapy with or without adjunct therapy.

Results

The search yielded 5 relevant studies (low to moderate quality) comprising 187 subjects. When the data was pooled, hippotherapy did not produce statistically significant improvements in balance (standardised mean difference = 0.14, 95% CI −0.19, 0.47, P = 0.4) or gait parameters (standardised mean difference = 0.04, 95% CI −1.04, 1.13 P = 0.94) when compared to control and measured immediately after the intervention. Long term effects remain unknown as no studies reported follow-up evaluation. This review indicates that hippotherapy is safe and well tolerated by stroke patients with no drop-outs or adverse events reported in the included studies.

Conclusions

This review highlights the need for further high quality research before hippotherapy can be endorsed as a modality in stroke rehabilitation.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

BLOOD PRESSURE AND FUNCTIONAL OUTCOME IN ACUTE ISCHEMIC STROKE ACCORDING TO RECANALIZATION STATUS

AI Martins ¹, J Sargento-Freitas ¹, F Silva ¹, J Jesus-Ribeiro ¹, I Correia ¹, JP Gomes ², M Gonçalves ², L Cardoso ², C Machado ¹, B Rodrigues ¹, GC Santo ¹, L Cunha ¹

Abstract

Background

The association between blood pressure (BP) and clinical outcome has been described as a “U” or “J”-shaped in stroke cohorts that did not consider the recanalization state of the affected arterial territory. The main objective of this study was to identify the relationship between BP during the first 24 hours after ischemic stroke and clinical outcome in patients submitted to intravenous and/or intra-arterial recanalization treatments.

Methods

We included consecutive ischemic stroke patients treated with intravenous thrombolysis and/or intra-arterial therapies in a retrospective cohort study. BP measurements were performed on regular intervals during the first 24 hours after symptoms onset. The mean systolic BP (SBP) and diastolic BP (DBP) during the first 24 hours were calculated. Recanalization was assessed at 6 hours by transcranial color coded Doppler, angiography or angio-CT. Functional outcome was assessed at 3 months by modified Rankin scale. Linear and quadratic multivariate regression models were performed to determine associations between BP and functional outcome for the whole population, recanalyzed and non-recanalyzed patients.

Results

We included 674 patients, mean age 73.28 (SD: 11.50) years, 363(53.90%) male. 355 (52.70%) patients had confirmed arterial recanalization at 6 hours. Multivariate analyses of SBP and DBP in the first 24 hours showed a “J”-shaped relationship with functional outcome in the total population and in the non-recanalyzed patients. Recanalyzed patients showed a linear association with functional outcome

Conclusions

Systemic BP in the first 24hours after ischemic stroke is related to 3 months functional outcome, reliant on the revascularization status.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

SPONTANEOUS FLUCTUATIONS OF BLOOD PRESSURE IN ACUTE ISCHEMIC STROKE ACCORDING TO HEMODYNAMIC STATUS

AI Martins ¹, J Sargento-Freitas ¹, F Silva ¹, I Correia ¹, J Jesus-Ribeiro ¹, JP Gomes ², M Gonçalves ², L Cardoso ², C Machado ¹, B Rodrigues ¹, GC Santo ¹, L Cunha ¹

Abstract

Background

Blood pressure (BP) is an independent predictor of functional outcome in acute ischemic stroke. However the impact of spontaneous BP fluctuations is still undetermined, particularly considering the specific hemodynamic status of each patient. The main objective of this study was to evaluate the clinical effect of acute BP variability after ischemic stroke in patients submitted to intravenous and/or intra-arterial recanalization treatments.

Methods

Consecutive acute stroke patients treated with intravenous thrombolysis and/or intra-arterial therapies were enrolled in an historical cohort study. Systolic BP (SBP) and diastolic BP (DBP) values were obtained on regular intervals during the first 24 hours after symptoms onset and its variation was quantified through standard deviation (SD) of the values registered. Recanalization was assessed at 6 hours by angiography, transcranial color-coded Doppler or angio-CT. Functional outcome was assessed at 3 months by modified Rankin scale. Linear multivariate regression models were performed to identify the relationship between BP SD and functional outcome for the whole population, recanalyzed and non-recanalyzed patients

Results

We included 674 patients, mean age 73.28 (SD: 11.50) years, 363(53.90%) male. In total population and in non-reanalyzed patients SBP’s fluctuations had a significant association with 3 months clinical outcome (OR: 1.020, 95%CI: 1.004–1.035, p = 0.016; OR: 1.022, 95%CI: 1.001–1.044, p = 0.039) while variations of DBP did not show statistical influence. In the recanalyzed patients neither SBP’s nor DBP’s variations revealed statistical relationship with functional outcome.

Conclusions

Systolic BP’s fluctuation is related to 3 months functional outcome depending on the revascularization status.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE USE OF VIRTUAL REALITY FOR BALANCE AMONG INDIVIDUALS WITH CHRONIC STROKE: A SYSTEMATIC REVIEW AND META-ANALYSIS

J Iruthayarajah ¹, A McIntyre ¹, A Cotoi ¹, S Macaluso ², R Teasell ¹

Abstract

Background

Virtual reality (VR) is becoming a popular adjunct to traditional upper and lower limb rehabilitation following a stroke. The purpose of this study was to conduct a systematic review and meta-analysis on the efficacy of VR interventions for balance impairments in a chronic stroke population.

Methods

Several databases (i.e., PUBMED, SCOPUS, CINAHL, EMBASE, Psycinfo, Web of Science) were searched for all English articles published up to and including August 2015. Studies were refined to randomized controlled trials assessing VR interventions for balance among individuals ≥6 months post stroke. Pooled mean differences (MD) ± standard error and p values were calculated for the Berg Balance Scale (BBS) and the Timed Up and Go test (TUG) using a fixed or random effects model as necessary.

Results

A total of 20 articles satisfied the inclusion criteria and evaluated Nintendo® Wii Fit balance board (n = 7), treadmill training integrated with VR (n = 7), and postural training using VR (n = 6). A fixed effects model demonstrated that, compared to controls, all VR interventions combined produced significant improvements in BBS (n = 12; MD = 2.94 ± 0.57; p < 0.001) and TUG (n = 13; MD = 2.49 ± 0.57; p < 0.001). A sub-analysis examining the individual types of VR interventions revealed that only postural VR interventions had significant effect sizes for BBS (n = 5; MD = 3.82 ± 0.79; p < 0.001) and TUG (n = 3; MD = 3.74 ± 0.97; p < 0.001). Additionally, VR combined with treadmill training produced significant improvement in TUG scores (n = 5; MD = 2.15 ± 0.89, p = 0.016).

Conclusions

VR interventions, particularly those combined with postural training, produce the greatest improvements in balance. These interventions should be considered for individuals in the chronic phase of stroke recovery.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

SYSTEMATIC REVIEW TO IDENTIFY THE BARRIERS AND ENABLERS FOR A TRIAGE, TREATMENT AND TRANSFER CLINICAL INTERVENTION TO MANAGE ACUTE STROKE PATIENTS IN THE EMERGENCY DEPARTMENT

S Middleton ¹, L Craig ¹, E McInnes ¹

Abstract

Background

Clinical guidelines recommend that the assessment and management of patients with stroke should commence early. The evaluation of the effectiveness of a multidisciplinary supported, nurse-initiated, organisational intervention to improve the triage, treatment and transfer of acute stroke patients in Emergency Departments (ED) is currently underway (T³ Trial).

Aim: To identify barriers and enablers to inform the development of an intervention focused on improving the management of triage, treatment and transfer of stroke patients.

Methods

Systematic review identified studies that reported barriers and/or enablers for the triage, treatment and/or transfer of stroke patients. Biomedical databases were searched using comprehensive search strategies. Barriers and enablers were categorised using the theoretical domains framework (TDF).

Results

Nine studies met the selection criteria. All reported barriers and enablers were classified to a TDF domain. The majority of barriers reported corresponded with the TDF domains of ‘environmental, context and resources’ (such as stressful working conditions or lack of resources), and ‘knowledge’ (such as lack of guideline awareness or familiarity). The majority of enablers corresponded with the TDF domains of ‘knowledge’ (such as education for physicians on the calculated risk of intracranial haemorrhage following thrombolysis), and ‘skills’ (such as providing opportunity to treat stroke cases of varying complexity).

Conclusions

These findings have been used to inform the development of an implementation intervention that targets these barriers. It is recommended that findings from similar future reviews are reported within the context of a theoretical framework to facilitate the comparison and synthesis of barrier and/or enabler data.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

SYSTEMATIC REVIEW OF CYSTEINE-SPARING NOTCH3 MISSENSE MUTATIONS IN PATIENTS WITH CADASIL CLINICAL SUSPICION

E Muiño ¹, C Gallego-Fábrega ¹, N Cullell ¹, C Carrera ², J Krupinski ³, J Roquer ⁴, J Montaner ², I Fernández-Cadenas ¹

Abstract

Background

The pathogenic mechanism of CADASIL (Cerebral Autosomal-Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy) is caused by mutations in the NOTCH3 gene. These mutations affect the number of cysteines in the extracellular domain of the receptor causing protein misfolding, with a crosslinking of sulfhydryl groups that produces receptor aggregation. However, the recent discovery of non-cysteine mutations in CADASIL patients has called this mechanism into question.

Methods

We performed a systematic review of articles about NOTCH3 sparing-cysteine missense mutations in patients with CADASIL clinical suspicion. Pathogenic mutations were considered if: 1) the 33 exons of the NOTCH3 gene had been analysed; 2) they were associated with neurological CADASIL symptoms and 3) they were not common polymorphisms.

Results

A total of 24 different mutations which do not affect cysteine number, from 35 index patients, were listed, describing epidemiological features, neuroimaging and genetic characteristics and if it was performed skin biopsies. Five mutations fulfill the above criteria: p.R75P, p.L1515P, p.R213K, p.V1762M, p.G149V. Patients with these five mutations had CADASIL-like symptoms, including severe leukoencephalopathy, that surprisingly did not involve the anterior temporal pole, characteristic of Caucasian CADASIL patients.

Conclusions

NOTCH3 sparing-cysteine missense mutations cause symptoms compatible with CADASIL and have a similar neuroimaging profile, but do not affect the anterior temporal lobe. This suggests that other mechanisms, distinct from receptor aggregation by crosslinking of sulfhydryl groups by cysteine mutations, could be involved in CADASIL like some authors propose.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

FUNCTIONAL OUTCOME MEASURES IN ANIMAL STROKE TRIALS

C Ostrowski ¹, L Feng ², Z Pei ², T Quinn ³

Abstract

Background

Functional outcomes are the preferred measure of a disabling condition like stroke. There is considerable heterogeneity in functional assessments used in human randomized control trials with subsequent effects on trial quality. We sought to describe the functional assessments used in animal stroke models.

Methods

Two independent researchers assessed the literature from eleven exemplar journals representing neuroscience and stroke titles. We performed a focus search in journals published between January 2005 and December 2014 which included articles investigating animal stroke models and functional outcomes (primary and secondary). We extracted details of the animal and stroke model used and the type and number of functional measures. We tabulated and presented frequencies and presented temporal trends in assessment.

Results

Across 95,984 articles in the selected journals, 22,136 had a stroke focus and of those 1,355 used animal models. In total, 445 (33%) articles presenting functional outcomes were reviewed. In total, over 67 different assessment methods were used of which over 29 conducted neurodeficit/battery scores, 32 assessed sensorimotor skills and 6 neurocognitive skills (Table1.).

graphic file with name 10.1177_2396987316642909-img31.jpg

Conclusions

Functional outcomes are not standard in animal models. Among trials that do measure against functional outcomes, there is significant heterogeneity in the assessment tools used. We would urge for greater consistency and harmonization to allow for more meaningful comparisons.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

STROKE SURVIVORS’ EXPERIENCES OF AND NEED FOR PRIMARY CARE AND COMMUNITY HEALTH SERVICES - A SYSTEMATIC REVIEW OF THEQUALITATIVE LITERATURE

D Pindus ¹, R Mullis ¹, L Lim ¹, I Wellwood ¹, V Rundell ¹, NAA Aziz ², F Walter ¹, J Mant ¹

Abstract

Background

Long-term community healthcare services for stroke survivors remain underdeveloped while patients report many unmet needs. We systematically reviewed qualitative literature on stroke survivors’ long-term needs and experiences of primary care and community healthcare services.

Methods

Four databases were systematically searched: MEDLINE, EMBASE, PsycINFO and CINAHL. We included peer reviewed qualitative studies in English which focused on community dwelling adults diagnosed with stroke. The quality was assessed using the Critical Appraisal Skills Programme (CASP) and Dixon-Woods criteria. Meta-ethnography was used to synthesise the findings by two independent reviewers.

Results

37 papers with 722 participants (565 survivors and 182 carers) were included. Studies originated from the UK (46%), North America (24%), Australia (16%), Scandinavia (13%) and Iran (2%). Stroke severity was reported in 27% of studies. Participants in the chronic post-stroke phase (at least 12 months) were represented in 62% of the studies. The review identified service-specific (structural and communication related) factors contributing to survivors’ feelings of abandonment following hospital discharge. The tension between service passivity and survivors’ need for proactive contact from services (e.g. GP-initiated follow-up, coordinated and personalised information about stroke and recovery) was identified as an overarching concept. The fragmented nature of community healthcare services made it difficult for survivors to access the help they needed.

Conclusions

The passivity of services limits survivor engagement with community healthcare services. Interventions focused on proactive contact of community health services with stroke survivors and improving communication between community health services have potential to address survivors’ feelings of abandonment after hospital discharge.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE EXPERIENCES OF AND NEED FOR PRIMARY CAREAND COMMUNITY HEALTH SERVICES IN INFORMAL CARERS OF STROKE SURVIVORS - A SYSTEMATIC QUALITATIVE REVIEW

D Pindus ¹, R Mullis ¹, L Lim ¹, I Wellwood ¹, V Rundell ¹, NAA Aziz ², F Walter ¹, J Mant ¹

Abstract

Background

This is the first systematic review of qualitative literature on the long-term needs and experiences of primary care and community healthcare services in carers of stroke survivors.

Methods

Four databases were systematically searched: MEDLINE, EMBASE, PsycINFO and CINAHL. We included peer reviewed qualitative studies in English which focused on community dwelling adults informal carers of adult stroke survivors. The quality was assessed using the Critical Appraisal Skills Programme (CASP) and Dixon-Woods criteria. Meta-ethnography was used to synthesise the findings by two independent reviewers.

Results

34 papers with 874 participants (362 survivors and 537 carers) were included. Studies originated from the UK (53%), North America (32%), Australia (12%) and Scandinavia (3%). Carers of stroke survivors who were at least 12 months after stroke were represented in 62% of the studies. A striking finding of the review was that carers talked primarily about survivors’ service needs. The key carer specific needs were: carer-focused training (e.g. what to expect and how to establish a routine, help with practical caregiving skills, information on recovery) and back-up services. Lack of service support and service providers’ assumptions that carers would just ‘get on with things’ contributed to feelings of isolation and concerns about continuing in the caregiving role.

Conclusions

There is scope to develop interventions that focus on basic caregiving knowledge and skills and ensure availability of support for the patient when the carer is under stress. Needs of carers are not addressed by community services with the result that some carers discontinue their caregiving role.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ACUTE ISCHAEMIC STROKE IN OCTOGENARIANS - IS IT WORTH TO INTERVENE?

M Reiser ¹, J Fiedler ², K Hes ³, M Nevsimalova ¹, S Ostry ¹, J Sova ³, L Sterba ³

Abstract

Background

Many trials on the acute ischaemic stroke (AIS) set upper age limit at 80 years. Incidence of stroke naturally increases with the age. Increasing the mean average age increases proportion of the octogenarians suffering from the stroke.

Aim of the study: Evaluate overall clinical outcome, predictors of the outcome after the treatment of AIS in the elderly.

Methods

From 1/2014 to 9/2015 were prospectively and consecutively enrolled all patients with AIS <4,5 h from the onset, with the age of ≥80 years.

Exclusion criteria: contraindication to the intravenous thrombolysis (IVT) or the mechanical trombectomy (MT). Subgroup analysis according to admission NIHSS, time to treatment (OTT), prestroke functional performace and the intracranial occlusion were made and compared the 3 month outcomes.

Results

There were enrolled 114 patients, 38 males (33.3 %), mean age 84,7 years (80–95); NIHSS 11.5 (0–31), median OTT 120 min (50–880). That represents 25.5 % of all patients with AIS treated in defined period.

Types of treatment: IVT alone in 86 (75.4 %); combined IVT + MT in 16 (14.0 %); other in 12 (10.5 %).

Overall 3 month outcome: symptomatic ICH 2.6 %, mRS 0–2: 22.8 %; mortality 35.1 %.

Subgroup analysis acording to admission NIHSS, OTT, prestroke performance and the large vessel intracranial occlusion in tables 1 and 2.

Conclusions

Overall good outcome exceeds 22% with very low rate of symptomatic hemorhage.

Increasing NIHSS, OTT, intracranial occlusion and prestroke disability are all negative predictors of clinical outcome.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

OCCURRENCE RATE OF DELIRIUM IN PEOPLE HOSPITALISED WITH ACUTE STROKE - SYSTEMATIC REVEIW AND META-ANALYSIS

R Shaw ¹, T Quinn ¹

Abstract

Background

Delirium impacts on mortality, length of stay and functional outcome. Published reports have assessed delirium at differing times post ictus, using various methods to define delirium. We sought to collate all available studies to estimate the occurrence (incidence and/or prevalence) of delirium in acute stroke.

Methods

We searched multiple, cross-disciplinary electronic databases (MEDLINE (OVID), EMBASE (OVID), PsycINFO (EBSCO), psycARTICLES (EBSCO), CINAL (EBSCO), Alois (Cochrane)) using a pre-specified search strategy; complemented by hand searching. We compared delirium occurrence between studies and used random effects models to describe a summary estimate. We assessed risk of bias using the Newcastle-Ottowa tool. We performed subgroup analyses looking at effect of duration of assessment period (<or>1week) and delirium diagnostic tool (Confusion Assessment Method (CAM); DSM; Other). We performed sensitivity analysis restricted to high quality studies.

Results

Of 5,743 titles, we included 20 papers (3,016 participants) in the meta-analysis. Summary estimate, occurrence of delirium, was 25.8% (95%CI:21.2%-31.1%). For sensitivity analysis 13 studies were included; 23.9% (95%CI:17.5%-31.7%). There was a trend noted in diagnosis technique and delirium occurrence (CAM 21.4% (95%CI:14.8%-30.1%) DSM 23.4% (95%CI:17.1%-32.2%), Other 37.3% (95%CI:26.2%-50%)). It was observed that testing for < or >1 week was not a significant indicator of delirium occurrence.

Conclusions

Delirium is common in the acute period post stroke. Assessment method seems to impact on detection rates. There was little difference between overall result and sensitivity analysis for both heterogeneity and delirium occurrence. This robust estimate of delirium occurrence can be used to benchmark performance, plan intervention studies and inform clinical practice.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CEREBRAL BLOOD FLOW AND WHITE MATTER HYPERINTNSITIES: SYSTEMATIC REVIEW AND META-ANALYSIS

Y Shi ¹, J Wardlaw ¹, M Thrippleton ¹, I Marshall ¹

Abstract

Background

White matter hyperintensities (WMHs) are a key neuroimaging finding in cerebral small vessel disease (SVD). Although the aetiology is incompletely understood, chronic hypoperfusion is thought to be a key mechanism. We meta-analysed all cross-sectional and longitudinal published studies with data on CBF in patients with WMHs.

Methods

We systematically reviewed the literature up to December 2015, for studies that assessed CBF in patients with SVD, performed meta-analyses of standardised mean difference (SMD) and pre-specified sensitivity analyses.

Results

38 studies (4006 participants) met the inclusion criteria, including 4 longitudinal and 34 cross-sectional studies. 23 cross-sectional studies could be meta-analysed. CBF measurement methods varied, including CT and several MRI techniques. CBF data for white matter were scarce. In longitudinal studies (range 1.5 to 7.7yrs, n = 40–575), high baseline WMH burden predated falling CBF; one small study (n = 40) found low CBF in regions that developed WMH. Meta-analysis showed CBF was lower in subjects with more WMH, globally and in most white and grey matter regions (overall SMD −0.77; 95% CI: −0.95 to −0.58 of CBF in subjects with high vs low WMH). However, these CBF differences were largely attenuated by excluding dementia studies. Sensitivity analysis of age was not possible (insuffient age-matched studies).

Conclusions

CBF is lower in subjects with more WMH, but evidence for falling CBF predating increasing WMH is limited. Future studies should be longitudinal, obtain more white matter data and distinguish between normal appearing white matter and WMH, report CBF methods clearly, use better age-matching and stratify by clinical diagnosis.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE EFFECT OF PARENTERAL FLUIDS ON SHORT & MEDIUM TERM OUTCOME IN ACUTE STROKE; A COCHRANE SYSTEMATIC REVIEW AND SURVEY OF PROFESSIONALS

A Visvanathan ¹, W Whiteley ², M Dennis ³, N Sprigg ⁴, W Sunman ⁵

Abstract

Background

The balance between benefit and harm for different parenteral fluid regimens in acute stroke is unclear.

Methods

We systematically searched for randomised trials of parenteral fluids in stroke patients to assess the effect of type, volume, duration and mode of fluid delivery on short term complications (pneumonia, pulmonary oedema, cerebral oedema), and death or dependence. In November 2015 we surveyed fluid prescription practice amongst UK stroke physicians.

Results

We included 12 studies (2351 participants: range 27–841) that compared patients randomized to colloids versus crystalloids. The odds of death or dependence were similar in participants allocated to colloids or crystalloid fluid regimens (OR 0.97, 95% CI: 0.79–1.21, 5 studies, I²= 58%) and between 0.9% saline and other fluid regimens (OR 1.04, 95% CI:0.82–1.32, 3 studies, I²= 71%). There were no trials of different fluid volumes, modes or duration of delivery.

We obtained 225 survey responses (88% junior doctors). Normal saline was prescribed most frequently (77%, 168/217). The intravenous fluid volume prescribed for the first 24 hours varied widely (16% 3.0 L, 38% 2.4 L, 18% 1.5 L, 3% 1.0 L, 26% other volumes). Fluid volume requirement was largely based on clinical judgement (105/202, 96%). Targeted fluid prescription was felt to be more feasible based on serum creatinine (128/202, 63%) rather than weight (105/202, 52%). Respondents rarely prescribed mannitol to treat cerebral oedema (65/202, 32%).

Conclusions

We found no evidence to guide the best volume, duration, or mode of parenteral fluid delivery for people with acute stroke. There is considerable variation in fluid prescribing practice.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

LOWER DOOR TO NEEDLE TIMES - IS IT THE PACE THAT KILLS?

R Advani ¹, H Ness ², M Kurz ¹

Abstract

Background

Acute ischemic stroke (AIS) treatment has been revolutionized by the advent of intravenous thrombolysis (IVT) and endovascular treatment (EVT). Both treatment modalities are dependent on the patient arriving promptly at the hospital. There is therefore great emphasis on reducing pre-hospital time consumption and also door-to-needle (DTN) time. We aimed to assess the effect on in-hospital mortality and number of IVT treatments in the pursuit of a lower DTN.

Methods

We started systematically working to improve routines around the IVT treatments in 2009. Data were analyzed from 634 patients with AIS receiving IVT treatment at our centre from 2009 up to and including 2015. Our aims were to look at trends in in hospital mortality, DTN time and numbers of patients treated year on year.

Results

The in-hospital mortality percentage decreased from 6.7% in 2009 to 3.0% in 2015 (p < 0.001).

In the same time frame, the number of IVT treatments increased from 45 to 130 (p < 0.0001), an increase of almost 290%.

The median DTN time fell from 64 minutes in 2009 to 29 minutes in 2015 (p < 0.0001).

Conclusions

Our study showed a dramatic increase in the number of IVT treatments as well as a continual decline in both in-hospital mortality and DTN time. These positive changes are due to continued efforts to inform and update both the patient population and the treatment chain on stroke treatment. The latter being perhaps more important in achieving sustained results as the effects of stroke awareness campaigns inevitably taper off.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

WHEN HEART MAKES A DIFFERENCE IN THROMBOLYSIS

E Agazzi ¹, B Censori ¹, T Partziguian ¹, MR Rottoli ¹

Abstract

Background

INTRODUCTION

Recent myocardial infarction is an exclusion criterion for thrombolysis in acute ischemic stroke in the United States of America, but not in Europe. We report a case of fatal heart rupture during intravenous thrombolysis for ischemic stroke.

Methods

CASE REPORT

A 69 year old, hypertensive, man, was admitted to our Emergency Department because of acute drowsiness, left hemiparesis, and slurred speech (NIH Stroke Scale score = 13) that had started three hours and fifty minutes before. Brain CT scan showed only an old lacunar stroke in left hemisphere. EKG showed an acute anterior myocardial infarction. The echocardiogram showed akinesia of the anterior septum and apex, with a stratified thrombus (28x10 mm). Intravenous thrombolysis was started 260 minutes after symptoms onset.

Results

RESULTS

Ten minutes after bolus and initiation of the intravenous infusion the clinical examination improved (NIH Stroke Scale score = 10), and remained stable thereafter. Forty minutes after rt-PA start arterial pressure dropped markedly, with a clinical picture of cardiac shock. Echocardiography showed a quickly growing pericardial effusion due to cardiac rupture. No cardiac surgery could be performed and the patient died.

Conclusions

CONCLUSIONS

This case clearly shows the risks of intravenous thrombolysis for stroke with recent myocardial infarction. This topic is not adequately covered in the stroke literature, and clearly needs better predictors in the acute setting of the risk-benefit ratio of thrombolysis.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

LONG TERM OUTCOME IN PATIENTS WITH ACUTE ISCHEMIC STROKE, TREATED WITH RT-PA

S Andonova ¹, E Kalevska ², D Georgieva-Hristova ²

Abstract

Background

The aim is to analyse the long term outcome in patients with acute ischemic stroke, treated with rt-PA.

Methods

The present prospective study is carried out in the period 2009–2013 and includes 5353 patients with acute ischaemic stroke hospitalised in the stroke unit at UMHAT- St. Marina. As there is no national register of acute ischemic stroke patients in Bulgaria, in order to analyze the research data, we compared our data: the period from onset of AISН to hospitalization, inhospital deaths, moratlity up to the 3rd month, neurological status at 24th hour, 7th day, at dehospitalization and on the 3rd month, assessed with the modified Rankin scale as well as NIHSS at the 24th hour and 7th day, with that of patients registered in SITS.

Results

The comparison of the treatment outcomes in patients with TL during hospitalization between our center and the other centers show that the largest percentage of patients are with favorable or very favorable outcome from the treatment – around 70%. There is no significant difference in the results between our center and the rest of the centers. Around the same percentage of patients have deteriorated - 7%, or died during hospitalization. Comparison of treatment outcomes on the 3-rd month between our clinic and SITS is shown high mortality rate in our patients 22.3% vs 16.4%.

Conclusions

Based on the analysis of the data, increased work organization efficiency is necessary in view of decreasing mortality after dehopsitalisation.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

6 MONTH FOLLOW UP MEASURES OF DISABILITY FOLLOWING THROMBOLYSIS FOR ACUTE ISCHAEMIC STROKE AT A HYPER-ACUTE STROKE UNIT

D Austin ^1,², G Quattrocchi ^1,², J Eng ², R Simister ²

Abstract

Background

UK Stroke Units routinely collect audit data showing door-to-needle time for intra-venous thrombolysis accompanied by patient disability scores at discharge. However, to date limited outcome data at 6 months have been reported. We sought to determine delayed outcome measures post thrombolysis in a cohort of stroke patients treated at a Central London HASU.

Methods

We reviewed UCLH SSNAP data from July 2014 to June 2015 and selected patients with a final diagnosis of stroke treated with thrombolysis. We matched these data with 6 month follow up data collected via telephone consultation with a trained researcher.

Results

886 patients were admitted with ischaemic stroke during the studied period, with 185 (20.9%) receiving r-tPA (average age 73.0yrs, range 25–100yrs). Follow up data was available for 155 patients. The median door-to-needle time was 35 minutes (IQR 27–50 minutes). 48 (25.9%) patients reported a good outcome at 6 months (mRS 0–2). For patients with a pre-stroke estimated good function (n = 133) 36.1% reported a good outcome at follow up. 7 patients (3.8%) died during hospital admission whilst 23.4% have died by 6 months. Ten (5.4%) patients had secondary intracranial haemorrhage post-thrombolysis of whom 5 died during the admission. Further analysis of outcome data according to ASPECTS score on admission CT is ongoing.

Conclusions

Limited “real world” outcome data exist for UK stroke services providing thrombolysis. We propose that these data, together with in-hospital mortality should routinely be presented with door-to-needle times to allow better assessment of thrombolysis services.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PROGNOSTIC VALUE OF TRANSCRANIAL DOPPLER IN THROMBOLYSED MIDDLE CEREBRAL ARTERY ISCHEMIC STROKE: THE PROGNOSIS AFTER REVASCULARIZATION THERAPY IN THE DIJON ISCHEMIC STROKE EVALUATION (PARADISE) STUDY

S Richelet ¹, B Daubail ¹, N Legris ¹, A Daumas ¹, B Terriat ², E Steinmetz ³, M Giroud ¹, Y Béjot ¹

Abstract

Background

We aimed to evaluate whether transcranial doppler (TCD) could help to predict functional outcome of patients with thrombolysed middle cerebral artery (MCA) ischemic stroke, when applied in clinical practice.

Methods

Patients with MCA ischemic stroke who received intravenous thrombolysis at the University Hospital of Dijon, France, were identified from the PARADISE study. Stroke severity was evaluated at onset and at 24 hours using the NIHSS score. Results of TCD performed in routine within the first three days following stroke onset were retrospectively analysed by an investigator blinded of patients’ outcome, and were classified as normal flow, partial occlusion, or complete occlusion. Associations between TCD findings and functional outcome at three months (mRS score) were analysed using ordinal logistic regression models.

Results

169 patients were included (mean age 62.1 ± 17.5, 54.5% men, mean NIHSS score 11.9 ± 5.8). In univariate analyses, partial (OR = 1.92, p = 0.033) and complete (OR = 5.99, p < 0.001) occlusion on TCD were both associated with an increased risk of poor outcome. After adjustment for age, sex, confounding vascular risk factors, and NIHSS score at admission, the association was still observed for complete (OR = 6.56, p < 0.001) but not for partial (OR = 1.68, p = 0.12) occlusion. Similar results were noted when adjusting for NIHSS score at 24 hours (OR = 4.56, p = 0.003 for complete occlusion, and OR = 1.45, p = 0.27 for partial occlusion).

Conclusions

TCD routinely performed in clinical practice may help to predict functional outcomes of patients with thrombolysed MCA ischemic stroke, independently on both severity at onset, and clinical recovery at 24 hours.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

DOES ANTIPLATELET THERAPY DURING BRIDGING THROMBOLYSIS INCREASE RATES OF INTRACEREBRAL HEMORRHAGE IN STROKE PATIENTS?

A Broeg ¹, P Mordasini ², A Slezak ¹, K Liesirova ¹, J Meisterernst ¹, G Schroth ², M Arnold ¹, S Jung ¹, H Mattle ¹, J Gralla ², U Fischer ¹

Abstract

Background

Symptomatic intracerebral hemorrhage (sICH) after bridging thrombolysis for acute ischemic stroke is a devastating complication. We aimed to assess whether the additional administration of aspirin during endovascular intervention increases bleeding rates.

Methods

We retrospectively compared bleeding complications and outcome in stroke patients who received bridging thrombolysis with (tPA + ASA) and without (tPA-ASA) aspirin during endovascular intervention between November 2008 and March 2014. Furthermore, we analyzed bleeding complications and outcome in antiplatelet naïve patients with those with prior or acute antiplatelet therapy.

Results

Baseline characteristics, previous medication, and dosage of rtPA did not differ between 50 tPA + ASA (39 aspirin naïve, 11 preloaded) and 181 tPA-ASA patients (p > 0.05). tPA + ASA patients had more often internal carotid artery (ICA) occlusion(p < 0.001), large artery disease (p < 0.001) and received more often acute stenting of the ICA (p < 0.001). 10/180 (5.6%) tPA-ASA patients and 3/49 (6.1%) tPA + ASA patients suffered a sICH (p = 1.0). Rates of asymptomatic intracerebral hemorrhage, systemic bleeding complications and outcome did not differ between both groups (p > 0.1). There were no differences in bleeding complications and mortality among 112 bridging patients with antiplatelet therapy (62 preloaded, 39 acute administration, 11 both) and 117 antiplatelet naïve patients. In a logistic regression analysis, aspirin administration during endovascular procedure was not a predictor of sICH.

Conclusions

Antiplatelet therapy before or during bridging thrombolysis in patients with acute ischemic stroke did not increase the risk of bleeding complications and had no impact on outcome. This finding has to be confirmed in larger studies.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

A GENOME WIDE ASSOCIATION STUDY REVEALS TWO LOCI ASSOCIATED WITH HEMORRHAGIC TRANSFORMATION AFTER T-PA RELATED WITH BLOOD BARRIER HOMEOSTASIS

C Carrera Vasconez ¹, J Jimenez-Conde- ², J Roquer ², J Martí-Fàbregas ³, V Obach ⁴, M Freijo ⁵, T Segura ⁶, G Serrano-Heras ⁷, J Arenillas ⁸, C Vives-Bauza ⁹, R Díaz-Navarro ¹⁰, M Castellanos ¹¹, JM Lee ¹², C Cruchaga ¹³, L Heitsch ¹⁴, D Strbian ¹⁵, T Tatlisumak ¹⁵, J Krupinski ¹⁶, J Montaner ¹, I Fernández-Cadenas ^1,¹⁷

Abstract

Background

Hemorrhagic transformation (HT) is a common stroke complication after t-PA treatment and appears to be genetically modulated. The studies performed have been based on candidate-gene strategy. We aimed to perform a genome-wide association study (GWAs) in stroke patients to find genetic risk factors associated with HT after t-PA.

Methods

We analyzed 1295 t-PA treated strokes from an international cohort of patients with Omniquad 1M, Omniquad 5M, Human Core Exome (Illumina) and Axiom Biobank (Affymetrix). Quality controls, 1000G imputation, association analysis and metanalysis were performed through PLINK, R, IMPUTE2, SNPTEST and METAL software following previous recommendations. The analysis was performed using sex, age, cardioembolic etiology and principal components as covariates. Furthermore, a previous clinical-genetics score including blood pressure, atrial fibrillation, onset to treatment time, baseline NIHSS and two polymorphisms in FXII and A2M genes was analyzed in a subgroup of patients.

Results

HT was present in 309 participants, and 4300000 genotyped/imputed polymorphisms were analyzed. Two loci with a genome wide significant association (P < 10E-08) were found associated with global HT and HT subtypes. The results were consistent among the five different cohorts. One genes was previously associated with oxidative stress and blood-brain-barrier homeostasis. Clinical-genetics score predicted the occurrence of HT (p-value < 0.05) after t-PA.

Conclusions

A GWAs in t-PA treated patients has revealed two potential new genes associated with HT. Replication and functional analysis will be needed to confirm these results. The combination of clinical and genetics data could be useful to detect the patients with high risk of suffering a HT.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE SIZE OF ISCHEMIC LESIONS ON MRI IS MORE CRITICAL TO DETERMINE OUTCOMES AFTER THROMBOLYSIS THAN KIDNEY FUNCTION IN ACUTE STROKE WITH DECREASED RENAL FUNCTION

JK Cha ¹

Abstract

Background

It has been reported that a decreased renal function might be a critical factor for poor outcomes or symptomatic intracerebral hemorrhage (SICH) after using IV t-Pa in acute ischemic stroke (AIS). In this study, we investigated the outcome of using IV t-PA based on MRI in AIS patients with a decreased renal function.

Methods

We studied 3809 AIS patients using IV t-PA between 2010 and 2015. Among them, we selected only those patients checked MRI before thrombolysis. The size of ischemic lesions was calculated by usingdiffusion-weighted imaging (DWI) on MRI. Renal dysfunction was defined as estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m² on admission. Primary outcome measures were poor functional 3-month outcome, defined as mRS scores 3 to 6 and SICH after using it.

Results

During observation period, we finally enrolled 407 patients using IV t-PA under MRI screening. Among them, 82 patients (20.1%) had a decreased renal function (eGFR < 60).At 3 month, the proportion of poor outcome (mRS 3–6) was much higher in patients with a decreased renal function than those without it. After multivariate adjustment for established outcome predictors, a decreased renal function itself was not an independent predictor but larger size of ischemic lesions on DWI (>22.2 CC; OR, 2.27; 95% CI, 1.29–5.40; p = 0.03) before thrombolysis showed independent significant significance for an occurrence of poor outcomes after using IV t-PA.

Conclusions

IThe present study suggests that patients with eGFR <60 presenting with AIS have no any obstacle to use IV t-PA if we consider the size of ischemic lesions before thrombolysis.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

DEGREE OF EARLY RECANALIZATION AFTER INTRAVENOUS THROMBOLYSIS PREDICTS FAVORABLE OUTCOME IN THE MAJOR VESSEL OCCLUSIVE STROKE

JY Chang ¹, SY Jang ², JY Ahn ³, MK Han ⁴

Abstract

Background

Reperfusion injury after recanalization following intravenous thrombolysis (IVT) is associated with poor outcome. We investigated the association between early recanalization degree after IVT, occurrence of hemorrhagic transformation, and functional outcome. We have also evaluated whether rtPA dosing error could have an impact on the outcome.

Methods

256 patients with major vessel occlusive stroke who underwent IVT were included. Actual rtPA dosage (mg/kg) was calculated as dividing total rTPA dosage administrated by actual body weight measured with in bed scale on admission. Recanalization status was confirmed by subsequent MRA or conventional angiography. Association between early recanalization degree and favorable outcome was evaluated using logistic regression analysis.

Results

Partial recanalization was achieved in 33 (12.9%), and complete recanalization in 7 (2.7%) patients. Hemorrhagic transformation tended to occur more frequently in patients with complete recanalization compared with patients with PR (57.1% vs 21.2%, P = 0.15). Patients with the highest quintile of rtPA dosage achieved complete recanalization more frequently than the lower 4 quintile (8.0% vs 2.0%, P = 0.03). The proportion of favorable MRS at 3 month was significantly lower in patients with the highest quintile of rtPA dosage used compared with patients with the lower 4 quintiles (40.8%, 57.0%, P = 0.04). In multivariable analysis, PR was significantly associated with favorable outcome (adjusted OR, 3.15; 95% CI, 1.06–9.35) but CR was not.

Conclusions

Early Partial recanalization after IVT could be and indicator of favorable outcome with low occurrence of any hemorrhagic transformation. Higher dosage of rtPA might be associated with early complete recanalization and poor outcome independent of hemorrhagic transformation.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

DURABILITY OVER TIME OF STRATEGIES TO REDUCE DOOR-TO-NEEDLE TIMES IN THROMBOLYSIS OF ACUTE ISCHAEMIC STROKE

A Moussaddy ¹, BY Chen ², M Keezer ¹, Y Deschaintre ³, AY Poppe ³

Abstract

Background

More timely administration of tissue plasminogen activator (tPA) for patients with acute ischaemic stroke yields greater clinical benefits. We implemented door-to-needle (DTN) time reduction strategies at our centre and evaluated their short- and long-term effects on in-hospital treatment delays and clinical outcomes.

Methods

Strategies including stroke team pre-notification, direct computed tomography (CT) transfer, not routinely waiting for labs and tPA delivery on CT table were implemented in June 2013. We included all thrombolysed patients admitted directly to our hospital between January 2012 and March 2015. In-hospital delays and clinical outcomes (Modified Rankin scale, mRS) at 3 months were compared between patients pre- and post-modification, and the latter period was divided into early (first 6 months) and late (beyond 6 months) phases to assess the durability of our modifications.

Results

Forty-eight individuals were treated pre-modification, compared to 58 post-modification. The median DTN time was reduced from 75 (interquartile range: 60–93) minutes to 46 (33–59) minutes (p < 0.0001). The median DTN time in the early and late post-modification phases was not different (41 versus 46 minutes, p = 0.4085). Functional outcome at 3 months was not different in the two groups (proportion of mRS ≤ 1: 34% versus 28%, p = 0.882).

Conclusions

We were able to decrease our DTN time for treatment of acute stroke by implementing relatively simple modifications and these improvements persisted over time.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

HIGH MORTALITY OF PATIENTS WITH ACUTE BASILAR ARTERY OCCLUSION IN BRAZIL

F Antunes Dias ¹, F Fernandes Alessio-alves ¹, P Telles Cougo-pinto ¹, C Monteiro Antunes Barreira ¹, L Henrique Castro-afonso ¹, M Rodrigues Camilo ¹, G Seizem Nakiri ¹, D Giansante Abud ¹, O Marques Pontes-neto ¹

Abstract

Background

Acute basilar artery occlusion (BAO) usually leads to severe disability and mortality. Intravenous thrombolysis (IVT) and endovascular therapy (EVT) in proximal occlusions of the anterior circulation were proven safe and effective. However, the most appropriate recanalization strategy in BAO is still controversial.

Methods

Objective

To assess the impact of recanalization strategies on outcomes of patients with BAO at an academic hospital in Brazil.

Methods

Retrospective analysis of patients with BAO from a prospective stroke cohort at Ribeirão Preto Medical School. Primary outcomes were mortality and a favorable outcome (mRS ≤ 3) at 90 days. After univariate analyses, we used multivariate logistic regression to identify the independent predictors of mortality and favorable outcome.

Results

Between August/2004 and December/2015, 63 patients (65% male) were diagnosed with BAO. The median NIHSS was 30 [IQR:18–36], and median onset-to-arrival time was 4.6 hours [IQR:2.6–8.2]. Twenty-nine patients received no recanalization therapy, 15 received IVT and 19 received EVT (68% treated with stent retriever). Twenty-four (83%) patients treated conservatively died and only 2 of those patients (7%) achieved a mRS ≤ 3. Among those treated patients, 15 (44%) died and 9 (26.5%) had favorable outcome. On multivariate analysis, after adjusting for the baseline NIHSS, achieving recanalization (OR:0.23;CI:0.07–0.80;p:0.021) was the only independent predictor of mortality. There was no significant difference between IVT and EVT groups in terms of functional outcomes and mortality.

Conclusions

BAO is a catastrophic event with high morbidity and mortality in Brazil. Access to current recanalization therapies including IVT and EVT may decrease mortality of those patients.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CLINICAL FRAILTY IS INDEPENDENTLY ASSOCIATED WITH LONGER HOSPITAL ADMISSIONS BUT NOT SHORT-TERM MORTALITY AFTER STROKE THROMBOLYSIS

N Evans ¹, J Wall ², S Wallis ², R Romero-Ortuno ^2,³, E Warburton ¹

Abstract

Background

Clinical frailty is characterised by loss of physiological reserves and increased mortality. Our pilot study demonstrates frailty’s effect upon outcomes following thrombolysis for ischaemic stroke.

Methods

Individuals 75 years and over thrombolysed at Addenbrooke’s Hospital were retrospectively dichotomised into two cohorts using the premorbid Clinical Frailty Scale (CFS): ‘non-frail’ (CFS 1–4) and ‘frail’ (CFS 5–8). Continuous data was analysed using Mann-Whitney U-tests and categorical data using Z-tests of two proportions. Multivariate analysis included variables significant on bivariate analysis.

Results

38 individuals were included: 24 non-frail, 14 frail. Frail patients were older; mean age 87.5 (SD 6) versus 82.7 (SD 6), p = 0.02. Median modified Rankin scale (mRS) scores were the same for frail and non-frail cohorts: 2 (IQR 1.75) and 2 (IQR 1) respectively (p = 0.13). Median baseline NIHSS did not differ; non-frail: 12.5 (IQR 10.3), frail: 13.5 (IQR 7.75) (p = 0.58). Cohorts did not differ in prevalence of hypertension, diabetes, ischaemic heart disease, atrial fibrillation (all p > 0.05).

Frail patients had longer median LOS (19.9 days, IQR 34.2) than non-frail (6.45 days, IQR 10.8) (p = 0.02) despite no difference in median 24-hour NIHSS (non-frail: 7 (IQR 13.5), frail: 10 (IQR 16), p = 0.62).

After multivariate adjustment for age and frailty, only frailty remained significantly associated with LOS (p = 0.049) whilst age was non-significant (p = 0.88).

28-day mortality did not differ; non-frail: 12.5%, frail: 7.1% (p = 0.6).

Conclusions

Clinical frailty is an important independent risk factor for longer LOS following thrombolysis, independent of conventional cardiovascular risk factors, premorbid mRS, or residual disability. Importantly, there was no difference in short-term mortality between cohorts.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PRESTROKE ANTIPLATELET EFFECT ON SYMPTOMATIC INTRACRANIAL HEMORRHAGE AND FUNCTIONAL OUTCOME IN PATIENTS TREATED WITH INTRAVENOUS THROMBOLYSIS

KS Hong ¹, JC Choi ², JS Lee ³, JT Kim ⁴, JK Cha ⁵, JM Park ⁶, SJ Lee ⁷, BC Lee ⁸, J Kang ⁹, MU Jang ¹⁰, TH Park ¹¹, DE Kim ¹², WJ Kim ¹³, KB Lee ¹⁴, DI Shin ¹⁵, SI Sohn ¹⁶, J Lee ¹⁷, YJ Cho ¹, BJ Kim ¹⁸, HJ Bae ¹⁸

Abstract

Background

About 30–40% of stroke patients are taking antiplatelet at the time of their strokes, which might increase the risk of symptomatic intracranial hemorrhage (SICH) with IV-TPA (intravenous tissue plasminogen activator) therapy. We aimed to assess the effect of prestroke antiplatelet on the SICH risk and functional outcome in Koreans treated with IV-TPA.

Methods

From a prospective stroke registry, we identified patients treated with IV-TPA between Oct 2009 and Nov 2014. Prestroke antiplatelet use was defined as taking antiplatelet within 7 days before the stroke onset. The primary outcome was SICH. Secondary outcomes were discharge mRS score and in-hospital mortality.

Results

Of 1715 patients treated with IV-TPA, 441 (25.7%) were on prestroke antiplatelet. Prestroke antiplatelet users versus non-users were more likely to be older, to have prestroke disability, hypertension, diabetes, dyslipidemia, atrial fibrillation, prior stroke, and coronary heart disease, to take statins, and to have lower levels of blood pressure, total and LDL cholesterol, and hemoglobin. Prestroke antiplatelet use was associated with an increased risk of SICH (5.9% vs 3.0%; adjusted OR 1.74 [1.02–2.95]). However, at discharge, the two groups did not differ in mRS distribution (adjusted OR 0.90 [0.72–1.14]), mRS 0–1 outcome (34.2% vs 33.7%; adjusted OR 1.27 [0.94–1.14]), mRS 0–2 outcome (52.4% vs 52.9%; adjusted OR 1.21 [0.90–1.63]), and in-hospital mortality (6.1% vs 4.2%; adjusted OR 1.12 [0.67–1.89]).

Conclusions

In patients treated with IV-TPA, prestroke antiplatelet users versus non-users had a higher risk of SICH, but had comparable functional outcomes and in-hospital mortality.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EXTENSION OF THERAPEUTIC TIME WINDOW OF TISSUE PLASMINOGEN ACTIVATOR WITH SP-8203 COMBINATION THERAPY IN RAT EMBOLIC STROKE MODELS

C Ju ¹, A Anthony Jalin ¹, HY Song ¹, WK Kim ¹, JM Ryu ², GS Cho ², BS Kim ², EB Lee ³

Abstract

Background

Delayed treatment of tPA damages brain tissues similar to ischemic cascades by enhancing excitotoxicity, oxidative stress and inflammation. Thus, brain injury by both ischemia and delayed tPA treatment could be simultaneously reduced by the combined use of a multi-target directed neuroprotectant, SP-8203.

Methods

Rats were subjected to a clot-based embolic stroke and delayed tPA treatment (10 mg/kg, i.v. infusion at 4.5 or 6-h after the onset of embolic stroke). SP-8203 (3 mg/kg) was intravenously administered prior to or simultaneously with tPA treatment. Acute brain damages, hemorrhagic conversion, and mortality were assessed at 24-h after stroke. Long-term efficacy of combined therapy was examined over 30-days. Inflammatory biomarkers and matrix metalloprotease activities were examined in the brain and plasma.

Results

In contrast to effective 3-h reperfusion with tPA, 6-h tPA treatment did not decrease infarction but instead worsened hemorrhagic conversion and mortality of embolic stroke. Pre-treatment of SP-8203 prior to tPA infusion alleviated the aggravation of infarct volume, edema and neurobehavioral deficit caused by delayed tPA treatment. Moreover, SP-8203 significantly reduced cerebral hemorrhage and mortality. Co-treatment of tPA and SP-8203 at 4.5-h post-ischemia increased survival rates and reduced brain atrophy over 30-days. In situ zymography study revealed that SP-8203 largely decreased MMPs activities being well-correlated with reduced cerebro-hemorrhage and mortality.

Conclusions

The combined treatment with SP-8203 would be a clinical therapeutic strategy to overcome the limitation of tPA therapy, reducing ischemic injury and maximizing clinical outcome. A currently undergoing Phase 2a proof-of-concept study evaluates the safety and exploratory efficacy of SP-8203 in tPA-treated stroke patients.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PREDICTION OF STROKE PROGNOSIS AFTER INTRAVENOUS THROMBOLYSIS USING DRAGON SCORE IN BULGARIAN ELDERLY POPULATION

E Kalevska ¹, S Andonova-Atanasova ¹, D Georgieva-Hristova ¹

Abstract

Background

At present intravenous thrombolysis with alteplase is the only approved therapy for acute ischaemic stroke. Despite its proven efficacy less than 50% of i.v. alteplase-treated patients have a favorable outcom at the 3-rd month. Using assessment scales for the effect of thrombolysis is essential in acute settings for the long-term outcomes and identification of nonresponders of alteplase. Our aim is to evaluate the clinical benefit of DRAGON score in the Bulgarian stroke population

Methods

In our research are included 139 acute stroke patients treated with intravenous thrombolysis between 09.2011–09.2015 in University Hospital “St. Marina” in Varna- Bulgaria. At admission all patients were physical and neurological examinated using the National Institutes of Health Stroke Scale along with non-contrast CT scans. We made calculations of the DRAGON score, and for the clinical outcome at the 3-rd month we used the modified Rankin Scale (mRS).We assessed the score performance with area under the receiver operating characteristic curve (AUC-ROC).

Results

Proportions of patients with good outcome (mRS score 0–2) were 100%, 91,7%, 91,7%, 72%, 41,2%, 38,5%, 23,1%, 0%, 0% for 1,2,3,4,5,6,7,8,9 points DRAGON, respectively. Proportions of patients with miserable outcome (mRs 5–6) were 0%, 8,3%, 8,3%, 28%, 58,8%, 61,5%, 76,9%, 100%, 100 % for 1,2,3,4,5,6,7 8, 9 points DRAGON, respectively. AUC-ROC was 0.793 (CI = 0.71–0.86, p ≤ 0.05)

Conclusions

In our research the DRAGON score showed good prognostic performance for the functional outcome after treatment with tissue-type plasminogen activator.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CLOT LENGTH AND OUTCOME OF INTRAVENOUS THROMBOLYSIS IN CARDIOEMBOLIC STROKES

D Khurana ¹, S Kamath ¹, C Ahuja ²

Abstract

Background

Clot length may predict outcome after IV thrombolysis (IVT) in Acute ischemic stroke (AIS).Difference in lysable clot lengths in cardioembolic and non-cardioembolic strokes have not been determined.

Objective:To determine clot length cut off for successful recanalisation in anterior circulation stroke in cardioembolic strokes.

Methods

Prospective observational hospital based single blind study carried out between January 2014 and December 2015. AIS patients with complete occlusion of anterior circulation arteries (Internal carotid artery(ICA), tandem ICA + middle cerebral artery (MCA), isolated M1 or M1 + M2 segments of MCA)treated with IV rTPA or IVT followed by Endovascular therapy(bridging)were included.NCCT and CT Angiography was done on admission and follow-up (24 hours ± 4hours) after thrombolysis.Clot length was calculated using the MIP(Maximum Intensity Projectiion) reconstruction (2-mm section width).Patients were categorized into cardioembolic (group A) and non-cardioembolic (group B) strokes.90 day follow up for clinical outcome using mRS was done.

Results

20 patients(Group A-12 and Group B-8)were recruited out of 70 patients thrombolysed or bridged.11 patients(55.0%) (group A = 7, group B = 4) received only IV rTPA while rest were bridged.6 patients(group A = 3, group B = 3)had successful recanalisation with IVT alone (TICI score:2b and 3) (30.0%).In IVT alone patients, mean clot length was 13.36(±5.99) mm (p value = 0.048).Among recanalized patients, clot Length in group A was 15.88 mm (±7.69) and in Group B was 10.9 mm (±1.6) mm (p = 0.025). ROC analysis of clot length recanalizing with IVT alone showed a length of 13.6 mm(sensitivity = 83.3%,specificity = 71.4%)

Conclusions

No significant difference was observed in lysable clot lengths with r-tPA in the 2 groups. However, trend towards longer clots lysable by r-tPA was seen in cardioembolic strokes.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

DOES THE PROPORTION OF SINGLE-CHAIN RTPA INFLUENCE THE RISK OF EPILEPTIC SEIZURES IN PATIENTS TREATED BY THROMBOLYTIC THERAPY FOR CEREBRAL ISCHAEMIA?

C Jacquet ¹, D Leys ², I Sibon ³, JL Mas ⁴, T Moulin ⁵, M Giroud ⁶, R Bordet ², D Vivien ⁷

Abstract

Background

Patients treated with intravenous (i.v.) recombinant tissue-plasminogen activator (rtPA) for cerebral ischemia may develop more seizures than patients who are not. RtPA is given under 2 forms with different proportions in different blisters: single-chain (sc) rtPA and two-chain (tc). Both are thrombolytic, but only sc-rtPA is neurotoxic. If the pro-epileptic effect of rtPA is an expression of the neurotoxicity of rtPA, patients treated with a higher proportion of sc-rtPA should develop more seizures. Our objective was to evaluate the influence of the sc/(sc + tc) ratio on the occurrence of seizures in patients treated with i.v. rtPA for cerebral ischemia.

Methods

We prospectively included consecutive patients treated with i.v. rtPA in 13 French centers, and determined the sc/(sc + tc) ratio in the treatment administered for each patient. We studied the association between sc/(sc + tc) ratios and the occurrence of epileptic seizures, at day-7 and at month-3. OPHELIE was registered under ClinicalTrials.gov Identifier n° NCT01614080.

Results

Of 1004 patients, 18 patients (1.8%) developed seizures within 7 days, and 46 (4.6%) within 3 months. The sc/(sc + tc) ratio did not significantly differ between patients with and without seizures, but patients with seizures within 7 days were more likely to have a sc/(sc + tc) ratio > 80.5 (90^th percentile) (OR: 3.61; 95%CI: 1.26–10.34).

Conclusions

Our study provides a signal that the neurotoxicity of rtPA plays a role in the risk of seizures after thrombolysis for cerebral ischemia, but this effect is small, present only during the first days in patients with a sc/(sc + tc) ratio of more than 80.5%.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

DEVELOPMENT OF THROMBOLYSIS-RATES AND PATIENT-CHARACTERISTICS OF tPA-TREATED PATIENTS OVER 12 YEARS IN THE AUSTRIAN STROKE UNIT REGISTRY

M Marko ¹, V Lang ², L Seyfang ³, J Ferrari ², W Lang ², P Sommer ¹, S Greisenegger ¹

Abstract

Background

Intravenous tissue plasminogen activator (tPA) is an established treatment for acute ischemic stroke (AIS) for over ten years. We sought to determine changes in thrombolysis-rates as well as changes in patient characteristics of tPA-treated patients over the last 12 years in a large cohort of consecutive patients with AIS.

Methods

We analysed data of tPA-treated patients from 2003 to 2015 in the Austrian Stroke Unit Registry (ASUR) and compared them to the demographic development of the entire patient group (i.e. tPA-treated and not-treated patients). In addition, a subgroup of selected patients (age <80years, NIHSS at admission >3, ODT < =3.5 h) was analysed separately.

Results

Overall, 80 700 patients with AIS were enrolled in ASUR from 2003 to 2015. Of those, 12 548 (15,5%) were treated with tPA. Rates of tPA-treatment increased substantially (2003: 5.0%, 2008: 13.3%, 2015: 19.7%). In the subgroup of selected patients rates increased from 24.8% to 65.8%. Proportions of patients >80 years receiving iv-tPA increased from 6.5% to 29% and proportions of patients with minor stroke increased from 3.2% to 26.5%. Proportions of patients treated within 3–4.5hours of symptom-onset increased significantly (2003–2008: 7.4%, 2009–2015:14.2%, p < 0.001). We also detected a small improvement of door-to-needle-times (2005–2008: median 50 minutes, 2009–2015: 45 minutes, p < 0.001).

Conclusions

In Austria, rates of tPA-treatment for AIS increased fourfold over the last 12 years. In 2015 almost a third of tPA-treated patients was aged >80 years and over 25% had minor symptoms at presentation.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THE STROKE CHRONOMETER - A NEW STRATEGY TO REDUCE DOOR-TO-NEEDLE TIME

JP Marto ¹, C Borbinha ¹, S Calado ^1,², M Viana-Baptista ^1,²

Abstract

Background

In acute stroke treatment the functional outcome inversely correlates with the time between stroke onset and treatment initiation. Many strategies have been considered to reduce door-to-needle time (DNT) in acute stroke. We present a new strategy to reduce DNT.

Methods

Objective

To evaluate the impact of implementing a countdown timer in the acute stroke emergency room, alongside with an informative poster with the goal time limit, on door-to-computed tomography time (DCTT) and DNT.

Methods

Implementation of a protocol in which is activated a countdown timer when an acute stroke patient is admitted. DCTT and DNT in patients submitted to thrombolysis were compared, before and after the implementation of the chronometer, respectively, first and second semester of 2015. Only patients with stroke code activation by emergency medical services or at hospital admission were included. Data were analyzed with multiple linear regression adjusted to age, sex, NIHSS at admission, time from stroke onset to admission, and anterior circulation.

Results

76 patients were submitted to intravenous thrombolysis treatment, 71 respecting inclusion criteria. The results in the first and second semester were the following, respectively: 31 and 40 patients treated; mean age 74 (SD-11) and 72 (SD-12) years; 12 (38.7%) and 21 (52.5%) males; mean DCCT 27 (SD-12) and 18 (SD-8) minutes (p = 0.004; CI 95%: 2.56–12.45); mean DNT 53 (SD-26) and 39 (SD-14) minutes (p = 0.016; CI95%: 2.49–23.18).

Conclusions

Implementing a countdown timer in the acute stroke emergency room may be an effective strategy on the reduction of door-to-computed tomography time and door-to-needle time.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

TARGET STROKE IMPLEMENTATION: BEST PRACTICE STRATEGIES REDUCE DOOR TO NEEDLE TIME IN A SINGLE 1,550 BED ACADEMIC URBAN COUNTY HOSPITAL

E Marulanda-Londoño ¹, N Bhatt ¹, N Asdaghi ¹, A Malik ¹, N Akram ², K Atchaneeyasakul ¹, D D'amour ², K Hesse ², R Sacco ¹, J Romano ¹

Abstract

Background

The therapeutic window for acute ischemic stroke (AIS) with IV rtPA is brief and crucial. The AHA/ASA Target: Stroke Best Practice Strategies (TSBPS) aim to help hospitals improve thrombolysis door-to-needle (DTN) time. We assessed effectiveness of TSBPS to reduce DTN time in a tertiary care hospital.

Methods

We initiated a quality improvement program across one regional academic medical center (1,550 beds, 900 stroke admissions/year) that serves a multi-ethnic population by establishing a multidisciplinary DTN committee to assess causes of delayed DTN and implement focused TSBPS. Strategies included stroke team pre-notification, direct transfer to CT, storing/administering IV rtPA in CT, and same-day electronic feedback to stakeholders. DTN time was compared in consecutive rtPA treated patients 27 months pre-TSBPS implementation to 7 months-post-implementation.

Results

147 patients received IV rtPA in the pre-implementation period and 73 patients in the post-implementation period. In pre-implementation period 43.9% were female, median age 64 (28–99), median NIHSS 11 (1–31). In post-implementation period 47.3% were female, median age 67.5 (24–92), median NIHSS 12 (2–33). Median (IQR) DTN time was reduced from 60 (35–189) to 35 minutes (14–134) (p < 0.001). Volume of IV rtPA cases increased from 5.4/month to 10.4/month after implementation.

graphic file with name 10.1177_2396987316642909-fig151.jpg

Conclusions

DTN time can be reduced with implementation of a simple, low-cost method over a short time period. Individualized hospital gap analysis identifies specific and targeted interventions to shorten DTN time.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

STROKE THROMBOLYSIS IN THE VERY, VERY OLD (≥95 YEARS)

CW Masinter ¹, GJ Hubert ¹, R Backhaus ², N Hubert ¹, RL Haberl ¹

Abstract

Background

Intravenous thrombolysis (IVT) is beneficial in reducing disability in selected acute ischemic stroke patients. Although age >80 y is a contraindication to IVT, administration is considered safe in this age group. Safety in patients of very high age is yet unknown.

Our aim was to analyze safety of thrombolysis in patients aged 95 y and older at time of stroke occurrence.

Methods

The TeleStroke Unit network TEMPiS has set up a thrombolysis registry that includes all consecutive patients receiving IVT in 19 participating hospitals. Data from 01/2010 to 11/2015 (n = 4008) were searched for patients aged 95 y and older at time of IVT. Outcome parameters were intracranial hemorrhage, other IVT-related complications, in-hospital mortality and initiation of palliative care as well as modified Rankin scale (mRS) of surviving patients.

Results

39 patients aged 95–105 y received IVT (seven aged ≥100 y). Of these, 77% were female (n = 30). Median NIHSS was 16. Intracranial hemorrhage was seen in 4 patients (10%), non-intracranial hemorrhages in 3 patients (8%). Other non-bleeding complications associated to IVT were not observed. In total, 20 patients (51.3%) died or were put on palliative care during hospitalization. In the remaining patients median discharge mRS was 4.

Conclusions

Rate of IVT related complications in patients aged ≥95 y was comparable to previously published data on other age groups. Therefore we could not find any evidence that administration of IVT as off-label use may not be safe in these patients. As expected, mortality is high in this age group, but not related to IVT.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

HEALTH INSURANCE STATUS AND PRESENTATION FOR STROKE THROMBOLYSIS

A McDonough ¹, L Chapman ¹, J Harbison ¹

Abstract

Background

Studies have shown a socioeconomic effect on patient outcome following stroke. The cause of this may relate to comorbid disease or ability to access appropriate care. In Ireland, although hospital care is free, subjects frequently hold supplementary health insurance. Other subjects are eligible for means tested, subsidised primary care (General Medical Scheme (GMS)). Acute stroke admissions are managed by emergency protocols with admitting clinicians unaware of insurance status. We performed a study to determine whether, despite this universal protocol, there was a difference in the insurance status of subjects thrombolysed for ischaemic stroke.

Methods

We identified records of patients who had been thrombolysed for ischaemic stroke over a 3 year period from the hospital stroke register. These were compared with age and gender matched historical controls from the same time period in a 1:2 ratio. Whether or not a patient had medical insurance or GMS cover scheme was recorded.

Results

114 thrombolysed patients were compared with 228 controls (52% female, 48% male. Median age 74 years, range 33–96 years). 29 patients (25.4%) in the thrombolysed group had medical insurance, compared with 44 in the control group (19.3%) (p = 0.23 Chi Square). 77 patients (67.5%) in the thrombolysed group were GMS, compared with 168 (73.6%) of the control group (p = 0.20 Chi Square). There was no significant difference between mortality or length of stay between groups.

Conclusions

Our results show a small but not statistically significant trend toward higher thrombolysis rates in patients who hold medical insurance, and lower rates in those with GMS cover.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

OUTCOME OF ACUTE ISCHAEMIC STROKE THROMBOLYSIS IN IRELAND - FINDINGS OF THE NATIONAL STROKE AUDIT 2015

P McElwaine ¹, J McCormack ², C Brennan ³, H Coetzee ⁴, P Cotter ⁵, R Doyle ⁶, A Hickey ⁷, F Horgan ⁸, P Kelly ⁹, C Loughnane ¹⁰, C Macey ¹¹, P Marsden ¹², R Mulcahy ¹³, D McCabe ¹⁴, I Noone ¹⁵, E Shelley ¹⁶, D Williams ¹⁷, T Stapleton ¹⁸, J Harbison ¹

Abstract

Background

In the setting of a national audit of acute stroke services, we looked at the delivery of thrombolytic therapy for ischaemic stroke, and whether current practice was achieving safe outcomes.

Methods

We assessed 27 acute hospitals throughout Ireland with a survey of service organisation and clinical chart review of 874 stroke cases including 81 thrombolysis patients.

Results

82% (22/27) provided 24/7 access, the remaining sites using local arrangements to redirect patients to appropriate sites outside working hours. Decision to thrombolyse was made by stroke trained consultants in 63% (17/27) of units, with general physicians and emergency medicine consultants covering the other units. Thrombolysis rate for non-haemorrhagic stroke was 11% (n = 81/742). Rate varied regionally between 3%-37%. Average age was 71.4 (36–93), 83% described as independent and 7.4% living in residential care preadmission.

80% of cases were managed in a stroke unit at some time during admission versus 54% of the national total cases, a large proportion of thrombolysed patients (48%) are initially managed in high dependency beds (ICU/HDU). With 23.5% having previously had a stroke/TIA, AF was identified as causal factor in 38% of cases.

37% of patients were ≥80 years. The mortality rate was 11.1% versus the national mortality rate for nonthrombolysed strokes of 14.1% (p > 0.5) and this is comparable to SITS-MOST 2007 study 3 month mortality rate of 11.3% (p > 0.5). 8.3% of thrombolysed cases were newly discharged to long term care compared with 7.6% of non thrombolysed cases (p > 0.5).

Conclusions

Stroke thrombolysis is safely provided in acute stroke services in Ireland.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EFFECT OF EXTRACORPOREALLY AND SIMULTANEOUSLY APPLICATION OF Nd:YAG LASER AND ELECTROHYDRAULIC SHOCK WAVES ACCOMPANIED BY PESDA MICROBUBBLES ADMINISTRATION ON EMBOLIC COMMON CAROTID ARTERY

H Mehrad ¹, SM Sajjadian Ghazani ¹

Abstract

Background

A plaque may rupture with high risk of subsequent thrombus- mediated acute clinical events such as myocardial infarction and stroke. The aim of this study was to investigating the feasibility of extracorporeally and simultaneously Nd:YAG laser therapy and electrohydraulic shock wave therapy accompanied by PESDA microbubbles administration on clot embolism (thromboembolus) reduction in the rabbit common carotid artery.

Methods

Briefly, Male New Zealand white rabbits were submitted to common carotid artery thromboembolism. Then treatment group underwent extracorporeally and simultaneously Q-switched Nd:YAG laser (30 w, 5 ns) therapy and electrohydraulic shock wave (0–20 kv, 0.2 Hz) therapy accompanied by PESDA microbubbles (100 µl/kg, 2- 5 × 10⁵ bubbles/ml) administration. Blood volume flow and blood mean velocity were measured by color Doppler ultrasonography. Moreover, percentage of luminal cross-sectional area of stenosis was measured by B-mode ultrasound at the occlusion region. Moreover, occlusion region was evaluated by histopathology.

Results

Quantitative ultrasonography and histopathological results showed a significant reduction in the mean value for blood mean velocity and the percentage of luminal cross-sectional area of stenosis and a significant increase in the mean value for blood volume flow in the treatment group compared with the other groups (P < 0.05).

Conclusions

Enhanced thrombolytic effect of cavitating PESDA microbubbles, induced by Q-switched Nd:YAG laser and electrohydraulic shock waves, can cause to reduce the thrombosis and significantly dilate the luminal cross-sectional area of stenosis. Anti-thrombotic effect of this protocol may be a potential treatment to thromboembolism occlusion.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PATIENT BEHAVIOUR AT THE TIME OF STROKE ONSET. A CROSS-SECTIONAL SURVEY OF PATIENT RESPONSE TO STROKE SYMPTOMS

L Mellon ¹, F Doyle ¹, D Williams ², L Brewer ³, P Hall ¹, A Hickey ¹

Abstract

Background

Despite its proven benefits, thrombolysis therapy is under-utilised, with patient delay in presenting to hospital with symptoms identified as the leading barrier. Increased population knowledge of stroke warning signs has been reported internationally following widespread advertisement of the stroke awareness message ‘Act F.A.S.T.’ (Face, Arm, Speech, Time).This study aimed to examine help-seeking behaviour at stroke onset, in order to understand delays in accessing acute medical care for stroke symptoms.

Methods

A cross-sectional prospective design was employed, with 149 consecutive ischaemic stroke patients hospitalised with ischaemic stroke interviewed at 72 hours post-stroke with the Stroke Awareness Questionnaire and the Response to Symptoms Questionnaire. The primary outcome was pre-hospital delay, as defined by Onset-to-Door time (OTD) greater than 3.5 hours.

Results

Forty percent of stroke cases presented to the Emergency Department (ED) longer than 3.5 hours of stroke onset, excluding them from potential thrombolytic trreatment. Knowledge of stroke symptoms and risk factors was poor amongst stroke surviviors, with 40% unable to correctly define a stroke. Bystander recognition of symptoms (p = 0.03) and bystander initiation of Emergency Medical Services was associated with ED presentation within 3.5 hours (p = 0.03).

Conclusions

Knowledge of stroke warning signs and risk factors was low amongst stroke survivors. This study provides insights into patient response when a stroke occurs, with the presence and action of others highlighted as critical in fast response to stroke symptoms. The results highlight the complexity of changing help-seeking behaviour during stroke onset and provide directions for public education efforts to reduce pre-hospital delay.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

A NATIONAL SURVEY TO ESTABLISH ADMINISTRATION PRACTICES OF INTRAVENOUS THROMBOLYSIS FOR PATIENTS WITH ACUTE ISCHAEMIC STROKE IN AUSTRALIA

S Middleton ¹, L Craig ¹, D Cadilhac ², A W Alexandrov ³, L Lightbody ⁴, CL Watkins ⁵, L Churilov ⁶, L Olenko ⁶, H Hamilton ¹, S Dale ¹

Abstract

Background

Strict criteria for the eligibility for intravenous thrombolysis (rt-PA) for acute stroke are available, yet a recent United States of America (USA) survey revealed 81% of stroke centres added local criteria to the patient selection stipulated by the USA licence. This raises issues for other countries and their approach to patient eligibility.

Aim: To examine the criteria used by clinicians in Australia in the selection of patients for rt-PA.

Methods

Designed based on the USA survey, a questionnaire was mailed to Stroke Unit Co-ordinators of Australian hospitals (n = 87) known to provide rt-PA as identified by the National Stroke Foundation. From a list of 48 indications, contraindications and warnings specified by the Australian rt-PA license and 15 additional criteria not stipulated by the licence (non-standard criteria) also were included, participants were ask to indicate their local criteria for rt-PA eligibility.

Results

Response rate 72.4%. Mean number of inclusion criteria was 5 (SD 1.7); 28.6 % of hospitals selected ≥ 2 non-standard inclusion criteria. The most common stated non-standard criteria was NIHSS score >4 (49.2%). Mean number of exclusion criteria selected was 26 (SD 8.5); 66.7 % of hospitals selected ≥2 of the non-standard exclusion criteria. The most common stated non-standard exclusion criteria was level of consciousness severely depressed (61.9%). Associations between non-standard criteria and rt-PA administration will be reported.

Conclusions

Similar to the USA, our findings suggest that Australia’s low rt-PA rates could, in part, be due to the altering of licence stipulated in/exclusion criteria and adding of non-standard criteria.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

DESIGNING STROKE CLINICAL TRIALS WITH A BINARY ENDPOINT: DETERMINING THE APPROPRIATE SAMPLE SIZE INFLATION FACTOR FOR NON-ADHERENCE

Y Mu ¹, A Pavlov ², S Yeatts ³, P Khatri ⁴

Abstract

Background

Determination of the optimal sample size is an important task of clinical trial planning. Unnecessarily large sample size increases completion time and cost of the trial, while a smaller sample size may result in a trial which is under-powered. For a binary endpoint, sample size is determined based on specified statistical error probabilities, treatment effect, the proportion of favorable outcomes anticipated in the control arm, and the level of anticipated non-adherence. In stroke trials, mechanisms of non-adherence could include treatment cross-overs, stroke mimics, and dropouts, all of which decrease the power of the trial.

Methods

Sample size formulas for a binary endpoint are derived to account for each of these non-adherence types independently and in combination. The ample size inflation factor corresponding to each non-adherence type is plotted against the non-adherence rate (Figure 1). The commonly used linear ((1/(1-r)) and squared (1/(1-r)²) inflation factors are also plotted as reference lines.

Results

The impact on the sample size varies according to the type of non-adherence considered. The commonly used linear inflation factor is not sufficient to recover the power lost due to non-adherence.

graphic file with name 10.1177_2396987316642909-fig159.jpg

Conclusions

It is not optimal to have a common sample size inflation factor for all non-adherence types.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ANALYZING THE MODIFIED RANKIN SCALE IN ACUTE STROKE CLINICAL TRIALS: WHEN DOES THE DICHOTOMOUS APPROACH OUTPERFORM THE ORDINAL?

Y Mu ¹, A Pavlov ², S Yeatts ³, P Khatri ⁴

Abstract

Background

It is increasingly common in acute stroke trials to use the ordinal, as opposed to dichotomized, modified Rankin Scale (mRS) as the primary endpoint. Research by the Optimising Analysis of Stroke Trials [OAST] collaborators suggests that the ordinal approach achieves higher statistical power than the binary approach in most trials, but delineation of the circumstances under which this holds true is lacking. To assist in planning of future trials, we compare the binary versus the ordinal approach in terms of statistical power under a fixed sample size.

Methods

Power is calculated for a specified control distribution of mRS while varying the pattern of treatment effect across the categories of mRS. For illustration purposes, a control distribution of mRS anticipated in a mild stroke population is chosen, difference in power comparing the binary (mRS ≤ 1) versus the ordinal mRS is shown for a range of patterns in treatment effect sizes under a given sample size (Figure 1).

Results

The binary approach outperforms the ordinal approach under certain scenarios when the proportionality of odds is violated. Specifically, in the case of mild stroke, the ordinal approach may not compare favorably to the binary approach.

graphic file with name 10.1177_2396987316642909-fig152.jpg

Conclusions

The ultimate decision to use the ordinal outcome should be based on a careful consideration of the distributional assumptions for the outcome in each treatment arm.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

DIABETES MELLITUS AND PREVIOUS ISCHEMIC STROKE IN STROKE THROMBOLYSIS: ANALYSIS OF SITS-EAST REGISTRY DATA

J Neumann ¹, P Kadlecová ², A Tomek ³, A Kobayashi ⁴, Z Gdovinová ⁵, V Svigelj ⁶, K Fekete ⁷, J Kõrv ⁸, D Jatuzis ⁹, R Mikulík ¹⁰

Abstract

Background

The European drug license for alteplase and current recommendations for ischemic stroke excludes from intravenous thrombolysis (IVT) patients with diabetes mellitus and previous ischemic stroke (DM + pIS positive). Our aim was to evaluate safety and effectiveness of IVT in stroke patients with diabetes mellitus and previous ischemic stroke.

Methods

We analyzed the data from the register SITS-EAST between January 2002 and August 2013. DM + pIS positive and DM + pIS negative groups of patients were compared with respect to safety (symptomatic intracerebral hemorrhage [sICH]) and efficacy (modified Rankin scale [mRS]). Adjustment for baseline difference was performed with general estimating equation.

Results

Of 12888 patients treated with IVT, 465 (4%) had DM + pIS. DM + pIS positive group had more severe ischemic stroke (median NIHS score 12 versus 11) and less frequently prestroke mRS 0–1 (70% versus 89%, P < 0,001) as compared to DM + pIS negative patients. DM + pIS positive patients had significantly lower adjusted odds to achieve mRS 0–1 (OR 0.69; 95% CI: 0.51–0.94) but not functional independence at 3 months (mRS 0–2, OR 0.75; 95% CI: 0.48–1.17). Adjusted odds for death (OR 1.32; 95% CI: 0.96–1.82) or disability was not significantly increased. No association between sICH and DM + pIS was found (e.g. for MOST definition of ICH, OR was 1.73; 95% CI: 0.88–3.39).

Conclusions

Patients with diabetes mellitus and previous ischemic stroke do not have increased risk of SICH, death or disability, but achieve less favorable outcome. Patients with diabetes mellitus and previous ischemic stroke should not be excluded from thrombolytic treatment.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

UTILITY OF CT PERFUSION IN THROMBOLYSIS FOR MINOR STROKE

F Ng ¹, S Coote ¹, T Frost ¹, C Bladin ^1,², P Choi ^1,²

Abstract

Background

Acute thrombolytic therapy in minor strokes is controversial. We aimed to study the safety and efficacy of Intravenous alteplase (IV-tPA) on acute minor stroke patients with demonstrable penumbra on CT Perfusion (CTP).

Methods

Acute minor strokes (NIHSS < 4) were identified from a prospective departmental stroke database from 2011 to 2015. Two readers visually inspected all CT Perfusion and CT Angiogram studies blinded to treatment received. Cases with demonstrable penumbra were analysed. Patients receiving IV-tPA were compared with those managed conservatively with standard stroke unit care without thrombolysis.

Results

73 cases were included. The overall median age was 73.2 (IQR, 67.3–82.8), median premorbid modified rankin scale (mRS) and presenting NIHSS was 0 and 2 respectively. Baseline clinical characteristics were similar between the thrombolysed (n = 34) and standard care group (n = 39). Similar rate of identifiable vascular occlusion on CT Angiogram (38.24% vs 38.46%, p = 1.00) and mean penumbra volume on CTP (41 ml vs 25 ml, p = 0.15) was observed.

Neither group developed a symptomatic intracerebral haemorrhage. More patients in the thrombolysis group had an excellent functional outcome (mRS 0–1) at discharge (88% vs 54%, p = 0.002) and 90 days (91% vs 70%, p = 0.042). There was a shift in the distribution of mRS on ordinal analysis in favour of thrombolysis at discharge (odds ratio 5.23; 95% CI 1.83–12.20) and 90 days (odds ratio 4.35; 95% CI 1.77–11.36).

Conclusions

In selected hyperacute minor stroke with demonstrable penumbra on CTP, IV-tPA is safe and associated with improved functional outcome at discharge and 3-months

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

THROMBOLYSIS IN MILD STROKE. OUTCOMES FROM THE RECCA REGISTRY

W Meyer ¹, PM Lavados ^2,³, V Olavarria ²

Abstract

Background

There are concerns about the risk/beneft of using thrombolysis in mild stroke, considering its potential good prognosis versus the risk of symptomatic intracranial hemorrhage (ICH).

Aim: To evaluated the outcome of mild stroke in our prospective Registro de Enfermedades Cerebrovasculares de Clínica Alemana de Santiago (RECCA), Chile.

Methods

Patients with mild stroke defined as National Institutes of Health Stroke Scale (NIHSS) score ≤ 5, were included from our database. Main risk factors, etiology and good outcome, defined as modified Rankin Scale score (mRS) at discharge 0–1, were compared by thrombolysis therapy using Chi 2 and Fisher´s test. A multiple linear regression (MLR) was performed to assess the independent effect of thrombolysis. RECCA has IRB approval.

Results

From January 2003 to December 2015, 1462 stroke patients were identified. 891 patients (62%) corresponded to mild stroke, 42.4% being female, and mean age was 67.8 (SD 16.7) years old. 71 (8%) mild stroke received thrombolysis. Non thrombolyzed patients were older, 63.7 (SD 17,4) years old versus 68.2 (SD 16.6) (p = 0.03), and lacunar etiology was more frequent in thrombolysis group, 21.1% versus 11.8%, (p = 0.02). Good outcome was more frequent in thrombolysis group, 69,5% versus 57,2%, p = 0.04, OR 1.7 (CI95% 1.01–2.9). There were no differences in case fatality and symptomatic ICH. MLR showed that thrombolysis produced a change in mRS after controlling for age and admission NIHSS.

Conclusions

Thrombolysis in mild stroke produced good outcome and is associated with a change in mRS at discharge, independent of age and NIHSS at admission.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EXPERIENCE OF THROMBOLYSIS IN PATIENTS WITH MILD STROKE (NIHSS 0-4): SENTINEL STROKE NATIONAL AUDIT PROGRAMME (SSNAP) REGISTRY DATA IN ENGLAND AND WALES

L Paley ¹, G Cloud ², M James ³, P Tyrrell ⁴, B Bray ⁵, A Hoffman ¹, E Vestesson ¹, A Rudd ⁶, OBO, SSNAP Collaboration ¹

Abstract

Background

Mild stroke patients are often considered ‘too good to thrombolyse’. National stroke register data was analysed to describe the safety and outcomes of thrombolysis in patients with mild stroke (NIHSS 0–4).

Methods

Data were extracted from the national stroke register (SSNAP) of adults with acute ischaemic stroke treated in all hospitals in England and Wales from April 2013-March 2015 (N = 127975 admitted to 197 hospitals).

Results

44.3% (56663) arrived within 4 h of onset, 45310 (80.0%) had completed arrival NIHSS. 18248 (40.3%) had mild stroke, and 1825 (10.0%) were treated with intravenous alteplase (iv-tPA), compared to 13070 (48.3%) with NIHSS 5–42.

Following iv-tPA, mild strokes had fewer clinician-reported complications (5.4% vs 9.3%,p < 0.001) including fewer symptomatic intracranial haemorrhage (1.9% vs 4.2%,p < 0.001).

Of 1455 mild stroke patients (79.7%) with completed NIHSS 24 h post-thrombolysis, the median improvement was 2 points on the scale (IQR 0–3) compared to 4 (IQR 1–8) for the 81.7% of NIHSS 5–42 strokes. There was no significant difference in rates of deteriorating NIHSS over the first 24 h between the two groups (10.5% vs 11.1%, p = 0.481).

Inpatient mortality was 2.2% for thrombolysed mild strokes, 83.4% of survivors were independent upon discharge (Rankin 0–2) and 0.8% were newly institutionalised into care, compared to 3.0%, 75.1% and 3.0% respectively (p = 0.067, p < 0.001, p < 0.001) for mild strokes arriving within 4 h and not thrombolysed.

Conclusions

Mild strokes arriving within 4 h of onset are less likely to receive iv-tPA than moderate/severe strokes, but are less likely to have thrombolysis complications. Outcomes are better for mild strokes receiving thrombolysis than those not receiving it.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ANGIOGRAPHIC AND CLINICAL FACTORS RELATED WITH GOOD FUNCTIONAL OUTCOME AFTER MECHANICAL THROMBECTOMY IN ACUTE CEREBRAL ARTERY OCCLUSION

SK Park ¹, HW Ro ²

Abstract

Background

The aim of this study is to investigate good prognostic factors for an acute occlusion of a major cerebral artery using mechanical thrombectomy.

Methods

Between January 2013 to December 2014, 37 consecutive patients with acute occlusion of a major cerebral artery treated by mechanical thrombectomy with stent retrievers were conducted. We analyzed clinical and angiographic factors retrospectively. The collateral flow and the result of recanalization were sorted by grading systems. Outcome was assessed by National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) at 90 days. We compared the various parameters between good and poor angiographic and clinical results.

Results

Twenty seven patients demonstrated good recanalization (TICI 2b or 3) after thrombectomy. At the 90-day follow up, 19 patients had good (mRS, 0−2), 14 had moderate (3−4) and four had poor outcomes (5−6). The mRS of older patients (≥75 years) were poor than younger patients. Early recanalization, high TIMI risk score, and low baseline NIHSS were closely related to 90-day mRS, whereas high TICI was related to both mRS and the decrease in the NIHSS.

Conclusions

NIHSS decreased markedly only when recanalization was successful. A good mRS was related to low initial NIHSS, good collateral, and early successful recanalization.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

INFLUENCE OF ACUTE HOSPITAL STROKE CARE CHARACTERISTICS ON THE OUTCOME OF ACUTE ISCHEMIC STROKE PATIENTS OVER 80 YEARS OLD TREATED WITH INTRAVENOUS THROMBOLYSIS

F Purroy ¹, S Abilleira ², D Cánovas ³, A Chamorro ², A Dávalos ⁴, M Garcés ⁵, J Krupinski ⁶, M Ribó ², J Roquer ², J Sanahuja ³, J Saura ⁷, J Serena ⁸, X Ustrell ⁹, A Vena ¹⁰, M Gallofré ²

Abstract

Background

The use of intravenous thrombolysis (IVT) over 80 year-old is initially based on expert opinions or the review of trials archives or registries and not on randomized controlled trials. The objective of this study was to determine safety and effectiveness of intravenous thrombolysis in routine practice among old patients according to hospitals’ characteristics.

Methods

We included 1189 consecutive over 80 year-old patients only treated with IVT from the prospective multicenter population-based registry of acute stroke patients treated with reperfusion therapies in Catalonia (SONIIA). Symptomatic intracranial hemorrhage, mortality, and favorable outcome (modified Rankin Scale score 0 to 2) at 3 months were evaluated according to hospitals’ characteristics. We classified the referral hospital that treated the patients in three categories: comprehensive stroke center (CSCs), primary stroke centers (PSCs), and community hospitals operating on a telestroke system (TS).

Results

Median age was 85.0 (SD 3.6) years, with a baseline National Institutes of Health Stroke Scale score of 13 (interquartile range: 8, 19), and door to treatment time of 55 minutes (interquartile range: 40, 72 minutes). Ninety-day mortality was 23.2% and 38.7% showed a favorable outcome at 3 months. Symptomatic intracranial hemorrhage (SITS-MOST definition) [SICH] was observed in 4.7% patients. The 3 modalities of hospitals achieved similar outcomes even after adjusted by stroke severity measured by NIHSS. However TS and CRI had significantly higher proportion of SICH (6.3% and 6.3% versus 3.2%).

Conclusions

Older IVT treated patients had similar outcomes with independence of the characteristics of the acute hospital stroke care.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

TELESTROKE THROMBOLYSIS: SINGLE "SPOKE" EXPERIENCE FROM SINGAPORE

M Saini ¹, R Singh ²

Abstract

Background

Telestroke neurologist consultation is an established means of providing thrombolytic therapy for acute ischemic stroke (AIS) patients in hospitals lacking round-the-clock neurology services. We describe a single centre (spoke) experience of intravenous thrombolysis in Singapore.

Methods

Study population comprised consecutive patients with AIS who underwent Telestroke Neurologist consultation at Changi General Hospital (Spoke); (Hub: National Neuroscience Institute) between February 2011- October 2013, and were given intravenous r-TPA. Clinical records reviewed to collate clinical, laboratory, radiological data. Neurological deterioration (ND) defined as increase in NIHSS ≥ 2 from baseline, within 24 hours of admission.

Results

Of 399 Telestroke consultations, 335 had symptoms of AIS; 113 received iv r-TPA. Commonest reasons for no thrombolysis: mild/rapidly improving symptoms (103), beyond time window (39), high NIHSS (22), lack of consent (17).

For thrombolysed patients: Mean age 65.5 ± 13.6 years (22.1% ≥ 80 years); 38.6% female.

Vascular risk factors: Hypertension 69.3%, Hyperlipidemia 56.1%, diabetes 32.5%, AF 12.3%, previous stroke/TIA 20.2%.

Mean NIHSS at presentation 11.9 ± 6.1 (range 3–32); 3.8% wake-up strokes.

Mean door-to-needle time 98 ± 40 minutes (<60 minutes: 10)

ND (24 hours) in 18 (15.9%)- haemorrhagic transformation (HT) 10, stroke progression 7, edema 1.

Mean 24 hour NIHSS 8.5 ± 7.8.

Mortality 6 (5.3%; 4 had HT). mRS ≤ 2 at discharge 51 (45.1%).

Conclusions

Thrombolysis via Telestroke consultation has increased its usage locally, albeit incurring relatively long door-to-needle time. This may underlie higher rate of haemorrhagic transformation and ND seen. Measures to address these shortcomings are critical for ensuring optimal implementation.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EMERGENCY MEASUREMENT OF PLASMA LEVELS FOR RIVAROXABAN IN PATIENTS WITH ACUTE STROKE IS FEASIBLE IN A MEDIAN OF 34 MINUTES

D Seiffge ¹, C Traenka ¹, A Polymeris ¹, L Hert ¹, N Peters ¹, GM De Marchis ¹, P Lyrer ¹, L Bonati ¹, D Tsakiris ², S Engelter ¹

Abstract

Background

Calibrated anti-factor Xa assays measure drug specific plasma levels for Rivaroxaban. We sought to investigate if determination of drug specific plasma levels in patients with acute cerebrovascular emergencies is fast enough to guide clinical decisions.

Methods

Subgroup analysis from the ongoing prospective NOACISP registry (ClinicalTrials.gov: NCT02353585). Patients admitted to the Stroke Center at the University Hospital Basel from 1^st January to 31th December 2015 suffering acute ischemic or hemorrhagic stroke while under treatment with Rivaroxaban with emergency measurement of plasma levels were included. Rivaroxaban plasma level was determined by an automated anti-factor Xa-based chromogenic assay using specific Rivaroxaban calibrators (Hyphen-Biomed). If values were >150 ng/ml a second test for higher levels was done (DiXal, Hyphen-Biomed). We calculated the turnaround time (TAT), i.e. time from registration of the blood sample in the central lab to first result published.

Results

We included 38 patients (mean age 77 years, 44% female). Mean plasma level was 160 ng/ml (range 10–509 ng/ml), mean INR 1.8+/-0.74. Median TAT was 34 minutes (IQR 29–65 minutes). For patients admitted within 270 minutes after symptom onset (n = 16), median TAT was 33 minutes (IQR 30–40 min). Based on plasma levels, 3 patients received intravenous thrombolysis (IVT), 4 patients otherwise eligible for IVT were excluded because of plasma levels >100 ng/ml (no patient had proximal vessel occlusion eligible for mechanical thrombectomy). No symptomatic intracranial hemorrhage occurred.

Conclusions

Measuring drug-specific plasma levels of Rivaroxaban in patients with acute cerebrovascular emergencies within median timeframe of 34 minutes allows physicians to include drug specific plasma levels into decision making for acute treatment.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

INCIDENCE AND PREDICTORS OF EARLY RECANALIZATION FOLLOWING INTRAVENOUS THROMBOLYSIS. A SYSTEMATIC REVIEW AND META-ANALYSIS.

P Seners ¹, G Turc ¹, B Maïer ¹, JL Mas ¹, C Oppenheim ², JC Baron ¹

Abstract

Background

Following the demonstration of efficacy of bridging therapy, reliably predicting early recanalization (ER; ≤3 hrs after start of intravenous thrombolysis; IVT) would be essential to limit futile, resource-consuming interhospital transfers. We present the first systematic review on the incidence and predictors of ER following IVT alone.

Methods

We systematically searched for studies including patients solely treated by IVT that reported incidence of ER and/or its association with baseline variables. Using meta-analyses we estimated pooled incidence of ER, including according to occlusion site, and summarized the available evidence regarding predictors of no-ER.

Results

We identified 24 studies that together included 1987 patients. The overall incidence of partial or complete ER was 35% (95%CI: 28–42). It varied according to occlusion site: 55% (42–68) for distal middle cerebral artery (MCA), 35% (28–43) for proximal MCA, 15% (7–24) for intracranial carotid artery, and 13% (0–35) for basilar occlusion. Corresponding rates for complete ER were 40% (23–58), 22% (14–30), 4% (1–8) and 4% (0–22), respectively. Proximal occlusion, tandem occlusion and higher NIHSS were the most consistent no-ER predictors. Other imaging predictors, such as thrombus visualization, long or totally occlusive thrombus and poor collateral circulation emerged as potential predictors but will need confirmation.

Conclusions

The overall incidence of ER following IVT is substantial, highlighting the importance of reliably predicting ER to limit futile inter-hospital transfers. Incidence of no-ER is particularly high for proximal occlusion and severe strokes. Given the scarcity of published data, further studies are needed to improve no-ER prediction accuracy.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

STROKE CODE IN PARAGUAY. A DESCRIPTIVE ANALYSIS

L Seró ¹, A Flores ¹, C Otto ¹, F Riquelme ¹, R Mernes ¹, G Godoy ¹, S Reyhani ¹, J Cortti ¹

Abstract

Background

There is strong evidence that successful reperfusion treatments are highly time-dependent. Despite of its relevance, there is no available data about stroke code and temporal profile in Paraguay. Our aim was to describe clinical variables related to stroke code in our population.

Methods

This is a descriptive, observational, single centre study. Data was collected from a prospective registry of patients with presumed stroke who arrived to the emergency department(ED) in our hospital, from april to december 2015.

Results

From 152 stroke patients, 58 were female(40.8%). 16% patients had undetermined onset of symptoms. 35 were stroke code(24.8%). Only 41 patients(32%) arrived to ED in therapeutic window for intravenous thrombolysis(IT). 8 stroke code patients received reperfusion therapy with IT(22.8 % of stroke code patients)

In all stroke patients, the mean time from symtoms onset to hospital door was 456.9 minutes(SD ± 559), whereas in stroke code patients was 112.5(SD ± 56). In all patients, the mean time door to cranial tomography (CT) was 72.7 minutes(SD ± 74), and in stroke code patients was 43 minutes(SD ± 59). This comparison reached stadistical significance(p = 0.008). The mean time door-to-treatment in stroke code patients was 76.6 minutes(SD ± 48).

Conclusions

We have a high rate of patients who arrive out of therapeutic window and a low percentage of stroke codes, compared with prior studies, and our intrahospitalary times don't reach the standards of care. Public health campaigns to establish the extrahospitalary stroke code and strategies to improve intrahospitalary stroke code protocol need to be developed to improve our patients clinical outcomes.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

INTRAVENOUS THROMBOLYSIS IS EFFECTIVE AND SAFE IN YOUNG ADULTS WITH ACUTE ISCHEMIC STROKE: RESULTS FROM THE SOOCHOW STROKE REGISTRY

J Shi ¹, Y Cao ¹, C Liu ¹, J Xu ¹, S You ¹

Abstract

Background

The efficacy of intravenous thrombolysis in young stroke patients is relatively rare. In this paper, we aimed to investigate whether intravenous thrombolysis is effective and safe in young adults aged 18–45 years from the Soochow Stroke Registry.

Methods

A total of 321 acute ischemic stroke patients aged ≥18 years were included in this study. The patients was treated within 4.5 hours of stroke onset and hospitalized from May 2009 to October 2015. Of these, 34 (10.6%) were aged 18–45 years and 287 (89.4%) >45 years. Intravenous rt-PA was administered at a dose of 0.9 mg per kilogram (maximum, 90 mg). The functional recovery and mortality rate at 3 months, and sICH within 7 days according to ECASS II criteria were assessed.

Results

Compared toyoung patients, the patients >45 years had higher incidence of hypertension (69.7% vs. 41.2%, p < 0.05), diabetes (15.0% vs. 2.9%, p < 0.001) and atrial fibrillation (27.9% vs. 2.9%, p < 0.001). In young patients, 85.3% (n = 29) had favorable outcome at 3 months (mRS 0–2) (OR = 1.87; 95% CI, 0.59–2.73; p = 0.012), compared to patients > 45 years (n = 187, 65.2%) (OR = 1.31; 95% CI, 0.48–2.16; p = 0.023).

There were statistically significant differences in young patients compared to patients > 45 years for the incidence of sICH (0 vs. 3.1%, p < 0.001) and mortality (2.9 vs. 11.8%, p < 0.001). However, the recurrence of stroke and TIA was higher in young adults(8.8 vs. 3.1%, p < 0.05).

Conclusions

Our results demonstrate that intravenous thrombolysis is effective and safe in young patients with acute ischemic stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CEREBRAL THROMBOLYSIS IN PATIENTS WITH ISCHEMIC STROKE AND HEART FAILURE

P Sobolewski ¹, G Kozera ², W Szczuchniak ¹, A Sobota ¹, K Chwojnicki ³, M Gruchała ⁴, W Nyka ³

Abstract

Background

Heart failure (HF) is common among patients with ischaemic stroke (IS), however it’s impact on outcome after iv-thrombolysis has not been fully determined. The aim of our study was to evaluate the relationship between HF and the long-term outcome, mortality and the presence of hemorrhagic complications in patients with acute IS treated with iv-thrombolysis.

Methods

We retrospectively evaluated data from 328 Caucasian patients with IS consecutively treated with iv-thrombolysis. HF was defined as NYHA class II–IV and left ventricular systolic dysfunction with ejection fraction (LVEF) <45%; long-term outcome was assessed with modified Rankin Scale (mRS) score and mortality rate on 90^th days after IS.

Results

The incidence of HF did not differ between patients with favorable (mRS 0–2) and unfavorable (mRS 3–6) functional outcome (10.4% vs 15.5; p = 0.17) and between those who survived and died within 90 days after IS (11.7% vs. 20.0; p = 0.27). Multivariate analysis showed no impact of HF diagnosis on outcome (p = 0.55) or mortality (p = 0.55).

Conclusions

The presence of systolic HF does not determine safety and efficacy of cerebral iv-thrombolysis in patients with IS. Estimation of EF brings no benefit for qualification for cerebral thrombolysis.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

FUNCTIONAL OUTCOME AFTER THROMBOLYSIS FOR POSTERIOR CIRCULATION STROKE: RESULTS FROM THE AUSTRIAN STROKE UNIT REGISTRY

P Sommer ¹, L Seyfang ², J Ferrari ³, W Lang ³, E Fertl ¹, W Serles ⁴, S Greisenegger ⁴

Abstract

Background

Thrombolysis with recombinant tissue-plasminogen-activator (rt-PA) is an approved treatment for acute ischemic stroke (AIS) irrespective of infarct–localization. However, there is limited evidence whether rt-PA-treatment is equally effective in posterior circulation stroke (PCS) and anterior circulation stroke (ACS).

Methods

We analyzed 90-day functional outcome measured by the modified Rankin Scale (mRS) of patients with AIS enrolled into the Austrian Stroke Unit Registry stratified by infarct localization according to the Oxfordshire Community Stroke Project Classification. A proportional odds model was used; model specification was done using bidirectional stepwise variable selection. Explanatory variables included demographic factors, infarct localization and vascular risk factors.

Results

Among 77 322 patients with AIS enrolled in the ASUR between 2003 and 2015, the mRS at 90-days was available in 26 976 patients. 3453 patients with ACS and 355 with PCS were treated with rt-PA.

Rates of symptomatic intracranial hemorrhage were lower in PCS (1.4% vs. 4.5%, p = 0.003). After adjustment for age, sex, stroke severity, ODT, DNT and vascular risk factors, PCS was a negative predictor of functional outcome at 90 days (odds ratio 1.32; 95% confidence interval 1.25–1.4, p < 0.001). These results were confirmed in different sensitivity analyses. Overall, earlier treatment was associated with better outcome independently of stroke localization.

Conclusions

In our study, PCS was a negative predictor of functional outcome, despite lower rates of SICH.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EFFECT OF rt-PA THROMBOLYSIS IN PATIENTS WITH EMBOLIC STROKE OF UNDETERMINED SOURCE (ESUS)

R Suzuki ¹, M Ayano ¹, K Nakanishi ¹, T Johno ¹, E Sato ¹, Y Shiokawa ¹, T Hirano ¹

Abstract

Background

It remains unknown whether the effect of acute revascularization therapy differs between patients with Embolic Stroke of Undetermined Source (ESUS) and those with other etiologies (non-ESUS). We compared their clinical features and outcomes in whom rt-PA thrombolysis were performed.

Methods

Consecutive patients with acute ischemic stroke who were performed acute revascularization therapy between May 2013 and May 2015, were divided into two groups, i.e. ESUS or non-ESUS. ESUS was defined according to the Cryptogenic Stroke/ESUS International Working Group criteria. We compared admission NIHSS, site of vessel occlusion, usage of rescue endovascular therapy (EVT) and modified Rankin Scale (mRS) between the 2 groups. Statistical analysis was performed using JMP 9.0.2 (SAS Institute, Cary, NC).

Results

Among 48 patients (25 men, 76.5 ± 11.9 y.o.) enrolled, 11 patients (23%) were diagnosed as having ESUS. There were no differences in age (74.1 ± 12.7 vs. 77.2 ± 11.8 y.o, p = 0.38), gender (Men 63.6% vs. 48.7%, p = 0.50) or admission NIHSS (median 14, IQR 7.5–22 vs. 13, 8–25, p = 0.93). In patients with ESUS, however, ICA/M1 proximal occlusion was less frequently observed (18.2% vs. 51.4%, p = 0.08). The utilization of EVT was not different between groups (18.2% vs. 47.2%, p = 0.16). mRS 0–2 was achieved in 1/11 (9.1%) and 3/37 (8.1%) patients with ESUS and non-ESUS, respectively (p = 1.00).

Conclusions

Although our sample size is limited, patients with ESUS tend to have less proximal vessel occlusion. The effect of acute revascularization therapy is identical in patients with ESUS compared to non-ESUS patients.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CHARLSON COMORBIDITY INDEX IN STROKE THROMBOLYSIS OUTCOME

R Targa Martins ¹, M Bianchin ²

Abstract

Background

The Charlson Comorbidity Index (CCI) is a validated and useful tool for evaluating clinical comorbidity in several clinical situation, including stroke. Here we evaluated the use of CCI and the impact of its clinical comorbidities in ischemic stroke thrombolysis

Methods

A prospective cohort study of 96 thrombolysis stroke patients divided in high or low CCI, according with the severity of clinical comorbidities. National Institute Health Stroke Scale (NIHSS) scores pre-thrombolysis, post-thrombolysis, 24 hours, 7 days later, and 3 months modified Rankin Scale (mRS) were compared between these two groups of patients

Results

High and Low CCI groups showed a significant difference in NHSS evolution after thrombolysis (p < 0.001). Low CCI patients experienced a significant reduction in NIHSS from 10.13 to 2.90 points (p = 0.001), while patients with high CCI experienced a minimal and not significant reduction from 14.38 to 11.93 (p = 0.17). Intracranial bleeding occurred in 18 (27%) patients with high CCI and in only 1 (3%) patient with low CCI (RR = 8.18; 95%; 95%CI = 1.14–58.49; p = 0.005). Twenty three patients (76%) with low CCI, but only nine (14%) patients with high CCI showed good clinical outcome (mRankin scale of 0 and 1) after thrombolysis, a clinically significant difference (RR = 5.62; 95%CI = 2.97 to 10.65; p < 0.001)

graphic file with name 10.1177_2396987316642909-fig153.jpg

Conclusions

CCI is a good and useful predictor of thrombolysis outcome. Clinical comorbidities, as measured by CCI, attenuate thrombolysis reduction of stroke symptoms severity and increase risk of bleeding in patients leading higher frequency of disabled patients

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

REMOTE INTRACEREBRAL HEMORRHAGE AFTER INTRAVENOUS THROMBOLYSIS: A SINGLE-CENTER EXPERIENCE

H Tejada Meza ¹, J Artal Roy ¹, P Ruiz Palomino ¹, GJ Cruz Velásquez ¹, A Fernández Sanz ¹, P Modrego Pardo ¹, J Marta Moreno ¹

Abstract

Background

In up to 7% of patients with ischemic stroke treated with intravenous thrombolysis have an intracerebral hemorrhage (ICH) anatomically unrelated to the ischemic lesion. The aim of this study was to describe our case series of symptomatic remote intracerebral hemorrhages after intravenous thrombolysis (sRH) and compare it with those who had a symptomatic intracerebral hemorrhage only in the infarcted area (sHIA).

Methods

All patients with ischemic strokes who were thrombolized in our hospital between 2005 and 2015 were included. Data from every patient who had a sRH were obtained and compared with those who had a sHIA.

Results

From 560 patients that were thrombolyzed, 31 had a symptomatic ICH, 12 of them were sRH. 72.7% of sRH had a left infarct, 75% a total anterior circulation infarct (TACI), 25% were cardioembolic strokes. They were thrombolyzed with a mean onset of symptoms-to-needle time of 137 minutes. 33.3% of sRH also bled in the infarcted area, 33.3% had leukoaraiosis in the initial CT scan. Patients with sRH had a higher mortality than those with sHIA (58.3% vs 26.7%). In the multivariate analysis we found no statistically significant differences between both groups.

Conclusions

Remote intracerebral hemorrhages are not rare in patients with symptomatic ICH after an intravenous thrombolysis. In our small sample we found no statistically significant differences in the variables studied between the sRH and sHIA group. More studies are needed to clarify the mechanisms responsible for these hematomas.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

INTRAVENOUS TROMBOLYSIS IN PATIENTS WITH ISCHEMIC STROKE AND INTRACRANIAL MENINGIOMA

J Artal Roy ¹, H Tejada Meza ¹, M González Sánchez ¹, P Ruiz Palomino ¹, GJ Cruz Velásquez ¹, A Fernández Sanz ¹, J Marta Moreno ¹

Abstract

Background

The risk of intracranial bleeding in patients with ischemic stroke and coexisting intracranial tumors treated with intravenous thrombolysis is not well known. Some reports suggest that the risk of bleeding in benign and extra-axial neoplasms may be low. The aim of this study is to describe our experience with thrombolized ischemic strokes that had a coexisting meningioma as an incidental finding.

Methods

All patients with ischemic strokes who were thrombolized in our hospital between 2005–2015 were included. We looked for patients with coexisting meningiomas and obtained their baseline data, subtype of stroke, presence of intracranial bleeding, intratumoral hemorrhage, mortality and functional outcome at hospital discharge.

Results

From 560 patients that were thrombolyzed, five had also an intracranial meningioma. No one had an intratumoral hemorrhage, two had hemorrhagic transformation of the infarct areas (which were not related to the meningioma), and one of them died for this cause. Three patients had a modified Rankin Scale (mRS) <3 at hospital discharge.

Conclusions

In our case series, we didn’t find an association between meningiomas and intracerebral bleeding after intravenous thrombolysis; those two cases that bled were in the infarcted areas, had high NIH scores and were cardioembolic strokes, so we think the hemorrhages had no direct relationship with the meningiomas. In our experience the presence of meningiomas don’t contributes to bad outcomes in thrombolyzed patients, and might not be an exclusion criteria for it, but larger studies are needed.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

OUTCOME OF INTRAVENOUS THROMBOLYSIS WITHIN THREE HOURS IN ACUTE ISCHEMIC STROKE IN NEPALESE PATIENTS: A PRELIMINARY STUDY FROM NEPAL

L Thapa ¹, S Bhattarai ², A Shrestha ², P Shrestha ³, U Devkota ³

Abstract

Background

The number patients receiving intravenous thrombolysis for acute ischemic stroke in the developing countries is extremely low. We studied the outcome of intravenous thrombolysis in Nepalese patients presenting within three hours of acute ischemic stroke for the first time in Nepal.

Methods

This retrospective study was conducted after the ethical approval from the institutional review board. Patients with acute ischemic stroke who received intravenous thrombolysis within three hours of stroke onset, from July 2012 to August 2015, were included. Clinical profiles, risk factors, type of thrombolytic used, and outcomes as measured by modified Rankin scale (mRS) at discharge (Table 1) were systematically recorded and analyzed.

Results

Out of 282 acute ischemic stroke patients, a total of eight patients (2.83%) were thrombolysed (Table 2 and Table 3). The mean time from the onset of stroke symptoms to first dose of thrombolytic was 1.25 hours. Five patients (62.5%) had good and three patients (37.5%) had poor outcome. The thrombolysis-related post-treatment complication was noted in four patients (50%), out of which non-fatal intracranial bleed occurred in two patients (25%).

Conclusions

Although our study has an inherent limitation of a retrospective study and small sample size, it clearly demonstrates the beginning of an effective thrombolysis with a good outcome in the treatment of Nepalese patients with acute ischemic stroke.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

"WELSINKI", THE HELSINKI MODEL IN WELS: DOOR-TO-NEEDLE-TIME <30 MINUTES, THROMBOLYSIS RATE >30%

B Hörmanseder ¹, G Schustereder ¹, S Einsiedler ¹, R Radlberger ¹, U Straka ¹, W Sperl ², H Lugmayr ³, R Topakian ¹

Abstract

Background

The benchmark door-to-needle time (DNT) for IV stroke thrombolysis is ≤30 minutes. In our large academic teaching hospital, since 10/2014 there have been multidisciplinary efforts under neurological guidance to gradually reinforce key components of the famous Helsinki model to reduce median DNT ≤30 minutes and further increase thrombolysis rate.

Methods

Retrospective analysis of prospectively collected local registry data to evaluate DNT, safety outcomes, thrombolysis rate, and “drip & ship management” of candidates for thrombectomy in 18 months from 7/2014 to 12/2015.

Results

From 259 patients with IV thrombolysis, we excluded 15 patients from DNT analysis, as they had suffered the event while in the hospital due to other causes. Prenotification by EMS personnel via stroke phone increased from 29.6% in the first 3 months to 72.0% in the last 3 months of the studied period (p = 0.022). Median (IQR) DNT improved from 49 (31, 63) minutes in the first 3 months to 30 (9, 48.5) in the last 3 months (p = 0.007). DNT ≤ 10 minutes was achieved in 39 (16%) patients. Comparing “in-hours” (Monday to Friday, 7.30am-4 pm) vs. “out-of-hours” service, frequencies of prenotification (57.3% vs. 57.4%, p = 0.98) and median DNT in minutes (36.5 vs. 30.5, p = 0.80) did not differ. Safety outcomes: SICH 1.2%, in-hospital mortality 6.2%, stroke mimics 4.9%. The stroke thrombolysis rate rose to 31.2% in 1–9/2015 (19% in 2013; 23.2% in 2014). 18 (7.4%) patients received bridging IV alteplase before transfer for thrombectomy.

Conclusions

In Wels, successful strengthening of essential components of the Helsinki model enabled substantial improvements of DNT and thrombolysis rates.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

DOIN´ IT QUICK: THE WELS EXPERIENCE 39 CASES OF STROKE THROMBOLYSIS WITH DOOR-TO-NEEDLE TIMES ≤10 MINUTES

S Einsiedler ¹, G Schustereder ¹, B Hörmanseder ¹, W Sperl ², H Lugmayr ³, R Topakian ¹

Abstract

Background

The benchmark door-to-needle time (DNT) for IV thrombolysis is ≤30 minutes, but a reduction ≤10 minutes may lead to even better outcomes. In our centre, since 10/2014 there have been multidisciplinary efforts under neurological guidance to gradually reinforce key components of the famous Helsinki model to improve stroke care and further reduce DNT.

Methods

Retrospective analysis of data prospectively collected in the local thrombolysis registry to evaluate safety outcomes and clinical determinants of DNT ≤10 minutes versus DNT >10 in the time period 7/2014–12/2015. Key components of the Helsinki model that were strengthened included: prenotification by EMS personnel via a “stroke phone”; prehospital patient registration into electronic system; emptying of the scanner; direct transfer on the ambulance stretcher to the CT table; premixed alteplase bolus in CT immediately after neurologist´s interpretation of scans.

Results

Of 244 stroke patients with IV thrombolysis in the 18 months of the analyzed period, 39 (16%) patients had a DNT ≤10 minutes. Compared to patients with DNT >10 minutes, patients with DNT ≤10 minutes had more often prenotification (49.8% vs. 97.4%, p < 0.005) and CT instead MRI (59% vs. 100%, p < 0.005), and less often posterior circulation syndromes (26.5% vs. 5.1%, p = 0.004). There were no differences in safety outcomes: overall in-hospital mortality 6.2%, SICH 1.2%, stroke mimics 5.9% in the DNT group >10 minutes and nil in the group with DNT ≤10 minutes.

Conclusions

In clinical scenarios and physician access to full patient information, dedicated care can keep the DNT ≤10 minutes improving the odds for favorable outcomes.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

INTRAVENOUS THROMBOLYSIS VERSUS ENDOVASCULAR THERAPY IN PATIENTS WITH ACUTE ISCHEMIC STROKE ATTRIBUTABLE TO CERVICAL ARTERY DISSECTION

C Traenka ¹, S Jung ², R Kurmann ², B Goeggel Simonetti ³, H Gensicke ¹, H Mueller ⁴, I Meyer ⁵, S Wegener ⁶, G Kaegi ⁷, K Nedeltchev ⁸, A Luft ⁶, R Sztajzel ⁴, P Michel ⁵, P Lyrer ¹, M Arnold ², S Engelter ¹

Abstract

Background

Cervical Artery Dissection (CeAD) is a major cause of stroke in the young. Intravenous thrombolysis (IVT) is effective and safe in acute ischemic stroke. In anterior circulation stroke with large vessel occlusion, endovascular therapy (EVT) including mechanical thrombectomy with or without IVT has been shown superior to IVT alone. Data on EVT in patients with stroke attributable to CeAD is scarce. Aim: To compare 3-month outcome and complications of EVT versus IVT in CeAD patents with stroke.

Methods

In a Swiss multicenter IVT-/EVT-register based cohort study, we selected all patients with stroke attributable to CeAD. We compared CeAD patients receiving EVT (with or without IVT) to those receiving IVT. Outcome measures were (i) excellent 3-month outcome (mRS 0–1) and (ii) symptomatic intracranial hemorrhage (sICH) according to ECASS-III criteria. Unadjusted and stroke severity-adjusted odds ratios with 95%-confidence intervals (OR [95% CI]) were calculated.

Results

Among 1496 patients, 84 patients had CeAD (5.6%, median age: 49.6 years). Of these, 51 patients (61%) received IVT, 33 patients (39%) received EVT. Excellent outcome was equally frequent in IVT- and EVT-treated patients (28% vs 24.2%; OR_unadjusted 1.2 [0.4–3.3]; OR_adjusted 1.2 [0.4–3.7]). sICH occurred in the EVT-treated group only (6/33 patients, 18%) (OR_unadjusted 0.35 [0.25–0.47]).

Conclusions

In this cohort study, there was no clear signal of superiority of EVT over IVT in CeAD patients. Although, to our knowledge, being the largest cohort reporting on EVT-treated CeAD stroke patients, our results have to be interpreted cautiously, as this analysis is based on observational, non-randomized data.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

RESULTS AFTER 1000 THROMBOLYSIS

R Vera Lechuga ¹, A Cruz Culebras ¹, A De Felipe-Mimbrera ¹, MC Matute-Lozano ¹, J Garcia ¹, M Guillán ¹, J Valcarcel ¹, S Victor ¹, MJ Lopez ¹, M Alonso ¹, J Masjuan ¹

Abstract

Background

One thousand patients with acute ischemic stroke (IS) have been treated with intravenous (iv) tPA in our Comprehensive Stroke Centre during the period 2003–2013

Methods

Baseline clinical data, outcome and treatment related complications from consecutive patients with IS who were treated with iv tPA in our Stroke Unit, were recorded in a prospective registry from our first case in 2003 to our thousandth in 2013

Results

Among 1000 patients (male, 47.4%; mean age 71.9 ± 14.4 years), hypertension (68.3%), dyslipidemia (33.5%) and atrial fibrillation (26.3%) were the most frequent risk factors. Cardioembolic stroke (44.3%) and atherosclerosis without stenosis (21.5%) were the most common subtypes of IS. Median NIHSS was 12 [7–18]. Door to needle mean time was 59 ± 36 minutes. After 2010 (when endovascular treatment for acute IS started in our hospital was available), 4.4% (44) of patients underwent endovascular treatment after iv tPA. TPA was administered off-label in patients older than 80 years (27.8%), diabetes and previous stroke (3.4%), beyond therapeutic window (2.9%), recent surgery or trauma(1.7%), NIHSS > 25 (1.3%) and patients under anticoagulant therapy with INR > 1.7 (0.7%). The number of patients treated per year increased from 17 initially (2003) to 140 (2013). Symptomatic intracranial haemorrhagic transformation occurred in 1.6%. Good Functional outcome (mRS 0–2) was achieved in 60.4%. Mortality rate was 13.8%

Conclusions

Safety and efficacy of intravenous tPA is maintained throughout the period with a very low rate of SICH even in patients treated off label

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

AN INTERNATIONAL COMPARISION OF THROMBOLYSIS IN ENGLAND AND WALES, AND SWEDEN USING NATIONAL REGISTERS

E Vestesson ¹, B Bray ², M James ³, L Paley ¹, M Kavanagh ¹, P Tyrrell ⁴, G Cloud ⁵, M Eriksson ⁶, B Norrving ⁷, A Rudd ⁸, OBOTSC On behalf of the, SSNAP collaboration ⁹

Abstract

Background

International benchmarking provides an opportunity to learn from other healthcare systems and improve the quality of care.

Methods

Data for patients treated in 2014 were extracted from the Sentinel Stroke National Audit Programme (SSNAP) (England and Wales) and Riksstroke (Sweden). Both registers have national coverage and are estimated to include approximately 95% of admitted stroke patients.

Results

The percentage of ischaemic strokes thrombolysed was higher in England and Wales (13%, 8929) than in Sweden (11%, 2271). The trend is similar for patients aged over 80 (11% vs 9%). A lower number of hospitals per population provided thrombolysis in England and Wales compared to Sweden (3 vs 7 per 1000000 population) whilst the median number of patients thrombolysed per hospital was higher in England and Wales compared to Sweden (55 vs 25 patients per year). Thrombolysed patients in England and Wales had suffered more severe strokes compared to Sweden with median NIHSS (if fully completed) of 10 and 8 respectively. Clinician-reported levels of symptomatic intracranial haemorrhage post-thrombolysis were similar in England and Wales, and Sweden (4% vs 5%).

Onset-to-arrival and door-to-needle times were slower in England and Wales compared to Sweden (77 min vs 67 min and 55 min vs 45 min). Only 28% of patients were thrombolysed within 40 minutes in England and Wales compared to 43% in Sweden.

Conclusions

According to data from two national registers patients are more likely to receive thrombolysis in England and Wales and thrombolysed patients had suffered more severe strokes. Median door-to-needle times are faster in Sweden.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

URIC ACID AND FUNCTIONAL OUTCOME IN STROKE PATIENTS SUBMITTED TO INTRAVENOUS FIBRINOLYSIS: A NON-LINEAR AND GENDER DEPENDENT RELATION

J Beato-Coelho ¹, C Duque ¹, L Vieira ¹, A Inês Martins ¹, I Vidal ², C Machado ¹, B Rodrigues ¹, F Silva ¹, G Cordeiro ¹, J Sargento-Freitas ¹, L Cunha ¹

Abstract

Background

Uric acid (UA) is a product of the purine metabolism with anti-oxidant properties. Previous studies have revealed endogenous UA as an independent risk factor for ischemic stroke (IS) or, on the other hand, as a neuroprotective agent in stroke patients undergoing fibrinolytic therapy (rtPA). However, its’ precise pathophysiological contribution is still not understood, impairing the design of clinical trials of exogenous UA.

Our objectives are to evaluate the role of endogenous UA in the functional outcome of patients with IS treated with rtPA.

Methods

Historical cohort study including consecutive patients, from January 2010 to December 2014, with IS treated with intravenous rtPA. We evaluated the levels of UA in the acute phase, and analysed both genders. Functional outcome was defined by modified Rankin scale at 90 days (mRS90). We applied models of linear and quadratic multivariable regressions to predict outcome.

Results

We included 546 patients, 54.80% men. Female patients (FP) had lower levels of UA at admission: 5.29 ± 2.04 mg/dl vs. 5.87 ± 1.71 mg/dl, p = 0.043. In the total population and in the male population (MP) there was an “U” relation between UA and the mRS90 (OR: 0.92, IC95%: 0.76–1.06, p = 0.214; R² change: 1.13, p = 0.010). Women showed a linear association with mRS90 (OR: 0.74, IC95%: 0.48–1.16, p = 0.195; R² change: 1.01, p = 0.122).

Conclusions

The total population and the MP had an “U”-shaped relation between UA levels and mRS90. Female patients presented lower levels of UA and a linear association with functional outcome.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

RECOMBINANT TISSUE PLASMINOGEN ACTIVATOR ALTERS PHAGOCYTOSIS OF GRANULOCYTES AND MONOCYTES IN VITRO

C Lange ¹, S Rümpel ¹, C Kessler ¹, A Dressel ¹, A Vogelgesang ¹

Abstract

Background

Stroke induces profound immune alterations which on the one hand influence stroke lesion size and on the other hand promote post stroke infections.

Mechanical thrombectomy and iv thrombolysis with recombinant tissue plasminogen activator (rt-PA) are the two proven strategies to achieve recanalization in acute ischemic stroke patients.

The aim of this study was to investigate the possible impact of rt-PA on the immune response by quantifying cytokine production and phagocytosis.

Methods

Cell culture: PBMC from healthy donors EDTA or heparinized whole blood were isolated. Cells were either stimulated with phytohemagglutinin or anti-CD3/CD28 beads. n = 4 per condition. Cells were incubated in RPMI complete medium for 72 h (37°C, 5% CO2). The following cytokines were determined in cell culture supernatants by Legendplex Multi-Analyte Flow Assay Kit (Biolegend).

Phagocytosis was determined by Phagotest Kit (Glycotope) after incubation of healthy donors' whole blood with 0,5 µg/ml or 1 µg/ml or w/o rt-PA for 4 h at 37°C, 5% CO2. n = 10.

Results

Neither IFN-g, IL-2, IL-4, IL-5, IL-6, IL-9, IL-10, IL-13, IL-17 A, IL17F, IL-21, IL-22 nor TNF-a production were altered significantly by rt-PA. But in vitro incubation of whole blood with rt-PA did reduce the amount of phagocytosed bacteria per granulocyte or monocyte respectively (p < 0,001) while the percentage of granulocytes that phagocytosed bacteria was slightly increased at 1 µg/ml rt-PA.

Conclusions

Our in vitro experiments demonstrate that rt-PA can affect immune cell function in vitro. Future studies will have to determine whether our finding is of relevance for rt-PA treated patients.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

REDUCING DOOR-TO-NEEDLE TIME TO LESS THAN 15 MINUTES: DOES IN-HOSPITAL RUSH INCREASE THE AMOUNT OF SICH AND STROKE MIMICS?

P Ylikotila ¹, RO Roine ¹

Abstract

Background

Efficacy of thrombolytic therapy is reduced by time elapsed and therefore every effort must be made to reduce out-of-hospital and in-hospital delays. In Turku University Hospital, we have managed to reach a median Door to Needle Time (DNT) of 14 minutes, to our knowledge the shortest in-hospital delay ever reported. The median DNT was reduced by five minutes since 2014.

We wanted to investigate whether ultra-early thrombolysis in 2015 was associated with increased number of symptomatic ICH (sICH) or increased number of stroke mimics being thrombolysed as compared with 2014.

Methods

All patients who received iv-thrombolysis in the year 2015 (n = 164) in Turku University Hospital were included. Data was collected prospectively. Of those 164 patients thrombolysed, 32 patients also had mechanical thrombectomy. SITS-MOST criteria for sICH were used. Stroke mimics were defined as patients with both a negative 3T DWI MRI and a diagnosis other than stroke according to the best clinical judgment by an experienced stroke neurologist.

Results

The rate of sICH was 1.5 % (n = 2) in thrombolysed patients, as compared with 1.0 % the year before. In addition, 7.1 % (n = 3) of patients who received both iv-thrombolysis and endovascular treatment had sICH. The rate of stroke mimics was 4.3% in 2015, as compared to 4.0 % in 2014.

Conclusions

Ultra-early thrombolysis is not associated with an increased number of patients with sICH or stroke mimics receiving thrombolytic therapy.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

PREDICTORS OF OUTCOME IN PATIENTS WITH ACUTE ISCHEMIC STROKE TREATED WITH INTRAVENOUS THROMBOLYSIS

Z Zivanovic ^1,², S Gvozdenovic ², A Lucic-Prokin ^1,², J Sekaric ², T Kokai-Zekic ², S Popovic ², M Zarkov ^1,², T Rabi-Zikic ^1,², I Divjak ^1,², P Slankamenac ^1,²

Abstract

Background

Intravenous thrombolysis (IVT) remains the main treatment of acute ischemic stroke. This study aimed to identify factors determining outcome after IVT in stroke patients in Vojvodina.

Methods

From 2008–2015, 210 patients were treated with IVT in Clinical Centre of Vojvodina. Early neurological improvement (ENI) was defined as a reduction of NIHSS score for ≥50%, or NIHSS score 0–3, after 24 hours. Favorable clinical outcome was defined as the modified Rankin Scale 0–2 after three months.

Results

There were 89 (42,4%) patients with ENI. Older age (66,4 vs. 62,6 years; p = 0,015), higher NIHSS score at admittance (14,2 vs. 11,7; p < 0,001), lower ASPECT score (9,1 vs. 9,54; p = 0,003), and haemorrhagic transformation (23,3% vs. 9,9%; p = 0,023), were associated with absence of ENI. NIHSS (OR 1,10; 95%CI 0,45–0,88) and ASPECT (OR 0,63; 95%CI 0,45–0,88) scores were the most significant predictors of ENI. One hundred seventy patients (55,7%) were functionally independent (mRS 0–2) after three months. Older age (68,8 vs. 61,9 years; p < 0,001), higher NIHSS score at admittance (15,7 vs. 11,3; p < 0,001), as well as after 24 hours (14,9 vs. 5,0, p < 0,001), lower ASPECT score (9,0 vs. 9,50; p = 0,001), higher glycemia at admittance (8,9 vs. 7,3 mmol/l; p < 0,001), hyperdense artery sign (32,5% vs. 52,7%, p = 0,005), leukoaraiosis (8,5% vs. 24,7%, p = 0,003), and diabetes (10,3% vs. 26,9%; p = 0,003), were associated with mRS >2 after three months. NIHSS score 24 hours after IVT was the best predictor of favorable clinical outcome.

Conclusions

Predictors of short-term and the 3-month outcomes were similar. Early neurological improvement is hopeful for a favorable outcome.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

EFFECT OF NON-WORKING HOURS ADMISSION ON OUTCOME AFTER INTRAVENOUS THROMBOLYSIS: THE THROMBOLYSIS IN ISCHEMIC STROKE PATIENTS (TRISP) STUDY

T Zonneveld ¹, S Curtze ², S Zinkstok ¹, C Nolte ³, S Engelter ⁴, P Nederkoorn ¹

Abstract

Background

In recent years, an unfavorable ‘non-working hours effect’ has been suggested in patients treated with intravenous thrombolysis (IVT). Recent studies investigating the relationship between admission time and clinical outcome yielded conflicting results. We aimed to assess the effect of admission during non-working hours on clinical outcome in a large European IVT cohort.

Methods

In a large multicenter cohort study, the ThRombolysis in Ischemic Stroke Patients (TRISP), we compared functional outcome on the modified Rankin Scale (mRS), symptomatic intracranial hemorrhage (sICH) and mortality between patients admitted during non-working hours versus those admitted during regular working hours. Non-working hours were defined as admission during weekday nights, weekends or public holidays. We used binary logistic regression models to calculate adjusted odds ratios (aORs).

Results

After excluding in-hospital strokes, patients additionally treated with intra-arterial therapy and patients with missing admission time or outcome data, 9498 patients were eligible for our primary analyses. Among these patients, 3868 (40.7%) were admitted during working hours and 5630 (59.3%) were admitted during non-working hours. After adjustment for potentially confounding factors, admission during non-working hours was significantly associated with poor functional outcome (mRS 2–6; aOR: 1.10, 95%-confidence interval (CI): 1.00 to 1.21). It was not associated with sICH (aOR: 0.95; 95%-CI: 0.78 to 1.17) or mortality (aOR 1.04; 95%-CI: 0.91 to 1.19).

Conclusions

Non-working hours admission seems associated with poor functional outcome in our large IVT cohort. Administration of IVT during non-working hours is safe in terms of sICH and mortality. Analyses are preliminary and possible explaining factors will be investigated.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

HEART RATE VARIABILITY AS A GLOBAL INDICATOR OF AUTONOMIC DYSFUNCTION AND STRESS IS ASSOCIATED WITH CRITICAL ISCHEMIC EVENTS AFTER TRANSIENT ISCHEMIC ATTACK OR MINOR STROKE

L Guan ¹, Y Wang ², G Mazowita ³, D Harris ⁴, V Claydon ⁵, R Brant ⁶, Y Wang ², JP Collet ⁷

Abstract

Background

The likely reason for the limitation of ABCD2 tool is the non-inclusion of other important risk factors responsible for ischemia. We consider the comprehensive “stress” (i.e. responsible for homeostasis deregulation) regulated by the autonomic nervous system (ANS) is as the risk factor for the development of critical ischemic events (CIE) after TIA/minor stroke. We hypothesize that heart rate variability (HRV) and its changes as parameters of ANS function may represent an accurate synthetic indicator of the whole stress level, with good predictive property for 90 days’ CIE occurrence.

Objectives: Primary: To investigate if the 24 hours’ changes in HRV are associated with CIE in 90 days. Secondary: To investigate if the values and circadian changes of HRV, self-perceived stress and the level of inflammatory cytokines are associated with CIE in 90 days.

Methods

A prospective observational study conducted in Beijing Tiantan Hospital. Patients over age 40 developed TIA/minor stroke within 48 hours are eligible. Main metrics include HRV parameters and their changes derived from 24-hour Holter, Perceived Stress Scale score and levels of TNF-a, IL-2, IL-6. CIE including ischemic stroke, TIA recurrences, cardiac and peripheral ischemic events will be assessed and validated by neurologists over three months. 200 participants will provide 90% power to find a hazard ratio of 3 between groups with increased or decreased HRV. Survival analysis, correlation analysis and receiver operating characteristic curve will be used.

Relevance

Identification of a comprehensive stress assessment tool with good predictive values may represent an important add-on to clinical care.

Results:

Conclusions:

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

SPONTANEOUS INTRACEREBRAL HEMORRHAGE IS AFFECTED BY THE MONTH OF RAMADAN

A Honig ¹, Y Pikkel ¹, R Eliahou ², R Schneider ³, R Leker ¹

Abstract

Background

During Ramadan Muslims fast from sunrise to sunset but have a large, sodium reach meal just before dawn. This practice may lead to sharp increments in blood pressure and increase the risk for sustaining spontaneous intracerberal hemorrhage (sICH). Therefore, our goals were to examine whether sICH incidence and attributes change during the month of Ramadan (RsICH) and to compare them to non-Ramadan sICH (nRsICH).

Methods

During 2004–2015 consecutive sICH patients were included in a prospective data base. Demographics, clinical and radiological data were compared between Muslim RsICH patients and Muslims with nRsICH as well as non-Muslims.

Results

Of the 308 included patients 65 were Muslim (18RsICH and 47nRsICH) and 243 were non-Muslims. sICH incidence was significantly increased in Muslims during the Ramadan period compared to other months (1.8/month vs. 0.4/month, p < 0.001). A similar trend was not observed in non-Muslims. Muslim RsICH patients had larger hematoma volumes (76.7 ± 59 ml vs. 38.1 ± 50 ml, P = 0.029) and lower survival rates compared with nRsICH (6/18 vs. 31/47 ICH, p = 0.025). RsICH patients also more often showed renal function impairment with an estimated Glomerular Filtration Rate < 89 ml/min (16/18 vs. 28/47, p = 0.036). Hematoma volumes, survival and renal impairment rates did not differ for various months in non-Muslims.

Conclusions

Ramadan fasting may affect morbidity and mortality in patients with sICH. Vulnerability for sICH during Ramadan may be especially increased in patients with renal impairment where sodium reach meals may cause higher blood pressures leading to increased hematoma volumes and decreased survival.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CIRCADIAN BLOOD PRESSURE VARIATION, CEREBRAL HEMODYNAMICS, AND WAKE-UP STROKE IN PATIENTS WITH INTRACRANIAL ARTERIAL STENOSIS

X LENG ¹, L LAN ¹, HL IP ¹, H LIU ¹, TW LEUNG ¹, DS LIEBESKIND ², KS WONG ¹

Abstract

Background

Circadian variations of blood pressure (BP) and a morning surge of ischemic stroke have been well known. However, mechanisms underlying their correlations are understudied. According to our recent study, systemic BP exerts impact on cerebral hemodynamics in patients with intracranial arterial stenosis (ICAS). Thus, in the proposed study, we aim to investigate the inter-correlations between circadian BP variation, cerebral hemodynamics, and wake-up stroke in such patients, by using computational fluid dynamics (CFD) modeling methods.

Methods

Patients with acute ischemic stroke due to ICAS identified by computed tomography angiography (CTA) will be recruited within 7 days of ictus, and defined to be wake-up strokes and other strokes by the onset time. A series of CFD models will be built for each patient based on vessel geometry from CTA, with the same outlet conditions using blood flow measured by transcranial Doppler, but different inlet conditions using BP measured hourly. Hourly BP measures and cerebral hemodynamic features will be compared between wake-up strokes and others, and correlations between them will be analyzed.

Results

There probably will be significant correlations between hourly BP measures and cerebral hemodynamics, and there may exist unique patterns of circadian variations in BP and cerebral hemodynamics in patients with wake-up stroke compared with others.

Conclusions

The study may shed light on the mechanisms of occurrence of wake-up stroke in patients with ICAS, and may raise questions on how to manage BP to prevent stroke in patients with reduced cerebral flow due to ICAS.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

COMPARISON OF INTRACEREBRAL HEMORRHAGE DURING PREGNANCY AND NON-PREGNANCY BASED ON PATIENT CHARACTERISTICS AND PROGNOSIS

Z Liang ¹, W Gao ¹

Abstract

Background

The purpose of this study was to assess the differences in pregnant and non-pregnant patients’ characteristics and predictors that influence the prognosis of intracerebral hemorrhage (ICH) at Beijing Tiantan Hospital, China.

Methods

We identified 61 pregnant and 61 non-pregnant patients aged 18–40 years with ICH who were seen between 1997 and 2012. The patients’ clinical data and ICH characteristics were analysed. A stratified logistic regression assessed the effects of the predictors on pregnancy outcomes.

Results

Our hospital’s prevalence was 252 per 100,000 deliveries. There were 13 maternal deaths for a case mortality rate of 21.31%. The mortality of pregnancy-associated ICH was significantly higher than that of non-pregnancy ICH (P < 0.05). Specifically, the mortality and mRS of the surgical treatment, conservative treatment, cerebrovascular disease, low Glasgow score, and long O-D time subgroups of pregnancy-associated ICH were significantly higher than those of the corresponding non-pregnant ICH groups (Ps < 0.05). The correlation analyses found that the Glasgow score, the O-D time and pre-eclampsia/hypertension were significantly associated with prognosis in both pregnant and non-pregnant ICH patients. When the prognosis was poor, O-D time and pre-eclampsia were significantly relevant for the pregnant ICH patients, but not relevant for the non-pregnant.

Conclusions

The pregnant women with ICH had presenting symptoms, aetiologies and bleeding sites similar to those of the non-pregnant women with ICH. However, the pregnant women were more often in critical condition and had higher mortality rates. Glasgow scores, O-D time and pre-eclampsia were significantly associated with maternal prognosis in pregnant ICH patients

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

HEALTH PROFESSIONALS' KNOWLEDGE, ATTITUDES, BEHAVIOURS AND BELIEFS TOWARDS SECONDARY STROKE PREVENTION AND SELF-MANAGEMENT

C Longman ¹, M Lawrence ²

Abstract

Background

Stroke is currently one of the leading causes of death and adult disability in the developed world. Following transient ischaemic attack (TIA) or stroke, rates of recurrence are high; 8.1% within 48 hours, with the cumulative risk of recurrence 10 years post-stroke being 39.2%. Such high rates of recurrence highlight a need for effective secondary prevention interventions. Evidence-based clinical guidelines recommend implementation of multimodal lifestyle interventions that address modifiable risk factors. The need to reduce the risk of recurrence associated with behavioural risk factors coincides with worldwide imperatives which promote a move towards self-management of long-term conditions.

Methods

The aim of this PhD study, which commenced in October 2015, is to explore health professionals’ knowledge, attitudes, beliefs and behaviours regarding implementation of stroke secondary prevention lifestyle interventions which adopt a self-management approach. The study seeks to fill an important gap in the current evidence-base.

Adopting a mixed-methods approach, the study has three interrelated phases: a systematic review of the literature; qualitative interviews with key stakeholders; and a large-scale cross-sectional survey.

Results

The proposed paper will report on the systematic review methods, including protocol development, the search strategy, screening, data extraction and quality appraisal. Findings from the systematic review will also be shared.

Conclusions

It is important to understand the health professionals' perceptions and experiences as they are the 'gate keepers' of information and are central to the success of any prevention programme.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

ETIOLOGIES AND RISK FACTORS OF ISCHEMIC STROKE IN YOUNG WOMEN OF KYRGYZSTAN

I Lutsenko ¹

Abstract

Background

Given study was conducted to determine etiologies and risk factors for ischemic stroke in young women in Kyrgyzstan.

Methods

58 patients aged 18 to 44 (mean age: 37 years), were enrolled in an observational epidemiological study in the acute period of ischemic stroke, taking into account their residence (lowlands, middle lands, highlands). All patients were examined with general laboratory tests, heart, extracranial vessels ultrasound and brain MRI. Adjusted odds ratios (ORs) were calculated using conditional logistic regression.

Results

There were more highlands patients with severe stroke in women (OR = 8, 95% CI, 0.73 to 0.99). Among etiologies we revealed dominating cerebral venous sinuses thrombosis, vasculitis, and thrombophilia in pregnancy. Following investigations detected abnormalities associated with a higher risk of stroke: arterial dissection (2), carotid occlusion based on vasculitis (5), carotid atheroma (5), anticardiolipin antibodies (9), essential thrombocytaemia (3), thrombophilia in pregnancy (13), atrial fibrillation (3). Factors associated with an increased risk were heart disease (OR 7.8; 95% CI, 0.44 to 0.93), hypercoagulation (OR = 8.3; 95% CI, 0.72 to 0.88), previous venous thromboembolism (OR = 2; 95% CI, 0.62 to 0.90), migraine (OR = 2.3; 95% CI, 0.75 to 0.97), and use of combined oral contraceptives (OC) (OR = 2.3; 95% CI, 0.75 to 0.97). The risk of stroke in women with chronic migraine using OC was 7.2 compared with those without migraine not using oral contraceptives (P = 0.003).

Conclusions

The results of this observational study are consistent with international studies of ischemic stroke in young women. High altitude residency in combination with hypercoagulate state was significantly associated with severe ischemic strokes development.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

DEFINING A ‘DOSE-RESPONSE’ CURVE BETWEEN CARBON DIOXIDE AND DYNAMIC CEREBRAL AUTOREGULATION

JS Minhas ¹, RB Panerai ¹, M Nath ¹, TG Robinson ¹

Abstract

Background

Dynamic CA (dCA) can be estimated from the transient cerebral blood flow (CBF) response to rapid blood pressure (BP) changes, using the autoregulation index (ARI). Previous Transcranial Doppler ultrasound (TCD) studies demonstrate that dCA is impaired following acute stroke, though there is a lack of consistency, particularly with respect to stroke-subtype. Changes in PaCO2, a potent determinant of CBF and dCA, could be one factor to explain this. To address this, we have constructed dose-response curves for the influence of CO2 on dCA.

Methods

This prospective observational study of 43 healthy volunteers (18 male) aged 20–79 years of South-Asian (15) and White-European (29) extraction had TCD and beat-to-beat-BP at baseline, and under hypercapnic (5% and 8% CO2) and hypocapnic (−5 mmHg and −10 mmHg below baseline) conditions. ARI was calculated by transfer-function-analysis. A linear mixed model was fitted to explore the relationship between ETCO2 and dCA, along with gender and ethnicity.

Results

A curvilinear relationship exists between ETCO₂ and ARI (p < 0.001). The interaction effect of gender and ETCO₂ was statistically significant (p < 0.001) with females showing a steeper decline than males. There was weak evidence for an ethnicity (p = 0.048) and age effect (p = 0.059); White-European associated with higher ARI and increasing age with lower.

Conclusions

The dose-response curves obtained for the influence of pCO2 on dCA could be used to correct for different pCO2 levels in stroke patients, leading to more comparable values of ARI that could also take into account the influence of gender/ethnicity/age. Further work is needed to evaluate these results in a stroke population.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

COGNITIVE IMPAIRMENT AND MEDICATION ADHERENCE IN STROKE

D Rohde ¹, K Bennett ², D Williams ³, A Hickey ¹

Abstract

Background

Stroke is one of the leading causes of death and disability worldwide, and is associated with an increased risk of cognitive impairment. Cardiovascular risk factors appear to increase the risk of cognitive impairment, while effective risk factor control may reduce this risk. However, adherence to cardiovascular medications is often poor, and can be adversely affected by cognitive impairment. While use of cardiovascular medications may be related to a reduced risk of cognitive impairment, it is unclear how sub-optimal adherence affects the risk of cognitive impairment in stroke patients.

Methods

The aim of this PhD thesis is to investigate the bidirectional association between cognitive impairment and medication adherence in stroke, through three studies.

Results

Study 1 will systematically review the current evidence on the association between cognitive impairment and medication adherence in stroke. Study 2 will examine the prospective associations between cognitive impairment and medication adherence, and their impact on stroke recurrence, through recall of the ASPIRE-S (Action on Secondary Prevention Interventions and Rehabilitation in Stroke) cohort of stroke patients. Study 3 will explore these associations, and their impact on incident stroke, through secondary analysis of data from The Irish Longitudinal Study on Ageing.

Conclusions

Findings from these three studies will help to elucidate the bidirectional association between cardiovascular medication adherence and cognitive impairment, and will indicate whether improving medication adherence presents a potential strategy to prevent or delay cognitive impairment.

Eur Stroke J. 2016 May 10;1(1 Suppl):3–612.

CEREBRAL SMALL VESSEL DISEASE ASSOCIATED WITH THE CHANGE OF COGNITIVE FUNCTION IN ADULTS WITH TYPE 1 DIABETES

X Zhang ¹, C Fang ², Z Jiang ³, JW Zhang ³, ZC Huang ¹, YJ Cao ¹

Abstract

Background

Type 1 diabetes mellitus (TIDM) patients have an increased risk of cognitive deficits. The role of cerebral small vessel disease, in its pathogenic mechanisms, has not been explored. This study aims to identify cerebral white matter lesions(WML), lacunar infarcts and microbleeds(MB) in relation to cognition in T1DM adults

Methods

86 right-handed TIDM patients between 18 and 65 years diagnosed for >3 years, and 81 sex- and age-matched healthy controls are included. All subjects accept evaluation of MMSE and MoCA scales. A thorough clinical history is also recorded and some laboratory indices for T1DM patients, such as hemoglobin A1C(HbA1C), serum and urine creatinine, serum urea nitrogen, and urine microalbumin, are analyzed. Cranial magnetic resonance imaging (MRI) is carried out on all subjects with a 3D T1 and T2 magnetization-prepared rapid gradient-echo, fluid-attenuated inversion recovery (FLAIR) and gradient-echo T2*-weighted sequences. The number of MB and lacunar infarcts are rated and categorized into different locations. WMLs were manually segmented on FLAIR images and rated using the Age-Related White Matter Changes scale

Results

The differences of cognitive function between T1DM patients and healthy controls were compared. The relation of cognitive dysfunction of T1DM patients to the severity and location of cerebral small vessel disease is explored

Conclusions

The study has been first cross-sectional, case-control cohort study to evaluate the relation of cognitive dysfunction of T1DM patients to cerebral small vessel disease. It is hoped to supply evidences on pathogenic mechanisms of cognitive dysfunction of T1DM patients and find some new treatment approaches

PERMALINK

Poster Abstracts

HOSPITAL READMISSION FOR BLEEDING OR THROMBOEMBOLISM IN PATIENTS WITH NEW ONSET ATRIAL FIBRILLATION

D Bista

L Chalmers

G Peterson

L Bereznicki

Abstract

Background

Methods

Results

Conclusions

ATRIAL FIBRILLATION IN TRANSIENT ISCHEMIC ATTACK - COMMON BUT SUBSTANTIALLY UNDERTREATED

F Buchwald

B Norrving

J Petersson

Abstract

Background

Methods

Results

Conclusions

STROKE PREVENTION: COMMUNITY BASED 5 DAY SCREENING FOR ATRIAL FIBRILLATION IN HIGH RISK COHORTS

R Coary

R Collins

C Burke

J McCourt

T Coughlan

R Kelly

Abstract

Background

Methods

Results

Conclusions

CLINICAL PRACTICE WITH APIXABAN IN SECONDARY STROKE PREVENTION

A De Felipe-Mimbrera

R Alvarez-Velasco

C Matute Lozano

R Vera

A Cruz-Culebras

A Alonso-Canovas

S Sainz de la Maza

C Estevez Fraga

P Perez Torre

J Masjuan

Abstract

Background

Methods

Results

Conclusions

PREVALENCE OF AND RISK FACTORS FOR SILENT BRAIN INFARCTS IN PATIENTS WITH ATRIAL FIBRILLATION USING 3T-MRI

I Escudero

R Ocete

A López-Rueda

P Piñero

E Fajardo

JR Fernández-Engo

F Mancha

Á Vega

E Zapata

M Prieto

FJ De la Torre

R Rodríguez

F Moniche

J Montaner

Abstract

Background

Methods

Results

Conclusions

SPONTANEOUS SPINAL EPIDURAL HAEMATOMA DURING APIXABAN TREATMENT

C Estevez-Fraga

R Alvarez-Velasco

A De Felipe-Mimbrera

P Aguero-Rabes

E Viedma-Guiard

R Garcia-Latorre

L Crespo-Araico

V Nedkova

B Escribano-Paredes

A Cruz-Culebras