Poster Session II Thursday 31 May 2007
Cerebrovasc Dis 2007;23(suppl 2):1–147
Risk factors of stroke
1 Risk factors of stroke
LUNG FUNCTION AND LONG-TERM FATAL STROKE
U. Goldbourt, D. Tanne
Tel Aviv University Department of Epidemiolgy and Preventive Medicine, Tel
Aviv, Israel
Background: Research on lung function and incidence of stroke has yielded
conflicting results. Participants and methods: For 10,232 men of diverse countries
of origin, civil servants and municipal employees, who participated in the Israeli
Ischemic Heart Disease (IHD) study in 1963, extensive demographic, biochemical,
socioeconomic and clinical information was collected in 1963, 1965 and 1968. Of
these men, 4330 underwent an assessment of forced vital capacity (VC) and 1.0 sec
forced expiratory volume (FEV).
Results: Over a 23-yr follow up, 1297 men died, among whom for 136 the
recorded underlying cause of death was stroke. For quartiles of VC, as % of age
and height predicted level, there was a modest gradient of fatal stroke (18,16,14
and 13 per 10,000 person-years) which was erased upon age-adjustment. The
corresponding rates declined from to 23 to 18, 10 and 8 per 10,000 person years
for FEV, or 19,15,14 and 10 for FEV as percent of FVC, in the 1st,2nd,3rd, and
4th quartiles, respectively (P for trend=0.02 for the former and 0.55 for the latter
by Mantel-Cox trend test after age-adjustment and exclusion of baseline IHD and
cancer). Further adjustment for height which was markedly, inversely related to
stroke mortality eliminated both associations. There was no appreciable interaction
between smoking habits and lung function with respect to long-term fatal stoke.
Conclusions: In this cohort, low FEV, whether in absolute terms or in relation to
FVC, did not appear to be an independent marker of risk for fatal stroke beyond
age and height.
2 Risk factors of stroke
CLOPIDOGREL RESISTANCE: ROLE OF BODY MASS AND CONCOMITANT
MEDICATIONS
G. Feher, K. Koltai, B. Alkonyi, L. Szapary, G. Kesmarky, S. Komoly, K. Toth
University of Pecs, Medical School, Pecs, Hungary
Introduction: Platelets have a central role in the development of arterial thrombosis
and subsequent cardiovascular events. An appreciation of this has made antiplatelet
therapy the cornerstone of cardiovascular disease management. Recent studies have
described the phenomenon of clopidogrel resistance but the possible mechanisms
are still unclear.
Patients and methods: The aim of this study was to compare the characteristics
(risk profile, previous diseases, medications, hemorheological variables and plasma
von Willebrand factor and soluble P-selectin levels) of patients in whom clopi-
dogrel provided effective platelet inhibition with those in whom clopidogrel was
not effective in providing platelet inhibition. 157 patients with chronic cardio- and
cerebrovascular diseases (83 males, mean age 61±11 yrs, 74 females, 63±13 yrs)
taking 75 mg clopidogrel daily (not combined with aspirin) were included in the
study.
Results: Compared with clopidogrel-resistant patients (35 patients (22%), patients
who demonstrated effective clopidogrel inhibition had a significantly lower BMI
(26.1 vs. 28.8 kg/m2 , p<0.05). Patients with ineffective platelet aggregation were
significantly more likely to be taking benzodiazepines (25% vs. 10%) and selective
serotonin reuptake inhibitors (28% vs. 12%) (p<0.05). After an adjustment to
the risk factors and medications BMI (OR 2.62; 95% CI: 1.71 to 3.6; p<0.01),
benzodiazepines (OR 5.83; 95% CI: 2.53 to 7.1; p<0.05) and SSRIs (OR 5.22; 95%
CI: 2.46 to 6.83; p<0.05) remained independently associated with CLP resistance.
There was no significant difference in the rheological parameters and in the plasma
levels of adhesive molecules between the two examined groups.
Conclusion: The background of ineffective clopidogrel medication is complex.
Drug interactions may play a role on clopidogrel bioavailability, on the other hand,
Poster Session
Risk factors of stroke
the significant difference in BMI between the two examined groups suggests that
clopidogrel therapy should be weight-adjusted.
3 Risk factors of stroke
ASSOCIATION OF METABOLIC SYNDROME WITH ISCHEMIC STROKE IN
PATIENTS WITH INTRACRANIAL ATHEROSCLEROSIS
J.H. Park
Myongji Hospital, Kwandong University, College of Medicine, Goyang-si,
South Korea
Background and purpose: Metabolic syndrome (MetS) is associated with intracra-
nial atherosclerosis. Patients with more severe MetS components were reported
to be more likely to have intracranial atherosclerosis. To elucidate the association
between MetS and ischemic stroke, we attempted to demonstrate the association of
MetS and its individual components with frequency of ischemic stroke lesions and
investigated the independent associations between them in acute ischemic stroke
patients.
Methods: We evaluated 370 acute ischemic stroke patients who underwent brain
magnetic resonance (MR) imaging and MR angiography. The stroke subgroups
were categorized as intracranial large artery atherosclerosis (IC-LAA, n=151),
extracranial large artery atherosclerosis (EC-LAA, n=29), and nonatherosclerosis
(NA, n=190). MetS was defined using the criteria of the National Cholesterol
Education Program Adult Treatment Panel III.
Results: Patients with IC-LAA group showed a higher rate of previous ischemic
lesions and MetS than those with EC-LAA and NA (all P<0.001). The number of
previous ischemic lesions showed a tendency to increase as the number of MetS
components increased in the IC-LAA group (P=0.002). In the IC-LAA group, MetS
was independently associated with previous ischemic lesions (OR, 3.80 P<0.001)
which was prominent with more severe MetS components after adjustment for risk
factors (P<0.001). Among the component conditions, high blood pressure, im-
paired fasting glucose, and abdominal obesity were predominantly associated with
previous ischemic lesions (all P<0.001). Conclusions: MetS was associated with
ischemic stroke with IC-LAA. Controlling the MetS components is mandatory with
the aim of preventing from advanced intracranial atherosclerotic vascular damage
and ischemic stroke. Further studies of different ethnics need to be performed to
confirm whether MetS is more associated with those with IC-LAA.
4 Risk factors of stroke
DEATH AND DEPENDENCE ONE YEAR AFTER THE FIRST TRANSIENT
ISCHAEMIC ATTACK: A POPULATION-BASED STUDY IN RURAL AND
URBAN NORTHERN PORTUGAL
M. Correia, M.R. Silva, E. Moreira, R. Magalhães, M.C. Silva
Institute for Molecular and Cell Biology, University of Porto, Porto, Portugal
Background and purpose: Information about prognosis of transient ischaemic at-
tacks (TIA) is scarce, particularly in population-based studies. Recent data showed
a high early risk of stroke after a TIA, reaching 12.7% at seven days. In this study
prognosis of a first TIA is evaluated in terms of risk of death and dependence,
taking into account the occurrence of stroke after the index event.
Methods: The 141 patients with a first–ever-in-a-lifetime TIA occurred between
October 1998 and September 2000 in a rural population of 18677 and an urban
population of 86023 were entered a registry. A neurologist observed these patients
soon after the episode and also at three and twelve months after the TIA. Previous
dependence and dependence after the episode was determined by the modified
Rankin scale (score 3 or more).
Results: One year after the TIA, 10 out of 105 patients (9.5%) in the urban area
were death, compared to 6 out of 36 (16.7%) in the rural area. Amongst the
survivors 23.7% were dependent one year after the episode, 25.8% in the urban
area and 17.2% in rural area (excluding seven that were lost to follow-up). In the
urban area this proportion reduces to 22.8% taking into account those previously
dependent. Comparing the Rankin score before and one year after the episode, 77
Cerebrovasc Dis 2007;23(suppl 2):1–147 81
(57.5%) become more dependent or died, 53 (39.6%) kept their score and only consistent and robust in a variety of sensitivity analyses. Notably, soluble RANKL
four patients improved their score (Wilcoxon test, z=7.5, p<0,001). As expected was not associated with carotid or femoral artery atherosclerosis assessed and
the occurrence of stroke during the follow-up period worsened the prognosis at one monitored by high-resolution ultrasound.
year (Mann-Whitney, z=2.7, p=0.007). Conclusions: Our study lends large-scale epidemiological support to a role of
Discussion: The occurrence of a first TIA carries out not only an early risk of RANKL in CVD. In the absence of a significant association between RANKL and
stroke, but most of the patients showed an increased degree of dependence one year atherosclerosis the view that RANKL promotes plaque destabilization and rupture
after the episode. The occurrence of stroke after a TIA is partially responsible for is a highly appealing concept.
this prognosis.
Study supported by: FCT/FEDER project POCI/SAU-ESP/59885/2004
7 Risk factors of stroke
5 Risk factors of stroke INCREASED PREVALENCE OF VASCULAR RISK FACTORS BUT EQUAL
ACCESS TO HOSPITAL SERVICES IN A DEPRIVED TRANSIENT
AGE PREDICTS DELAYED TRANSIENT ISCHAEMIC ATTACK ISCHAEMIC ATTACK POPULATION
INVESTIGATION AND MANAGEMENT T.J. Quinn, J. Dawson, K.R. Lees, M.R. Walters
T.J. Quinn, J. Dawson, K.R. Lees, M.R. Walters Gardiner Institute of Cardiovascular and Medical Sciences, University of
Gardiner Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
Glasgow, Glasgow, United Kingdom
Introduction: Cerebrovascular disease is over represented in socially deprived
Introduction: Cerebrovascular events increase in frequency and severity with age. communities but traditional vascular risk factors do not account for all the vari-
Recent studies suggest that elderly UK patients diagnosed with transient ischaemic ation. Unequal access to and uptake of specialist management could contribute.
attack (TIA) are inappropriately denied evidence based intervention. Similar ex- We analysed data on TIA clinic attendance, seeking effects of socioeconomic
amples of “ageism” have been reported in many other areas of hospital medicine. deprivation.
Due to the frequency of events immediately following TIA, urgent assessment and Methods: We serve an urban population including the most affluent and deprived
initiation of treatment is essential. We examined if age influenced referral to a areas of the city. We prospectively record structured details of patients seen at clinic.
“fast-track” TIA clinic. Socio-economic deprivation was measured from postcodes and the 2001 census,
Methods: Our TIA clinics assess all suspected cerebrovascular events referred. using the Depcat ordinal hierarchical scale, ranging from 1=least deprived to
Patient details are prospectively recorded in a comprehensive database. Data were 7=most deprived. We analysed the association between social deprivation, referral
collated for patients seen between August 1992 and January 2005. Patients were and vascular risk factors by ANOVA. We interpreted delay from symptom onset to
categorised according to age: 0-40; 41-65; 66-75; 76+. Associations between age clinic referral as a marker of access to specialist care.
and: mode of referral (letter; phone call; other); time to referral; time from referral Results: We assessed 3462 patients between August 1992 to January 2005. The
to appointment and initiation of treatment prior to clinic were analysed using the most deprived areas were over represented, with 1711 patients in Depcat 6 - 7.
Kruskal-Wallis test. There was no association between clinic referral or attendance and Depcat. There
Results: Full data were available for 3495 of 3596 patients assessed during the were significant associations between Depcat and “lifestyle” factors of smoking
study period, median age 67 (range 16-95). There was no significant association and alcohol excess (each p<0.005).
between increasing age and delay from symptom onset to referral time (P=0.014);
mode of referral (P=0.131) or time to appointment (P=0.652). The youngest patients
Depcat1 Depcat2 Depcat3 Depcat4 Depcat5 Depcat6 Depcat7
were less likely to be prescribed antiplatelet (P<0.001).
Delay to clinic (days) 16.5 35.2 28.9 33.9 37.5 89.6 55.3
Smoking % 6.1 13.9 24.7 34.6 24.8 40.1 46.3
Age (years) Median Referral Median Appointment Number of Number on Hypertension % 39 27.9 44.1 42.3 46.3 44.4 44.1
Time (days) Time (days) Phoned Referral Anti-platelet Diabetes % 5.1 3.7 7.8 18.6 7.5 9.3 7.7
Dyslipidemia % 16.9 8.9 16.3 18.7 14.2 19 17.9
0–40 (n=188) 6 8 28 (14.9%) 35 (18.6%)
Alcohol % 2.3 1.2 4.8 3.7 3.8 4.3 5.2
41–65 (n=1431) 8 9 191 (13.3%) 511 (35.7%)
66–75 (n=1035) 7 9 164 (15.8) 337 (32.6%)
Over 75 (n=805) 6 9 120 (14.9) 271 (33.7%)
Discussion: The effect of deprivation on cerebrovascular health inequality is partly
explained by certain vascular risk factors but not by access to hospital services.
Discussion: We have found no evidence of ageism in access to TIA services.
However, delays to clinic assessment remain substantial. Public education strategies
to promote early presentation with TIA symptoms are required. 8 Risk factors of stroke
DO CONVENTIONAL VASCULAR RISK FACTORS INFLUENCE BRAIN
6 Risk factors of stroke ARTERIOVENOUS MALFORMATIONS? PROSPECTIVE,
POPULATION-BASED COHORT AND CASE-CONTROL STUDIES
SOLUBLE RECEPTOR ACTIVATOR OF NUCLEAR FACTOR-KB LIGAND T.M. Brock, R. Al-Shahi Salman
(RANKL) AND RISK FOR CARDIOVASCULAR DISEASE Division of Clinical Neurosciences, University of Edinburgh, Edinburgh, United
S. Kiechl, G. Schett, J. Schwaiger, K. Seppi, P. Eder, G. Egger, P. Santer, Kingdom
A. Mayr, Q. Xu, J. Willeit
Innsbruck Medical University, Innsbruck, Innsbruck, Austria Background: Conventional risk factors for cerebral infarction and haemorrhage
are thought to play little – if any – role in either causing brain arteriovenous
Background: Overexpression of RANKL is a prominent feature of vulnerable malformations (AVMs), or influencing their behaviour.
atherosclerotic lesions prone to rupture and was suggested to contribute to the Methods: We extracted data on vascular risk factors from the medical records
transition from a stable to an unstable plaque phenotype in both human and of 229 adults newly-diagnosed with a brain AVM, who were enrolled between
murine atherosclerosis because of its ability to promote matrix degradation, 1999-2003 in a prospective, population-based cohort study in Scotland (SIVMS).
monocyte/macrophage chemotaxsis and vascular calcification. A sample of 36 adults with brain AVMs were sex-matched and age-matched (to
Methods and results: The Bruneck Study is a prospective population-based survey within 5 years) with 36 controls.
of men and women 40-79 years old at the 1990 baseline examination. Levels of Results: In the case-control study, adults with brain AVMs were more likely than
soluble RANKL and other variables were assessed in 909 subjects (1990) and controls to have smoked at some stage in their life (75% versus 50%, p=0.028;
up-dated every five years. All cases of cardiovascular disease (CVD) were carefully odds ratio [OR] 3.0, 95% confidence interval [CI] 1.1 to 8.1), but this relationship
recorded between 1990 and 2005. did not hold for current smokers, nor was it found for hypertension, ischaemic
During follow-up, CVD (defined as ischemic stroke and TIA, myocardial infarction heart disease, alcohol consumption, hyperlipidaemia, or diabetes mellitus. In the
and vascular death) manifested in 124 subjects. The level of soluble RANKL whole cohort, 116 (72%) had smoked sometime in their life, and 29 (14%) had
emerged as a highly significant predictor of vascular risk (adjusted hazard ratio hypertension prior to the first presentation of their brain AVM. There was no
[95%CI] 1.27 [1.16-1.40]; P<0.001). Predictive significance was independent of significant difference between adults who did (n=114) and did not (n=115) present
that afforded by classic vascular risk factors, C-reactive protein and osteoprotegerin with intracranial haemorrhage in pre-presentation hypertension, smoking, or any
concentration and severity of carotid atherosclerosis. Findings were internally other vascular risk factors.

82 Cerebrovasc Dis 2007;23(suppl 2):1–147 16th European Stroke Conference

Discussion: Smoking appears to be associated with the occurrence of brain AVMs,
but this finding needs confirmation in other cohorts, and larger studies. Vascular
risk factors do not appear to influence whether a brain AVM first presents with
a haemorrhage or not, but their influence on the occurrence of haemorrhage after
AVM diagnosis requires further investigation.
9 Risk factors of stroke
NO INCREASED RISK OF RECURRENT STROKE IN PFO CARRIERS
H. Poppert, A. Bockelbrink, M. Morschhaeuser, J. Schwarze, P. Heider,
L. Esposito, D. Sander
Munich University of Technique, Munich, Germany
Background: Contrast-enhanced transcranial Doppler ultrasonography (cTCD) is
a sensitive noninvasive screening method for detection of a patent foramen ovale
(PFO). We aimed to investigate the relationship between a suchlike detected
right-to-left shunt (RLS) and subtypes of cerebral ischemia as well as the risk of
stroke recurrence.
Methods: The records of 763 patients with definite diagnosis of cerebral ischemia
at discharge were analyzed retrospectively. All patients had undergone TCD based
RLS detection. Stroke origin was subtyped using the TOAST classification criteria.
For follow-up all patients were contacted by mail. In case a patient did not answer,
we tried to contact the patient or the patients relatives and the family doctor by
telephone.
Results: A RLS was detected in 140 (28%) male and in 114 (42%) female patients.
These patients were younger (p<0.001) and in male patients presence of RLS
was associated with stroke of unknown origin (p=0.001). In female patients this
association was not significant (p=0.076). After adjustment for age no significant
association was found in either group.
Complete follow-up data with a median follow-up period of 4 years could be
collected in 639 patients (83.7%). 10 shunt-carriers (4.7%) and 32 patients (7.6%)
without RLS (p=0.180) had suffered a recurrent stroke. Logistic regression adjust-
ing for age, gender and stroke subtype confirmed the lack of a positive correlation
(OR 0.7 (95%CI 0.33-1.48)).
Conclusion: We found age and gender to be important confounders in the often
cited association of PFO and cryptogenic stroke. This has not been taken into
account in most previous studies. Furthermore, RLS did not correlate with stroke
recurrence, thus weakening the thesis of a PFO generally being an important risk
factor for stroke.
10 Risk factors of stroke
TYPE 3 PHOSPHODIESTERASE INHIBITORS MAY BE PROTECTIVE
AGAINST CEREBROVASCULAR EVENTS IN PATIENTS WITH
CLAUDICATION
W.M. Stone, S.R. Money, R.J. Fowl
Mayo Clinic Arizona, Phoenix, AR, USA
Objective: The risk of cerebrovascular events in patients with mild to moderate
peripheral vascular disease is significant. Cilostazol is a phosphodiesterase type 3
(PDE3) inhibitor that is effective in the treatment of symptoms of peripheral arterial
occlusive disease. The method of action includes antithrombotic, vasodilatory, and
antiproliferative effects.
Methods: The CASTLE trial was a prospective randomized double blinded trial
to establish the safety of this PDE3 inhibitor use in 1435 patients with mild
to moderate peripheral arterial occlusive disease. A post-hoc analysis of the
CASTLE trial was undertaken to evaluate Cilostazol usage on cerebrovascular
events. Blinded adjudication of all cerebrovascular events (stroke, TIA, and carotid
revascularization) in this trial was performed. Kaplan Meier analysis was used for
statistical evaluation.
Results: The overall rate of cerebrovascular events was 4.6% (66 of 1435 patients)
with a mean followup of 515 days. Ischemic vascular events were more common
(2.5%) than hemorrhagic events (0.3%), (p<0.05). The placebo group demonstrated
a greater risk for events, 5.8% (42 of 718 patients) vs. the Cilostazol treated group,
2.9% (21 of 717 patients), (p<0.05). Cerebrovascular risk factors were similar in
both groups.
Conclusion: The risk of cerebrovascular events in patients with mild to moderate
peripheral arterial occlusive disease is 4.6% with a mean followup of 515 days.
Treatment with PDE3 inhibitors may reduce this risk. Further evaluation of the use
of PDE3 inhibitors for prevention of cerebrovascular events should be considered.
Poster Session
Risk factors of stroke
11 Risk factors of stroke
DEPRESSIVE SYMPTOMS AND RISK OF STROKE: THE ROTTERDAM
STUDY
M.J. Bos, T. Lindén, P.J. Koudstaal, A. Hofman, I. Skoog, H.W. Tiemeier,
M.M. Breteler
Erasmus Medical Center, Rotterdam, Rotterdam, The Netherlands
Background: Results from previous studies that assessed whether self-reported
depressive symptoms predispose to stroke in the general elderly population are
controversial and they did not distinguish between men and women, nor did they
perform psychiatric workups in those who reported depressive symptoms. We
examined the association between depressive symptoms, depressive disorder, and
risk of stroke in the general population.
Methods: This prospective population-based cohort study was based on 4424
participants of the third Rotterdam Study survey (1997-1999), who at that time
were ≥61 years of age, free from stroke, and underwent Center for Epidemiological
Studies Depression Scale (CESD) interview. Depressive symptoms were considered
present if CESD score was ≥16. Participants with depressive symptoms underwent
diagnostic workup for depressive disorder. Follow-up for incident stroke was
complete until January 1, 2005. Data were analyzed with Cox proportional hazards
models with adjustment for relevant confounders.
Results: Men with depressive symptoms were at increased risk of stroke (adjusted
hazard ratio (HR) 2.15; 95% confidence interval (CI) 1.10-4.22) and ischemic
stroke (adjusted HR 3.25; 95% CI 1.62-6.50). In women there was no association
between presence of depressive symptoms and risk of stroke. The associations
that we found were at least partly attributable to persons who reported depressive
symptoms but who did not fulfil DSM-IV diagnostic criteria for depressive disorder.
Discussion: Presence of depressive symptoms is a strong risk factor for stroke in
men but not in women.
12 Risk factors of stroke
ASPIRIN RESISTANCE: POSSIBLE ROLES OF CARDIOVASCULAR RISK
FACTORS, PREVIOUS DISEASE HISTORY, CONCOMITANT MEDICATIONS
AND HAEMORRHEOLOGICAL VARIABLES
G. Feher, K. Koltai, B. Alkonyi, L. Szapary, G. Kesmarky, S. Komoly, K. Toth
University of Pecs, Medical School, Pecs, Pécs, Hungary
Introduction: The aim of this study was to compare the characteristics (risk
profile, previous diseases, medications and haemorrheological variables) of patients
in whom aspirin provided effective platelet inhibition with those in whom aspirin
was not effective in providing platelet inhibition.
Patients and methods: 599 patients with chronic cardio- and cerebrovascular
diseases (355 men, mean age 64 ± 11 years; 244 women, mean age 63 ± 10
years) taking aspirin 100-325 mg/day were included in the study. Blood was
collected between 8:00am and 9:00am from these patients after an overnight fast.
The cardiovascular risk profiles, history of previous diseases, medication history
and haemorrheological parameters of patients who responded to aspirin and those
who did not were compared. Platelet and red blood cell (RBC) aggregation were
measured by aggregometry, haematocrit by a microhaematocrit centrifuge, and
plasma fibrinogen by Clauss’ method. Plasma and whole blood viscosities were
measured using a capillary viscosimeter.
Results: Compared with aspirin-resistant patients, aspirin sensitive patients had
a significantly lower plasma fibrinogen level (3.3 g/L vs 3.8 g/L; p < 0.05) and
RBC aggregation values (24.3 vs 28.2; p < 0.01). In addition, significantly more
patients with effective aspirin inhibition were hypertensive (80% vs 62%; p <
0.05). Patients who had effective platelet aggregation were significantly more likely
to be taking beta-adrenoceptor antagonists (75% vs 55%; p < 0.05) and ACE
inhibitors (70% vs 50%; p < 0.05), patients with ineffective platelet aggregation
were significantly more likely to be taking HMG-CoA reductase inhibitors (statins)
[52% vs 38%; p < 0.05]. Use of statins remained an independent predictor of
aspirin resistance even after adjustment for risk factors and medication use (odds
ratio 5.92; 95% CI 1.83, 16.9; p < 0.001).
Conclusions: Impaired hemorheological parameters are associated with aspirin
resistance. It is also possible that drug interactions with statins might reduce aspirin
bioavailability.
Cerebrovasc Dis 2007;23(suppl 2):1–147 83
 13 Risk factors of stroke
PSYCHO-SOCIAL FACTORS INFLUENECE STROKE OUTCOME
G. Szabó, L. Molnár, C. Óváry, Z. Nagy
National Stroke Centre/Budapest, Balassagyarmat, Hungary
Background: Factors influencing stroke outcome are subject of interest. The aim
of present study was to compare the impact of “traditional” risks factors and
psychosocial factors on modified Rankin scale.
Methods: In the stroke unite of a county hospital, 646 consecutive stroke patients
were include in this study. Determining disease outcome we used the modified
Rankin scale after 28 days of stroke onset. Stroke risk factors were recorded and
psychosocial data (Beck depression scale, coping skills, educational attainment,
and isolation) were collected using the standardized questionnaires. For statistics
we used a multiway contingency tables with log linear modelling.
Results: A log linear model fits well (p=0.786) to our data. Patients suffering form
repeated stroke showed significantly worse outcome (p<0.001). Hypertension,
diabetes mellitus, hyperlipidemia and smoking were not significant factors on
stroke outcome. On the other hand close relationship could be described in the
3-factors interaction among depression, isolation and stroke outcome, furthermore
among coping skills, depression, and stroke outcome, finally among coping skills,
educational attainment, and stroke outcome. The 2-factors interaction between
educational attainment and isolation, and between educational attainment and
depression could be also proved.
Discussion: The significant effects of depression, insufficient coping skills, low ed-
ucational level, and isolation on stroke outcome were documented. Better managing
of these factors may improve the quality of life after stroke.
14 Risk factors of stroke
STROKE IN CHRONIC KIDNEY DISEASE: PATTERNS OF STROKE,
FACTORS AFFECTING DEVELOPMENT OF STROKE
S. Jung, S.H. Hwang, S.B. Kwon, K.H. Kwon, I.S. Koh, K.H. Yu, B.C. Lee
Hallym University College of Medicine, South Korea
Background: Patients with chronic kidney disease (CKD) have increased risk for
stroke. Although they share conventional stroke risk factors, not all CKD patients
suffer stroke. We analyzed the pattern of stroke and tried to elucidate the factors
affecting development of stroke in patients with CKD.
Method: We used data from Hallym Stroke Registry (HSR) for enrolling patients
with stroke and chronic renal failure (CRF) or end stage renal disease (ESRD) as
CKD. Forty patients were included from total 55 patients with acute stroke within
7 days of onset who were diagnosed as CKD from July 1996 through June 2005.
35 patients with CKD who did not develop stroke were selected as the control
group. We classified patients according to the modified TOAST classification
and evaluated their neurologic manifestations. We also compared the properties
including stroke risk factors and laboratory findings between two groups.
Results: 29 patients had ischemic stroke and 11 patients had hemorrhagic stroke.
The percentage of hemorrhagic stroke was higher than general population in HSR
(5.3%). The most common ischemic stroke subtype was small artery occlusion
(25.0%) and followed by large atherosclerosis (20.0%). The hypertensive nephropa-
thy was most common cause of CKD (47.5%) and duration of causative disease
was 13.19±10.24 years. As compared to the control group, stroke patients with
CKD showed higher rate of hypertension, prolonged activated prothrombin time,
lower level of triglyceride and lower LDL cholesterol level.
Conclusion: Strokes in CKD differ from general population in their pattern and
the risk factors. There is relatively larger incidence of hemorrhages compared to
non-kidney disease patients. Low lipid profile in CKD patients may suggest the
protective effect of hyperlipidemia against the development of stoke as preventing
of malnutrition which is one of the most important cause of mortalities in CKD
patients.
15 Risk factors of stroke
TRANSCRANIAL DOPPLER HEMODYNAMIC PARAMETERS AND RISK OF
STROKE: THE ROTTERDAM STUDY
M.J. Bos, P.J. Koudstaal, A. Hofman, J.C. Witteman, M.M. Breteler
Erasmus Medical Center, Rotterdam, Rotterdam, The Netherlands
Background: We explored the association between transcranial Doppler (TCD)
hemodynamic indices and risk of stroke in the general population.
Methods: At baseline we assessed mean flow velocity, peak systolic flow velocity,
end diastolic flow velocity, and vasomotor reactivity (VMR) with TCD in 2022 Rot-
terdam Study participants of age 61 years and over in both middle cerebral arteries.
84 Cerebrovasc Dis 2007;23(suppl 2):1–147
All participants, who at baseline were free from previous stroke, were subsequently
followed for occurrence of stroke (average follow-up time 5.1 years). We calculated
hazard ratios (HRs) with 95% confidence intervals (CIs) for the association between
hemodynamic parameters and risk of stroke using Cox proportional hazards models
with adjustment for age, sex, systolic blood pressure, antihypertensive drug use,
diabetes mellitus, ever smoking, current smoking, carotid intima-media thickness,
and carotid distensibility.
Results: Risk of stroke (n=122) and ischemic stroke (n=89) increased with increas-
ing middle cerebral artery flow velocity: when comparing the tertile with highest
velocity to the tertile with lowest velocity, the HR was 1.74 (95% CI 1.09-2.77) for
the association between mean flow velocity and stroke, 1.63 (95% CI 1.03-2.58)
for end diastolic flow velocity and stroke, and 1.33 (95% CI 0.86-2.08) for peak
systolic flow velocity and stroke. These estimates increased 10-26% when only
ischemic strokes were included. We found no associations between vasomotor
reactivity and risk of stroke.
Discussion: Risk of stroke increased strongly with increasing middle cerebral
artery flow velocity as measured with TCD in the general population.
16 Risk factors of stroke
A PROSPECTIVE STUDY OF PREVALENCE AND PROGNOSIS OF PVD IN
PATIENTS ADMITTED WITH ISCHAEMIC STROKE
V. Paranna, A. Gupta, R. Prakash, L. Bachegowda, G. Shankar, K.K. Manda,
A. Watkins
West Wales Hospital, United Kingdom
Introduction: Atherosclerosis is a multisystemic,asymtomatic disease which is di-
vided into Cerebrovascular disease,Peripheral Vascular disease & Coronary Artery
disease.Patients presenting with acute stroke are likely to have PVD which may be
unrecognised.Presence of PVD increases the risk of Myocardial Infarction & stroke
by 2 fold.Early detection & management of PVD can avoid complications.Ankle
Brachial Pressure Index is simple bedside test useful in this process.
Objective: The aim of the study was to evaluate the prevalence of PVD in
stroke patients,to assess whether symptomatic or asymptomatic PVD,severity of
the disease & to evaluate whether PVD is an independent prognostic factor in the
outcome of stroke.
Method: Prospective comparative group study which was carried out in West
Wales Hospital,Carmarthen,UK.A total of 100 patients have been included in this
ongoing study.This includes 55study group and 45 control group.Patients admitted
with ischaemic stroke were included in the study group & age and sex matched
non stroke general medical acute admission were included in control group.Etical
committee approval obtained.
Intervention:The data collected included demographics,barthel index,abbreviated
mental test,associated vascular risk factors,whether symptomatic PVD in the
past,ABPI during hospitalisation,discharge destination & follow up 3months after
discharge.Ankle BP was measured using handheld Doppler & ABPI was calculated
as systolic ankle BP/systolic arm BP.Pvalue was determined from by unpaired t test
for continuous variables & chi square test for discrete variables.
Results: Average age of patients was 80yrs & 78yrs in the study & control group
respectively.The average length of stay varied from 40 days (control group) to
59 days(trial group) with no statistical difference.Average Barthel Index though
similar at admission(14),at discharge average BI was 14(trail gr) and 17(control
gr) with statistical significance(p=0.001).More number of pt had AMT<7 in study
gr with statistical significance(p=0.011).Study population had higher prevalence of
Hypertension(69%) & hypercholesterolaemia(18%) which was statistically signifi-
cant(p=0.002 & p=0.011).67-80% of study population had mild to moderate degree
of PVD based on ABPI which is statistically significant(p=<0.001 & p=0.001)
which was previously undetected and asymptomatic.
Conclusions: The results of this study favoured PVD as a common asymtomatic
and unrecognised condition in patients with stroke.Early detection of PVD could
prevent compilcations in high risk patients.There is also a need to educate,identify
& treat associated risk factors.The study is ongoing to include larger sample size
for multiple regressional analysis to evaluate the role of PVD as an independent
prognostic factor following stroke.
16th European Stroke Conference
 17 Risk factors of stroke
MIGRAINE MEDIATES THE INFLUENCE OF C677T MTHFR GENOTYPES
ON ISCHEMIC STROKE RISK WITH A STROKE-SUBTYPE EFFECT
A. Pezzini, M. Grassi, E. Del Zotto, A. Giossi, R. Monastero, G. Dalla Volta,
S. Archetti, C. Camarda, R. Camarda, A. Padovani
Dipartimento di Scienze Medico-Chirurgiche, Neurologia Vascolare, Spedali
Civili di Brescia, Brescia, Italy
Background: To investigate the role of C677T MTHFR polymorphism in migraine
pathogenesis and in the migraine-ischemic stroke pathway.
Methods: A first genotype-migraine association study was conducted on 100
patients with migraine with aura (MA), 106 with migraine without aura (MO), and
105 subjects without migraine, which provided evidence in favour of association
of the TT677 MTHFR genotype with increased risk of MA compared to both
control subjects (odds ratio [OR], 2.48; 95% CI, 1.11 to 5.58) and patients with
MO (OR, 2.21; 95% CI, 1.01 to 4.82). Based on these findings, mediational models
of the genotype-migraine-stroke pathway were fitted on a group of 106 patients
with spontaneous cervical artery dissection (sCAD), 227 young patients whose
ischemic stroke was unrelated to a sCAD (non-CAD), and 187 control subjects,
and a genotype-migraine partial mediation model was selected.
Results: Both migraine and the TT-genotype were more strongly associated to
the subgroup of patients with sCAD (OR, 4.06; 95% CI, 1.63 to 10.02 for MA;
OR, 5.45; 95% CI, 3.03 to 9.79 for MO; OR, 2.87; 95% CI, 1.45 to 5.68 for
TT genotype) than to the subgroup of patients with non-CAD ischemic stroke
(OR, 2.22; 95% CI, 1.00 to 4.96 for MA; OR, 1.81; 95% CI, 1.02 to 3.22
for TT genotype) as compared to controls. The prevalence of migraine sufferers
carrying the TT677 MTHFR genotype turned out to be higher among patients
with multiple-vessel dissection (3/16; 18.8%) than among those with single-vessel
dissection (12/90; 13.3%) and control subjects (5/187; 2.7%) and the log-odds trend
statistically significant (χ2 (df) for log-odds trend = 11.2 (1); P = 00008).
Discussion: Migraine may act as mediator in the MTHFR-ischemic stroke pathway
with a more prominent effect in the subgroup of patients with sCAD.
18 Risk factors of stroke
PATENT FORAMEN OVALE, THROMBOPHILIC DISORDERS AND
MIGRAINE IN YOUNG PATIENTS WITH ISCHEMIC STROKE
P. Martínez-Sánchez, B. Fuentes, M.V. Cuesta, J. Domínguez, L. Idrovo,
L. Gabaldón, M.A. Ortega-Casarrubios, E. Díez-Tejedor
La Paz University Hospital, UAM, Madrid, Spain
Background: Patent foramen ovale (PFO) has been associated to inherited throm-
bophilic disorders, stroke and migraine separately. Our goal is to asses the
relationship between PFO ± atrial septal aneurism (ASA), thrombophilic disorders
and previous history of migraine in young patients with cryptogenic stroke.
Methods: Observational study with inclusion of consecutive patients from the
Stroke Unit Data Bank (January 1995-October 2005). Patients under 55 years with
an acute cryptogenic cerebral infarction were selected. We analyzed: demographic
data, vascular risk factors, stroke subtype, previous migraine and the presence
of thrombophilic disorders by a battery of hematological test. The presence of
PFO ± ASA was assessed by transcranial Doppler sonography monitoring and
echocardiography.
Results: 235 patients, mean age 42.97 ± 9.353 years. 16.6% had a PFO, 7.7% had
previous migraine and 7.2% were diagnosed of a thrombophilic disorder. Patients
with PFO had less traditional risk factors such as hypertension, current smoking
or coronary arterial disease (P<0.05). PFO+ASA was more common in women
(9.3% vs 2.9%; P=0.044) and in patients with previous migraine (22.2% vs 4.1%;
P=0,011). Thrombophilic disorders were more frequent in PFO patients (15.4% vs
5.6%, P=0.043; OR 3.058: 95% CI 1.058-8.839) as well as in previous migraine
patients (22.2% vs 6%; P=0.031; OR 4.484: 95% CI 1.291-15.565). The frequency
of thrombophilic disorders was the highest in migraine + PFO patients (60% vs
6.1%, P= 0.003; OR 23.143: 95% CI 3.570-150.017).
Conclusions: In patients under 55 years, thrombophilic disorders are diagnosed
more frequently in PFO-related cerebral infarcts, especially in migranous patients.
19 Risk factors of stroke
RISK FACTOR ANALYSIS IN PATIENTS ADMITTED WITH RECURRENT
ISCHEMIC STROKES
P.K. Shibu, S.H. Guptha, P. Owusu-Agyei
Peterborough District Hospital, Peterborough, United Kingdom
Background: We studied patients admitted with recurrent ischaemic stroke to
Poster Session
Risk factors of stroke
assess the prevalence and incidence of risk factors for vascular disease. We also
assessed the control of known risk factors.
Methods: All adult patients admitted with recurrent stroke in the year 2005
were included in the study. The Royal College of Physicians guidelines 2004 on
secondary prevention for stroke were used as the gold standard. We used our local
diabetic guidelines to define the control of Diabetes Mellitus with a haemoglobin
A1C level of less than 8 as acceptable control.
Results: 81(24%) of 331 stroke inpatients in 2005 had a recurrent ischemic stroke.
52(64%) patients had known hypertension of which 17(33%) were well controlled
while 35(67%) patients had uncontrolled hypertension despite being on medication.
12(15%) patients had newly diagnosed hypertension. 19(23%) patients were known
to have diabetes mellitus of which 7(37%) had acceptable glycemic control and
12(63%) patients had poor control. There were no new diabetics. 37(45%)patients
had hypercholesterolemia despite being on statins. 10(12%) patients had untreated
hypercholesterolemia.12(14%) patients had new hypercholesterolemia. Significant
carotid artery stenosis was known in 3 patients and diagnosed in 2 new patients
following admission. 47(58%)patients had not had carotid dopplers after their
previous stroke. 13(16%) patients were current smokers and 39(48%) were ex
smokers. 12(15%) patients had known atrial fibrillation and 5 patients had newly
diagnosed AF.
Conclusions: Most patients with recurrent ischemic stroke had multiple risk factors
identified at their first stroke but a majority of these risk factors were either under
treated or untreated. There was evidence of substantial under-investigation with
carotid dopplers. A smaller number of patients had newly identified vascular risk
factors at their admission with recurrent stroke. Better identification of risk factors
after a stroke and more aggressive control could reduce the burden of recurrent
ischemic stroke.
20 Risk factors of stroke
ANEMIA AND CHRONIC KIDNEY DISEASE ARE RISK FACTORS FOR
MORTALITY IN STROKE PATIENTS
P. Del Fabbro, J.-C. Luthi, P. Michel, E. Carrera, M. Burnier, B. Burnand
CHUV Lausanne, Lausanne, Switzerland
Background: Chronic kidney disease (CKD) has been linked to higher stroke risk.
Anemia is a common consequence of CKD, and recent evidence suggests that
anemia is a risk factor for cerebrovascular disease. The purpose of this study was
to examine among stroke patients, the association between CKD, anemia, hospital
mortality and one year mortality.
Methods: We performed a retrospective cohort study with consecutive stroke
patients over a 3 year period hospitalized in the stroke unit of a single university
hospital. We recorded demographic characteristics and risk factors for stroke. Re-
duced kidney function was defined as a serum creatinine ≥80 μmol/L for women
and ≥106 μmol/L for men. Glomerular filtration rate (GFR) was also calculated.
Anemia was defined when hemoglobine was below 12 g/dl on admission. The main
outcome measures were hospital mortality and one year survival.
Results: 963 patients aged between 16 and 97 years were included. Fifty-five-
point-five percent had CKD according to our definition, and 12.1% had anemia.
Thirty-three (3.7%) patients died during their hospitalization; among those, 27
(81.8%) had CKD (p=0.002). 82 (9.6%) patients died during the first year after
discharge from hospital, among them 54 (65.9%) had CKD (p=0.035). Anemia on
admission to the hospital was associated with an increased risk of death during
hospitalization and at one year after discharge.
After adjustment for other factors, hemoglobine was independently associated with
an increased risk of death at the hospital and one year survival.
Conclusion: Both CKD and anemia are frequent among stroke patients and are
associated with an increased risk of hospital and one year survival.
21 Risk factors of stroke
SUBCLINICAL HEMODYNAMIC ABNNORMALITIES IN SYMPTOM-FREE
HYPERTENSIVE PATIENTS DURING HEAD UP TILT TABLE TEST
L. Csiba, Z. Bajkó, K. Csapó, P. Soltész
Debrecen University, Debrecen, Hungary
The dysregulation of the autonomic nervous system plays an important role in the
development of hypertension. The heart rate variability and baroreflex sensitivity
are established methodes for the evaluation of the cardiac autonomic activity and
provide the assessment of the sympathetic and vagal activity. Our purpose was
to measure the cardiac parameters of the autonomic nervous system in essentiel,
non-treated hypertensive patients and later the efficacy of the antihypertensive
treatment by non-invasive technique.
Heart rate variability calculated with spectral analysis and baroreflex sensitivity
Cerebrovasc Dis 2007;23(suppl 2):1–147 85
obtained by the sequence technique were measured in 28 healthy persons (age:
48,29±8,14 yrs, m/f rate: 1) and 28 hypertensive patients (age: 46,11±6,54 év, m/f
rate: 1,1) by Task Force Monitor during head-up tilt table test.
The number of the baroreflex sequences was significantly higher (66,9 vs 51,1;
p=0,031), the baroreflex effectiveness index was significantly lower (67,3 v 58;
p=0,027) and also significantly lower heart rate variability was measured in the low
frequency (LF-RRI) range(213 ms2 vs 468,2 ms2, p=0,018) in the hypertensive
group.
The decreased baroreflex sensitivity and heart rate variability proved the autonomic
dysfunction, the lower sympathetitc activity indicated long-standing systemic
hypertension in the hypertensive group.
The authors will also show the changes after 6 months antihypertensive therapy
(finished April, 2007).
22 Risk factors of stroke
PREVALENCE OF CONVENTIONAL VASCULAR RISK FACTORS IN
STROKE PATIENTS UP TO 45 YEARS OLD. A COMPARISON WITH
GENERAL STROKE POPULATION
J. Lopez-Fernandez, A. Gonzalez-Hernandez, O. Fabre-Pi, J.A. Suarez-Muñoz,
M. Vazquez-Espinar, S. Diaz-Nicolas, V. Araña-Toledo, A. Cubero-Gonzalez
Hospital de GC Dr Negrin, Spain
Introduction: Ischemic stroke is considered a heterogeneous entity that presents
differences in relation to aetiology, pathology and prognosis, which can vary
according to age groups. We have analysed the presence of conventional vascular
risk factors in a series of stroke in the young patient, which has been compared to
another series including the general population in our area.
Material and methods: We performed a retrospective revision of the clinical his-
tory of all patients admitted in our service in the interval 01/01/2001-31/12/2005.
All ischemic strokes (ISs) or transient ischemic attacks (TIAs) in patients up to
45 years-old were included. We recorded parameters related to the presence of
conventional vascular risk factors — high blood pressure (HBP), diabetes mellitus
(DM), dyslipemia (DLP), tobacco smoking, ischemic cardiopathy (IC), peripheral
arteriopathy and atrial fibrillation (AF) — and compared them to the number of
total strokes in 2004 and 2005.
Results: We included 536 patients (60,4% men and 39,6% women) in our period of
study; 70 of them (51,4% men and 48,6%) were up to 45 years-old. The prevalence
of HBP was 37,7% in the group <46 years-old and 62,9% in the total of strokes;
of DM, it was 7,24% vs. 34,9%; of DLP, it was 46,7% vs. 32,5%; of active tobacco
smoking, it was 59,4% vs. 42,4%; of IC, it was 8,6% vs. 14,1%; of FA, it was 1,5%
vs. 20%; and of peripheral arteriopathy, it was 0 vs. 4,3%.
Conclusions: In our series, the prevalence of some conventional vascular risk
factors (HBP, DM, IC, peripheral arteriopathy and AF) is evidently minor in
the up to 45 year-old stroke population, meaning that different etiopathogenic
mechanisms are involved. However, some conventional vascular risk factors (DLP
and tobacco smoking) show a higher prevalence in this group, which, associated
to other predisposing factors, could favour ischemic events. For this reason, both
primary and secondary prevention is highly necessary to avoid the conjunction of
prothrombotic disorders in the patient.
23 Risk factors of stroke
ASSOCIATION BETWEEN FAMILY HISTORY OF STROKE AND ISCHEMIC
STROKE SUBTYPE IN YOUNG ADULTS
K. Spengos, S. Vassilopoulou, M. Papadopoulou, A. Konstantinopoulou,
P.P. Zis, E. Koroboki, G. Tsivgoulis
Eginition Hospital, University of Athens, Athens, Greece
Background: Recent data have indicated that ischemic stroke (IS) subtype may
be associated with the family history of stroke (FHOS). Both population-based
and hospital-based studies have shown that FHOS is more prevalent in IS pa-
tients. However, the potential relationship between the etiopathogenic mechanism
of cerebral infarction and FHOS has not been studied in the former stroke
subgroup.
Methods: Consecutive first-ever stroke patients, aged between 15 and 45 years
and hospitalised in the stroke wards or referred to the stoke outpatient clinic
of our tertiary care University Hospital over a 5-year period, were prospectively
included in a computerized observational data bank. Demographic characteristics,
stroke risk factors and FHOS among any first-degree relative were documented
in all patients. According to the TOAST criteria, ischemic stroke was classi-
fied based on etiopathogenic mechanisms into the following groups: large artery
atherosclerotic stroke (LAA), cardioembolic stroke (CE), small artery occlusion or
lacunar infarction (LI), infarction of other determined origin (IOE) and infarction
86 Cerebrovasc Dis 2007;23(suppl 2):1–147
of undetermined cause (IUC). Statistical analyses were performed using uni- and
multi-variate logistic regression models
Results: FHOS was identified in 17 (11.4%) out of the 149 first-ever IS patients
(mean age 38±7 years, male gender 58%). The distribution of FHOS among the
TOAST subgroups was as follows: LAA 21% (4/19), CE 9% (2/22), LAC 17%
(4/24), IOE 13% (5/38) and IUE 4% (2/46). FHOS was more prevalent (p=0.045)
in the combined group of IS of vascular etiology (LAA/LA/IOE, 16%) than in the
group of patients with CE and IUE (6%). After adjusting for stroke risk factors and
demographic characteristics FHOS was independently (p=0.052) associated with
IS due to LAA, LAC or IOE (OR:3.1; 95%CI:1.0-10.1).
Discussion: Our findings indicate that young adults with IS of vascular etiology
are more likely to have a positive FHOS than patients with CE or IUE.
24 Risk factors of stroke
METABOLIC SYNDROME IN SYMPTOMATIC AND ASYMPTOMATIC
PATIENTS WITH SEVERE CAROTID STENOSIS
L. Tuskan-Mohar, I. Strenja-Linic, K. Blazina, I. Antoncic, S. Dunatov,
M. Bucuk, A. Jurjevic
University Hospital Center Rijeka, Croatia
Background: Metabolic syndrome (MS) is a constellation of interrelated abnor-
malities that increase the risk for the development of cerebrovascular disease. The
aim of this study was to analyze a group of symtomatic and asymptomatic patients
with severe occlusive disease of extracranial internal carotid artery (ICA) and the
presence of MS in these patients.
Methods: One hundred and forty seven patients with severe carotid stenosis,
treated at Department of Neurology, Rijeka University Hospital Center, Croatia,
were included into the study. Sixty two (42%) patients were asymptomatic and
eighty five (58%) were symptomatic. We analized a combination of vascular risk
factors such as obesity, diabetes mellitus, dyslipidemia and hypertension, which are
known elements of MS, in these patients.
Results: There were 147 patients with severe carotid stenosis, 101 (69%) men (age
65.5) and 46 (31%) women (age 68.3). MS with all its elements was documented
in 20% patients. The frequency of individual components of the MS: hypertension
79%; diabetes mellitus 29%; abnormal lipid profil 67%; BMI>25 in 20% (BMI>30
in 12%). The combination of hypertension and abnormal lipid profil was the most
common risk factor (43%). The all risk factors equally occurred in both sexses. MS
was more common in symptomatic than in asymptomatic patients (p=0.001).
Discussion: In our series one fifth of patients with severe carotid stenosis had MS
which was prevailing in symptomatic patients. The combination of hypertension
and atherogenic dislipidemia was the most frequent risk factor. Focusing on the
most prominent risk factors, which are modifiable, and treating them is the most
effective way to prevent stroke.
25 Risk factors of stroke
THE MOST FREQUENT RISK FACTORS FOR ISCHEMIC STROKE IN
YOUNG ADULTS
M. Jovicevic, I. Divjak, A. Jovanovic
Institute of Neurology, Clinical Centre Novi Sad, Univeristy of Novi Sad, Novi
Sad, Yugoslavia
Background: The objective of the study was to investigate risk factors for ischemic
stroke in young adults.
Methods: The study included 100 patients with ischemic stroke of both sexes
aged 15-45 years treated at the Institute of Neurology in Novi Sad. All patients
were divided into three age groups: 15-25, 26-35, 36-45 years. All study patients
met the clinical and radiological criteria for the ischemic stroke diagnosis. The
following risk factors were studied: family history, diabetes, cardiac disease, patent
foramen ovale, hypertension, previous stroke(s), smoking, hyperlipidemia, obesity,
alcohol abuse, migraine, oral contraception, immunological diseases, pregnancy
and puerperium.
Results: Cardiac disease was found in 26% of all patients, of which none was in
the youngest group, while it was most frequent in the group 26-35 years (p=0.011).
Patent foramen ovale was found in 6% of all patients and it was more frequent
in younger patients. Arterial hypertension was present in 51% of all patients
and the percentage of patients with this risk factor was significantly higher in
older age groups (8.3%:25%:63.9%) (p<0.001). Smoking was the most frequent
risk factor, present in 55.6% and equally distributed in all age groups (p=0.918).
Hyperlipidemia was the second most frequent risk factor (53.5%). Most patients
with hyperlipidemia were in the oldest group, however there was no significant
difference (p=0.406). Oral contraception was used by 4% of patients. Five female
patients were pregnant or in puerperium (2:1:2).
16th European Stroke Conference
Discussion: Smoking was the most frequent risk factor, registered in 55.6% of
all study patients. Study of risk factors is essential for adequate prevention and
treatment of ischemic stroke.
26 Risk factors of stroke
HEREDITARY TROMBOPHILIAS AND NEUROLOGICAL COMPLICATIONS
J. Szilasiova, B. Benova, D. Kozakova, E. Kahancova, E. Antolova,
Z. Gdovinova
Faculty of Medicine P.J. Safarik University and Faculty Hospital Kosice,
Slovakia
In patients with unknown etiology of stroke hereditary coagulation disorders can
be the reason of stroke. There are also other neurological disorders which can be
caused by thrombophilias. Studies have shown that trombophilia testing influences
less than 25% of physician’s treatment of stroke.
The authors present small study consists from 10 patients (8 women, 2 men),
mean age 28.5 years, with different types of hereditary coagulation disorders
affecting cerebral circulation. In 5 patients (50%) isolated and in the next 5
patients (50%) combined hereditary coagulation deffect were found. Deficit of
antithrombin (AT) III, mutation of gene for methylenetetrahydrofolate reductase
(MTHFR), hyperhomocysteinemia, high factor VIII, factor V Leiden, protein S and
C deficit, increased level of plasminogen activator inhibitor (PAI) webe detcted.
In four patients thrombosis of cerebral arteries and thrombembolic events were
preceded by delivery or using contraceptives. In four patients coagulopathy was
found also in family members. In 9 cases neurological complications were the first
manifestation of thrombophilia, in one stroke was preceded by phlebothrombosis
of lower extremities. In five patients brain infarcts, in two cases thrombosis of
brain venous sinuses were found and in the last three patients magnetic resonance
revealed demyelinating lesions.
After therapy two patients have mild hemiparesis, next two vascular epilepsy and
last six patients are without any consequences. In patient with AT III deficit was
in the same time present thrombembolia of pulmonal, radial, axillar and cerebral
arteries with numerous brain infarcts.
Hereditary thrombophilias are rare reasons of stroke, but with higher frequency in
younger patients. Their detection may provide prognostic information of the risk of
recurrent events as well as determine the most appropriate treatment.
27 Risk factors of stroke
INFLUENCE OF VASCULAR RISK FACTORS ON OXIDATIVE STRESS,
ASSESSED BY MEASUREMENT OF SERIC MDA LEVELS, IN ACUTE
ISCHEMIC STROKE SUBTYPES
A. Simion
Faculty of Medicine and Pharmacy Oradea/Clinical Hospital of Neurology and
Psychiatry, Oradea, Romania
Background: Oxidative stress has been involved in the pathogenesis of several
diseases considered as risk factors for ischemic stroke.
Material and method: A consecutive series of ischemic stroke patients admitted
were evaluated clinically, with brain CT and/or MRI, Duplex sonography, electro-
cardiography, transthoracic echocardiography, and biochemically (measurement of
lipid fractions and fasting glucose levels).Strokes were divided into large artery dis-
ease (LAD), small vessel disease (SAD) and cardioembolism (CE) according to the
TOAST criteria.Risk factors were diagnosed according to the international criteria
(JNC 7 for hypertension, ADA for diabetes, BMI>30 kg/m2 for obesity).Smoking
and alcohol intake were recorded as admitted by the patient.We recorded the NIHSS
score on admittance and Barthel index (BI) at discharge.Malondialdehyde (MDA)
levels were measured on admittance(day 1, viewed as baseline levels)and on day 3
and 7.
Results: Patients with fewer risk factors had lower baseline-MDA levels.Smoking
raised the MDA levels in LAD significantly(p<0,001)and lowered BI(2,43 to 4,6;
4,18 to 5,9; 3,13 to 5,3).In SAD only baseline-MDA level was significantly higher
(1,83 to 4,5, p<0,001).Diabetes significantly increased oxidative stress at first
determination and worsened outcome in SAD(1,83 to 4,1, p<0,001).In CE the
MDA values were not as high as in microangiopathy, but outcome was even poorer.
Dislipidemia, obesity and hypertension raised the baseline-MDA levels nonsignifi-
cantly, except obesity in CE in which both MDA(2,17 to 3,5, p<0,001)and outcome
were significantly altered.Alcohol intake raises (p<0,001) MDA level in LAD (2,43
to 5,1; 4,18 to 5,9; 3,13 to 5,3).
Conlusions: Based on our results preventive antioxidant therapy would be most
beneficial in diabetes.
Poster Session
Risk factors of stroke
28 Risk factors of stroke
THE RATE OF STROKE ASSOCIATED WITH THE USE OF THORATEC
VENTRICULAR ASSIST DEVICE IN OLDER PATIENTS
M.B. Vijayappa, B. Clemson, M. Alsorogi, S. Al-Hawarey, D. Joseph,
A. Talkad, M. Mathews, D. Wang
University of Illinois College of Medicine at Peoria, OSF, INI, Peoria, IL, USA
Background: Because of the shortage of heart donors, ventricular assist devices
(VAD) are used to provide mechanical circulatory support in patients with heart
failure awaiting planned heart transplant or in patients who are not candidates for
heart transplant. The use of VADs has been increasing due to the growth of the
aging population. However, it is unclear if there is an increased risk of developing
stroke relative to age. Our study was to determine the effect of age on the risk of
stroke after VAD implant.
Methods: This is a retrospective study exempted by the community IRB. From
1996-2006, we reviewed records of all patients who received VADs as a bridge
to transplant. Demographic data, clinical and radiographic findings were collected.
Descriptive statistics were applied. The patients were categorized according to age;
Group I, less than 55 and Group II, 55 or older.
Results: From 1996-2006, 45 patients received VADs. The number of patients in
group I was 24 (53%) and group II was 21 (47%). Group I had 8 (33%) strokes; 6
(23%) were ischemic and 2 (8%) hemorrhagic. Group II also had 8 (30%) strokes,
7 (32%) were ischemic and 1 (5%) hemorrhagic. In Group I; 4 (17%) had diabetes,
13 (54%) hypertension and 7 (29%) left atrial cannulation. In Group II; 11 (52%)
had diabetes, 11 (52%) hypertension and 6 (29%) left atrial cannulation. The overall
mortality in group I was 11 (46%) and 10 (48%) in group II. One (4%) death in
each Group was associated with stroke.
Conclusion: Regardless of patient’s age, the occurrence of stroke associated with
the implantation of a VAD was similar. There was no significant increase in stroke
related mortality. Given the known benefit of VADs support to improve the rate
of successful transplantation and the absence of an increased risk of stroke in
older patients, the use of VAD support in appropriate patients should be carefully
considered regardless of age.
29 Risk factors of stroke
ASSOCIATION OF CAROTID INTIMA MEDIA THICKNESS AND PLAQUE
WITH AORTIC ARCH CALCIFICATION
B.-S. Shin, E.S. Lim
Chonbuk National University Hospital and Medical School, Jeonju, South
Korea
Introduction: Atherosclerosis is a generalized process and is the major cause of
cerebrovasculardisease. The more advanced atherosclerotic lesions contain calcium
deposits. Aortic arch calcification may represent a manifestation of generalized
atherosclerosis. The carotid intima media thickness (IMT) is also recognized as
independent predictors of adverse cerebrovascular outcomes. The purpose of this
study is to examine the relationship between the degree of aortic arch calcification
and carotid IMT and plaque.
Materials and methods: A total of 56 patients (31 men and 25 women) were
included. All patients had chest radiography in the posteroanterior view. Severity of
aortic arch calcification was graded as follows: grade 1 (small spots of calcification
or single thin calcification of the aortic knob), grade 2 (one or more areas of
thick calcification), grade 3 (circular calcification of the aortic knob). The degree
of carotid atherosclerosis was evaluated by measuring the maximum IMT of the
common carotid artery, carotid bulb, and internal carotid artery by duplex carotid
ultrasonography.
Results: The mean age of patients was 70.0 ± 9.1 years and the numbers of male
patients was 31. (55.4%). Severity of aortic arch calcification was grade 1 in 26
patients (46.4%), grade 2 in 18 patients (32.1%), grade 3 in 12 patients (21.4%).
Aortic arch calcification was observed more commonly in elderly patients. There
was no significant difference between aortic arch calcification and gender. There
was no significant relationship between severity of aortic arch calcification and
carotid IMT. But there was significance between severity of aortic arch calcification
and plaque number (p=0.012).
Cerebrovasc Dis 2007;23(suppl 2):1–147 87
 30 Risk factors of stroke
ISCHEMIC STROKE IN PATIENTS UNDERGOING DIALYSIS
S. Jung, S.H. Hwang, S.B. Kwon, K.H. Yu, I.S. Koh, B.C. Lee
Hallym University College of Medicine, National Medical Center, Seoul, South
Korea
Background: When we evaluated the patterns of stroke and risk factors in patients
with chronic kidney disease, it was difficult to analyze those results because the
included patients were not homogenous. In that study, we included ischemic and
hemorrhagic stroke patients with either chronic renal disease or end stage renal
disease (ESRD) undergoing dialysis. We performed this study in patient with
ischemic stroke with ESRD so as to elucidate the factors that affect developing
ischemic stroke in chronic kidney disease.
Methods: We enrolled patients with acute ischemic stroke in ESRD patients
undergoing dialysis using the data from Hallym Stroke Registry (HSR). Twenty
patients were included from July 1996 through June 2006. Thirty patients with
hemodialysis who did not develop stroke were selected as control group with age
and sex matching. We compared the demographic features, stroke risk factors,
laboratory findings in ESRD patients with or without ischemic stroke.
Results: The mean age of acute ischemic stroke patients was 60.75±10.19 and
male to female ratio was 0.82. The most common ischemic stroke subtype was
small vessel occlusion (SVO, 9 of 20 patients) and followed by large artery
atherosclerosis (LAA, 7 of 20). Ischemic stroke patients showed longer duration
of causative disease of ESRD, higher rate of hypertension history, and low serum
LDL cholesterol level compared with the patients with control group.
Discussion: Although low serum LDL level in stroke with CKD in our previous
study could be affected by relatively high frequency of hemorrhagic stroke, low
serum LDL was also observed in ischemic stroke patients undergoing dialy-
sis. These finding shows that serum cholesterol level can reflects the status of
malnutrition rather than atherosclerosis at least in CKD patients.
Stroke and diabetes
1 Stroke and diabetes
THE EFFECT OF STATIN PRE-TREATMENT ON INFARCT VOLUME AND
DISCHARGE DISPOSITION IN ISCHEMIC STROKE PATIENTS WITH
DIABETES
J.S. Nicholas, J.C. Thomas, Z. Rumboldt, P. Tumminello, S.J. Patel
Medical University of South Carolina, Charleston, SC, USA
Background: Studies have indicated reduced rates of stroke among patients with
diabetes treated with statins. In contrast to stroke prevention, the purpose of this
analysis was to examine post-stroke outcomes (infarct volume, discharge disposi-
tion) among patients with diabetes who were taking a statin at onset of ischemic
stroke relative to those who were not.
Methods: Study design was a retrospective cohort analysis of all verified ischemic
stroke patients admitted to our university hospital 2002-2006 with magnetic res-
onance diffusion weighted imaging (DWI). Of these patients, 131 presented with
diabetes or were newly diagnosed at admission. Infarct volume was calculated from
DWI, blinded to statin status. For patients with multiple infarcts, volume recorded
was the sum of all infarcts. Discharge disposition and clinical data were abstracted
from hospital records. Statistical comparisons between statin and no-statin groups
were made using 2-sided t-tests for continuous variables, chi-square for categor-
ical, and Mann-Whitney for nonparametric. Variables pre-specified as potential
confounders of infarct volume were time to imaging, location and type of stroke.
Results: Patients with diabetes who were taking a statin on admission had a statis-
tically significant 55.1% decrease in median infarct volume relative to the no-statin
group (1.02 cm3 statin versus 2.27 cm3 no-statin, Mann-Whitney p=.039, N=131,
46.6% on statins). While differences in discharge disposition were not statistically
significant, those on statins were discharged sooner (mean 4.75 days versus 5.82)
and were more likely to be discharged home (37/61=60.7% versus 38/70=54.3%).
Time to imaging, location and type of stroke did not differ significantly between
groups in univariate analysis, nor did age, gender, or race (all p values >.05).
Discussion: In this study, statin-pretreated patients with diabetes experienced
significantly smaller median infarct volumes following ischemic stroke than those
not pretreated. Given the potential importance to treatment practices, this finding
and its implications for clinical outcome should be further investigated.
88 Cerebrovasc Dis 2007;23(suppl 2):1–147
2 Stroke and diabetes
THE TEMPORAL PATTERN OF POST-STROKE HYPERGLYCAEMIA IS A
PREDICTOR OF LONG-TERM SURVIVAL
M. Koufali, R. Durairaj, R. Kumar, A.K. Sharma
Aintree Stroke Team for Audit and Research, Aintree University Hospitals NHS
Foundation Trust, United Kingdom
Background: Recent work has shown that persistent post-stroke hyperglycaemia
(PHG) affects infarct size and clinical outcome. The purpose of this study
was the detailed investigation of the association between blood glucose levels
(BGL)obtained over 24 hours and survival at 12 months following a stroke.
Patients & Methods: 1496 patients, admitted during 2000-2005, with a confirmed
diagnosis of ischemic stroke and not previously known to be diabetic were included
in this retrospective analysis. Only Caucasian patients with confirmed onset, ad-
mission, discharge and death dates were included in the study. BGL values were
obtained upon admission and at 24 hours.
Results: Median admission BGL was 6.3 mmol/L, while median BGL at 24 hours
post admission was 5.5 mmol/l. 987(66%) of patients survived at 12 weeks, 568
(38%) survived at 12 months, while 284(19%) patients died in hospital.
807 patients (54% of total) were hyperglycaemic upon admission (glucose >6.1
mmol/L) with 256 of them (32%) remaining hyperglycaemic at 24hours post-
admission.
Multiple regression analysis demonstrated that 24 hour PHG is independently
associated with: Death in hospital (p=0.017), survival at 12 months (p=0.009) and
increased lengths of stay (p=0.005).
Conclusion: Evidence is presented that patients with persistent hyperglycaemia
over 24 hours have poorer outcomes. Further research is thus warranted which
would allow us to target this group of patients for aggressive therapy for blood
sugar control following a stroke.
3 Stroke and diabetes
POST-STROKE HYPERGLYCAEMIA IS NOT AN EPIPHENOMENON OF
ISCHAEMIC STROKE SEVERITY
M.T. McCormick, T.A. Baird, K.W. Muir
University of Glasgow, Glasgow, United Kingdom
Introduction: Post stroke hyperglycaemia (PSH) is common and is associated with
a worse outcome. It is postulated that hyperglycaemia reflects the stress response
of a severe stroke. We sought to establish the prevalence of PSH within 48hours of
ictus and describe its association with stroke severity.
Methods: Patients presenting within 24hours of a suspected stroke (April 2004-
January 2006) underwent 4 hourly capillary blood glucose (CBG) monitoring for
48hours. Baseline demographics, NIHSS, OCSP and time of stroke onset were
collected. Stroke severity was described as severe (NIHSS > 15); moderate (NIHSS
7–15) or mild (NIHSS 0–6). Hyperglycaemia was defined as a CBG > 7mmol/l,
Results: 353 patients underwent CBG profiling. Median Age 72 (IQR 62,80);
Median NIHSS 6 (3,13). 17% had diabetes. At presentation 29% of patients had
PSH; Median time to CBG was 238 minutes (IQR 165,494). Over the 48hour moni-
toring period 75% developing Hyperglycaemia, with 25% euglycaemic throughout.
Glycosylated Haemoglobin was statistically lower in patients with euglycaemia
compared to hyperglycaemia (p = 0.001). Stroke severity was not predictive
of admission hyperglycaemia whereas glycosylated haemoglobin was (OR 2.97;
95%CI 1.84-4.78; p < 0.001). There was no statistically significant difference
between mean blood glucose on initial monitoring between groups. However at 48
hours, blood glucose was significantly lower in more severe strokes (NIHSS > 15),
CBG = 5.8mmol/l compared to milder strokes (NIHSS 0–6), CBG = 6.6mmol/l (p
= 0.015).
Discussion: Post stroke Hyperglycaemia is common. Overall prevalence for the
48hour period was 75%. Stroke severity was not predictive of post stroke hy-
perglycaemia with more severe strokes having a statistically lower blood glucose
compared to milder strokes at 48hours.
4 Stroke and diabetes
DIABETES MELLITUS AND THE EARLY RISK OF STROKE AFTER
TRANSIENT ISCHEMIC ATTACK: A HOSPITAL-BASED CASE SERIES
STUDY
G. Tsivgoulis, S. Vassilopoulou, E. Manios, P.P. Zis, K. Spengos
Eginition Hospital, University of Athens, Athens, Greece
Background: California- and ABCD-scores reliably predict short-term risk of
stroke after TIA. Both scores contain similar components. However, diabetes
16th European Stroke Conference
mellitus (DM) is only included in the California Score. Aim of the present study
was to evaluate the potential relationship of DM with the early risk of stroke in a
cohort of hospitalised TIA patients.
Methods: All patients hospitalised in our Department with definite TIA during a
5-year period were identified and their medical charts as well as their Emergency
Room records were retrospectively reviewed by two investigators blinded to follow-
up. Patients with previous history of stroke and those who missed their follow-up
evaluations at the outpatient clinic of our Department at 1 month after admission
were excluded. DM was specified as fasting serum glucose ≥7.0 mmol/L, nonfast-
ing serum glucose ≥11.1 mmol/L, or use of oral blood sugar-lowering drugs or
insulin. The outcome events of interest in all TIA patients were subsequent strokes
during the 1-month follow-up period. Statistical analyses were performed using
the Kaplan-Meier product-limit method and stepwise Cox’s proportional hazards
model.
Results: The 30-day risk of stroke in the present case series (n=226) was 9.7%
(95%CI:5.8-13.6%; 22 events). The 30-day risk of stroke was higher in patients with
DM (17.3%; 95%CI:7.6-27.0%) than in non-diabetic patients [(7.1%; 95%CI:3.2-
11.0%); log-rank test=5.20; df=1; p=0.0225]. After adjustment for demographic
characteristics, stroke risk factors, history and number of prior TIAs, duration and
symptoms of TIAs, as well as secondary prevention treatment strategies during
hospitalisation, DM was independently (p=0.015) associated with a three-fold
greater 30-day risk of stroke (HR:2.98; 95%CI:1.28-6.94).
Discussion: DM is an independent predictor of subsequent stroke in patients
presenting with TIA. It should be taken into account by prognostic scores that
stratify the risk of early stroke in TIA patients.
5 Stroke and diabetes
PATIENTS WITH STROKE HAVE A HIGH PROBABILITY OF
DYSGLYCAEMIA AS ASSESSED USING AN ORAL GLUCOSE TOLERANCE
TEST
S.H. Naqvi 1 , J.D. Lee 2 , V. Patel 3 , K.M. Sharobeem 1
1
Sandwell General Hospital, Rowley Regis; 2 Department of Cardiology, George
Eliot Hospital NHS Trust, Nuneaton; 3 Warwick Medical School, United
Kingdom
Background and aims: In the UK, the recently published Joint British Societies’
Guidelines on the Prevention of Cardiovascular Disease recommend performing an
oral glucose tolerance test (OGTT) on subjects with an acute cardiovascular event.
In this study, we report our experience of performing an OGTT in those suffering a
recent acute stroke in a district general stroke unit.
Methods: An OGTT was performed in clinically stable consecutive patients ad-
mitted to the stroke unit with a diagnosis of acute stroke. The study was conducted
over a period of 3 months. Those with known diabetes mellitus were excluded.
Results: Data on 71 patients were available. Mean age of subjects was 70 years
(Range 24-96). 49% were male. 86% suffered a non-haemorrhagic stroke. The
mean time of admission to OGTT was 8.5 days. Only 43% had a normal OGTT. The
proportions of those with impaired fasting glycaemia, impaired glucose tolerance
and diabetes mellitus were 3%, 34%, and 20% respectively.
Conclusions: Our data suggests that, based on the results of an OGTT, patients
suffering an acute stroke have a high probability of having dysglycaemia. The
gold standard OGTT for diagnosing dysglycaemia should be employed as there is
data supporting the prevention of diabetes mellitus in those with impaired glucose
tolerance. Furthermore, early treatment of diabetes mellitus can potentially offset
the appearance of classic diabetes complications.
6 Stroke and diabetes
ETHNIC DIFFERENCES IN COMORBIDITIES AND STROKE SUBTYPES OF
DIABETIC STROKE PATIENTS: THE SOUTH LONDON STROKE REGISTER
(SLSR)
A. Elmarimi, T. Rashid, J. Adie, O. Wood, P.U. Heuschmann, A.M. Toschke,
A.G. Rudd, C.D.A. Wolfe
King’s College London, London, United Kingdom
Background: Major differences in underlying risk factors of stroke have been
identified between ethnic subgroups, which may have implications in directing
secondary preventive strategies. Data are lacking about differences in comorbidities
and stroke subtypes between black and white diabetic stroke patients.
Methods: Data were collected from the South London Stroke Register (SLSR),
a population-based stroke register covering a multiethnic source population of
271.817 inhabitants (2001). Analysis was restricted to those with known diabetes
and to patients of black or white ethnic group. Demographics, major vascular
risk factors and stroke subtype were compared between black and white ethnic
Poster Session
Etiology of stroke
groups. Detected differences were adjusted for age and sex by multivariable logistic
regression.
Results: Between Jan 1995 and Dec 2004, diabetes was identified in 419 patients
(16.9%). The mean age of black diabetic patients was significantly lower than that
of whit patients (68.9y versus 73.4y, respectively; p<0.001); no differences were
found for sex. Among black diabetic patients, the prevalence of atrial fibrillation
(OR 0.2; 95% CI 0.1-0.4) and of smoking (OR 0.5; 95% CI 0.3-0.7) was lower,
and presence of hypertension higher (OR 2.7; 95% CI 1.5-4.8) compared to white;
no other statistically significant differences for vascular risk factors were found.
Distribution of stroke pathology and of clinical subtypes showed no statistically
significant variation between the two ethnic groups.
Conclusions: Substantial ethnic differences were found in the prevalence of vascu-
lar risk factors between black and white diabetic stroke patients. These differences
might reflect different risk factor profiles and possibly point to 2 clusters with
different interactions between risk factors
Etiology of stroke
1 Etiology of stroke
CEREBRAL HEMODYNAMIC FEATURES OF ALCOHOLIC ABSTINENT
SYNDROME AND OPIATE ABSTINENT SYNDROME
I. Voznyuk, N. Artemyeva, S. Scherbak
Military Medical Academy, Russian Federation
Background: Chronic alcoholization and heroinism are characterized by various
hemodynamic disorders, that promote the development of the cerebral pathology.
Methods and materials: The research involved 55 patients with the alcoholic
abstinent syndrome (26-59 years old) and 40 patients with the opiate abstinent
syndrome (25-41 years old). The control group included 34 men and women
(18-47 years old). The clinical data and results of the Doppler sonography were
investigated.
Results: The similar decrease of the linear blood flow velocities in both middle
cerebral arteries was registered in 60% of the patients with the alcoholic abstinent
syndrome and in 54,5% of the patients with the opiate abstinent syndrome; in
both anterior cerebral arteries – in 56,4% and 43,8% correspondingly; in both
posterior cerebral arteries – in 47,3%, in both vertebral arteries – in 32,7% of the
patients with the alcoholic abstinent syndrome. The decrease of the linear blood
flow velocities in the basilar artery was detected in 58,2% of the patients with the
alcoholic abstinent syndrome and in 20,7% of the patients with the opiate abstinent
syndrome; the diffuse increase of the vascular tone – in 54,5% and 48,5%; the
decrease of the integrated index of the cerebrovascular reactance – in 85,5% and
68,8% correspondingly. Restriction of the cerebrovascular reactivity was registered
in 41,8% of the patients with the alcoholic abstinent syndrome (vasodilatation)
and in 28% of the patients with opiate abstinent syndrome (vasodilatation and
vasoconstriction).
Conclusion: The decrease of the linear blood flow velocities in the intracranial
arteries, the diffuse increase of the vascular tone and the decrease of the integrated
index of the cerebrovascular reactance occurs reliably more often in the patients
with the alcoholic abstinent syndrome and opiate abstinent syndrome, than in the
control group. The similar bilateral decrease of the linear blood flow velocities was
predominantly registered in the middle cerebral arteries and in the anterior cerebral
arteries.
2 Etiology of stroke
INTERPRETATION OF COMPUTED TOMOGRAPHY AND
DIFFUSION-WEIGHTED IMAGING DURING ACUTE NEUROLOGICAL
EVENTS IN MITOCHONDRIAL RESPIRATORY CHAIN DISORDERS
S. Mittal, W. Watson, M. Aribandi, J.P. Hosey
Geisinger Medical Center, Danville, PA, USA
Sudden neurological events are common and mimic acute stroke in mitochondrial
respiratory chain disorders characterized by disruption of intracellular metabolic
pathways and energy failure. We had the opportunity to examine four separate
sets of computerized tomography (CT), diffusion-weighted imaging (DWI) and
apparent diffusion coefficient (ADC) data collected during acute neurological
events from two patients with defects in the mitochondrial respiratory chain
function. Both had prior histories of mental retardation and seizures but no known
mitochondria disorder. Clinically the events were characterized by acute onset
hemispheric symptoms suggesting stroke. Initial evaluation with CT brain showed
hypodensity involving the temporoparietal region of the symptomatic hemisphere
Cerebrovasc Dis 2007;23(suppl 2):1–147 89
with effacement of sulci and surrounding edema indicative of subacute stroke.
DWI and ADC map were obtained within the first 48 hours; there was a delay
of 168 hours in one event. All four DWI/ADC data were strikingly similar and
showed restricted diffusion mixed with increased ADC in the temporoparietal
area indicating a combination of cytotoxic and vasogenic edema. One patient had
A3243G mutation and the other a deficiency of cytochrome c oxidase activity and
partial deficiency of NADH dehydrogenase. Though presented acutely CT scans
in all four events suggested subacute stroke. With newer treatment modalities for
ischemic stroke widely available it is important to distinguish them from acute
events in mitochondrial encephalopathies. DWI helps distinguish between cytotoxic
and vasogenic edema. Membrane ion pump failure and ingress of sodium into the
cell during acute ischemia cause restriction of movement possibilities of water
molecules. Resultant uniformly reduced values of ADC are seen in infracted area
confined to a vascular territory. In our observation restricted diffusion was notably
confined to the cortical areas while the adjacent white matter showed increased
ADC which was felt to be unique to patients with mitochondrial encephalopathy
presenting as acute neurological events.
3 Etiology of stroke
STROKE PATTERNS IN PATIENTS WITH INTERNAL CAROTID ARTERY
DISSECTION – THE SIGNIFICANCE OF VESSEL PATENCY
L.H. Bonati, S.G. Wetzel, J. Gandjour, R.W. Baumgartner, P.A. Lyrer,
S.T. Engelter
University Hospital Basel, Basel, Switzerland
Background: Spontaneous dissection of the internal carotid artery (ICAD) is an
important cause of stroke in young and middle-aged patients. ICAD may lead to
a complete vessel occlusion or residual flow through a stenotic artery. Diffusion-
weighted imaging (DWI) has the potential to highlight differences in the pattern of
cerebral ischemia between occlusive and non-occlusive ICAD.
Methods: DWI, Doppler and color duplex sonography, and angiographic studies
were assessed in 40 consecutive patients (median age 47 years, interquartile range
[IQR] 39-56) with ischemic stroke caused by spontaneous ICAD, referred to two
university hospitals. Number, size and location of hyperintense lesions on DWI
were correlated with vessel patency.
Results: Patients with non-occlusive ICAD (n=15) presented with more ischemic
lesions (median 5, IQR 1-10) than patients with complete ICA occlusion (n=25)
(2, 1-3; p=0.014). In contrast, ischemic lesions were larger in occlusive ICAD (62,
50-99 mm) compared to non-occlusive ICAD (25, 10-50 mm; p=0.007). Stroke
patterns differed significantly between the two groups (p=0.002). Non-occlusive
ICAD was associated with disseminated lesions involving borderzone territories,
whereas most patients with occlusive ICAD had large territorial infarcts.
Conclusions: Our data suggest different stroke patterns in ICAD patients with
occluded ICA compared to those with stenotic ICA. These findings may be of
relevance in the ongoing controversy about the acute treatment of stroke in ICAD.
4 Etiology of stroke
STROKE IN PATIENTS WITH CANCER IN A GENERAL HOSPITAL:
DIFFERENCES BETWEEN CLINICAL AND AUTOPSY SERIES
G.S. Silva, D.L. Gomes, M.M. Alves, J.A. Fiorot Jr, A.R. Massaro
UNIFESP- Universidade Federal de São Paulo, São Paulo, Brazil
Background: Cerebrovascular disorders (CVD) are frequent causes of neurological
symptoms in cancer patients. Clinical and autopsy series differ in the importance
of cancer specific conditions as causes of CVD in these patients. Our aim was to
describe the clinical features of patients with CVD and cancer admitted to a general
hospital, and to compare them to autopsied patients with the same diagnosis.
Methods: A retrospective analysis of patients with the diagnosis of CVD and
cancer in their discharge summaries from July 2005 to July 2006 was performed.
The necropsies executed in our hospital from January 2004 to June 2005 were
reviewed. Data collected included: demographic, stroke and cancer features.
Results: Eleven patients (mean age 54 ± 13 years, 7 women) had a diagnosis
of CVD and cancer. Intracerebral hemorrhages (ICH) (55%- 9% subdural and
46% intraparenchimal) were more frequent than ischemic strokes. Primary cancers
were: leukemia (36.4%), lung (18.2%), primary intracerebral cancer (18.2%),
colon, prostate and genitourinary tract (9.1% each). TOAST classification was
cardioembolic in 50% of the patients and undetermined in 50%. Oxfordshire
classification was partial anterior circulation in 66.7% and posterior circulation
in 33.3% of the patients. 66.3% of the patients died, and in 57.1% death was
stroke related. Echocardiogram was performed in 18.1% of the patients, magnetic
resonance imaging in 9% and Doppler in 9%. From 350 necropsy studies, four
patients had a diagnosis of CVD and cancer (mean age 48 ± 63, 3 women). One
90 Cerebrovasc Dis 2007;23(suppl 2):1–147
patient had an ICH into a germinative cell tumor metastases and the other three
had ischemic strokes- two had identified intracardiac emboli source (a fungi and a
nonbacterian thrombotic endocarditis).
Discussion: Patients with CVD and cancer in our hospital seem to receive a less
thorough investigation of stroke etiology. Autopsy data seem to differ from clinical
ones, maybe due to the severity of patients evaluated. A better investigation of these
patients could help identify preventable causes of stroke recurrence.
5 Etiology of stroke
EMBOLIC LESION PATTERN ON DIFFUSION WEIGHTED BRAIN IMAGING
AND AETIOLOGY OF STROKE
J.N.E. Redgrave, A. Chandratheva, D. Briley, P.M. Rothwell
Stroke Prevention Research Unit, Department of Clinical Neurology, Oxford
University, Oxford, United Kingdom
Background: Diffusion-weighted MR-imaging (DWI) is highly sensitive to acute
cerebral ischaemia and may help to determine the likely underlying aetiology.
For example, several studies have reported an association between multiple acute
ischaemic lesions and ipsilateral 50% carotid stenosis, although none has quantified
the predictive value.
Methods: Consecutive patients referred to a specialist clinic with TIA or minor
stroke had DWI and carotid MR-angiography. Ipsilateral 50% carotid bifurcation
stenosis was related to the presence of solitary and multiple acute ischaemic lesions
on DWI.
Results: 500 patients (278 men) were studied. DWI showed acute ischaemic
lesion(s) in 179/280 (63.9%) patients with minor stroke vs. 33/220 (15%) with
TIA (p<0.0001). 52 (10.4%) patients had symptomatic 50% carotid stenosis. A
solitary DWI lesion was not associated with symptomatic carotid stenosis (OR
1.00, 0.51-1.99, p=0.99) but multiple acute DWI lesions in the ipsilateral carotid
territory was strongly associated (OR 5.87, 2.68-12.86, p<0.001) with carotid
stenosis, particularly the presence of >3 lesions (OR 8.87, 3.26-24.15, p<0.001).
However, the corresponding sensitivities for prediction of the presence of 50%
ipsilateral carotid stenosis were nevertheless low (25% and 15% respectively) and
the imaging appearance was also associated with cardioembolic aetiology.
Conclusion: Multiple acute ischaemic lesions on DWI are strongly associated
symptomatic 50% carotid bifurcation stenosis, but the appearance is likely to be of
limited use in aetiological classification.
6 Etiology of stroke
PREVALENCE OF FABRY’S DISEASE IN YOUNG MALE PATIENTS WITH
STROKE OR TRANSIENT ISCHEMIC ATTACK
A. Viguier, T. Levade, V. Larrue
CHU de Toulouse, Toulouse, France
Background: Fabry’s disease is a rare inherited, X-linked storage disease that may
cause stroke or transient ischemic attack (TIA) in young subjects. We sought to
determine the prevalence of this disease in an unselected population of young male
patients with stroke or TIA.
Methods: Peripheral blood leukocyte alpha-galactosidase A activity was deter-
mined in male patients aged 18-55 years, consecutively admitted to a tertiary stroke
unit for acute stroke or TIA. Causes of stroke or TIA were classified using the
TOAST classification.
Results: 108 patients were recruited from January 2004 to June 2005. The mean
age ± SD was 45 years ± 9. There were 71 ischemic strokes, 27 TIAs, 8 cerebral
hemorrhages and 2 venous cerebral thrombosis. Causes of stroke or TIA were un-
determined in 51/98 (52%) patients. No patient had a deficient alpha-galactosidase
A activity.
Discussion: These findings confirm the rarity of Fabry’s disease among unselected
young male patients with stroke and TIA.
7 Etiology of stroke
WHITE MATTER LESION LOAD IDENTIFIED BY MAGNETIC RESONANCE
IMAGING IS NOT RELATED TO IPSILATERAL CAROTID ARTERY
STENOSIS
F.N. Doubal, J.M. Wardlaw, M.S. Dennis
University of Edinburgh, Edinburgh, United Kingdom
Introduction: Cerebral white matter hyperintensities (WMH) on T2-weighted
magnetic resonance (MR) are common but their aetiology is unknown. They are
associated with hypertension, diabetes and atherosclerosis, and may be caused by
16th European Stroke Conference
small vessel disease or microemboli (e.g. from the heart, aortic arch or carotid artery
stenosis). Studies have linked the severity of any carotid stenosis to the severity
of whole brain WMH load but have not specifically examined brain ipsilateral to
a stenosis. We hypothesised that if microemboli cause WMH, e.g. from carotid
stenoses, more WMHs would be found in the cerebral hemisphere ipsilateral to a
stenosis than in the hemisphere distal to a non-stenosed carotid.
Methods: We prospectively recruited patients with lacunar or mild cortical
stroke from a tertiary hospital. Patients were imaged with a 1.5T MR scanner
(T2/DWI/GRE/FLAIR) and carotid doppler ultrasound. We dichotomised carotid
stenosis as >or <50% NASCET. MRI scans were scored for deep and periventricu-
lar WMHs in each hemisphere using the Fazekas method, blind to carotid stenosis.
We compared hemispheric Fazekas scores between patients with or without uni or
bilateral carotid stenosis.
Results: Of 79 patients, 14 had asymmetrical carotid stenosis (one > and one
<50%), 1 had bilateral >50% stenoses and 64 had bilateral <50% stenoses. In the
14 with asymmetrical stenoses there was no difference in deep or periventricular
WMHs between the ipsilateral (mean deep Fazekas 1.78; mean periventricular
Fazekas 1.42) or contralateral hemisphere (1.78;1.36) to the stenosis. In the 64 with
no stenosis bilaterally there was no difference in mean deep and periventricular
Fazekas scores between the left (1.64;1.03) and right (1.62;1.08). The patient with
bilateral stenoses had identical scores in each hemisphere.
Conclusions: We found no link between cerebral hemisphere WMH score and
ipsilateral carotid artery stenosis, suggesting that microemboli, at least from carotid
stenoses, are unlikely to cause most WMHs.
8 Etiology of stroke
VASCULAR RISK FACTORS IN TRANSIENT ISCHAEMIC ATTACKS AND
LATE-ONSET EPILEPSY
M.O. McCarron, A. Hunter, M. Watt
Altnagelvin Hospital, Derry, United Kingdom
Background: There is emerging evidence that late onset seizures may be the first
manifestation of occult cerebrovascular disease. We sought to compare the vascular
risk profiles in patients with transient ischaemic attacks and patients with late-onset
epilepsy for which no other cause was identified.
Methods: Consecutive patients attending a neurovascular clinic with a diagnosis
of transient ischaemic attack (TIA) or epilepsy were eligible for study. Vascular
risk factors were prospectively recorded and compared in each group with the chi
square test.
Results: One hundred patients were enrolled in each group. The distribution of
vascular risk factors was as follows: atrial fibrillation (2 in seizure group versus 0
in TIA group, NS), hypertension (59 versus 52, NS), diabetes (9 versus 10, NS),
cigarette smoking (52 versus 45, NS), heart failure (1 versus 0, NS), hyperlipi-
daemia (35 versus 33, NS), ischaemic heart disease (18 versus 23, NS), previous
cerebrovascular disease (33 in seizure group versus 7 in TIA group, p<0.001),
excess alcohol (19 versus 16, NS), and family history of stroke (52 versus 50, NS).
Discussion: Vascular risk profiles are very similar among TIA and late-onset
epilepsy patients. This study also supports existing evidence that previous cere-
brovascular disease is a risk factor for late-onset epilepsy.
9 Etiology of stroke
PATTERN OF INTRACRANIAL VERSUS EXTRACRANIAL
ATHEROSCLEROTIC CEREBROVASCULAR DISEASE IN INDIAN PATIENTS
WITH STROKE- AN ANGIOGRAPHY STUDY
S. Husain, S. Sukumaran, A. Vajpayee, S.U. Khan, K.M. Rahman,
S. Chaturvedi Gopal, S. Sharma
Sir Ganga Ram Hospital, New Delhi, New Delhi, India
Objective: To evaluate the intracranial atherosclerosis among patients of atheroscle-
rotic stenos-occlusive extracranial carotid artery disease undergoing cerebral DSA
for the evaluation of the cerebral haemodynamic.
Material & methods: Between May 1999 to March 2005, 224 cerebral DSA were
performed in symptomatic patients referred to us with evidence of extracranial large
vessel disease, either on Doppler, CTA or MRA. The percentage diameter stenosis
for extracranial vessel was calculated by NASCET method and for intracranial ves-
sels as per WASID method. They were categorized as nonsignificant stenosis (0%
to 49%), significant stenosis (50% to 99%), and total occlusion. The intracranial
vessels were involved when a lesion was distal to the ophthalmic artery. For the
vertebral artery, the distinction was made at the point where the artery pierced the
dura at the level of foramen magnum. The intracranial extent of the stenosis was
included in this study up to the M2 and A2 segments in the anterior circulation and
the P1-P2 segments of the posterior cerebral artery.
Poster Session
Etiology of stroke
Results: A total 404 lesions were present in 224 patients. Among these patients,
single lesions were found in 64 (15.8%) and multiple lesions in 160 (84.2%).
Of the single lesions 24(37.5%) were intracranial stenosis and 50(62.5%) were
extracranial. Lesions were located in the anterior circulation in 42 patients (65.62%)
and in the posterior circulation in 22 (34.37%).
Among the 340 stenoses in the 160 patients with multiple lesions, 38 (23.75%)
patients had 88 lesion in the intracranial, and 92 patients (57.5%) had 186 lesions
in the extracranial vessels solely and both intra and extracranial in 30(18.75%)
patients harboring 66 lesions.
Overall 142(35.1%) lesions were intracranial and 262(64.9%) were extracranial.
Conclusion: Intracranial atherosclerosis is common in Indian patients with
atherosclerotic stenosis involving extracranial carotid artery disease.
10 Etiology of stroke
HOMOCYSTEINE IN STROKE SUBTYPES IN THE SOUTH LONDON BLACK
POPULATION
U. Khan, C. Crossley, P. Collinson, H. Markus
St. George’s University of London, London, United Kingdom
Introduction: Cerebral small vessel disease (SVD) is increased in black popula-
tions but the underlying mechanisms are poorly understood. In Caucasians elevated
serum homocysteine (Hcy), and genetic variants causing increased Hcy levels,
have been associated with SVD particularly in cases which have accompanying
leukoaraiosis where pathological studies suggest an underlying small vessel arteri-
opathy and endothelial dysfunction is a proposed disease mechanism. We compared
Hcy levels from black strokes enrolled in the in the prospective South London
Ethnicity and Stroke Study with community controls.
Methods: Hcy, B12, folate and creatinine were measured in black strokes (N=483)
from three South London hospitals and controls recruited by random sampling of
family practices (N=276). All patients were subtyped by one rater using modified
TOAST criteria based on investigations. In SVD patients, leukoaraiosis was graded
according to severity (modified Fazekas scale) and patients divided into two groups:
isolated lacunar infarction (ILI) and lacunar infarction in the presence of confluent
leukoaraiosis (ischaemic leukoaraiosis (ILA)).
Results: Hcy (μmol/L) was increased in black stroke patients (14.22 (8.80)) vs.
controls (11.13 (5.34)) (OR: 4.63 (2.50-8.58), P<0.001) after adjusting for age,
gender, vascular risk factors, B12, folate and creatinine. Hcy levels were signif-
icantly raised in the following groups: SVD (OR: 7.16 (3.32-15.44), P<0.001),
intracerebral haemorrhage (OR: 5.53 (2.07-14.72), P=0.001), cardioembolism
(OR: 7.85 (2.87-21.42), P<0.001) and unknown aetiology (OR: 2.28 (1.15-4.52),
P=0.018) with highest levels seen in SVD (16.19 (11.48)). Within the SVD group
Hcy was higher in the ILA subgroup (19.63 (14.61)) vs. ILI (13.41 (7.06)) (OR:
4.75 (1.53-14.69), P=0.007) and correlated with radiological leukoaraiosis severity
(R=0.265, P=0.001).
Conclusions: Hcy is a risk factor for cerebral SVD in blacks, especially in confluent
leukoaraiosis. This is consistent with a role for endothelial dysfunction in SVD
pathogenesis in this ethnic group.
11 Etiology of stroke
DETECTION OF RIGHT-TO-LEFT SHUNTS IN PATIENTS WITH
HEPATOPULMONARY SYNDROME IS POSSIBLE USING TRANSCRANIAL
DOPPLER
G.S. Silva, D.L. Gomes, M.G. Vasconcelos, J.A. Fiorot Jr, M.M. Alves,
C.H. Fischer, A.R. Massaro
UNIFESP - Universidade Federal de São Paulo, São Paulo, Brazil
Background: Patients with liver failure can present with a large spectrum of neu-
rologic symptoms. Cerebrovascular disease has been described as one of the most
frequent neuropathology findings after liver transplantation. Right-to-left shunts
(RLS) were described in patients with hepatopulmonary syndrome, related to in-
trapulmonary vascular dilatations. We assessed the hypothesis that intrapulmonary
RLS in patients with hepatopulmonary syndrome can be detected by transcranial
Doppler (TCD).
Methods: Patients with liver failure and hepatopulmonary syndrome, selected
from the gastroenterology outpatient clinic of our hospital, and with a confirmed
intrapulmonary RLS on transesophagealechocardiography (TEE) were evaluated.
A group of patients with intracardiac RLS on TEE was also studied. All patients
were submitted to middle cerebral artery TCD monitoring by transtemporal ap-
proach after the injection of saline solution (9ml) and air agitated, in the right
antecubital vein. Monitoring was performed during normal breathing and after
Valsalva maneuver. The presence of microembolic signs (MES) was evaluated by
three examiners, blinded to the patient‘s diagnosis.
Cerebrovasc Dis 2007;23(suppl 2):1–147 91
Results: Eight patients with hepatopulmonary syndrome (mean age 53,2 ± 12,3
years, 6 men) and 20 patients with intracardiac shunts (mean age 47 ± 16,8 years,
8 men) were evaluated. MES were detected by TCD with a sensitivity of 87,5%
in patients with intrapulmonary shunts and 90% in those with intracardiac shunts.
Time delay to first MES detection was higher in patients with intrapulmonary
shunts (15s X 10 s in patients with intracardiac shunts) (p=0,04).
Discussion: TCD can detect intrapulmonary shunts in patients with hepatopul-
monary syndrome, with a sensitivity slightly lower than for the detection of
intracardiac shunts. Time delay for intrapulmonary shunts detection is higher when
compared to intracardiac shunts. Paradoxical emboli should be investigated as a
potential cause of neurologic symptoms in patients with liver failure and TCD can
be a useful screening method for this evaluation.
12 Etiology of stroke
RELATIONSHIP OF CAROTID ATHEROSCLEROSIS WITH
LEUKOARAIOSIS IN ISCHEMIC STROKE PATIENTS
E. Ben-Assayag, M. Mijajlovic, S. Shenhar-Tsarfaty, I. Bova, L. Shopin,
S. Berliner, I. Shapira, N.M. Bornstein
Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
Background: Previous studies have shown that white matter lesions are associated
with increasing age, hypertension, diabetes and history of stroke. Although several
lines of evidence suggest a role of atherosclerotic processes in atherothrombotic
vascular events, their involvement in leukoaraiosis (LA) remains to be determine.
Our study examines the association between atherosclerosis, reflected as intima-
media thickness (IMT) and carotid plaques and LA in a group of ischemic stroke
patients.
Methods: One hundred sixty four consecutive ischemic stroke patients were
included (mean age 66.7± 3.4 years, 61% males). All patients underwent brain
computed tomography (CT) and carotid dupplex with measurements of IMT in the
common carotid artery. The extent and number of white matter lesions (WML)
were recorded by 2 independent readers.
Results: Seventy two patients (44%) were found to have 1 or more WML on CT
images located in frontal, parietal or occipital region. Of whom, 30% were recorded
to have advanced LA. Mean IMT was significantly higher in stroke patients with
LA (p=0.004) compared to those without it. Also, carotid plaque occurrence was
associated with LA (χ2 =6.154, p=0.013) and advanced LA (χ2 =7.673, p=0.006).
In logistic regression analysis, including age, gender, body mass index, and all
vascular risk factors, LA was found to be associated with age and IMT (O.R.
1.041, 95% CI 1.011-1.072, p=0.007; O.R. 2.365, 95% CI 1.129-4.954, p=0.022;
respectively). White matter lesion severity was also found to be associated with age
and IMT (O.R.1.064, 95% CI 1.028-1.1, p=0.001; O.R. 2.84, 95% CI 1.248-6.462,
p=0.013; respectively).
Discussion: Stroke patients with LA present strong relationship with increased
carotid IMT and plaque occurrence. Association was independent of gender, body
mass index and all vascular risk factors. This suggests that advanced atherosclerotic
process in LA.
13 Etiology of stroke
FIBRO MUSCULAR DYSPLASIA AND CERVICAL ARTERY DISSECTIONS:
VALUE OF RENAL ARTERY ANGIOGRAPHY
J.M. de Bray, A. Pasco, F. Dubas, B. Vielle, J.F. Subra
University Hospital, France
Fibro muscular dysplasia (FMD) is a potential cause of cervical artery dis-
section(CAD).Moderate forms of FMD are undiagnosed by magnetic resonance
angiography.The use of renal intra-arterial digital subtraction angiography(DSA)in
identifying FMD in CAD has not yet been validated. An ancillary study from a
prospective study was performed to determine the prevalence of the association
of cervical and renal artery FMD in CAD assessed by DSA and to define the
diagnostic impact of renal DSA in these patients.
Methods: A prospective study on symptomatic recurrence of CAD was performed
from 1994 to 2004 and is in press in Cerebro.Vasc.Dis.103 patients were con-
secutively included for a CAD diagnosed by cervical MRI or suggested by 2
concordant cervical imaging methods.FMD(17 patients)was defined as a string of
beads image located in a non dissected vessel.The design of the ancillary study
consisted in including patients with CAD investigated by both cervical and renal
artery DSA.Population:54 patients fulfilled our subgroup criteria were 31 women
and 23 men.The Chi square test and Fisher’s exact test were used for assessing the
association between renal FMD and vascular risk factors.
Results: According to the presence of FMD,4 sub-groups of patients were iden-
tified.I (n:4),showed renal FMD but no cervical FMD;II(n:5), had cervical and
92 Cerebrovasc Dis 2007;23(suppl 2):1–147
renal FMD;III (n:12), isolated cervical FMD;IV (n:33) without FMD. Renal FMD,
bilateral in half of the cases,was significantly associated with an age over 40
years.Two out of patients with renal FMD had arterial hypertension.
Conclusion: The prevalence of combined cervical and renal artery FMD is 9% in
patients with CAD.More FMD cases(7%)are detected by cervical and renal DSA
than by cervical DSA alone.The diagnosis of renal FMD could help in identify-
ing patients at risk of renal artery dissection and renovascular hypertension.The
presence of an arterial hypertension is not predictive for renal FMD.
14 Etiology of stroke
CAUSES HETEROGENEITY OF LACUNAR STROKE
O. Vinogradov, A. Kuznetsov
National Pirogov Centre of Therapy and Surgery, Moscow, Russian Federation
Background: Cerebral microangiopathy owing to hypertension or diabetes mellitus
is considered to be main cause of lacunar stroke (LS). But other causes of LS are
known too. The purpose of this study was to determine etiologies of LS other than
small-artery disease.
Material and methods: We have examined 105 patients with acute LS. We used:
diffusion-weighted MRI (Giroscan INTERA NOVA, Holland), transthoracic or
transesophageal echocardiography, carotid duplex sonography (VIVID 7, USA),
transcranial Doppler sonography with microemboli detection (Sonomed-300, Rus-
sia); scale evaluation was performed according to NIHSS.
Results: Patients with LS according to diffusion MRI were divided in 3 groups:
group I – single small (less than 15 mm) lacunar focus – 59 patients (56,5%); group
II – large focus (more than 15 mm) or multiple small foci at the same vascular
territory – 24 patients (22,9%), group III – multiple foci in different vascular
territory – 22 patients (20,9%). LS caused by small-artery disease was revealed
in 69 patients (65,7%). Stroke mechanism different from small-artery disease was
revealed in 36 patients (34,3%). Significant differences in potential sources of
cerebral embolism were revealed in group I in comparison with group II (p<0,05)
and group III (p<0,001). Multiple lacunas or combination of lacunas and cortical
strokes is reliable cerebral embolism marker. Neurological deficiency was more
severe in LS patients with embolism (p<0,01).
Conclusions: Causes of LS are heterogeneous. Choice of secondary prevention
regime demands of determination true cause of LS.
Stroke and lipids
1 Stroke and lipids
DEPLETION OF THE LIPID RAFT COMPONENTS CHOLESTEROL AND
SPHINGOMYELIN PREVENTS NMDA-INDUCED NEURONAL DEATH
J. Ponce, N. Perez de la Ossa, O. Hurtado, M. Dolade, M. Millan, J. Arenillas,
A. Davalos, T. Gasull
Fundacio Institut d’Investigacio en Ciencies de la Salut Germans Trias i Pujol,
Badalona, Spain
Background and purpose: Excess brain extracellular glutamate in cerebral is-
chemia leads to neuronal death through overactivation of N-methyl-D-aspartate
(NMDA) receptors. The cholesterol lowering-drugs statins have been reported to
protect from NMDA-induced neuronal death but, so far, the mechanism underlying
this protection is unknown. Since NMDA receptors have been reported to be
associated with the cholesterol- and sphingomyelin-rich membrane domains known
as lipid rafts, we have investigated the effect of treatments that deplete cholesterol
or sphingomyelin levels on NMDA-induced neurotoxicity. In addition, we have
investigated the effect of simvastatin on the percentage of NMDA receptors
associated to lipid rafts.
Methods: Primary neuronal cultures were pre-treated with simvastatin, the inhibitor
of cholesterol synthesis AY9944, or the inhibitor of sphingomyelin synthesis fu-
monisin B1. Cell death was determined 24 h after the addition of NMDA. Lipid
rafts from control and simvastatin-treated neurons were isolated, and Western blots
were performed using an antibody specific for the subunit 1 of NMDA receptors
(NMDAR1).
Results: Sustained treatment with either simvastatin, AY9944, or fumonisin B1,
protected neurons from NMDA-induced neuronal death by 70%, 56% and 30%,
respectively. Simvastatin (250 nM) reduced by 40% the association of NMDAR1
to lipid rafts and did not change total expression of NMDAR1.
Discussion: The inhibition of the synthesis of main components of lipid rafts
protects from NMDA-induced neuronal damage. This protection might be mediated
by a reduced association of NMDA receptors to lipid rafts. Taken together these
16th European Stroke Conference
findings suggest that lipid raft integrity is necessary for signalling to death through
NMDA receptors.
2 Stroke and lipids
STATIN USE, LIPID PROFILE AND SYMPTOMATIC INTRACEREBRAL
HAEMORRHAGE FOLLOWING IV THROMBOLYSIS
M.W. Koch, M. Uyttenboogaart, P.C. Vroomen, J. De Keyser, G.J. Luijckx
University Medical Centre Groningen, Groningen, The Netherlands
Background: Intravenous thrombolysis with tissue plasminogen activator (tPA)
improves outcome of acute ischaemic stroke, but increases the risk of symptomatic
intracerebral haemorrhage (sICH). It has been suggested that lower cholesterol
levels may be associated with higher incidence of primary ICH as well as with
sICH following tPA treatment.
Methods: From a prospective hospital based tPA registry comprising 309 patients,
we selected all patients with known serum concentrations of total cholesterol (TC),
HDL, LDL and triglycerides (TG), modified Rankin Scale (mRS) scores at three
months and statin use (n=214). Lipid profiles were compared between patients with
and without sICH following tPA treatment and between patients with and without
favourable outcome (mRS 0-2).
Results: Patients with sICH (n=10) had significantly higher TG (2.6 SD 1.9 vs 1.8
SD 1.0 mmol/l, p=0.049) and lower HDL levels (1.0 SD 0.3 vs 1.2 SD 0.4 mmol/l,
p=0.049) Neither LDL (3.0 SD 0.8 vs 3.2 SD 1.0 mmol/l, p=0.59), TC (5.0 SD
1.0 vs 5.1 mmol/l SD 1.2, p=0.78) levels nor statin use (2 vs 30 patients, p=0.65)
were significantly different between patients with and without sICH. There were no
significant differences for any of these variables between patients with favourable
and unfavourable outcome: TC (5.2 SD 1.3 vs 5.0 SD 1.1), HDL (1.2 SD 0.4 vs
1.2 SD 0.4), LDL (3.2 SD 1.1 vs 3.1 SD 0.9), TG (1.9 SD 1.2 vs 1.7 SD 1.0), statin
use (15 vs 17 patients).
Conclusion: Although patients with sICH had marginally higher TG and lower
HDL levels, statin treatment or overall lipid profile seem unrelated to functional
outcome at 3 months.
3 Stroke and lipids
HIGH TRIGLYCERIDE LEVELS IN SINGAPOREAN ACUTE ISCHEMIC
STROKE PATIENTS REDUCES THE RISK OF POOR OUTCOME AT 1 YEAR
AFTER STROKE
J.L. Pascual, H.M. Chang, M.C. Wong, C.P. Chen
National Neuroscience Institute, Singapore General Hospital Campus,
Singapore, Singapore
Background: Cholesterol reduction lowers risk for recurrent vascular events in
stroke patients. However, low total cholesterol (TC) and low triglyceride (TG) levels
have been linked to increased risk for hemorrhagic stroke, and poorer outcomes
after stroke, respectively. We investigated the effect of lipid-lowering therapy on
the outcomes of Singaporean acute ischemic stroke patients.
Method: Consecutive acute ischemic stroke patients had fasting TC, high-density
lipoprotein(HDL), low-density lipoprotein (LDL) and TG determinations. Elevated
lipids were defined as follows: TC ≥ 5.2 mmol/L, LDL ≥ 2.6 mmol/L, and TG
≥ 1.7 mmol/L. Prior lipid-lowering therapy was documented. At 1 year follow-up,
functional outcome was assessed using the modified Rankin score (MRS).
Results: 805 patients gave informed consent for fasting lipid profiles and 1 year
follow-up. The mean TC was 5.66 mmol/L, mean LDL was 1.31 mmol/L, and
mean TG was 1.73 mmol/L. Patients with prior stroke, ischemic heart disease or
lipid therapy had lower TC and LDL levels (p < 0.05). At 1 year after stroke, 28%
of patients had mRS 3 or worse. Elevated TG independently predicted for good
functional outcome (HR = 0.41, 95% CI: 0.23 – 0.75).
Discussions: In agreement with previous studies, high TG is associated with better
outcomes after stroke. Whether elevated TG is itself protective or is associated with
a higher probability of receiving lipid-lowering drugs remains to be elucidated.
4 Stroke and lipids
ROLE OF STATINS IN FUNCTIONAL OUTCOME FOLLOWING AN ACUTE
ISCHEMIC STROKE
L. Vaidyanathan, G. Kumar, D. Nash, W.W. Decker, L.G. Stead
Mayo Clinic, Rochester, USA
Hypothesis: Similar to the beneficial effect in acute coronary syndrome, daily
statin improves functional outcome following acute ischemic stroke by mechanisms
other than lowering LDL levels.
Poster Session
Acute stroke: clinical patterns and practise
Methods: The cohort included all patients presenting to the Emergency Department
with an acute ischemic stroke over a 22-month period (March 04 to December
05). The lipid profile (cholesterol, triglyceride, LDL and HDL levels) measured
prior to or following admission was abstracted. Measurement of the panel ranged
between 15 days prior to the stroke to 17 days after the event (Mean 0.79 days ±
SD 2.53). Daily statin intake prior to the event and prescription on discharge was
also recorded. The primary outcome variable, functional disability, was determined
using the modified Rankin scale (mRs, 0-2=good outcome, 3-6=bad outcome),
which was calculated for each patient at the time of discharge. A Pearson’s
chi-square test was performed analyzing the relationship between the functional
outcomes at discharge and statin intake at the time of the event.
Results: Of 508 patients, 207 (40% female) presented with an LDL of ≤100
mg/dL. This group was divided into those who were on a statin on admission
(n=100) and those who were not (n=107). There was no significant difference in
the admission stroke severity measured by the NIHSS (p=0.18), age (p=0.31) and
gender (p=0.06) between the 2 groups. The patients on a statin were significantly
more likely to have a good functional outcome, (OR 0.5; 95% CI 0.29-0.95;
p=0.033). Following adjustment for age and NIHSS, statin intake still predicted a
better functional outcome (p<0.0001).
Conclusion: Daily statin intake appears to be associated with a better functional
outcome following an acute ischemic stroke despite ideal LDL levels (≤100)
and similar stroke severity on admission. Other mechanisms of action of statins
like plaque stabilization, improved endothelial cell function, anti-inflammatory,
antiplatelet, anti-oxidant and antithrombotic effects may play a role in a better
functional outcome.
5 Stroke and lipids
SERUM CHOLESTEROL LEVELS AND SHORT TIME OUTCOME IN
STROKE PATIENTS
P. Milia, M. Paciaroni, V. Caso, S. Biagini, M. Venti, A. Billeci, F. Palmerini,
A. Alberti, A. Baldi, G. Agnelli
University of Perugia, Perugia, Italy
Background: Although cholesterol and stroke disorders has been extensively
studied, the relationship between serum cholesterol levels and short time outcome
after stroke has not been widely investigated.
Objective: To identify if serum cholesterol levels measured at admission after
stroke have any prognostic value on outcome at discharge.
Methods: Patients consecutively admitted to our stroke unit suffering of any type
of stroke were analysed. Fasting serum cholesterol was measured at 24 hours after
admission. Outcome was evaluated using mRS: we identified adverse outcome as
mRS ≥3 at discharge. Data were analysed by univariate and logistic regression
analysis.
Results: We collected 935 patients suffering of stroke (mean age 74.65±11; 789
ischemic, 146 hemorrhagic; mean NIHSS 8.67±6.5). Mean values of cholesterol
at admission was 195.2±51 in the overall group with no differences between all
types of stroke (I 195.65±50; H 192.43±38). Functional outcome at discharge
(mRS&≥3) was not influenced by levels of cholesterol in all the population after
logistic regression analysis (OR 0.99 CI 0.99-1.0, p 0.4) and also in either ischemic
(OR 0.99 CI 0.99-1.0 p 0.7) and hemorrhagic strokes (OR 0.99 CI 0.98-1.0, p 0.2).
Conclusions: Serum levels of cholesterol are not associated with outcome in the
early phase after ischemic and/or hemorrhagic stroke, suggesting that it doesn’t
need to be treated in the acute phase as negative prognostic risk factor. Still remains
uncertainty about its role at early and medium time on stroke patients.
Acute stroke: clinical patterns and practise
1 Acute stroke: clinical patterns and practise
EVALUATING THE USE OF HAND MITTENS IN POST STROKE PATIENTS
WHO DO NOT TOLERATE NASO-GASTRIC FEEDING
Y.-Y.K. Kee, W. Brooks, R. Dhami, A. Bhalla
Epsom and St. Helier University Hospitals NHS Trust, United Kingdom
Background: Early naso-gastric (NG) and consistent feeding in acute stroke
patients has been shown to improve patient morbidity and mortality. However, after
an acute stroke, patients can be agitated and may frequently pull out NG tubes.
Recurrent NG tubes placements are associated with complications such as trauma
and chest infections. The use of restraints such as hand mittens may improve
nutrition and reduce complications of NG placements. This practice although
uncommon in the UK, is used commonly in other countries. Few studies have been
Cerebrovasc Dis 2007;23(suppl 2):1–147 93
done to evaluate the use of such restraints in acute stroke patients. This study aims
to evaluate the use of hand mittens in such patients.
Methods: We carried out a retrospective case control study with 18 patients over
a period of one year period (8 with, 10 without mittens). The following data was
collected: number of NG tubes inserted during the patient’s admission, number of
aspiration pneumonias treated with antibiotics, number of chest x-rays the patient
received, amount of feed received, weight loss/gain during admission, length of
stay. Results were analysed using GraphPad Prism 4 software
Results: The median age in both groups was 81.5 years. 89% of patients had total
anterior circulation stroke. Patients in the mitten group needed fewer ng tubes; 7
vs 10 p<0.05. There were less episodes of aspiration pneumonia, p<0.05. Patients
with mittens experienced less weight loss; 0.7kg vs 5.2kg, p<0.05. There were
fewer deaths in the mitten group, 2 vs 7, p<0.05. There was a small reduction in
the length of stay 40 vs 48.5 days, p=0.15.
Discussion: The use of physical restraint is not universally accepted in the UK. The
decision to use mittens in our patients was taken after discussions with the patient
or next of kin. The use of mittens resulted in better nutrition in our patients, as well
as a reduction in mortality and should be considered in patients who do not tolerate
their NG tubes.
2 Acute stroke: clinical patterns and practise
HEMOGLOBIN: A PREDICTOR OF FUNCTIONAL OUTCOME FOLLOWING
AN ACUTE ISCHEMIC STROKE
L. Vaidyanathan, D. Nash, M.F. Bellolio, S. Enduri, S. Mishra, R. Kashyap,
R.D. Brown, W.W. Decker, L.S. Stead
Mayo Clinic College of Medicine, Rochester, USA
Aim: To assess if the hemoglobin levels measured at the time of presentation to
the Emergency Department in a patient with Acute Ischemic Stroke (AIS) would
predict the severity and functional outcome.
Methods: The cohort included all patients presenting to the Emergency Department
with an AIS over a 3.5 year period (from December 2001 through June 2005).
Hemoglobin levels measured at the time of admission was recorded. Stroke severity
on presentation was assessed retrospectively using the 42-point NIHSS scoring
system and the functional disability was scored at discharge from the stroke service
using the modified Rankin scale (mRs). A statistical analysis of the data was
conducted using the JMP statistical software. Analysis of variance (ANOVA) was
used to analyze the variables.
Results: Of the total cohort, (n=1018), 47.2% were female. The mean age was 72.3
years ±SD 14.7. Hemoglobin levels were documented in 96.2% (n=979) of the
patients. Lower levels of hemoglobin predicted a more severe stroke (p=0.0067) and
poorer functional outcome (p<0.0001). This significance was retained following
adjustment for age in men (RANKIN p<0.0001 and NIHSS p=0.0004) and women
(RANKIN p<0.0001 and NIHSS p=0.0004).
Conclusion: Lower hemoglobin levels measured at the time of admission to the
Emergency Department seem to predict more severe strokes with poorer functional
outcome at discharge regardless of the gender probably due to greater ischemia
resulting from the decreased oxygen carrying capacity of the blood. With early
recognition, active methods could be taken to raise the patient’s hemoglobin and,
thereby, possibly improve functional outcome.
3 Acute stroke: clinical patterns and practise
PURE MIDBRAIN INFARCTION: CLINICAL RADIO ANATOMY
CORRELATIONS
R. Allibert, F. Vuillier, L. Tatu, T. Moulin
University Hospital Besançon, Besançon, France
Background: Clinical anatomical correlation in pure midbrain infarct has not been
widely established in a standardised manner. The aim of the study was to analyse
patients with pure midbrain infarcts using standardised protocols (clinical and
imaging analyses).
Method: Using a previously published arterial territories mapping, a correlation
between the clinical patterns, arterial territories and anatomical structures involved
was established. Patients with pure midbrain infarct were selected from all patients
admitted with first-ever stroke in our stroke unit. Clinical and imaging data were
standardised according to Besançon stroke registry criteria. All MRI images were
retrospectively reviewed by 2 neurologists to confirm infarct location, vascular
arterial territories and brain stem structure.
Results: 14 pure midbrain infarcts were included. Clinical manifestations in-
cluded gait ataxia in 2/14 patients, dysarthria in 4/14, limb ataxia in 10/14, sensory
symptoms in 1/14, third nerve palsy in 9/14, definitive limb weakness in 6/14 and in-
ternuclear ophthalmoplegia. In most cases (9/14), the infarct was located in the high
94 Cerebrovasc Dis 2007;23(suppl 2):1–147
level of the midbrain. Only 1 arterial territory was involved in 7/14 cases and which
corresponded to the antero-medial territory in 6/7 cases. Antero-medial infarcts
were always present in patients with diplopia and controlateral cerebellar ataxia.
Among patients with III nerve palsy, infarct affected the nuclear (2/3) or fascicular
fibers (1/3). Motor deficit was associated with anterolateral infarct (5/6 patients).
Discussion: The link between diploplia and controlateral cerebellar ataxia seemed
to relate specifically to a midbrain infarct located in the antero-medial territory and
with no predictive value for an antero-posterier extension of the infarct. A brachio-
facial motor deficit clearly implied the involvement of the anterolateral territory, as
expected by the somatotopy of the corticospinal tract. The use of a practical tool
to determine location of pure midbrain infarct enables the establishment of a good
correlation.
4 Acute stroke: clinical patterns and practise
PURE DYSARTHRIA AND DYSARTHRIA-FACIAL PARESIS SYNDROME
K. Yonemura, Y. Hashimoto, M. Uchino
Kumamoto City Hospital, Kumamoto, Japan
Background: Pure dysarthria (PD) and dysarthria-facial paresis (DFP) are rarely
encountered clinical stroke syndromes, and seem to be regarded as an atypical
lacunar syndrome. We sought to clarify the clinical characteristics of PD and DFP
in acute ischemic stroke patients.
Methods: We selected patients with PD or DFP from 1,043 consecutive patients
with first-ever acute ischemic stroke admitted over a 7-year period. Vascular risk
factors, emboligenic heart disease, occlusive cerebral artery disease, infarct size
and location, stroke subtype according to the TOAST classification, and outcome
data were evaluated. Acute infarcts were all identified by diffusion-weighted MRI
(DWI).
Results: A total of 34 patients were reviewed. They consisted of 16 patients with
PD and 18 patients with DFP. Hypertension was the most frequent in the vascular
risk factors (13 patients with PD and 14 patients with DFP). Emboligenic heart
disease and/or cerebral artery disease were detected in 13 (38%) patients (5 with PD
and 8 with DFP). DWI identified infarcts on the cortical motor area, centrum ovale,
or corona radiata in 25 (74%) patients (12 with PD and 13 with DFP), whereas
brainstem infarct was demonstrated only in 1 patients with PD. 18 (53%) patients
(11 with PD and 7 with DFP) had infarcts <15mm in maximal diameter, and 15
(44%) patients (10 with PD and 5 with DFP) met the diagnostic criteria of lacunar
stroke. Neurological deterioration occurred after hospitalization in 2 patients with
DFP, but patients were discharged usually with mild or no disability.
Discussions: Infarcts in the higher levels of cerebral hemisphere are responsible
for the majority of the PD and DFP syndromes. The predictive value of these
syndromes for lacunar stroke is rather low, particularly in DFP.
5 Acute stroke: clinical patterns and practise
ACUTE VERTIGO OF UNDETERMINED ORIGIN: DIAGNOSTIC VALUE OF
MAGNETIC RESONANCE IMAGING
L. Huang, A. Villringer, A. Hartmann
Charité Campus Benjamin Franklin, Berlin, Germany
Background: The origin of acute vertigo often remains undetermined after neuro-
logical, otological, and CT examination in the emergency room. We investigated
the diagnostic yield of magnetic resonance imaging (MRI) in these patients.
Methods: Patients were included in the study if they had presented with sudden
onset of vertigo to our Department between 01/2002 and 06/2005, and complete
neurological, otological and cranial CT investigation allowed no definite allocation
to peripheral or central origin of the vertigo. Results of cranial MRI including
diffusion-weighted imaging (DWI), clincal, and epidemiological information were
taken to compare the patients with (group 1) and those without (group 2) acute
lesions on MRI using univariate statistics.
Results: In the 108 patients with acute vertigo (mean age 61 years, 62% women),
acute ischemic lesions were detected in 12% on DWI. Affected regions were
medulla oblongata, cerebellum, pons, thalamus, corpus callosum, temporo-occipital
lobe, parietal lobe, both periventricular areas, and frontal lobe. Higher prevalence of
vertigo-unrelated ischemic CT changes (p=0.01) and non-significant trends towards
elevated serum cholesterol (p=0.06), older age (0.07) and higher blood glucose
levels (0.09) were observed in group 1 compared with group 2. All other clinical
and epidemiolgical variables were similar in both groups.
Conclusion: In patients with acute vertigo and inconclusive clinical and CT
examinations, the diagnostic yield of cranial MRI is low. Patients with old ischemic
lesions on CT are more likely to have a central vertigo origin. Clinical and
epidemiological characteristics are not associated with higher detection rates of
acute brain lesions.
16th European Stroke Conference
 6 Acute stroke: clinical patterns and practise
COURSE OF CEREBROVASCULAR INCIDENTS IN PATIENTS WITH
PERMANENT AND PAROXYSMAL ATRIAL FIBRILLATION
J. Staszewski, J. Kotowicz, A. Stepien
Military Medical Institute, Warsaw, Poland
Permanent atrial fibrillation (pAF) is an important risk factor for cerebrovascular
incidents (CVI). The frequency and prognosis of CVI in patients with paroxysmal
AF (plAF) is not well known. The aim of this single center study was to assess the
course and risk factors of unfavorable outcome of CVI in ptAF and plAF.
Patients with established AF and acute, ischemic CVI were included to prospec-
tive study with 6-months follow-up. The patients were classified on admission,
discharge and after 6-month as non-dependent (mRS ≤ 2) or dependent (mRS
≥ 3 ≤ 5). The course of CVI was categorized as favorable (non-dependence) or
unfavorable (dependence or death). The risk of embolic complication in AF was
assessed in CHADS2 scale.
Of 178 included patients 70 (39%) had plAF and 108 (61%) had ptAF. Groups
were similar in vascular risk profile. Cardioembolic strokes were more common in
ptAF than in plAF group (56% vs 44%, p=0.03). The proportions of dependent
patients at admission, discharge and at 6-month visit in ptAF were higher than
in plAF (50% vs 19%, 81% vs 45%, 71% vs 40%; p<0.001). In-hospital and
6-month mortality rates were higher in ptAF than in ptAF group (13% vs 3% and
32% vs 13%, p<0.001). Unfavorable risk factors for short- and long-term outcome
were: ptAF (OR 2.05, p=0.01), lack of chronic anticoagulation treatment (OR
3.48, p=0.02), chronic heart failure (OR 2.54, p=0.05), diminished left ventricular
ejection fraction (LVEF) (OR 2.15, p=0.01), non-lacunar cerebral infarction (OR
1.74, p=0.001) and increased (moderate to very high) risk of embolic complications
(OR 1.92, p=0.004).
Results suggest significantly different course of CVI in patients with ptAF and
plAF. Those with plAF had more favorable short- and long-term prognosis of CVI.
Risk factors for unfavorable stroke outcome were: ptAF, chronic heart failure, lack
of chronic anticoagulation, diminished LVEF, non-lacunar cerebral infarction and
presence of increased risk of embolic complications.
7 Acute stroke: clinical patterns and practise
COMPARISON BETWEEN THE OCSP AND TOAST CLASSIFICATION
SYSTEMS IN THE DIAGNOSIS OF CEREBRAL SMALL VESSEL DISEASE IN
THE SOUTH LONDON BLACK AND WHITE POPULATIONS
U. Khan, P. Jerrard-Dunne, L. Kalra, A. Rudd, C. Wolfe, H. Markus
St. George’s University of London, London, United Kingdom
Background: Stroke classification systems based on clinical criteria, such as the
Oxfordshire Community Stroke Classification (OSCP), have been widely used in
epidemiological studies to diagnose lacunar stroke but may be inaccurate compared
with systems based on investigation results. We compared OSCP with a pathophys-
iological classification (modified TOAST) in diagnosis of lacunar stroke in blacks
and whites in the South London Ethnicity and Stroke Study.
Methods: African and African-Caribbean strokes presenting to three South London
hospitals were prospectively recruited (N=600). 600 consecutive Caucasian strokes
presenting to the same three centres were also recruited. All cases underwent
standardised clinical assessment, demographic and risk factor data collection and
investigations (brain imaging (CT 65.4%, MRI 8.3%, both CT and MRI 26.3%),
imaging of the extracranial cerebral vessels (97%), echocardiography (56.7%)).
All cases were subtyped using modified TOAST criteria (excluding the use of
hypertension as a criterion for diagnosis) by one observer with review of original
imaging. Cases were also subtyped using the OCSP classification.
Results: Using TOAST, lacunar stroke was more prevalent in blacks (OR 2.94(1.97-
4.39)p<0.001) compared to whites. Similarly, OCSP-defined lacunar infarction was
increased in blacks but the association was weaker (OR 1.94(1.39-2.73)p<0.001).
Taking TOAST classification as the gold standard the sensitivity of OCSP for
detection of lacunar stroke was 84% (76% specificity). Positive predictive value
(PPV) for lacunar stroke detection was 56.5% (negative predictive value (NPV):
92.8%). Accuracy of OSCP for lacunar stroke diagnosis was worse in black
patients: PPV 66.7% (NPV: 88.6%) compared to a PPV of 41.4% (NPV: 96.0%) in
whites.
Conclusions: Lacunar stroke is increased in blacks compared to whites but use
of OCSP underestimates the difference. OCSP is less accurate at lacunar stroke
diagnosis in blacks, and this may introduce bias in studies comparing subtype
differences between ethnic groups if OSCP is used.
Poster Session
Acute stroke: clinical patterns and practise
8 Acute stroke: clinical patterns and practise
ISCHEMIC STROKE REVEALING SMALL INTRACRANIAL ANEURYSM.
NATURAL HISTORY, MANAGEMENT AND RECOMMENDATION
H. Desal, B. Daumas-Duport, F. Herisson, E. Auffray-Calvier, B. Guillon
Hopital Laennec, Centre Hospitalier Universitaire de Nantes, Nantes, France
Background: Ischemic stroke may be the first manifestation of small intracranial
aneurysm, secondary to clot embolization from the aneurysmal sac. Pathophys-
iology, clinical characteristics and outcome are not clearly identified leading to
undetermined management.
Methods: Patients admitted over a 6-year period in our stroke unit with ischemic
stroke distal to small (< 25 mm) sacciform intracranial aneurysm, in the ab-
sence of other causes for the infarctions, were selected. Patients demographics,
characteristics of aneurysms, outcome and management were analysed.
Results: Eight patients fulfilled our selection criteria (5 women; mean age 50, range
38-58). Ischemic stroke and intracranial aneurysm involved the anterior circulation
in 3 patients and the vertebrobasilar system in 5. The mean size of the aneurysms
was 11 mm (range 3-18). Digital angiography showed partial or complete aneurysm
thrombosis in 4 patients with occlusion of the parent artery in 2. An unexpected
subarachnoid haemorrhage was diagnosed in 3 patients. Two patients died during
the 72-hours period following their admission because of severe subarachnoid
haemorrhage. In the other cases, prognosis was excellent after early endovascular
embolisation (3 patients) or spontaneous thrombosis (3 patients) of the aneurysm.
However, in these last 3 patients, 2 had a late partial recanalisation of the aneurysm
that justified endovascular treatment.
Discussion: Our results suggest that ischemic strokes revealing intracranial
aneurysm might be associated with an asymptomatic subarachnoid haemorrhage,
that should be ruled out by CSF analysis (with spectrophotometry). Antithrombotics
should also be used cautiously in these high risk patients for haemorrhage. Early
endovascular or surgical treatment could prevent subsequent subarachnoid haem-
orrhage or stroke recurrence. Radiological follow up is required to detect further
recanalisation, particularly in cases with early spontaneous aneurysm thrombosis.
9 Acute stroke: clinical patterns and practise
CEREBRAL MICROEMBOUS DETECTION IN PATIENTS WITH ACUTE
ISCHEMIC STROKE
J. Lee, S.J. Lee
Yeungnam University College of Medicine, South Korea
Background: Microembolic signals(MES) detected by transcranial Doppler(TCD)
have been considered as an independent predictor of recurrent ischemic stroke.
However, the association between the presence of MES and the risk of stroke has
predominantly been studied on small and selected patients. To evaluate the clinical
significance of MES in patients with acute ischemic stroke, we investigated the
prevalence of MES and analyzed the relationship between MES and stroke subtype.
Methods: We intended to perform TCD monitoring for 30 minutes to detect MES
from the bilateral middle cerebral arteries in patients within 15 days of stroke onset.
The strokes were subtyped using the TOAST classification criteria.
Results: Of a total of 884 consecutive ischemic stroke patients admitted to our
stroke unit within 7 days of stroke onset, TCD study performed 590 patients, and
65 were excluded because there was a long interval between onset of symptoms
and examination, an artificial heart valve, and inadequate temporal bone window.
MES were detected in 23(4.2%) despite the fact that all patients were receiving
an antiplatelet or an anticoagulant treatment. Among patients with positive MES
detection, 7(31.8%) had recurrent MES during follow-up TCD monitoring within
3 days after the first examination. MES were detected in 3.1% of patients with
large-artery atherosclerosis stroke, 4.1% of cardioembolic stroke, 2.1% of lacunar
stroke, 9.1% of cryptogenic stroke, and 4.1% of undetermined stroke(p=0.241). In
6 of the 8 patients(75%) with the anterior circulation infarct, MES were observed
ipsilateral to the affected territories.
Discussion: During antithrombotic treatment in patients with acute ischemic stroke,
the prevalence of MES is low and MES detection dose not improve ischemic stroke
subtype classification. The MES are frequent in the territories of symptomatic
arteries in the anterior circulation stroke and recurrent MES are common during a
short follow-up.
Cerebrovasc Dis 2007;23(suppl 2):1–147 95
 10 Acute stroke: clinical patterns and practise
FIRST-DAY BODY TEMPERATURE DYNAMICS – A CLINICIAN’S TOOL FOR
MONITORING PENUMBRAL TISSUE TRANSFORMATION AND UPDATING
PROGNOSIS AFTER ISCHEMIC STROKE?
J. Mau, S.D. Jayavel
Heinrich Heine University Hospital, Duesseldorf, Germany
Background: Early normal but later rising body temperature (BT) was recently
shown to robustly and independently reduce the likelihood of complete dependency
or death after hemispheric ischemic stroke. To substantiate this unexpected finding,
first-day BT dynamics were to be studied in data from the first European Cooper-
ative Acute Stroke Study (ECASS) and explained within a model of progressive
stroke.
Methods: The ECASS had randomized and treated 615 patients to either 1.1mg/kg
rt-PA or placebo IV within 6 hours from symptom onset; 461 patients had
complete 0-2-24h profiles of 3 BT measurements. BT profiles were grouped
into 37(10%) "ever constant", 34(7.4%)"early only rising", 123(26.7%) "late only
rising", 107(23.2%) "ever rising", 49(10.6%) "decreasing", 35(7.6%) "convex",
and 76(16.5%) "concave", their association with baseline covariates tested with
stratified chi-squares and dichotomized 90-day modified Rankin scores (mRS)
logistically regressed on known predictors and trial medication.
Results: Profile groups were equally distributed between rt-PA and placebo and all
baseline covariates but for initial BT (P<0.0001), initial stroke severity (P=0.0298),
hypo-density extent in infarct territory (P=0.0164), and presence of infarct signs
(P=0.0033) on baseline computed tomography. Specific interactions were signif-
icant for the latter (P=0.041) and in BT > 37°C (P<0.0001) and BT<36°C
(P=0.0025). "Ever rising" profiles increased 90-day fatality and "ever constant"
profiles reduced risk of long-term dependency (mRS 4-5) among survivors after
24h, independently. Hence, associations of BT profiles were found for only the
lesion parameters and for specific long-term outcomes.
Discussion: A dynamic model of progressive stimulation of metabolic and apop-
totic regulation after focal ischemia explains that BT dynamics appear closely
correlated with evolving transformations in the ischemic penumbra.
Conclusion: Beyond clinically updating baseline prognosis after 24 hours, moni-
toring BT might also be used for timing neuro-protective interventions.
11 Acute stroke: clinical patterns and practise
DOES ACUTE STROKE UNIT CARE CHANGE DURING A REHABILITATION
CLINCIAL TRIAL (AVERT PHASE II)?
J. Collier, J. Bernhardt
National Stroke Research Institute, University of Melbourne, Heidelberg West,
VIC, Australia
Objectives: During A Very Early Rehabiliation Trial (AVERT) Phase II, we
randomised recruited stroke unit patients from two hospitals to receive either a
very early mobilisation (VEM) protocol or standard (usual) care. Both patient
groups were treated on the same ward. Given the potential for contamination effects
using this design, we aimed to investigate whether levels of physical activity for
non-recruited patients changed as a response to the trial embedded within each
stroke unit.
Methods: Prior to the trial, behavioural mapping procedures were used to evaluate
the proportion of the day patients were in bed, sat out of bed, and were standing or
walking. Behavioural mapping requires structed observation and recording of pa-
tient activity over a single day. During AVERT, mapping procedures were repeated
to determine activity levels of patients receiving standard care. All patients <14
days post stroke were eligible, with the exception of those requiring palliative care.
We excluded clinical trial participants. Ten-minute observations were conducted
between 0800 to 1700 with patient activity documented, who was present and
where patients were located. Stepwise binomial logistic regression was used to
assess difference in activity between time periods (2001/2; 2004/5), controlling for
differences in patient characteristics.
Results: 51 patients (mean age 74.0 years, 51% male) were recruited at Austin
Health and St. Vincents Hospital, Melbourne. Patients spent 65% of the day resting
in bed and 9% of the day in standing/walking activities. This was similar to
the activity patterns of patients in the pre-trial sample (60% of day in bed, 13%
standing/walking). No statistical differences between time periods was found (bed:
CI 95%-1.02.0, P=0.926; stand/walk: CI 95% -6.22.1, P=0.315).
Conclusion: The level of physical activity of stroke patients receiving standard
stroke unit care did not change during conduct of an acute rehabilitation trial.
This finding supports the feasibility of conducting an individually randomised
rehabilitation clinical trial.
96 Cerebrovasc Dis 2007;23(suppl 2):1–147
12 Acute stroke: clinical patterns and practise
ALBUMIN TO CREATININE RATIO (ACR) IS ASSOCIATED WITH THE
SEVERITY OF ACUTE STROKE AND PREDICTS THE OUTCOME OF ACUTE
STROKE AND TRANSIENT ISCHEMIC ATTACK (TIA)
K. Koniari, E. Gialouri, K. Makris, I. Drakopoulos, O. Glezakou
General Hospital KAT, Athens, Greece
Background: Although microalbuminuria is associated with clinical risk factors
for stroke, there is surprising little information regarding it as an independent risk
factor for stroke or as a predictor of stroke outcome.
Methods: In our study we investigated the prevalence of microalbuminuria in acute
stroke patients and its association with the patients’ clinical status at admission
and outcome. We studied 60 patients (mean age 75 years) who were admitted
in our hospital’s ER within 6 hours of their first neurological symptom. A urine
sample was collected at the time of admission, along with morning collections
at 24, 48, 72 hours and at the 7th day of hospitalization. ACR was measured on
a POCT instrument (Bayer DCA-2000). CT-scan was performed on all patients.
Neurological deficit and clinical status was assessed by the Glasgow Coma Scale
(GCS) on admission and on days 1, 2, 3 and by Glasgow Outcome Score (GOS) on
discharge from the hospital.
Results: The mean value of ACR, on the admission sample, in patients with severe
clinical status (GCS<8) was 354 mg/g, significantly higher than in patients with
better clinical status (GCS 9-13 and GCS 14-15) 114 and 122 mg/g respectively
(p<0,01). The mean value of ACR on the last day of hospitalisation was highly
correlated with the outcome (reflected by GOS). It was 348 mg/g in patients
with GOS=1, 209 mg/g in patients with GOS 2 -4 and 53 mg/g in patients with
GOS=5 (p<0,01). In addition concerning the question if ACR levels can predict
the outcome, only in non-diabetic patients with poor outcome (GOS=1), the mean
value of ACR of the 24 hours measurement was significantly higher than in those
with better outcome (GOS 2-4 and GOS=5) 262, 199 and 58 mg/g respectively
(p<0,01).
Discussion: Our preliminary results from this ongoing study suggest that this
marker, when determined on admission and within 24 hours might be useful in
determining the severity of the stroke independently of the type of stroke, and that
these early measurements can be of value in predicting outcome in non-diabetic
patients.
13 Acute stroke: clinical patterns and practise
RATE OF INTRACEREBRAL HAEMORRHAGE IN PATIENTS WITH MINOR
STROKE: A CLINICAL RULE TO REDUCE CT MISDIAGNOSIS
C.E. Lovelock, J.N. Redgrave, D. Briley, P.M. Rothwell
University of Oxford, Oxford, United Kingdom
Background: Most studies of acute stroke management focus on the initial hours
following symptom-onset. However many patients with non-disabling strokes
present late. In a recent clinic-based Scottish study of patients presenting late (>4
days after the event) with minor stroke, around 4% had intracerebral haemorrhage
(ICH) on MRI, 75% of which appeared as infarcts on CT brain imaging. MRI was
recommended when patients could not be CT scanned within one week of a minor
stroke. We aimed to determine the frequency of ICH in two cohorts of patients with
minor stroke, and to identify clinical predictors for ICH, which might be used to
prioritise patients for MRI where resources were limited.
Method: We studied 343 consecutive patients with minor stroke (NIHSS≤3) in
patients ascertained in the Oxford Vascular (OXVASC) Study (scanned using CT
after a median delay of 4 days) and 245 consecutive patients presenting to a
hospital-based stroke clinic, all of whom had MRI.
Results: The rates of ICH were 4.1% (95%CI: 2.5-6.8%) on CT in OXVASC and
4.5% (95% CI 2.5-7.9%) on MRI in the clinic cohort. In a pooled analysis (25 ICH
in 588 patients), severe hypertension (BP ≥ 180/110 mmHg) on assessment (OR
5.4, 95%CI 2.3-12.3, p<0.001), vomiting (OR 9.9, 3.7-26, p=0.001), confusion
at onset (OR 8.2, 3.1-21.4, p=0.001), and premorbid anticoagulation (OR 6.1,
2.1-17.7, p=0.01) were predictive of ICH. The 178 (30%) patients who had at least
one of these risk factors included 92% of patients with ICH.
Conclusion: The rate of ICH in minor strokes in our cohorts is consistent with that
in the only previous study. Several clinical variables were predictive of ICH, and if
independently validated could form the basis of a simple rule to select patients who
require MRI.
16th European Stroke Conference
 14 Acute stroke: clinical patterns and practise
MRI PERFUSION-DIFFUSION MISMATCH IN PATIENTS WITH ACUTE
ISCHEMIC STROKE
S. Di Legge, M. Diomedi, F. Sallustio, S. Napolitano, G. Koch, B. Rizzato,
R. Floris, P. Stanzione
University of Tor Vergata, Rome, Italy
Background: The MRI perfusion-diffusion mismatch is viewed as a marker of
still-salvageable tissue amenable to reperfusion therapies. Whether its presence is
an independent predictor of clinical outcome in non-thrombolytic series has not
been extensively investigated.
Objectives: To evaluate the occurrence, evolution, and clinical correlates of MRI
perfusion-diffusion abnormalities in patients with acute ischemic strokes not treated
with thrombolytics.
Methods: Patients with acute ischemic stroke (AIS) admitted to our emergency
room (ER) within 12 hours of symptom onset were screened for MRI eligibility.
The MRI protocol included DW, PW MRI and intracranial MR angiogram (MRA).
All patients were admitted to a stroke unit and managed according to the current
guidelines. Stroke severity was assessed by the NIH Stroke Scale (NIHSS) score at
scheduled times. Patients with and without PW-DW mismatch were compared for
demographic, clinical and imaging variables.
Results: Over a 12-month period 189 patients with symptoms suggestive of AIS
were seen by the stroke team. Of them, 116 (61%) had an MRI study within 12
hours. Thirty (26%) patients did not complete the MRI study for lack of compliance
or clinical instability. A perfusion-diffusion mismatch (M+) was detected in 29/86
(34%) patients. The presence of PW-DW mismatch was associated with higher
baseline NIHSS scores (p=0.02), intracranial stenosis (p=.001), lesion enlargement
on follow-up MRI (p=.001) and higher three-month mRS (0.04). At logistic
regression analysis the only independent predictor of poor outcome (mRS 3-6) at 3
months was onset NIHSS (OR 1.7, 95% CI 1.1-2.8; p=0.02).
Conclusions: Up to one third of our AIS patients who completed the MRI protocol
within 12 hours of stroke onset had a PW-DW mismatch. Its detection was
associated with more severe strokes, intracranial artery occlusion, lesion growing,
and worse outcome. This information may help in establishing the efficacy of
thrombolitic therapy beyond the 3-hour window based on MRI parameters.
15 Acute stroke: clinical patterns and practise
SYSTEMIC THROMBOLYSIS WITH RT-PA IN POSTERIOR CIRCULATION
STROKE
B. Dimitrijeski, A. Villringer, H.C. Koennecke, A. Hartmann
Charité Campus Benjamin Franklin, Berlin, Germany
Objectives: Ischemic stroke in the posterior circulation (PCS) accounts for 10-15%
of all strokes, representing a major cause for disability and death in stroke patients.
Treatment with rt-PA for acute ischemic stroke within a 3-hour time window has
been proven to be effective and reduces significantly disability. However, most data
on systemic thrombolysis refer to stroke in the anterior circulation (ACS).
We compared the clinical outcome at 3 months in patients with PCS and ACS
treated with rt-PA.
Methods: 242 patients were treated between 1998 and 2006 within a 3-hour time
window according to the NINDS-trial protocol, 216 (89%) with ACS, 26 (11%)
with PCS, 3 (1%) with basilar occlusion.
Infarct localisation was n=11 brain stem, n=6 occipital lobe, n=2 thalamic, n=2
cerebellar and n=5 combined.
Neurological status was measured at admission and at 3-month follow-up using the
NIH-Stroke-Scale (NIHSS) and the modified Rankin Scale.
Results: A total of 26 patients suffered from PCS (42% female, Mean NIHSS at
admission 13, mean age 68y).
Good functional outcome defined as Rankin ≤ 2 occurred in 16 patients (62%)
with PCS compared to 107 patients (50%) with ACS (p=0.25).
The mortality rate was n=4 (15%) in PCS and n=30 (13%) in ACS (p=0.51) and
symptomatic intracranial hemorrhage occurred in n=1 (4%) in PCS and in n=7
(3%) in ACS (p=0.60).
Conclusions: In our study population clinical outcome at 3-month follow up,
mortality and intracranial hemorrhage rates are similar in patients with ACS and
PCS after treatment with systemic thrombolysis.
It seems to be a safe and effective treatment in patients with posterior circulation
stroke.
Poster Session
Acute stroke: clinical patterns and practise
16 Acute stroke: clinical patterns and practise
TRANSIENT ISCHEMIC ATTACK IN ADULT ONSET MOYAMOYA DISEASE
J.-M. Kim, S.-H. Lee
Seoul National University Hospital, Seoul, South Korea
Background and objective: There have been few reports about initial manifes-
tations in adult onset moyamoya disease. In this study, we described the initial
manifestations of adult onset MMD including TIA symptom characteristics, and
investigated the relationship between the initial manifestation and intracranial
stenosis.
Method: Between 1999 and 2006, total of 65 patients who are older than 14 years
were admitted and diagnosed as moyamoya disease at Seoul National University
Hospital. The patients were categorized into TIA, ischemic stroke, hemorrhagic
stroke, and nonspecific group due to the initial symptoms. The outcome after
surgical revascularization was evaluated in terms of two domains, which are the
number of TIAs and stroke recurrence after surgery.
Result: Out of 65 subjects, the numbers of patients who had initial manifestation
as TIA, ischemic stroke, hemorrhagic stroke and nonspecific symptom were 29
(44.6%), 11 (16.9%), 15 (23.1%), and 10 (15.4%), respectively. TIA manifestations
were variable among subjects. Twenty subjects out of 29 experienced motor
dominant symptoms, whereas only two had sensory dominant symptoms. Isolated
cognitive dysfunctions such as language dysfunction occurred in four subjects. The
means of Suzuki grade in TIA group and ischemic stroke group were 2.90 ± 0.9
and 3.64 ± 0.8 (p=0.022), showing significantly severe stenosis in ischemic stroke
group compared to TIA group. There was no statistically significant difference in
the surgical outcome in terms of TIA numbers and stroke recurrence between the
TIA and stroke groups.
Discussion: This study demonstrated that TIA is frequent as initial symptom
among adult onset MMD, and TIA manifestations are variable among subjects.
Patients whose initial manifestation is TIA have lower intracranial arterial stenosis
than stroke group, implying that TIA is earlier manifestation in the disease process
than ischemic or hemorrhagic stroke.
17 Acute stroke: clinical patterns and practise
INSULAR INVOLVEMENT IN ACUTE MIDDLE CEREBRAL ARTERY
TERRITORY INFARCTION
B.G. Yoo, J.K. Kim, J.H. Ko, E.G. Kim
Kosin University College of Medicine, Busan, South Korea
Background: The frequency and extent of insular involvement in middle cerebral
artery (MCA) territory infarction and its relationship with stroke severity and
clinical relevant disorders are not well established. The purpose of this study is to
determine insular involvement in MCA territory infarction and its relationship with
clinical and laboratory parameters.
Methods: We analyzed a total of 73 consecutive patients with acute non-lacunar
MCA territory stroke proved by an MRI scans.
Results: Insular involvement were present in 52 patients (73%); 34 (65%) had
major insular lesions and 18 (35%) had minor lesions. The major insular in-
volvement was associated with elevated serum CK-MB (p=0.044) and fibrinogen
(p=0.024), and size of MCA infarction (p=0.018) than minor insular lesion. The
anterior insular alone was involved in 14 (27%) patients, and the posterior insular
alone was involved in 4 (7.7%) patients. Among patients with insular involvement,
twenty-three patients (44%) had lenticulostriate territory infarction. Insular involve-
ment was associated with larger MCA territory infarctions, more severe clinical
deficits, and mortality. Isolated anterior insular infarcts were often accompanied by
other infarcts in the superior territory, whereas posterior insular infarcts were often
accompanied by inferior division infarction.
Conclusions: The insular involvement is a common in patients with acute non-
lacunar MCA territory infarction. Major insular involvement is associated with
large MCA territory infarction, proximal MCA occlusion, elevated serum CK-MB,
and greater neurologic severity than minor and no insular infarction.
18 Acute stroke: clinical patterns and practise
COMPARATIVE ELIGIBILITY FOR ACUTE HEMORRHAGIC AND
ISCHEMIC STROKE TREATMENTS IN A DISTRICT GENERAL HOSPITAL
M.O. McCarron, M. Armstrong, P. McCarron
Altnagelvin Hospital, Derry, United Kingdom
Background: Thrombolysis treatment fot acute ischemic stroke (AIS) benefits
patients. Recombinant activated factor VII (rFVII) is emerging as a similar
time-dependent treatment for acute intracerebral hemorrhage (ICH). We sought to
Cerebrovasc Dis 2007;23(suppl 2):1–147 97
determine the relative proportions and absolute numbers of patients eligible for
acute stroke treatments in an Irish district general hospital.
Methods: In a prospective observational study delays in admissions, demographic
details, and stroke severity were recorded in consecutive stroke patients admitted to
a district general hospital over a 12 month period. The eligibility criteria for acute
treatments were adapted from the NINDS study group for ischemic stroke and a
phase two study of rFVII treatment, which excluded patients with any history of
thrombotic or occluusive disease.
Results: 171 patients (96 men, 75 women, mean age 69.9±12.7 years) were
assessed. Multiple logistic regression showed that less severe strokes, living alone
and attending a general practitioner all independently delayed hospital admission.
Patients with ICH arrived in hospital faster than AIS patients, p=0.03. ICH patients
had more severe strokes than AIS patients (median NIHSS 8 versus 4, p=0.006).
Nineteen of 152 or 12.5% of AIS patients were in hospital within 2.5 hours of
stroke onset with a NIHSS>4 and fulfilled the NINDS thrombolysis criteria. Seven
of 19 or 37% of ICH patients were admitted within 3.5 hours and were eligible for
rFVII treatment.
Discussion: Although proportionately more ICH patients may potentially avail of
acute treatment than AIS patients, almost three times as many AIS patients were
eligible for acute treatment in this district general hospital. There may be less
potential to decrease admission delays for ICH patients.
19 Acute stroke: clinical patterns and practise
A LINK BETWEEN LUNAR PHASE AND MEDICALLY UNEXPLAINED
STROKE SYMPTOMS
F. Ahmad, T.J. Quinn, M. Walters, J. Dawson
Gardiner Institute of Medical and Cardiovascular Sciences, Glasgow, United
Kingdom
Background: Possible lunar effects on health have been postulated for centuries.
Association between phase of the moon and vascular; neurological and psychiatric
disease have been reported. There are no published studies on the effect of lunar
phase on cerebrovascular disease. A consistent proportion of stroke unit admis-
sions remain medically unexplained despite extensive investigation. This cohort of
Medically Unexplained Stroke Symptoms (MUSS) patients have been previously
described and show a high rate of psychiatric comorbidity. We hypothesised that
admission to an acute stroke unit, with true stroke or MUSS, may be influenced by
lunar cycle.
Methods: All admissions to our Acute Stroke Unit are recorded in a comprehensive
database. Those admitted between 1st January 1993 and 30th September 2006
(MUS) were included in the study. The association between admission rate and
phase of the moon was calculated using a X2 test across the groups. We observed
admission rate for confirmed stroke and MUSS.
Results: There were 7219 admissions during the study period, which comprised
167 complete lunar cycles. Stroke admissions were evenly spread throughout lunar
phases (p=0.72). Admission with medically unexplained stroke-like symptoms was
significantly increased during full moon phases (p=0.023).
Discussion: There was a statistically significant association between full moon
lunar phase and diagnosis of medically unexplained stroke-like symptoms. There
was no association with other stroke diagnoses. This study adds to the growing
literature regarding lunar effects on health.
20 Acute stroke: clinical patterns and practise
IMPLEMENTATION OF FAST-TRACK ASSESSMENT OF PATIENTS WITH
TRANSIENT ISCHAEMIC ATTACKS IS MORE EFFECTIVE THAN WEEKLY
ONE-STOP CLINICS
S. Goode, N. Altaf, J. Riley, J. Gladman, S. MacSweeney
Queens Medical Centre, United Kingdom
Introduction: The risk of stroke is highest immediately after an initial transient is-
chaemic attack (TIA). Current guidelines highlight the need for the rapid assessment
of patients with TIA. There is, however, a significant delay in the assessment of
patients with TIA in a weekly one-stop clinic. The aim of this study was to ascertain
the impact of an urgent daily TIA clinic on waits for assessment and treatment.
Methods: Retrospective analysis was performed on the delay between initial TIA,
referral and clinic dates. This data was collected for a 3 month period during which
the weekly one stop clinic was used to assess patients with suspected TIA. In
addition, data was also collected during the 3 month period during which the pilot
fast-track TIA assessment as well as the weekly one-stop clinic was functional.
Results: 288 patients with suspected TIA were assessed over the study period. The
mean age of the patients was 68 years (SD 10) and 51% were male. The mean
interval between TIA (n= 120) and review in the weekly TIA clinic in the initial
98 Cerebrovasc Dis 2007;23(suppl 2):1–147
3 month period was 66.9 [72.0] days. The mean wait for fast-track assessment of
patients (n=62) from initial TIA to review was 4.5 [6.9] days. This decreased the
overall wait (n=168) in the 2nd 3 months to 29.6 [33.2] days, p<0.005.
Conclusion: The urgent daily assessment of TIAs provides significantly faster
assessment, investigation and treatment compared with weekly one-stop clinics.
This is essential to decrease the risk of recurrent stroke in patients with TIAs, in
particular those with high grade carotid stenosis that may need subsequent Carotid
Endarterectomy.
21 Acute stroke: clinical patterns and practise
ATRIAL FIBRILLATION IN ISCHEMIC STROKE PATIENTS: EVALUATION
OF THE USAGE OF ORAL ANTITHROMBOTICS IN EUROPE
B.M. Hamad, P. Nasuti, E. Yeung
IMS Health, London, United Kingdom
Background: It is clinically known that atrial fibrillation (AF) is associated with
higher in-hospital mortality in ischemic stroke patients. The purpose of this study
is to assess the use of oral antithrombotics among patients with AF and to illustrate
the diffusion of recommended guidelines into clinical practice.
Methods: We conducted a patient-diary study in 296 hospitals in France, Germany,
Italy, Spain and UK. They treated total of 2,659 ischemic stroke patients, during
the period of July 2005 and December 2005, with a mean of 9 patients per hospital.
Hospitals were selected to be representative by geographic regions, size and stroke
unit facilities in each country.
Results: Among the 2,659 patients, 478 (18%) pts were found to have chronic AF
of whom 123 (26%) also developed AF acute event during the stroke hospitalisa-
tion. Also, 70 (3%) patients had experienced an acute event of AF for the first time.
We report data from 548 ischemic stroke patients with AF, 75% were classified
as cardioembolic, 20% non-cardioembolic and 5% of uncertain cause. On-therapy
analysis showed that 54% of pts received aspirin, 46% oral anticoagulants (OAC),
13% clopidogrel, 3% dipyridamole and 1% Aggrenox. We also analysed mono
and dual therapies; 31% pts had aspirin only, 26% OAC only, 16% aspirin+OAC,
6% clopidogrel only, 6% aspirin and clopidogrel only, and interestingly 10%
didn’t receive any oral antithrombotic therapy. In-hospital mortality accounted for
12% of the patients, 27% discharged home independently, 15% discharged home
dependently and 43% transferred to rehab and long term care facilities.
Conclusion: European guidelines recommend oral antithrmobotic therapy for
ischemic stroke associated with AF for secondary prevention and this has been
adopted widely in European hospitals treating ischemic stroke patients, however
still 10% of patients are not receiving any form of oral antithrombotic therapy to
prevent recurrent stroke, and only 45% are receiving OAC.
22 Acute stroke: clinical patterns and practise
TRANSIENT ISCHEMIC ATTACK IN ADULT MOYAMOYA DISEASE
J.-M. Kim, S.-H. Lee, J.-K. Roh
Seoul National University Hospital, Seoul, South Korea
Background: Transient ischemic attack (TIA) is a frequent initial manifestation in
adult onset moyamoya disease (MMD). However, clinical characteristics of TIA
in adult MMD have not been fully understood, as compared with the numerous
reports on child MMD. In this study, we investigated the initial manifestations of
adult MMD including TIA symptom characteristics, and the relationship between
the initial manifestations and the extent of the disease progression.
Method: We recruited 65 MMD patients of adult onset between 1999 and 2006,
who visited and diagnosed at the Seoul National University Hospital. We obtained
their basic demographic data, imaging files, and clinical information. The study
groups were categorized into TIA, ischemic stroke (IS), hemorrhagic stroke (HS),
and nonspecific (NS) according to the initial manifestations. Symptoms of TIA
were described via detailed interview. The outcomes after surgical revascularization
were evaluated in terms of stroke or TIA recurrence during the follow up.
Result: Out of 65 subjects, there were 29 (45%) TIA, 11 (17%) IS, 15 (23%) HS,
and 10 (15.4%) NS patients. TIA manifestations were variable among subjects.
Twenty subjects out of 29 experienced motor dominant symptoms, whereas only
two had sensory dominant symptoms. Isolated cognitive dysfunctions such as
language dysfunction occurred in four subjects. Stages of MMD evaluated by
Suzuki’s method were significantly higher in IS group (3.64 ± 0.8) than in TIA
group (2.90 ± 0.9; p=0.022). There was no significant difference in the surgical
outcome in terms of TIA and stroke recurrence among the groups.
Conclusion: We showed that TIA is very frequent initial manifestation among
adult MMD and that involvement of intracranial arteries are less extensive in TIA
group. Our results suggest that TIA as initial manifestation mainly occurs in the
earlier stage of the MMD.
16th European Stroke Conference
 23 Acute stroke: clinical patterns and practise
THE ULTRASOUND SIGNS OF ENDOTHELIAL DYSFUNCTION IN ACUTE
ISCHEMIC STROKE
M.A. Domashenko, A.O. Chechetkin, Z.A. Suslina
Institute of Neurology, RAMS, Moscow, Russian Federation
Background: The aim of the study was to evaluate the ultrasound signs of
endothelial dysfunction in patients with acute ischemic stroke [IS].
Methods: The ultrasound evaluation of the endothelium-derived vasodilatation of
the brachial artery [BA] was performed in 27 patients (age 67 [55; 79] years; 14
males, 13 females) with IS in the first 48 hours of stroke onset. The maximal
increase of BA diameter after “cuff test” [CT] with the transient occlusion of BA by
the cuff of manometer was evaluated. 20 patients (age 64 [51; 72] years; 10 males,
10 females) with the chronic ischemic cerebrovascular diseases were investigated
in the control group.
Results: The neurological deficit in IS patients was 79 [58,5; 90] on ESS and 4,5
[2,5; 9] on NIHSS. The initial linear speed of the blood flow [LSBF] on BA was 62
cm/s [54; 65] and 58 cm/s [50; 65] and the initial diameter of BA was 4,6 mm [4,0;
5,1] and 5,1 mm [4,6; 5,4] in patients with IS and control group accordingly. After
the CT the LSBF on BA increased on 121% [103; 219] and 184% [126; 223] in
patients with IS and control group (p=0,07). The increase of BA diameter after the
CT was 5,4% [4,3; 9;5] and 8,5% [6,8; 11,5] in patients with IS and control group
(p=0,035). The increase of BA diameter was directly correlated with ESS score (R
0,35; p=0,047) and indirectly correlated with NIHSS score (R -0,33; p=0,049).
Conclusion: The BA dilatation after CT in patients with IS was decreased com-
pared to patients with the chronic cerebrovascular diseases. The ultrasound signs
of endothelial dysfunction in patients with IS and their correlation with the stroke
severity were demonstrated.
24 Acute stroke: clinical patterns and practise
S100B AS A BIOMARKER: ITS OPTIMAL ROLE IN STROKE
P. Dassan, G. Keir, R. Jager, M.M. Brown
UCL, Institute of Neurology, London, United Kingdom
Background: Blood biomarkers may be important in three areas of acute stroke:
diagnosis; as a surrogate marker for severity of brain damage; and predicting
prognosis. The S100B protein has been studied in each area individually in selected
patients but there are no studies directly comparing its utility in these areas. We
correlated all three measures with serial measurements of S100B in an unselected
series to determine its optimal role.
Method: Blood samples and National Institute of Health Stroke Scale (NIHSS)
scores were taken on arrival to hospital and daily, where possible, for up to 6 days
after onset of symptoms in 40 consecutive patients with suspected ischaemic stroke
(26 acute infarcts and 14 stroke mimics). Serum S100B was measured by enzyme-
linked immunosorbent assay. Infarct volumes were measured on diffusion-weighted
images.
Results: In patients venesected within 24 hours of symptom onset there was no
significant difference in S100B levels between acute infarction and stroke mimics
(mean 0.19 ng/ml vs 0.12 ng/ml). Peak S100B levels after 24 hours however,
correlated well with both infarct volume and maximum NIHSS scores (r = 0.89,
P<0.001 and r = 0.81, P<0.001 respectively). The highest level was seen in a
patient with malignant middle cerebral artery infarction. Peak S100B level was
a good predictor of dichotomised outcome after discharge (independent mean
0.14ng/ml vs dependent mean 0.36ng/ml, P<0.05).
Conclusion: Serum S100B measurements are not helpful in distinguishing infarc-
tion from stroke mimics in the emergency room. Measurement of blood S100B
levels after cerebral infarction is a useful measure of the severity of brain damage
and predicts prognosis. It may also be a useful predictor of malignant infarction.
25 Acute stroke: clinical patterns and practise
PREHOSPITAL TRANSPORT OF ACUTE STROKE PATIENTS AND TIME TO
INITIAL MEDICAL ASSESSMENT IN AN IRISH GENERAL HOSPITAL
R. Purcell, G. Bergin, C. Cooney, E. Farrelly, R. Morton, H. Logan, R. Lynch,
S. Murphy
Midland Regional Hospital, Mullingar, Co. Westmeath, Dublin, Ireland
The aims of acute stroke management are to minimise neurological impairment
and maximise functional recovery. Rapid patient transfer to acute stroke units is
essential to achieve these aims. In Ireland, there is no nationally agreed policy on
acute stroke care.
A retrospective study was performed to examine prehospital transport of acute
Poster Session
Acute stroke: complications and early
outcome
stroke patients to a general hospital. HIPE identified patients with acute stroke
presenting to our hospital from 01-01-05 to 30-06-05. Data was collected from
the emergency service’s and hospital’s records. Time intervals from initial contact
with the emergency services to medical assessment in hospital were recorded. Data
on time of symptom onset was available for patients who arrived via personal
transport.
Forty-six patients presented with an acute stroke (84.78% infarcts). Thirty-one
patients arrived by ambulance [12 by 999 call= (1), 19 non-999 call= (2)],15 via
personal transport (3). Mean interval from the time of the ambulance call to arrival
at scene was 24 mins (1) vs 28 mins (2) [NS]. Mean interval from time of call to
arrival in the emergency department was 66.3 mins (1) vs 74.4 mins (2) [NS]. Mean
interval from time of emergency department arrival to medical assessment was 95
mins(1), 105 mins(2) and 43 mins(3) [(1)/(2) vs (3) p=0.01/p=0.002].The average
time from symptom onset to arrival in the emergency department was 861.6 mins
for patients arriving by personal transport.
The rapid ambulance response contrasts with the delayed medical response to acute
stroke at our institution. Better public and medical awareness of the urgency of
acute stroke management is necessary. This study has provided useful baseline data
on our current performance regarding the transport and medical assessment of acute
stroke patients. We plan to put in place an integrated response for acute stroke in
order to maximise patient outcomes.
Acute stroke: complications and early outcome
1 Acute stroke: complications and early outcome
THE RELATIONSHIP BETWEEN THE LOCATIONS OF DEEP-VEIN
THROMBOSIS AND MOTOR IMPAIRMENT IN ACUTE ISCHEMIC STROKE
PATIENTS
D.G. Sherman, G.W. Albers, C. Bladin, C. Fieschi, A.A. Gabbai, C.S. Kase,
W. O’Riordan, G.F. Pineo, for the PREVAIL Investigators
University of Texas Health Science Center at San Antonio, San Antonio, TX,
USA
Introduction: Studies of major orthopaedic surgery have shown that deep-vein
thromboses (DVT) do not always occur on the same side of the body as the surgical
intervention suggesting that reduced mobility is not the only factor triggering
thrombus formation. We assessed the relationship between the side of the body
affected by motor impairment and the side with DVT in PREVAIL, a study of VTE
prophylaxis in acute ischemic stroke patients.
Methods: Patients with acute ischemic stroke, confirmed by CT scan or MRI, and
unable to walk unassisted due to motor impairment of the leg were randomized
within 48 h of stroke symptoms to enoxaparin 40 mg SC qd or UFH 5000 IU
SC q12h for 10±4 days. DVT was confirmed by venography, or ultrasonography
when venography was not practical. PE was confirmed by VQ or CT scan, or
angiography.
Results: The PREVAIL study showed a 43% relative reduction in the risk of
symptomatic or asymptomatic deep-vein thrombosis (DVT), symptomatic pul-
monary embolism (PE), or fatal PE with enoxaparin compared with UFH in acute
ischemic stroke patients (10.2% vs 18.1%; p=0.0001), with no increase in clinically
important bleeding. A post-hoc analysis showed that 7.0% of patients developed a
DVT on the same side as the motor impairment, and 3.5% developed a DVT on the
contralateral side.
Conclusion: Although more DVT events occur on the same side as the motor
impairment, about one third occur in the contralateral leg. This suggests that while
flow-dependent thrombogenic factors (i.e. stasis) are triggers for thrombus forma-
tion, some other factors may also be important. Rehabilitation and nursing care
should focus on mobilization of the patient as well as providing VTE prophylaxis.
2 Acute stroke: complications and early outcome
PREVALENCE AND RISK FACTORS OF FAECAL INCONTINENCE IN
STROKE PATIENTS ADMITTED TO THE ACUTE STROKE UNIT AND TO
REHABILITATION WARDS (PILOT STUDY)
U. Khan
Oxford Redcliff, Abingdon, United Kingdom
Background and purpose: Faecal incontinence [FI] commonly affects patients
after stroke. This is an observational study to assess the prevalence of and risk
factors for FI in stroke patients admitted to the acute stroke unit & to rehabilitation
wards.
Methods: 50 patients admitted in Oxford Radcliffe Hospital stroke unit from May
Cerebrovasc Dis 2007;23(suppl 2):1–147 99
2006 for a period of 10 wks were enrolled and followed up in rehabilitation wards
and in the community. The prevalence of FI was assessed over a time period of
3 months and risk factors were assessed in the1st wk after admission. The main
comparative statistical tool used was the Chi squared test or Fisher’s exact tests.
Results: Pre-stroke FI was 2%.Post-stroke FI at wk1 was 34%, at wk 4 was 26%
& at wk 12 was 21%.
The characteristics of 17 FI patients were compared with 33 without FI.Total
anterior circulation stroke syndrome was strongly associated with FI (P<0.0001)
as was stroke severity, measured by NIHSS >14; GCS<15 (P<0.0001).There
was a significant association between poor cognition [MMSE score <25] and FI
(P=0.009). Disability [Barthel Index<15] was also significantly associated with
FI (P=0.002). Concurrent urinary incontinence [UI] (P<0.0001) and diarrhoea
(P=0.027) were but constipation (P=0.70) and faecal impaction (P=0.327) were not
associated with FI. Enteral feeding was strongly associated with FI (P<0.0001).
Advanced age (>80) was not a significant factor when adjusted for gender
(P=0.061) but showed a positive trend.
Conclusion: FI is common in older stroke patients & resolves in <50% within
3 months. Stroke severity, conscious state, level of disability, co-existing UI,
diarrhoea and enteral tube feeding are significant risk factors. This pilot provides
data to plan future larger studies of FI in stroke patients.
3 Acute stroke: complications and early outcome
COMPARISON OF 2 TYPES OF PROGRESSION AFTER ACUTE ISCHEMIC
STROKE: CONTINUOUS DETERIORATION VS. FLUCTUATION OF STROKE
SEVERITY
Y.-J. Cho, K.-S. Hong, J.-.S. Koo, K.-H. Yu, H.-J. Bae, M.-K. Han,
M.-K. Jeong, D.-W. Kang, J.-M. Park, B.-C. Lee
Inje University Ilsan Paik Hospital, Goyang-si Gyeunggi-do, South Korea
Background: To investigate the frequency, possible attributable factors and the
prognosis of 2 types of progression after acute ischemic stroke.
Methods: All consecutive patients with first-ever ischemic stroke within 24 hours
from onset were recruited prospectively, who admitted 4 university hospitals in
Seoul metropolitan region. Baseline demographics, stroke subtypes, past medical
history, medical complications after stroke, and modified Rankin Scale at 3 months
were assessed by predetermined protocol. Stroke severity was assessed by NIH
Stroke Scale (NIHSS) at admission, on hospitalization days 1, 2, 3, and week 1 and
2. Clinical deterioration was defined as decrease of 2 points in total NIHSS score
or 1 point in motor scale score.
Results: Among 566 patients recruited, 142 (25.1%) worsened. One hundred thirty
patients (91.6%) were deteriorated within 3 days after stroke onset. Continuous
deterioration (CD) was found in 94 (66.2%), and returning to initial status after
fluctuation (F) was found in 48 (33.8%). CD patients are older (68.6±11.2 vs.
62.0±12.4), and more likely to have higher initial NIHSS (median=7.5 vs. 6.0),
preceding systemic infection (24.5% vs. 12.5%), and worse functional outcome
(mRS 3-6=78.7% vs. 56.2%) at 3 months than F patients. After adjusting sex, hy-
pertension, diabetes, and stroke subtypes, age was the only significant independent
predictor of CD (OR=1.04, 95% CI=1.01-1.08) by logistic regression analysis.
Discussion: Continuous deterioration of stroke severity after acute ischemic stroke
results in poor functional outcome. Age, initial NIHSS, and preceding systemic
infection might predict further decline.
4 Acute stroke: complications and early outcome
COMPARISON OF NUTRITIONAL INTAKE IN POST STROKE PATIENTS ON
NORMAL, MODIFIED AND NG DIET
T. Nagarajan, A. Addison, M. Winder, A.G. Dyker
Freeman Hospital, Newcastle upon Tyne, United Kingdom
Patients with swallowing problems after stroke are at risk of developing nutritional
deficiencies.
Methods: Three groups of patients were studied: Normal diet (n=4), modified
thickened diet (n=5), and naso-gastric feeding(n=4). Patients were studied for seven
days. Full records were kept of patients’ nutritional intake. Patients were weighed
on day one and day 7. Results were tabulated using Excel (2003) and statistical
analysis was carried out using MINITAB (14). Test for normality was carried out
on all analysed data and students T test was used to compare normally distributed
data while Mann–Whitney Tests and Wilcoxon Signed Rank test were used to
compare non-normally distributed data.
Results: Mean daily calorie intake was significantly lower in those being fed
a modified diet compared with NG (difference 546, p<0.0005) and normal diet
(difference 868, p<0.0005).There was no difference in daily calorie intake between
NG and normal diet. Average daily calorie intake was significantly less than
100 Cerebrovasc Dis 2007;23(suppl 2):1–147
recommended (2000) in all groups, particularly those on modified diet (normal
diet mean 1311; SD 520, modified diet 765 SD 464, NG diet 1633 SD 780: all p
values<0.0001). Median daily protein intake was significantly lower in those on a
modified diet (39.2g) compared with NG feeding (56.9g, p=0.012) a normal diet
(50g, p=0.02) and recommended levels (50grams). Mean seven day total calorie
intakes were significantly lower than recommended levels (14000) in patients on
a normal diet (8854 p=0.023), and modified diet (5052 p=0.001) but not in those
being fed with NG (11436p=0.32). This interim analysis was not powered to
demonstrate reductions in weight, but patients on a modified and normal diet lost
3.5 kg in 7 days while those on NG lost 0.3kg. There was a strong negative
correlation between weight loss and both calorie and protein intake (Pearson -0.79,
and 0.-0.89 p= 0.001).
Conclusions: Patients on modified diet are at risk of malnutrition. Consideration of
feeding supplementation should be given to patients with swallowing difficulties
5 Acute stroke: complications and early outcome
THROMBOLYSIS WITH RT-PA DOES NOT PROMOTE EDEMA FORMATION
IN ACUTE ISCHEMIC STROKE
V. Sachsenmaier, I. Dzialowski, C. Disque, G. Gahn
Technical University of Dresden, Dresden, Germany
Background: There is ongoing controversy whether recombinant tissue plas-
minogen activator (rt-PA) treatment is associated with excessive edema formation
following acute ischemic stroke. Possible mechanism might be the toxic disruption
of the blood brain barrier and subsequent reperfusion injury. We studied the
hypothesis that patients with large middle cerebral artery (MCA) infarctions treated
with rt-PA develop larger cerebral edemae than controls.
Methods: We retrospectively studied patients with large MCA infarctions from
07/2001-10/2006 defined by an Alberta Stroke Program Early CT Score (AS-
PECTS) < 5 on day 1 – 7 follow-up imaging. Exclusion criteria were space-
occupying secondary hemorrhage, hemicraniectomy, and thrombolysis with non-t-
PA agents. We recorded baseline characteristics and rt-PA treatment status from the
patient chart. We prospectively assessed the extent of cerebral edema applying a 5-
scale grading system (0, no edema, 1, compression of external subarachnoid spaces,
2, compression of lateral ventricle, 3, midline deviation, 4, obstructive dilatation of
opposite lateral ventricle, Borovich scale). We compared Borovich scores among
rt-PA treated patients and controls using non-parametric statistical testing.
Results: We identified 90 patients for our study with a mean age of 66 ±13 years,
42% female, mean onset-to-imaging-time of 59 ±40 hours, median ASPECTS of 2
(iqr2-4). Of the 90 patients, 30 were thrombolysed and 60 were controls. Baseline
characteristics did not differ across the two groups. Distribution of Borovich scale
scores for the treatment (and control) group was 0 (0) % for grade 0, 0 (8) % for
grade 1, 43 (40) % for grade 2, 37 (33) % for grade 3, and 20 (18) % for grade 4.
Median Borovich scores among both groups did not differ significantly (median 3,
p=0.48).
Conclusion: In our retrospective study, t-PA treatment did not exacerbate cerebral
edema in patients with large MCA infarctions. Further prospective evidence is
needed to confirm this result.
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6 Acute stroke: complications and early outcome
ACUTE MORTALITY PREDICTION IN STROKE PATIENTS
M. Delobel, A. Viguier, M.C. Turnin, V. Larrue
CHU de Toulouse France, Toulouse, France
We examined the use of the Simplified Acute Physiology Score II (SAPS II) for
the prediction of in-hospital mortality in a large number of stroke patients managed
in a neurological intensive care unit.
Data on SAPS II were prospectively collected in patients with ischemic stroke,
cerebral hemorrhage, transient ischemic attack, or subarachnoid hemorrhage, con-
secutively admitted to a tertiary neurological intensive care unit. We constructed
receiver operating characteristic curves (ROC) to determine the ability of SAPS II
to predict in-hospital mortality.
2214 patients were included in this analysis. 321 (14.5%) patients died in hospital.
The area under ROC curve [95% confidence interval] was 0.83 [0.81-0.86]. With
a cut-off point of 30 the positive predictive value of SAPS II was 38.3%, and the
negative predictive value 94.8%. Findings were similar in an analysis restricted to
patients older than 40 years.
The findings indicate that SAPS II is a reliable tool to predict acute mortality in
patients managed for stroke in a neuroligical intensive care unit.
16th European Stroke Conference
 7 Acute stroke: complications and early outcome
A NOVEL POLYMORPHISM IN THE PROMOTER REGION OF THE
SURVIVIN GENE IS RELATED TO HEMORRHAGIC TRANSFORMATION IN
PATIENTS WITH ACUTE ISCHEMIC STROKE
M. Castellanos, C. Gubern, J. Serena, J. Castillo, M.A. Moro, M. Millán,
R. Rodríguez, F. Nombela, O. Hurtado, J. Mallolas
Hospital Universitari de Girona Doctor Josep Trueta, Girona, Spain
Background: The expression of survivin, a member of the inhibitor antiapoptotic
proteins family, has been shown to increase after cerebral ischemia in response
to the release of angiogenic growth factors. This protein has been mainly located
at the microvaculature within the infarcted and peri-infarterd area, and so we
aimed to investigate whether survivin gene polymorphisms were associated with
hemorrhagic transformation (HT) of cerebral infarction.
Methods: DNA was isolated from peripheral blood samples of 97 patients with
a hemispheric ischemic stroke and 38 controls. Polymorphism screening of the
survivin gene was performed by polymerase chain reaction, single-strand con-
formation polymorphism and sequencing analysis. DWI sequences were obtained
within 12 hours from symptoms onset and at 72±12 hours by using a 1.5-T MRI.
The presence of HT was determined on the second DWI sequence and classified
according to ECASS II criteria.
Results: Forty-seven patients (48%) had HT: 27 patients had hemorrhagic infarc-
tion and 20 had parenchymal hemorrhage (PH). Thirty-two patients (32%) received
rt-PA. A novel polymorphism was identified in the promoter region of the survivin
gene which corresponded to an C-to-T transition at -241 bp from the transcription
start site. The prevalence of the mutant allele (T) was similar in patients and
controls (14% vs. 16%, respectively; p=0.985). Seven patients (26.9%) with allele
T had HT compared to 40 (56.3%) of wild-type (p=0.009). Logistic regression
analysis showed that the presence of the polymorphism was associated with a
lower risk of HT (OR 0.28; 95% CI, 0.08 to 0.97; p=0.045) independently of age,
baseline stroke severity, temperature, platelet count, glucose levels, systolic blood
pressure, DWI lesion volume and rt-PA administration.
Discussion: The -241 C/T polymorphism in the promoter region of the survivin
gene is associated with a lower risk of HT in patients with acute ischemic stroke.
This polymorphism might be related with a decrease of survivin expression and
secondary down-regulation of the angiogenic process.
8 Acute stroke: complications and early outcome
STROKE PATIENT PROGRESSION IN DIJON FROM 1985 TO 2004
P. Decavel, Y. Bejot, G.V. Osseby, B. Parratte, T. Moulin, M. Giroud
Besançon University Hospital, Besançon, France
Background: Development of stroke management over a number of years has
changed the vital and functional prognosis of patients.
Method: The main aim was to test the outcome of patients with first-ever stroke
over a long period among a random population. A study was carried out into
the progression of the number of deaths over 20 years, handicap development
according to the modified Rankin scale and the clinical state of patients coming
into the department with a first-ever stroke identified in an ongoing registry of the
population between 1985 and 2004.
Results: The distribution of stroke type was as follows: 3142 infarctions, 341
hematomas and 74 subarachnoid hemorrhages. Over 20 years, mortality has de-
clined by 0.94% per year (p<0.01), the number of patients able to walk 28 days
after stroke has increased by 0.78% (p=0.02) per year, with no increase in the
number of patients severely handicapped (p=0.43). If the age at which the first-ever
stroke took place has risen, the number of patients initially comatosed has not
changed (p=0.06).
Discussion: The decline in mortality observed in Dijon confirms the tendency
observed in the majority of other registries. The Dijon registry is, however, the only
one to be ongoing. The improvement in stroke patient progression is significant
despite the increase in the age at which the first event took place. Over a period of
20 years, a 50% decrease in stroke patient mortality with no rise in severe handicap
has been observed in Dijon.
Poster Session
Acute stroke: complications and early
outcome
9 Acute stroke: complications and early outcome
EARLY HEMORRHAGIC EVENTS AFTER INTRAVENOUS THROMBOLYSIS
OF HEMISPHERIC AND BASILAR ISCHEMIA: RESULTS OF THE HELSINKI
STROKE THROMBOLYSIS STUDY
T. Bogoslovsky, O. Häppölä, L. Soinne, O. Salonen, P.J. Lindsberg, M. Kaste
Helsinki University Central Hospital, Biomedicum, Neuroscience Program,
Helsinki, Finland
Early cerebral hemorrhages after ischemic stroke are the most feared adverse event
following the theapeutic use of recombinant tissue plasminogen activator. The
reason for bleeding is not known, but their incidence has been associated with
various premorbid factors, such as diabetes, the use of antithrombotics, the duration
and extent of cerebral ischemia as well as the perithrombolytic levels of blood
glucose and blood pressure (BP). Onset-to-treatment times tend to be longer in
basilar occlusions, but it is not known, if their bleeding tendency is different.
We aimed to asses the rate of hemorrhagic events within 24 hours after thrombolysis
and the associated factors in consecutive anterior and posterior circulation stroke
patients treated in Helsinki University Central Hospital during years 2003 to 2005.
Of 335 strokes 304 were hemispheric (HS) and 31 basilar occlusions (BAO). BAO
patients had more severe strokes (median NIH Stroke Scale 20 vs. 10, p<.001) and
longer onset-to-treatment times (873±1453 min vs. 127±43 min, p<.0001) and
less antiaggregatory treatment (22.6% vs 43.1%, p=.03), but similar age (64±17
vs. 69±12 years, p=.14) and prevalence of diabetes [4(15%) vs. 33(12%),p=.72].
BAO patients had comparable prethrombolytic glucose (7.0 vs 7.1 mmol/l) and BP
levels (systolic 152 vs 156 mmHg, diastolic 81 vs 82 mmHg). Overall incidence of
postthrombolytic hemorrhages was 64 (21%) in HS and 5 (16%) in BAO (p=.52).
There was no difference in distribution into subgroups of hemorrhagic events
according to ECASS II classification or extraischemic or subarachnoidal bleeding.
Despite 7-fold longer treatment delay and 2-fold stroke severity, thrombolysis of
BAO is not associated with more major hemorrhages than that of HS.
10 Acute stroke: complications and early outcome
ENDOTHELIAL DYSFUNCTION IN ACUTE ISCHEMIC STROKE IS
CORRELATED WITH STROKE SEVERITY AND THE SIZE OF THE BRAIN
INFARCTION
M.A. Domashenko, S.V. Orlov, M.M. Tanashyan, V.G. Ionova, M.V. Kostyreva,
R.M. Umarova, A.S. Suslin, M.V. Krotenkova, Z.A. Suslina
Institute of Neurology, RAMS, Moscow, Russian Federation
Background: The aim of the study was to evaluate the concentration of von
Willebrand factor [vWf] in acute ischemic stroke [IS] compared with the stroke
severity and the size of the brain infarction.
Methods: The concentration of serum vWf was investigated in 40 patients (age 65
[57; 74] years; 22 males, 18 females) with IS in the first 48 hours and on 21 day
of IS onset. The size of the brain infarction was measured on diffusion-weighted
(DWI) MRI images (in the first 48 hours of IS) and on T2 MRI images (on 21
day of IS). Correlation analysis of vWf concentration, NIHSS score and the size of
brain infarction was performed.
Results: The vWf concentration was 158% [130; 181] and 170% [147; 200] in
the first 48 hours and 21 day of IS accordingly (p=0,03). The neurological deficit
on NIHSS was 4,5 [2,5; 9] and 1,5 [0; 4] in the first 48 hours and 21 day of
IS accordingly. The vWf concentration in the first 48 hours of IS was directly
correlated with NIHSS score (R 0,33; p=0,049). The size of the brain damage on
DWI was 16,1 sm3 [4,7; 40,4] in the first 48 hours of IS and was directly correlated
with vWf concentration (R 0,59; p=0,046). The size of brain infarction on T2 MRI
was 11,2 sm3 [6,8; 32,2] on the 21 day of IS and also was directly correlated with
vWf concentration (R 0,71; p=0.009).
Conclusion: The serum vWf level is correlated with the stroke severity and the
size of the brain infarction in patients with IS.
11 Acute stroke: complications and early outcome
IS THE ASSOCIATION OF COAGULATION ACTIVATION MARKERS
WITHPROGRESSING STROKE DUE TO THE ACUTE-PHASE RESPONSE?
J.M. Barber, P. Welsh, P. Langhorne, A. Rumley, G.D. Lowe, D.J. Stott
Royal Infirmary, University of Glasgow, Glasgow, Airdrie, Scotland, United
Kingdom
Introduction: Early progression of ischaemic stroke is common, occurring in
around 25% of patients. This complication is associated with poor outcome. We
have demonstrated that progression is associated with elevation of markers of co-
agulation activation. We aimed to determine whether the association of progressing
Cerebrovasc Dis 2007;23(suppl 2):1–147 101
stroke with haemostatic activation is due to an underlying enhanced acute phase
inflammatory response.
Methods: Consecutive ischaemic stroke patients were recruited. Progressing stroke
was defined by deterioration in components of the Scandinavian Stroke Scale
over the first 72 hours. Measures of Interleukin (IL)-6, IL-18 and tumour necrosis
factor-alpha (TNF-A) were made in addition to highly sensitive C-reactive protein
(hsCRP).
Results: We studied 150 patients of whom 35 (23%) had progressing stroke by
European Progressing Stroke Study criteria. IL-6 levels [11.3 (6.0-16.6) v. 7.0
(3.3-13.8), p=0.02] and hsCRP [8.66 (3.69-30.4) v. 5.26 (1.64-18.4), p=0.05] were
higher in the progressing group. IL-18 [median 295 (216-452) v. 280 (212-375),
p=0.42] and TNF-A levels [2.53 (1.86-3.67) v. 2.24 (1.58-3.10), p=0.18] were
similar in progressing and non-progressing cases. In binary logistic regression none
of the acute phase markers were independent predictors of progressing ischaemic
stroke; thrombin-antithrombin complexes (odds ratio (OR) 7.74), admission mean
arterial blood pressure (OR 1.4 for each 10mmHg rise) and age (OR 1.05) were
independent predictors of progressing stroke.
Conclusions: Circulating levels of IL-6 and hsCRP are elevated in subjects with
progressing ischaemic stroke. However, these inflammatory markers are not inde-
pendent predictors of stroke progression. The acute phase inflammatory response
is unlikely to be a major contributor to haemostatic activation in progressing
ischaemic stroke.
12 Acute stroke: complications and early outcome
THE EFFECT OF DYSPHAGIA ON COMPLIANCE AND OUTCOME IN THE
‘EFFICACY OF NITRIC OXIDE IN STROKE’ (ENOS) TRIAL
G.M. Sare, L. Gray, T.J. England, P.M.W. Bath, for the ENOS Investigators
Institute of Neuroscience, University of Nottingham, Nottingham, United
Kingdom
Introduction: About 50% of stroke patients have dysphagia at presentation and
this may result in the discontinuation of pre-stroke medical therapy and delay the
initiation of acute oral therapy. Enteral access is unreliable since naso-gastric tubes
can be difficult to insert and are often pulled out. Here we examine the relation
between the administration of oral and transdermal medication in patients with
acute stroke.
Methods: ENOS is an international, randomised controlled trial in 5,000 patients
with acute ischaemic or haemorrhagic stroke which is investigating the safety
and efficacy of lowering BP with transdermal glyceryl trinitrate (GTN, given for
7 days). Patients taking pre-stroke antihypertensive therapy are also randomised
in a partial-factorial design to continue or temporarily stop this. We compared
treatment compliance and outcome (Modified Rankin Scale (mRS) at 90 days post
randomisation) between those with and without dysphagia.
Results: As of 10 January 2007, 559 patients (28 centres, 9 countries) had been
recruited into ENOS. 283 (51%) of these patients had dysphagia. In analyses
blinded to treatment assignment, 87% of dysphagic patients received all of their
randomised treatment between days 1-4 in the GTN patch versus No GTN arm of
the trial compared to 76% in the stop versus continue arm (p=0.01). Those with
dysphagia had more severe strokes at baseline and significantly worse outcome at
90 days compared to those without: median mRS 3 (inter quartile range, IQR 2-5,
n=283) compared to median 2 (IQR 1-3, n=276) (p<0.0001).
Discussion: Stroke patients with dysphagia were more likely to receive transdermal
treatment than oral antihypertensive medication. These data highlight the potential
benefits of transdermal medications in this high risk population.
13 Acute stroke: complications and early outcome
SIDE DIFFERENCES ON THE EXTENT OF SALVAGEABLE ISCHEMIC
TISSUE IN HYPERACUTE STROKE
R. Delgado-Mederos, M. Ribo, A. Rovira, J. Alvarez-Sabin, M. Rubiera,
J. Munuera, E. Santamarina, P. Delgado, O. Maisterra, C.A. Molina
Hospital Vall d’Hebron, Barcelona, Spain
Background: Previous research has suggested that right hemisphere stroke (RHS)
may achieve worse outcome after thrombolysis. We aimed to evaluate the influence
of the side of affected hemisphere on the extent of baseline MRI abnormalities
in acute stroke and to assess the value of MRI-based selection approach for tPA
treatment in RHS.
Methods: We prospectively studied 145 acute stroke patients due to proximal MCA
occlusion imaged with MRI within the first 6 h from symptoms onset. Those with
unclear onset time were excluded. DWI and time-to peak (PWI) lesion volumes
were measured. MRI inclusion criteria for tPA were PWI/DWI mismatch>20%
and DWI volume<50% of MCA territory. Recanalization was assessed by TCD at
102 Cerebrovasc Dis 2007;23(suppl 2):1–147
6 h and hemorrhagic transformation (HT) on MRI at 24-48 h. mRS score was used
to assess 3-month outcome.
Results: 66 (45.5%) patients had RHS. Baseline NIHSS was lower in RHS (median
17 vs 19, p=0.0001). Time to MRI was similar between both hemispheres. RHS
patients presented with larger DWI volume (73.9 vs 38.5 cc; p=0.004) and smaller
PWI/DWI mismatch (63% vs 79%, p=0.011). Only 13 (16.5%) patients with LHS
did not meet MRI criteria for thrombolysis, compared to 21 (31.8%) of those
with RHS (p=0.03). 85 (58.6%) patients were treated with tPA (34 RHS, 51 LHS;
p=0.112). Among those treated with tPA, baseline NIHSS was lower in RHS (16 vs
19; p=0.0004), whereas DWI and PWI/DWI mismatch volumes were comparable.
Recanalization rates (RHS 53.1% vs 52.2%, p=0.934) did not differ between both
hemispheres. Only 1 patient had symptomatic HT. At 3 months, good clinical
outcome (mRS 0-2, RHS 33.3% vs 39.1%, p=0.609) and mortality (RHS 15.2% vs
23.9%, p=0.339) were similar between RHS and LHS.
Conclusion: Patients with a RHS present with larger infarct volumes and lesser
salvageable penumbral tissue, suggesting a possible less efficient pattern of collat-
eral circulation in the right hemisphere. A MRI-based screening for thrombolysis,
irrespective of the time window, may improve the selection of patients with RHS
likely to benefit from tPA.
14 Acute stroke: complications and early outcome
IS RENAL FAILURE A PREDICTOR FACTOR OF POOR EVOLUTION IN
ACUTE STROKE?
L. Gabaldón, B. Fuentes, J. Fernández, L. Idovro, P. Martínez, E. Díez-Tejedor
University Hospital La Paz, UAM, Madrid, Spain
Background: Previous studies have pointed out that renal failure is an independent
factor of poor outcome in patients with cardiac failure, myocardial infarction and
coronary surgery. However, no studies analysing its possible influence on stroke
outcome are available.
Methods: Observational study including consecutive first-ever acute stroke in-
patients with a two-years recruitment period. Renal failure was defined as
creatinine level 3 1.2 mg/dl on admission or previous diagnosis of it. In-hospital
mortality and outcome at discharge (modified Rankin Scale) were the main outcome
measures.
Results: 445 patients were included, mean age 69.7±13.2. In the univariate
analysis creatinine >1.2 mg/dl was associated to more in-hospital mortality (31.7
vs 20.7%; p=0.04) but not to poor outcome at discharge. In multivariate logistic
regression analysis the predictive factors independently associated to in-hospital
mortality were: stroke severity on admission (OR 0.49; 95% IC 0.39-0.63) and the
development of systemic (OR 17.97; 95% IC 5.47-59) or neurologic complications
(OR 23.49; 95%IC 7.25-76.01) without any influence of renal failure.
Conclusions: Renal failure measured by creatinine serum level does not signif-
icantly influence in-hospital mortality or outcome at discharge in acute stroke
patients. However, new studies analysing other parametres of renal function such
as creatinine clearance are need to get definite conclusions.
15 Acute stroke: complications and early outcome
SIGNIFICANCE OF COMMON COMPLICATIONS DURING THE FIRST
WEEK POST STROKE: IMPACT ON FUNCTIONAL OUTCOME AT 90 DAYS
G. Rohweder, E. Naalsund, P. Oksnes, B. Indredavik
St. Olavs University Hospital, Department of Neuroscience, NTNU,
Trondheim, Norway
Background: Little is known about the prognostic impact of acute post-stroke
complications. The aim of this study was to define the longterm functional outcome
in patients who experienced a common (>2.5%) complication during the first week
after a stroke, while admitted to an acute comprehensive stroke unit and followed
up by an early supported discharge service.
Methods: 244 patients consecutively admitted to our stroke unit and with a mod-
ified Rankin Scale (mRS) of < 2 were included on admission and followed with
assessment for 8 complications: fever, diffuse pain, progressing stroke, urinary tract
infection (UTI), isolated Troponin T elevation (Trop T), chest infection, non-serious
falls, and acute myocardial infarction (AMI). After discharge, the patients were
followed up for 90 days with weekly telephone assessments and a home-visit and
functional assessment after 3 months.
Results: The mean age of patients was 77 yrs., 56% were women. The frequency
of complications were as follows: fever 26%, diffuse pain 25%, progressing stroke
18%, UTI 17%, Trop T 13%, chest infection 12%, non-serious falls 7%, AMI 6%.
48% of all patients had an improvement >1 on the mRS. Frequencies of mRS >
1 were as follows: In pts with a chest infection: 18%, without 52% (p=0.001). In
pts with Trop T: 34%, without 50% (p=0.089). In pts with AMI: 30%, without
16th European Stroke Conference
49% (p=0.229). In pts with UTI 46%, without 48% (p=0.777). In pts with fever
49%, without 48% (p=0.876). In pts with progressing stroke 60%, without 46%
(p=0.080). In pts with diffuse pain 62%, without 44% (p=0.012). In pts with
non-serious falls 81%, without 46% (p=0.006).
Discussion: This study suggests that the occurrence of chest infection during the
first week after a stroke leads to a worsened outcome, while the occurrence of
Troponin T elevation and acute myocardial infarction may do so. Frequent falls
and diffuse pain are indicators of improved functional outcome at 90 days after a
stroke. Progressing stroke does not confer a worsened outcome under the current
management.
16 Acute stroke: complications and early outcome
EARLY PULMONARY EMBOLISMS IN PATIENTS TREATED WITH FACTOR
VIIA FOR INTRACEREBRAL HEMORRHAGE. CHANCE OR SAFETY
CONCERN?
W. Vadot, A. Jaillard, P. Bedouch, C. Chevallier, K. Garambois, O. Detante,
B. Hommel, M. Hommel
University Hospital of Grenoble, Grenoble, France
Introduction: Intracerebral hemorrhage (IH) was the least treatable type of stroke.
Activated Factor VII (rFVIIa) IH Trial (FIHT) suggested that treatment of IH with
rFVIIa within 4 hours improves outcomes despite thromboembolic adverse events
(Mayer et al. 2005). Our aim was to evaluate feasibility and safety of rFVIIa in a
stroke Unit.
Methods: We consecutively included patients with IH admitted during years 2005
and 2006, who met criteria for inclusion in FIHT. Patients admitted in 2006 were
administered 80 μg of rFVIIa per kilogram of body weight and were compared with
the historical controls admitted in 2005. Clinical outcome were NIHSS, Rankin
score and mortality. Safety was assessed using serum troponin and D-dimer at
baseline, 6 hours and on day 1, 2, 3 and later when necessary. Lower limb Doppler
and thoracic CT scan were performed in patients with high D-dimer levels in order
to assess deep venous thrombosis (DVT) and pulmonary embolism (PE).
Results: Among the 30 patients included (NIHSS=14), 15 received RFVIIa. In
this group, none had myocardial infarction, one died of cerebral edema, and two
suffered PE. The first PE occurred at day one and the other at day 2 with re-bleeding
at day 3. Both patients with EP recovered. Because each received 7.2 mg of RFVIIa
in relation to high weight and had no other risk factor, we limited later on the
highest dose at 4,8 mg. None of the next patients suffered PE but one had PVT. In
the control group, 2 patients died, 3 had DVT but none had PE. Clinical outcome
was not different in the two groups.
Discussion: At our knowledge, early PE was not reported as thromboembolic
complications in patients treated by RFVIIa for IH. A dose effect relation was
suggested by the high total dose received the two patients with PE.
17 Acute stroke: complications and early outcome
ASPIRIN RESISTANCE IS ASSOCIATED WITH INFLAMMATION, ISCHEMIC
STROKE SEVERITY, AND POORER FUNCTIONAL OUTCOME AT 6
MONTHS
N.A. Englyst, G. Horsfield, C.D. Byrne
University of Southampton, Southampton, United Kingdom
Background: Stroke is the largest cause of disability in the UK but little is
known about which factors influence recovery. Aspirin is used in primary and
secondary prevention of stroke. Aspirin resistance is associated with a higher risk
of developing stroke but its relationship with severity of stroke and functional
outcome after stroke is unclear. The aim of this study was to investigate the
relationship between aspirin resistance and inflammatory cytokines, stroke severity
and functional outcome at 6 months.
Methods: Aspirin resistance was assessed by thrombelastography in 100 people
with ischemic stroke and 100 community-based controls. Stroke outcome (degree
of disability) was assessed using the Rankin’s Stroke Scale within 72 hours of
stroke and at 6 months. Plasma interleukin IL-6 was measured by Enzyme Linked
Immunosorbent Assay (ELISA).
Results: Aspirin resistance was associated with a higher Rankin’s scale at baseline
(p=0.013), suggesting that aspirin resistance is associated with more severe strokes.
Aspirin resistance at baseline was also associated with higher Rankin’s scale
at 6 months (p=0.048). Aspirin resistance was associated with increased IL-6
(p=0.034) and higher levels of IL-6 were associated with poorer outcome from
stroke (p=0.017). IL-6 was independently associated with aspirin resistance in
multivariate analysis.
Discussion: Aspirin resistance in conjunction with increased plasma IL-6 may
indicate a high risk of poor functional outcome from stroke. These data suggest that
Poster Session
Acute stroke: complications and early
outcome
screening for aspirin resistance after a stroke might identify a sub-group of people
who may benefit from higher doses of aspirin and/or combination therapy.
18 Acute stroke: complications and early outcome
WHAT FACTORS INFLUENCE EARLY RECANALISATION DURING
THROMBOLYSIS IN ACUTE ISCHEMIC STROKE?
L. Sekoranja, H. Yilmaz, K. Lovblad, R. Grandjean, P. Temperli, R. Sztajzel
University Hospital of Geneva, Geneve, Switzerland
Purpose: We evaluated the factors determining récanalisation after thrombolysis.
Patients and methods: Patients with acute ischemic stroke (AIS) of < 3 h
underwent either IV or combined IV-IA lysis, if no recanalisation after 30’.
CT-angiography was done in all p and monitoring with TCCD during 60’ in case of
IV and during 30’ in case of IV-IA lysis. TIBI was used to assess the residual MCA
flow before the lysis and to evaluate presence or absence of early recanalisation
(TIBI >1 at 30’).
Results: 54 patients, 30 M, mean age 68.1 y. 33 p had IV and 21 IV-IA lysis. 43
(80%) p had an MCA and 11 (20%) a T occlusion. Hypertension had 30 (55%),
DM 8 (15%), and AF 23 p (43%); 18 (33%) were on ASA and 11 (20%) on statins.
Thrombolytic was given within 60 to 230’. NIHSS ranged from 5 to 21. Fifteen
(27%) p had a TIBI 0 before lysis, 9 a grade of 1(16%), 12 (22%) grade of 2 and
18 (33%) grade of 3; 17 (31%) p received contrast because of insufficient temporal
window. After lysis 25 (46%) p improved > 4 points on NIHSS. Factors increasing
the early recanalisation in univariate analysis: TIBI 1 to 3 respectively OR 8.1,
95% CI 1.1 to 59, p= 0.039; OR 8.7, CI 95% 1.3 to 59, p= 0.021 and OR 15.6;
95% CI 2.7 to 103, p= 0.002. The factors decreasing the early recanalisation: T
occlusion OR 0.02, 95% CI 0.003 to 0.20, p 0.001; M1 occlusion OR 0.11 95% CI
0.02 to 0.6, p 0.011. In a multivariate analysis factors increasing the likelihood of
early recanalisation: TIBI grades 1 to 3 respectively OR 11.9 95% CI 0.4 to 4.1, p=
0.025; OR 13.8, CI 95% 1.3 to 105, p= 0.014 and OR 24.7; 95% CI 0.07 to 1.1, p=
0.075 and atrial fibrillation OR 0.28, 95% CI 0.07 to 1.1, p 0.075.
Conclusion: Presence of a residual flow of the MCA on TCCD (TIBI 1 to 3) was
the best predictor of early recanalisation; presence of T or M1 segment occlusion on
Angio-CT were associated with a lower one, however only on univariate analysis.
19 Acute stroke: complications and early outcome
THE IMPACT OF HYPERTHERMIA AND INFECTION ON THE ACUTE
ISCHEMIC STROKE PATIENTS ADMITTED TO INTENSIVE CARE UNIT
W. Seo, S. Yu, J. Kim, S. Koh
Korea University College of Medicine, Seoul, South Korea
Background: Despite well recognized deleterious effect of the hyperthermia on
critically ill neurological patients, few investigations were performed for the issue
about the fever after ischemic stroke in intensive care unit (ICU) setting. We tried
to prove the effect of hyperthermia on in-hospital outcome and the role of infection
on hyperthermia in the acute ischemic stroke patients admitted to ICU.
Methods: We reviewed medical records retrospectively for the acute ischemic
stroke patients admitted to ICU within 24 hours from the onset between March
2004 and December 2006. The patients were assigned into normothermia, mild
hyperthermia (MH, ≥37.6°C and <38.0 ≥1;, at least one time during ICU stay)
and severe hyperthermia (SH, ≥38.0 ≥1;). Causes of hyperthermia were divided
into infection and non-infectious cause. Outcomes were measured by in-hospital
mortality or long ICU stay (≥4 days). The logistic regression tests with factors
presumed to be related with hyperthermia were performed to predict the outcomes.
Result: Among the 150 patients included (63.38 ± 12.13 years old, male 57.3%),
MH and SH were observed in 15 and 40 patients, respectively. SH was indepen-
dently related to in-hospital mortality (OR 10.3, p < 0.01) and long ICU stay (OR
7.8, p < 0.01). MH was related with long ICU stay (OR 4.2, p = 0.03). Among the
other factors, Glasgow coma scale was associated with in-hospital mortality (OR
0.77, p = 0.02) and long ICU stay (OR 0.82, p < 0.01). The patients with infection
(39 patients) was more prevalent in SH than in MH (p < 0.01) and had longer ICU
stay than non-infectious group (p = 0.01).
Discussion: Careful concern for the infection as well as effort for lowering body
temperature per se is needed to the acute ischemic stroke patients admitted to ICU.
Cerebrovasc Dis 2007;23(suppl 2):1–147 103
 20 Acute stroke: complications and early outcome
MAJOR NEUROLOGICAL IMPROVEMENT AFTER STROKE
THROMBOLYSIS IN A FRENCH COMMUNITY HOSPITAL
B. Barroso, C. Morisset, E. Bertandeau, H. Mangon, A. Dakar, J.M. Larrieu
F. Mitterrand Hospital, France
Objective: A significant advancement in the treatment of acute ischemic stroke
management has been the use of recombinant tissue plasminogen activator (rtPA).
In practice, French community hospitals experience difficulty in treating their
patients because stroke units (SU) are missing in Neurology wards. To improve
quality of care and to provide modern stroke therapy, we decided to assess whether
thrombolysis was feasible in the Emergency department of our community hospital
located in Pau (south-west of France).
Methods: Select patients were treated with rtPA and observed for 24 hours in the
Emergency department. They were then transferred to the neurological department
for follow-up. By reference to French legislation this use of rtPA therapy was
defined as an "off-label use". NIHSS was obtained on admission, immediately
after treatment and 24 hours post treatment. At that time we collected all major
neurological improvements defined as an NIHSS score equal to 0 or 1 or an
improvement of more than 8 points compared to baseline.
Results: Results from the first 40 patients are reported. They were treated between
September 2004 and June 2006. A total of 1169 patients were admitted for stroke
during this period. We collected 349 transitory ischemic attacks, 192 hemorrhagic
strokes and 628 ischemic strokes. A total of 3.4% of strokes was treated by rtPA. A
major neurological improvement was present in 14 patients (35%).
Conclusions: According to the infrastructural local criteria and preparatory pre-
requisites described in this study, thrombolysis is a viable and feasible treatment
option for stroke patients in Emergency departments of French community hospitals
even in lack of SU. It has been shown elsewhere that good outcome in the first 24
hours is an independent predictor of good functional outcome at 3 months. So, such
an emergency organisation could be used as a compromise as long as SU are not
available enough.
21 Acute stroke: complications and early outcome
OUTCOME OF PATIENTS NOT TREATED WITH RT-PA DUE TO
SPONTANEOUS IMPROVEMENT
J. Martí-Fàbregas, E. Martínez, S. Martínez-Ramírez, D. Alcolea, D. Cocho,
M. Martínez-Corral, M. Marquié, M. Suárez, L.A. Querol, J.-L. Martí-Vilalta
Hospital de la Santa Creu i Sant Pau, Spain
Background: Rapid and significant spontaneous clinical improvement is an exclu-
sion criteria for intravenous thrombolysis. However, there is controversy about the
short- and long-term outcome of these patients. We report a prospective study of
consecutive patients.
Methods: We studied patients with a focal neurological deficit admitted within
3 hours of onset of symptoms with the following characteristics: 1) Duration of
symptoms >30 minutes, 2) NIHSS score of 5 or more points, obtained either by
anamnesis (when it occurred outside the hospital) or by neurologic examination.
3) A spontaneous decrease in the NIHSS score to values <5 points that occurred
before the 3 hours-limit. Improvement was assessed either by anamnesis (when it
occurred outside the hospital) or by direct examination. We used the SITS-MOST
criteria for intravenous thrombolysis. Favourable outcome at 24 hours was defined
as a NIHSS below 5 points. Favourable outcome 1 and 3 months after stroke was
defined as a score < 2 on the Rankin scale. The diagnosis of an acute infarction
demonstrated by neuroimaging within the study period was recorded.
Results: We evaluated 15 patients, with a mean age of 69 ± 13.2 years, and
80% were men. Median NIHSS score at onset was 8, and median NIHSS score at
inclusion was 3. Favourable outcome was observed in 13 (87%) patients at 24h, 11
(73%) at 1 month and 8/12 (67%) at 3 months. During the study period 11 (73%)
patients developed a cerebral infarction. Mortality at 3 months was 13%.
Discussion: The outcome of patients not given rt-PA due to spontaneous im-
provement is not uniformly favourable. One third of patients had an unfavourable
outcome and 73% developed an acute infarct.
104 Cerebrovasc Dis 2007;23(suppl 2):1–147
22 Acute stroke: complications and early outcome
PREDICTORS OF INTRACEREBRAL HEMORRHAGE AFTER
INTRAVENOUS RTPA THERAPY FOR ACUTE ISCHEMIC STROKE IN
CLINICAL PRACTICE
D. Gasecki, G. Kozera, M. Swierkocka-Miastkowska, K. Chwojnicki,
B. Karaszewski, S. Szczyrba, M. Wisniewska, W.M. Nyka
Medical University of Gdansk, Gdansk, Poland
Background: Intravenous recombinant tissue plasminogen activator (rtPA) is an
effective therapy for acute ischemic stroke, but it is associated with risk of
intracerebral hemorrhage (ICH). Our aim was to identify baseline factors that are
associated with thrombolysis-related ICH and to assess the clinical course of those
patients compared to patients without ICH.
Methods: we analyzed 52 patients (18 women) with acute stroke treated with IV
rtPA within 3 hours of stroke symptom in Medical University of Gdansk, Poland,
between 2000 and 2006.
Results: 2 (3,8%) patients developed symptomatic ICH, and 4 additional patients
(7,7%) had asymptomatic ICH identified on a routine follow-up CT (within 22-36
hours of stroke symptoms). In analyses based on clinical and radiological variables,
the attributes associated with ICH were advancing age (p<0,05), early ischemic CT
changes (p<0,05), a history of atrial fibrillation (p<0,05), and elevated pre-bolus
diastolic blood pressure (p=0,06). No association between diabetes mellitus, serum
cholesterol, the initial stroke severity, neurological outcome at 7 or 90 day and ICH
was found. Clinical relevant was only parenchymal type of ICH, in 2of 3 cases
associated with early neurologic deterioration.
Conclusions: Advanced age, embolic stroke, elevated diastolic blood pressure and
ischemic changes on CT could be predictive of ICH. Only PH-ICH seems to be of
clinical significance.
23 Acute stroke: complications and early outcome
THE "NO-REFLOW" PHENOMENON AFTER THROMBOLYSIS IN ACUTE
STROKE - A MARKER OF POOR STROKE OUTCOME?
A.Y. Jin, O. Islam, F.W. Saunders, A.M. Demchuk, D.G. Brunet
University of Calgary, Calgary, Canada
Background: The “no-reflow” phenomenon after thrombolysis-induced recanal-
ization in acute stroke has not been well-described. We assessed the hypothesis
that reperfusion failure despite thrombolysis-induced recanalization, i.e. no-reflow,
is common and is associated with a poor early stroke outcome.
Methods: Patients treated with thrombolysis over a three year period (2001-2004)
at Kingston General Hospital were considered in this retrospective study. Inclusion
criteria were: admission noncontrast CT (NCCT) scan with either transcranial
Doppler sonography (TCD), CT angiography (CTA), or CT perfusion (CTP) scan
done before thrombolysis; follow-up NCCT and CTP scans done between Days 1 to
5 with either serial TCD examinations or CTA; and a modified Rankin Scale (mRS)
score evaluated before hospital admission and at hospital discharge. Cerebral blood
volume (CBV) and cerebral blood flow (CBF) maps were used to compare the
affected and contralateral hemispheres before and after thrombolysis. Reperfusion
failure was defined as any area with decreased CBV and CBF after thrombolytic
therapy. Recanalization of the primary arterial occlusive lesion was evaluated by
either serial TCD examinations or follow-up CTA. Reperfusion failure despite
recanalization of the primary arterial occlusive lesion was classified as “no-reflow”.
Results: 20 patients were included in this study. 19 patients showed recanalization
of the primary arterial occlusive lesion at follow-up. Of these patients, 7 (37%)
showed reperfusion failure on follow-up CTP scan. Among patients with recanal-
ization, those with no-reflow had a median hospital discharge mRS of 4 (range 2 to
6), compared to a median mRS of 1 (range 0 to 4) in patients without no-reflow
(Mann Whitney U test: p (two-tailed) = 0.002).
Discussion: The no-reflow phenomenon is common despite thrombolysis-induced
recanalization and is associated with a poor early stroke outcome. Possible causes
of no-reflow may include distal embolization, arterial reocclusion, and persistent
branch vessel occlusion.
16th European Stroke Conference
Acute stroke: treatment concepts of recanalisation rates after intravenous (IV) thrombolysis for stroke comparing
studies where contrast was administered to those where it was not.
Methods: Search results for MEDLINE and Embase from inception to October
1 Acute stroke: treatment concepts 2006 were screened and studies reporting recanalisation rates for IV thrombolysis
for anterior circulation stroke were selected. Additional data were sought from
OXIDATIVE STRESS, DOCUMENTED BY DETERMINATION OF MDA, IN two authors. We compared recanalisation rates for contrast (CS) and non-contrast
ACUTE ISCHEMIC STROKE SUBTYPES, ACCORDING TO TOAST (NCS) studies.
CRITERIA Results: We identified 31 studies (7 CS, 24 NCS). Non-ionic contrast was admin-
A. Simion istered for CT perfusion images (CTp) in 2 studies (40mls, n=1; 50mls, n=1), CTp
Faculty of Medicine and Pharmacy/Clinical Hospital of Neurology and +/- angiography (CTa) in 1 study (50mls +/- 50mls), and CTp and CTa in 1 study
Psychiatry, Oradea, Romania (weight adjusted; max 140mls). 3 studies involving catheter angiograms did not
specify type or volume of contrast. The mean time limit for thrombolysis was 6.1h
Background: In ischemic stroke, oxidative stress has been shown to worsen the (SD 2.1) in CS and 4.9h (SD 1.6) in NCS. Recanalisation rates were assessed by
extent of cerebral injury. Our study tries to correlate oxidative stress with the CTa, magnetic resonance angiogram and transcranial doppler ultrasound. Recanali-
subtype and outcome of ischemic stroke. sation was assessed late (>24h) in 6 CS, and 15 NCS. Precise occlusion site was
Material and method: We studied a consecutive series of 104 ischemic strokes, specifically indicated in 4/7 CS and 19/24 NCS.
evaluated with CT and/or MRI or MRA, Duplex sonography, transthoracic echocar- Recanalisation was non-significantly more frequent in CS (56/89, 63%) compared
diography, and electrocardiography. Strokes were divided into large-artery disease to NCS (841/1496, 56%) OR 1.32 (95% CI 0.85, 2.06). This remained true for late
(LAD), small-artery disease (SAD) and cardioembolism (CE), according to the recanalisation (OR 1.34, 95% CI 0.79, 2.29). and for MCA M1 or M2 occlusions
TOAST criteria. Cases with uncertain or unknown etiologies were excluded. Each (OR 1.17, 95% CI 0.47, 2.91).
patient was scored on the NIHS scale at admittance and had the Barthel index Discussion: This was an indirect comparison and not a randomised study, and there-
(BI) evaluated at discharge. Beside a complete laboratory evaluation, oxidative fore limited. However, we found no evidence that contrast impaired recanalisation
stress was assessed by measuring the seric malondialdehyde (MDA) levels with the rates with IV fibrinolytic therapy.
tiobarbituric acid method at admittance (day 1), and on days 3 and 7.
Results: We found different patterns for the course of oxidative stress in the stroke
subtypes. By day 3 we obtained significantly (p<0,001) higher level of MDA in all 3 Acute stroke: treatment concepts
ischemic subtypes (view Table 1), but by day 7 MDA levels were increased only in
CE (p<0,001) whilw in LAD they decreased (p<0,02) and showed non-significant PROGNOSTIC FACTORS OF THROMBOLYTIC THERAPY IN HYPERACUTE
variations (p>0,05) in SAD (view Figure 1). MDA values do not correlate with ISCHEMIC STROKE
NIHSS, or with BI. Complications, especially infectious ones, raise the MDA values J.H. Rha, B.N. Yoon, K.H. Ji, J. Lee
on the second and third determination, but only bronchopneumonia significantly Inha University Hospital, Seoul, South Korea
influenced the outcome.
Background: To investigate the prognostic factors of intravenous thrombolysis, we
Table 1. MDA values in stroke subtypes and overall evaluated 121 consecutive patients treated with IV tPA. Methods: Demographic and
LAD SAD CE Ischemic stroke clinical profiles, laboratory results, transcranial Doppler, and brain imaging were
evaluated. Clinical assessment was done by National Institutes of Health Stroke
MDA2 2,43±0,31 1,83±0,34 2,17±0,32 2,2±0,4 Scale (NIHSS) for one week, and by modified Rankin Scale (mRS) at baseline and
MDA3 4,18±0,43 3,86±0,46 3,07±0,43 3,7±0,6
three months. Early improvement was defined as the complete resolution of the
MDA3 3,13±0,43 4,06±0,64 4,61±0,52 3,9±0,5
neurological deficit or an improvement of 4 or more points by NIHSS within 24
hours of the stroke onset, and good outcome as mRS score of 2 or less at three
months. We assessed the possible relationship of the factors with early improvement
and good outcome, and also analyzed the correlation of TCD grade with NIHSS
score. Comparisons of variables were performed using Fisher’s exact test, t-test and
Mann-Whitney test. The predictors of early improvement and good outcome were
analyzed by logistic regression, and the correlation of TCD grade and NIHSS score
were analyzed by Spearman correlation.
Results: On univariate analysis, younger age, absence of abnormal CT findings
(hyperdense middle cerebral artery sign [HMCAS], focal hypodensity in the total
MCA territory > 33%) were significantly associated with early improvement.
Good outcome was associated with younger age, lower levels of baseline NIHSS
score, mean blood pressure, fasting glucose, lipoprotein (a) [Lp(a)], and absence
of abnormal CT findings. Multivariate analysis revealed age < 63 years and no
HMCAS as independent predictors of early improvement. Thrombolysis in brain
ischemia grade by TCD monitoring significantly correlated with NIHSS score for
24 hours.
Conclusions: These results suggest that younger age, normal CT findings are
important prognostic factors of acute thrombolytic therapy, whereas age, CT
findings, baseline NIHSS, blood pressure, blood sugar and Lp (a) level might be
associated factors of long term outcome. TCD can be a useful indicator of clinical
Fig. 1 improvement.

Conclusions: We presume that the high levels of MDA on day 7 in CE could be

tied to reperfusion. If so, antioxidant therapy would be most beneficial if given to
patients with embolic strokes or after thrombolysis.
2 Acute stroke: treatment concepts
SYSTEMATIC REVIEW OF THE EFFECT OF CONTRAST AGENTS ON
RECANALISATION RATE AFTER INTRAVENOUS THROMBOLYSIS FOR
ACUTE STROKE
K.A. Dani, K.W. Muir
University of Glasgow, Glasgow, United Kingdom
Background: Recent assertions that contrast agents impair fibrinolysis are based
on limited evidence from animal models. We undertook a systematic review
4 Acute stroke: treatment concepts
STATES OF LEPTOMENINGEAL COLLATERALS AND RESPONSE TO
THROMBOLYSIS IN PATIENTS WITH ACUTE MCA INFARCTS
K.H. Kang, H.C. Park, E.H. Kim, Y.S. Kim, C.K. Suh, Y.H. Hwang
Kyungpook National University Hospital, South Korea
Background: MR-based thrombolysis using DWI/PWI mismatch is feasible
method in selecting thrombolysis candidate. However, state of leptomeningeal col-
laterals in conventional angiography (CA) may also affect response to thrombolysis
and clinical outcome. The purpose of this study is to correlate state of collaterals
with response to thrombolysis.
Methods: We retrospectively analyzed 16 patients from May to December 2006
who performed CA for Intra-arterial thrombolysis (IAT) in presumed MCA occlu-

Poster Session Cerebrovasc Dis 2007;23(suppl 2):1–147 105

Acute stroke: treatment concepts
sion with DWI/PWI mismatch. Angiographic states of leptomeningeal collaterals
were defined as minimal (retrograde flow to M4 segment), moderate (retrograde
flow to M3 or M2 segment), and maximal (retrograde flow to distal to site of
occlusion). IAT was done using urokinase or tPA infusion and/or mechanical
thrombus crushing.
Results: Mean values of onset to door and door to IAT were 231.9±53.3 min and
143.4±11.5 min. Among them, 11 patients regained angiographic recanalization
(69%, TIMI Grade 2 or 3) and 6 patients had good clinical outcome (38%, mRS 0-1
at 1-3 months). There was no statistically significant results in recanalization rate
and clinical outcome among each collateral groups [response to thrombolysis - 3/3
in maximal, 4/5 in moderate, and 4/8 in minimal, (P=0.23); good clinical outcome
- 2/3 in maximal, 3/5 in moderate, and 1/8 in minimal, (P=0.12)]. However, the
rates of recanalization and good clinical outcome were much higher in maximal
collateral group.
Discussion: Unfortunately, we did not show statistically significant results about
effect of collateral circulation on response to thrombolysis and clinical outcome.
However, we found trend that good collateral circulation is related to recanalization
success and better clinical outcome. In future, standardized method of collateral
grading system is needed for multi-center controlled study.
5 Acute stroke: treatment concepts
PERSONAL EMAILS: A SIMPLE MEASURE TO IMPROVE THE QUALITY OF
CARE IN THE STROKE PATIENTS
M.F. Bellolio, R. Kashyap, L. Vaidyanathan, S. Enduri, A.M. Hoff, A.S. Yassa,
S. Mishra, R.D. Brown, W.W. Decker, L.S. Stead
Mayo Clinic College of Medicine, Rochester, USA
Background: Embolic or thrombotic arterial occlusion is a frequent cause of
cerebral infarction, making antithrombotic therapy an important part of the care in
stroke patients. Aspirin (ASA) reduces the risk of early recurrent ischemic stroke
when given within 48 hours of initial symptom onset.
We hypothesized that sending a friendly remainder by email to the consultant who
saw a patient with Stroke or TIA in the Emergency Department (ED) and for any
reason did not give ASA during the ED stay, could improve the rate of patients
receiving aspirin.
Methods: A consecutive cohort of patients presenting into the ED with a suspected
diagnosis of TIA or Stroke were prospectively enrolled. We excluded patients with
suspected diagnosis of intracerebral hemorrhage and those receiving thrombolytics.
The intervention was to track ASA administration and send out timely follow up to
those who did not provide the drug. This was done via individual (rather than group)
email, specifically stating the name and clinic number of the patient, and noting
lack of aspirin administration as well as lack of documentation for not doing so.
Results: Our study group was 64 patients in the pre-intervention period (Aug-Sept)
and 59 post-intervention (Oct-Nov).
During the pre-emails period 43.8% of the patients received ASA, and 66.1% after
sending the emails (p=0.013)
After the intervention, the patients with stroke or TIA were 2.51 times more likely
to receive aspirin in the ED (95%CI 1.21-5.21)
Discussion: This simple method of personal emails has been improving not only
the rate of patients who receive aspirin, but also the quality of the documentation
(reasons why the patient is not a candidate for ASA, such as suspected hemorrhage
or ASA given by the pre-hospital services personnel) and has been maintained over
the months.
6 Acute stroke: treatment concepts
CAN WE USE THE ABCD SCORE TO SCREEN PATIENTS FOR A WEEKLY
TIA CLINIC? RETROSPECTIVE APPLICATION OF THE SCORE TO ASSESS
IT’S SUITABILITY
B. Brady, M. Sekiguchi, B. Silke, J. Harbison
Stroke Service, St James’s Hospital, Dublin, Ireland
Background: Prior to the establishment of a weekly TIA in St James’s Hospital
in 2006 suspected TIA patients were routinely admitted for investigation. In
developing protocol for the clinic we considered the ABCD score (1) as a potential
means of screening patients for the clinic rather than admission. The original paper
reports a score of 5 or 6 being associated with a recurrence rate of >25% implying
need for immediate admission. To assess the scores utility we applied the score
retrospectively to a sample of patients admitted with suspected TIA.
Method: 100 sets of notes on patients admitted with suspected TIA were reviewed
by 2 doctors. Diagnosis was reviewed, ABCD score applied from available admis-
sion data and prior and subsequent admissions with TIA/stroke identified. Changes
in management resulting from admission were noted.
106 Cerebrovasc Dis 2007;23(suppl 2):1–147
Results: Of the 100 subjects, 83 were felt to have suffered a cerebrovascular
event. Twenty eight of the 83 subjects (34%) had symptoms lasting >24 hours. A
decision had been made that such patients should be admitted. Of the 55 remaining
subjects, 15 (27%) had suffered other events in the preceding month (1-5 events,
median 1) necessitating admission. Of the 40 left, 19 (47%) had an ABCD score
of 5 or 6. Two patients had subsequent events in the following month. One had
an ABCD score of 3 and the other a score of 5. The patient with the score of 3
was young, normotensive but suffered a prolonged event (>1 hour). None of the
patients underwent intervention other than the commencement of anti-platelet and
antihypertensive therapy. None had suffered an intracerebral haemorrhage.
Conclusion: Use of the ABCD score 1-4 as a means of selecting suitable subjects
for outpatient management would have prevented the admission of 38% of the
referrals (non-strokes and TIAs). It would have missed one subject who suffered a
recurrent event, however admission of that subject did not alter his outcome. We
decided to adopt the ABCD score but not use it in isolation and to admit subjects
with events >30 minutes duration.
7 Acute stroke: treatment concepts
ANTICOAGULATION AND THE RISK OF ICH AFTER CARDIOEMBOLIC
STROKE
H. Hallevi, K.C. Albright, A.D. Barreto, S. Martin-Schilde, A. Khaja,
E.A. Noser, N.R. Gonzales, K. Illoh, J.C. Grotta
University of Texas-Houston, Fannin, TX, USA
Background: Heparin has not been shown to be effective in reducing mortality
and morbidity after acute cardioembolic stroke, however anticoagulation (AC)
eventually needs to be instituted for secondary stroke prevention. We aimed to
study the timing and mode of starting AC in cardioembolic stroke patients.
Methods: We conducted a retrospective analysis of all cardioembolic strokes cared
for by our Stroke Team over 3 years. Patients were monitored in our Stroke Unit.
Neuroimaging was done on admission, at 24 hours and with any neurological
deterioration.
Results: We included 204 patients with cardioembolic stroke in the analysis.
Full dose AC with IV Heparin or Low Molecular Weight Heparin (LMWH) was
given to 73 patients. Warfarin was started subsequently in 87% (63/73). Low dose
AC (DVT prophylaxis dose) with or without aspirin was given to 131 patients.
Warfarin was given subsequently to 26.7% (35/131). There were 22 (10.8%) cases
of asymptomatic hemorrhagic transformation (HT). All but one occurred during the
first three days. Three patients experienced symptomatic HT 6 to 12 days from their
stroke. In all three, warfarin was started while patients were “bridged” with full
dose LMWH and aspirin (3/21, 14.3%, p=0.001). Two cases of serious systemic
hemorrhage occurred among patients treated with IV heparin (2/48, 4.2%, p=0.054).
Overall acute anticoagulation was associated with 6.8% (5/73) serious bleeding
(p=0.05). Recurrent strokes occurred in two cases despite effective anticoagulation
in one (0.1%, p=0.53). There were no cases of hemorrhage in patients treated with
low dose AC and warfarin.
Discussion: Symptomatic HT after cardioembolic stroke occurred late and was
associated with aggressive anticoagulation and simultaneous ASA use in our series.
Early asymptomatic hemorrhage seems unrelated to anticoagulation. Low dose
AC appears safe, even in the setting of asymptomatic HT. Our data suggest that
“bridging” patients with full dose LMWH until anticoagulated with warfarin may
not prevent early stroke recurrence and is associated with an unacceptable risk of
symptomatic HT.
8 Acute stroke: treatment concepts
EFFECTIVENESS OF THROMBOLYSIS IN PATIENTS OVER 80 YEARS OF
AGE
C. Rueckert, T. Staudacher, D. Bengel
St. Elisabeth Hospital, Ravensburg, Ravensburg, Germany
Background: Despite the fact that the clinical trials leading to the approval of
thrombolysis excluded patients over 80 years, in many centers this therapy is
offered to patients above this age.
Methods: In our series of 324 patients treated with thrombolysis between 12/2000
and 01/2007 we analyzed the outcome of all 77 patients over the age of 80 (max:
92 years).
Results: Overall median age was 71 years; 45,2% were women, 54,8% were men;
in the subgroup of over 80 years 59,7% were women, 40,3% were men. 29,4% of all
patients but 40,8% of the patients 80+ were admitted to the hospital within 1 hour
of onset of symptoms. There was no difference in mean door-to-needle-time (55
minutes), mean time from onset of symptoms to therapy (131 minutes), and stroke
severity at onset (mean National Institute of Health Stroke Scale=NIHSS 16).
16th European Stroke Conference
57,8% of all patients versus 77,5% of patients over 80 had a cardio-embolic origin,
17,7% (8,4%) an arteriosclerotic origin.
At discharge mean NIHSS was 10 (overall) versus 11 (80+). While median
Modified Rankin Stroke Scale (mRS) at discharge was 4 in both groups, there was
a difference at three months: 2,7 (overall) versus 3,4 (80+). Accordingly, 25,6% of
all (14,7% of 80+) have reached Rankin 0/1, 36,6% of all (35,3% of 80+) have
reached Rankin 2/3.
Overall in-hospital mortality was 18,5%, in the group of 80+ 29%, but the inci-
dence of symptomatic intracerebral hemorrhage was only slightly different: 3,7%
vs. 5,3%.
Discussion: In good correlation with previous reports our data show a slightly
but not significantly higher incidence of symptomatic intracerebral hemorrhage in
elderly patients. In-hospital mortality is higher and the proportion of favourable
outcome lower than in younger patients. Nevertheless more than 20% of treated pa-
tients over 80 years reached Rankin 0-2 and about 50% Rankin 0-3. In our opinion
these data show the practicability of thrombolysis and support the effectiveness of
this therapy in selected patients over 80.
9 Acute stroke: treatment concepts
PREVIOUS TREATMENT WITH ANGIOTENSIN II RECEPTOR BLOCKERS
COULD PLAY A POSSIBLE PROTECTOR EFFECT IN ACUTE STROKE
M.A. Ortega-Casarrubios, B. Fuentes, B. San José, M.J. Aguilar-Amat, I. Ybot,
P. Martínez, E. Díez-Tejedor
Stroke Unit, Department of Neurology, La Paz University Hospital, UAM,
Madrid, Spain
Background: Previous studies with angiotensin II receptor blockers (ARB) have
demonstrated a protective effect in spontaneously hypertensive rats from cerebral
ischemia. It is not known if all the hypotensor drugs share this property. Our goal is
to analyse the impact of pre-stroke use of hypotensor drugs in stroke severity and
outcome.
Methods: Observational study from the Stroke Unit data bank of the Department
of Neurology, with inclusion of consecutive stroke patients (January 2000-October
2005). Parameters analysed: Risk factors, previous hypotensor drug treatment,
severity on admission(Canadian Stroke Scale, CSS),in-hospital complications,
mortality and functional state at discharge (Modified Rankin Scale, mRS)
Results: 1738 patients were included in the study, 55,9% were men. Average
age: 69,61 ±12 years. 63,3% had high blood pressure and 27,9% DM. 39,4%
received hypotensor drugs (90,2% of them for hypertension). Patients with ARB
presented lower stroke severity on admission (EC ≤ 16 vs 29,4%, p=0,011) and
better functional state at discharge (mRS ≤ 78 vs 63,6%, p=0,008) The multivariate
logistic analysis showed that ARB pre-treatment was a predictive factor of lower
stroke severity, independent of age, sex and stroke subtipe (OR 0,4; 95% IC 0,2-0,7)
Patients treated with diuretic drugs had higher severity on admission (EC ≤ 34,5
vs 27,3, p=0,023) and worse outcome (mRS ≤ 58,9 vs 65,8%, p= 0,044). Other
groups of hypotensor drugs did not show significant benefit on stroke severity.
Conclusions: Previous treatment with ARB was associated with a lower acute
stroke severity on admission and better evolution, being an independent predicitive
factor of lower stroke severity. More studies are needed to confirm this posible
protector role.
10 Acute stroke: treatment concepts
LACK OF KRINGLE 2 DOMAIN AND HIGH FIBRIN SPECIFICITY
DIFFERENTIATE THE NOVEL PLASMINOGEN ACTIVATOR
DESMOTEPLASE FROM RT-PA
D.B. Bharucha, M.K. Pugsley, K.-U. Petersen, M. Soehngen
Forest Laboratories/PAION Deutschland GmbH, Jersey City, NJ, USA
Background: Thrombolytic therapy with recombinant tissue plasminogen activator
(rt-PA) is effective in treating acute ischemic stroke (AIS) within the first 3 hours
after symptom onset. Desmoteplase, or rDSPAα1 (recombinant Desmodus Salivary
Plasminogen Activator α1), is a novel plasminogen activator (PA) shown to treat
AIS up to 9 hours post-stroke onset with a positive risk:benefit ratio (in a Phase
IIa study in patients with penumbra) not shown in previous trials with rt-PA when
treating patients beyond 3 hours. The observed clinical benefit of rDSPAα1 may
relate to its unique structural features.
Methods: Pharmacological and structural characteristics of desmoteplase are re-
ported using in vitro studies. Fibrin specificity was determined for desmoteplase
and rt-PA using an enzymatic assay for the kinetics of plasminogen activation.
Neurotoxicity was determined using ischemic murine models.
Results: rDSPAα1 is a glycosylated serine protease structurally similar to rt-PA
(with finger, epidermal growth factor-like, kringle 1, and serine protease domains),
Poster Session
Acute stroke: treatment concepts
but it lacks the plasmin-sensitive cleavage site and the lysine-binding kringle 2
domain found in rt-PA. The lack of the kringle 2 domain may explain the fact that
rDSPAα1 has the highest fibrin selectivity among PAs, with a 100,000-fold increase
in catalytic activity compared to a 550-fold increase for rt-PA and an absence of
neurotoxicity in animal models of ischemic and hemorrhagic stroke.
Discussion: The unique structural features of rDSPAα1 suggest an advantageous
risk:benefit ratio and may explain the observed favorable clinical results including
the potential for use in later time windows.
11 Acute stroke: treatment concepts
BRIDGING WITH GPIIB/IIIA-RECEPTOR-ANTAGONISTS COMBINDED
WITH INTRA-ARTERIAL PHARMACOMECHANICAL THROMBOLYSIS IN
ISCHEMIC STROKE
R. Dabitz, U. Leppmeier, L. Fuhry, V. Collado-Seidel, R. Michailow,
K. Schoeneboom, S. Triebe, H. Gunselmann, G. Ochs, D. Vorwerk
Klinikum Ingolstadt, Ingolstadt, Germany
Background: The prognosis of ischemic stroke due to occlusion of the internal
carotid artery, the middle cerebral artery in M1 and the basilar artery is even after
intravenous rt-PA usually very poor.
Patients: We report in a retrospective analysis about 76 consecutive patients (39m,
37f; age 64 ± 12.2 years), who were treated with GPIIb/IIIa-Rezeptor-Antagonists
combined with pharmacomechanical intra-arterial thrombolysis. 25 pat. with tan-
dem occlusion of the ICA and MCA, 26 pat. with occlusion of the MCA and 25
patients with basilar artery occlusion.
The mean NIH-Stroke-Scale was 16.4, analogical to a mean modified Rankin Scale
(mRS) of 4.7.
Materials: After exclusion of ICH 39 patients were bridged with Abciximab (due
to the Abestt trial) and in 37 cases with Tirofiban followed by an intra-arterial
thrombolysis with rt-PA.
Results: At the time of discharge the mean mRS was 2.8.
23 pat. mRS: 0-2 (=31%); 2 pat. mRS: 3 (=3%); 21 pat. mRS: 4 (=28%); 6 pat.
mRS: 5 (=8%).
At the time of re-evaluation after rehabilitation the mean mRS was 1,8.
32 pat. mRS: 0-2 (=42%); 13 pat. mRS: 3 (=17%); 5 pat. mRS: 4 (=7%), 2 pat
mRS: 5 (=3%).
24 of 76 (=32%) patients died nevertheless
23 pat. (=30%) showed ICH in the CT-scan, 10 (=13%) of them were symptomatic.
8 of these 10 patients showed already malignant infarction at the time of bleeding
due to unsuccessful rekanalisation. One patient died due to perforation of the
basilar artery.
Conclusion: Bridging with GPIIb/IIIa-Rezeptor-Antagonists combined with intra-
arterial pharmakomechanical thrombolysis is feasible and may help to reduce the
lethality and morbidity of ischemic stroke due to occlusions of the ICA, MCA and
BA. The rate of complications and intracranial haemorrhage is in the range of those
reported in other cohorts
12 Acute stroke: treatment concepts
WHY ARE EARLY ADMITTED STROKE PATIENTS EXCLUDED FROM TPA
THERAPY?
S. Debiais, I. Bonnaud, B. Giraudeau, D. Saudeau, D. Perrotin, B. de Toffol,
A. Autret
CHRU Tours, Tours, France
Introduction: Our University hospital (300 000 inhabitants) receives patients who
may benefit from IV thrombolysis from the whole region. Since June 2003, an
acute stroke network comprising 2 beds of admission and thrombolysis was created
in the intensive care unit.
Objective: To assess conditions of treatment with IV thrombolysis and to determine
why stroke patients admitted within 3 hours of symptoms onset (SO) are not treated
with IV TPA.
Methods: During 18 months were prospectively recorded the following data for
each patient: demographic data, delays of arrival and imaging, treatment and
outcome. For the patient arrived in the first 3 hours, the reason why IV TPA was
not administered was noticed.
Results: During 18 months, 364 patients were admitted, with a median delay of
admission after SO of 2 h 50. Two hundred patients were admitted within three
hours and among them, 17 (8,5%) patients received IV TPA. Among the patients
admitted in the first 150 minutes, the main reasons for exclusion were: mild stroke
or clinical improvement (NIHSS < 6) for 48 patients, a non vascular diagnosis in
41 patients, aged older than 80 yo for 22, intracerebral hematoma for 17, NIHSS >
23 for 13. For 13 patients the only cause was network internal dysfunction.
Cerebrovasc Dis 2007;23(suppl 2):1–147 107
Discussion: In our institution, 18% of ischemic stroke patients are treated with IV
TPA. For the early admitted patients, main reasons of therapy exclusion are non
vascular diagnosis, mild stroke with NIHSS< 6, and age > 80 yo, as found in
previous studies (Barber 2001; Huang 2006). Improvement of the pre-admission
selection, decrease of the delays of arrival and correction of the network dys-
functions could increase dramatically the proportion of treated patients. Moreover,
some patients with mild or improving deficits could also benefit from thrombolytic
treatment.
13 Acute stroke: treatment concepts
NOVEL APPROACH IN ACUTE STROKE MANAGEMENT THROUGH
L-LYSINE MONOHYDROCHLORIDE INDUCED ANGIOGENSIS AND
REVASCULARIZATION
S.C. Mukhopadhyay, G. Guha, M. Alam, A. Mukherjee, M. Hashini
Green Cross Therapeutics Pvt. Ltd., India
Background: The efficacy and safety of L-Lysine Monohydrochloride (LMH) as
angiogenic agent was studied in acute ischaemic stroke management.
Material and methods: 120 patients (mean age 61.3 yrs) with CT/MRI evidence
of ischaemic stroke was studied. 80 received LMH,1gm I.V. 6 hrly x 7 days, 40
did not receive LMH. Both LMH and non- LMH grs. did not receive thrombolytic
therapy but had routine stroke management. Modified NIHSS,MRS and BI were
used to assess clinical outcome, at baseline, 1 wk, 6wk, 3 mths and 6 mths. Basic
haematological biochemical and urine analyses were done at baseline, 1 wk, 1 mth.
MRI was done on a 1.5T whole body imager for T1 and T2 weighted, FLAIR,
DWI, Angiography imaging sequences at baseline, 7th day and 6 wks. Adverse
events noted.
Result: Patient Inclusion time for therapy varied between 6-98 hrs. There was no
mortality or significant change in biochemical, hematological and urine analyses at
any stage of therapy. Mean baseline Glasgow Coma Scale Score was 13.9. Imaging
revealed acute infarct in anterior, middle and posterior cerebral artery territory, but
most in MCA area (68.75%). Clinical outcome by NIHSS in LMH gr. revealed
15.05 ±3.52 at baseline, 7.95 ± 2.31 at 1 wk, 4.14 ±1.16 at 6 wks., 1.81 ± 0.88 at
6 months, vs. to 15.17 ± 3.50 (baseline)12.17 ± 2.92 (1wk), 8.61 ±1.85 (6wks),
4.33 ± 0.84 (6months) in non LMH gr. with P Value 0.08(1wk), 0.02 (6 wk), 0.01
(6 months). Decrease in NIHSS become more pronounced as time progresses in
LMH gr. Parallel improvements were seen in B.I at 90 days (≥95) and MRS (≤1).
Infarct area in DWI/T2 imaging at 7th day showed remarkable improvement in
LMH gr. compared to non- LMH gr.
Discussion and conclusion: LMH significantly increases both short term and long
term clinical, functional and imaging recovery and was due to revascularization
through angiogensis.Both anterior and posterior circulation improved equally. LMH
can be given with much wider therapeutic window (upto 96 hrs) and has no adverse
effect.
14 Acute stroke: treatment concepts
COMPARISON OF INTRA-ARTERIAL AND INTRAVENOUS
THROMBOLYSIS FOR ISCHEMIC STROKE WITH HYPERDENSE MIDDLE
CEREBRAL ARTERY SIGN
H.P. Mattle, M. Arnold, D. Georgiadis, C. Baumann, K. Nedeltchev,
D. Benninger, L. Remonda, C. von Büdingen, G. Schroth, R.W. Baumgartner
University Hospitals Bern and Zurich, Bern, Switzerland
Background: It is unclear whether intra-arterial (IAT) or intravenous (IVT) throm-
bolysis is more effective for ischemic stroke with hyperdense middle cerebral
artery sign (HMCAS). The aim of this study was to compare IAT and IVT in such
patients.
Methods: Comparison of data from two stroke units with similar management of
stroke associated with HMCAS, except that one unit performed IAT with urokinase
and the other IVT with plasminogen activator. Time to treatment was up to 6 hours
for IAT and up to 3 hours for IVT. Outcome was measured by mortality and the
modified Rankin Scale (mRS), dichotomized at three months into favorable (mRS
0-2) and unfavorable (mRS 3-6).
Results: 112 patients exhibited a HMCAS, 55 of 268 patients treated with IAT and
57 of 249 patients who underwent IVT. Stroke severity at baseline and patient age
were similar in both groups. Mean time to treatment was longer in the IAT group
(244 ± 63 minutes) than in the IVT group (156 ± 21 minutes; p=0.0001). However,
favorable outcome was more frequent after IAT (n=29, 53%) than after IVT (n=13,
23%; p=0.001) and mortality was lower after IAT (n=4, 7%) than after IVT (n=13,
23%; p=0.022). After multiple regression analysis IAT was associated with a more
favorable outcome than IVT (p=0.003) but similar mortality (p=0.192).
Conclusion: Intra-arterial thrombolysis was more beneficial than IVT in stroke
108 Cerebrovasc Dis 2007;23(suppl 2):1–147
associated with HMCAS, even though IAT was started later. Our results indicate
that a randomized trial comparing both thrombolytic treatments in patients with
middle cerebral artery occlusion is warranted.
15 Acute stroke: treatment concepts
IS INTRAVENOUS TPA TREATMENT BENEFICIAL IN ACUTE ISCHEMIC
STROKE RELATED TO INTERNAL CAROTID DISSECTION?
B. Fuentes, M. Alonso de Leciñana, J. Masjuán, J. Egido, P. Simal,
F. Díaz-Otero, A. Gil-Nuñez, E. Díez Tejedor
University Hospitals La Paz, Ramón y Cajal, Clínico San Carlos and Gregorio
Marañón, Madrid, Spain
Background: Small series reported the safety of intravenous tPA treatment in
acute ischemic stroke (IS) related to extracranial internal carotid artery dissec-
tion (eICAD). However, no studies analysing specifically the posible benefits on
outcome are available.
Methods: Multicentre, prospective study conducted in 4 university hospitals. Con-
secutive IS patients were included. Stroke severity (NIHSS) and 3-months outcome
(mRS) were compared: (1) tPA-treated patients with IS related to eICAD vs
tPA-treated patients with other causes of stroke; (2) tPA-treated vs non tPA-treated
eICAD patients.
Results: 265 IS patients received intravenous tPA (7 of them with eICAD). There
were no diferences in baseline NIHSS between patients with or without eICAD
(14.3 vs 14.3; ns). However, NIHSS scores at 24 h and day 7 were significantly
worse in eICAD patients (17 vs 9.6 at 24h; 15.6 vs 7.3; p<0,05). No eICAD
patients developed a significant improvement at 24h (decrease in NIHSS ≥ 8
points) as compared to 67 (32%) of patients with other IS causes. When comparing
tPA-treated eICAD (n=7) with non-treated eICAD patients (n=7), a trend to higher
improvement in 24h and day 7 was found in the non tPA-treated eICAD group
(NIHSS 7.6 vs 17 at 24h; 6.4 vs 15.6;p=0.205) with no differences in baseline
NIHSS. At 3 months, 80% of tPA-treated eICAD and 20% of non-treated eICAD
patients were dependent (mRS>2).
Conclusions: Although intravenous tPA treatment in IS related to eICAD seems to
be safe, the benefit on outcome is significantly minor than in other causes of IS,
and possibly worse than in non tPA-treated eICAD.
16 Acute stroke: treatment concepts
AN EMERGENCY CLINICAL PATHWAY FOR THE MANAGEMENT OF
CRITICAL STROKE PATIENTS: RESULTS OF A RANDOMISED CLINICAL
TRIAL IN THE LAZIO REGION (ITALY)
A. De Luca, D. Toni, L. Lauria, M.L. Sacchetti, M. Barbolini, E. Puca, M. Ferri,
M. Prencipe, G. Guasticchi
Public Health Agency, Lazio Region, Rome, Italy
Background: Emergency Clinical Pathways (ECP) may play a crucial rule in the
management of critical stroke patients. Objects To evaluate the effectiveness of
introducing an ECP for the management of critical stroke patients in the emergency
system of Lazio region (Italy).
Methods: A cluster-randomized controlled trial (ISRCTN41456865) was designed
to compare the practice of a test group of health professionals (HP) pertaining to
Emergency Medical Services (EMS) and to Emergency Rooms (ERs), trained to
use the ECP, with that of non trained EMS and ERs control groups. Groups were
compared by chi2 or Fisher’s exact tests.
Results: the two groups were similar at baseline as type and number of EMS
ambulances and ERs. Over six months in 2005, 3298 suspected stroke patients
were enrolled (1353 in the test groups: 573 by EMS and 780 by ERs; 1945 in
the control groups: 485 by EMS and 1460 by ERs). Both the test groups referred
to our hospital more suspected stroke patients than the control groups: EMS:219
(38.2%) vs 8 (1.6%) (p<0.05); ERs: 147 (18.8%) vs 116 (7.9%) (p<0.05).
Confirmed ischemic stroke were (test groups: EMS =70, Ers=26; control groups:
EMS=4, ERs=13). Among ischemic stroke patients eligible for i.v. thrombolysis
(test groups: EMS=19, ERs=17; control groups: EMS=2, Ers=10), those referred
by the test groups were treated more frequently than those of the control groups
(EMS: 8 (42%) vs 0 (p>0.05); ERs:7 (41%) vs 2 (20%) (p>0.05).
Discussion: Adherence to the ECP improved the appropriateness of stroke patient
referral and treatment in the SU, particularly by the EMS. Hence, the educational
program on early detection and timely transportation of stroke patients to the
appropriate ward will be extended to all emergency health personnel.
16th European Stroke Conference
 17 Acute stroke: treatment concepts
REMOTE CEREBRAL HEMORRHAGE IN PATIENTS TREATED WITH
INTRAVENOUS RT-PA
J. Martí-Fàbregas, E. Martínez, M. Marquié, D. Alcolea, D. Cocho,
M. Martínez-Corral, S. Martínez-Ramírez, M. De Juan, R. Marín,
J.-L. Martí-Vilalta
Hospital de la Santa Creu i Sant Pau, Spain
Background:The frequency, clinical presentation and prognosis of remote cerebral
hemorrhage (rPH) after thrombolysis is poorly known. We report our experience in
patients with ischemic stroke treated with intravenous rt-PA.
Methods: A retrospective review of consecutive patients treated at our Hospital
from 1999 to 2006, according to the ECASS II and the SITS-MOST (since 2004)
criteria. A control Computed Tomography scan was routinely obtained in all
patients within the first 36 hours of treatment. Cerebral hemorrhagic complications
were classified according to the ECASS study in hemorrhagic infarction (HI-1
and HI-2) and parenchymal hematoma (PH-1 and PH-2). rPH was defined as
any extraischemic hemorrhagic lesion observed in the control CT. Neurologic
worsening was defined as an increase in more than 3 points on the NIHSS score. A
favourable outcome was defined as a score <2 on the Rankin scale.
Results: We studied 163 patients (mean age 67.6 ± 11.8 years, 57% of them were
men). The frequency of hemorrhagic complications was: HI-1 (2.4%), HI-2 (4.9%),
PH-1 (3.6%), PH-2 (2.4%), rPH (2.4%), rPH+PH-2 (0.6%). Patients with rPH
(n=5) had a mean age of 70.4 ± 8.1 and 40% were men. The median NIHSS score
was 15 and mean time to treatment was 134 ± 47.6 minutes. rPH were multifocal
in 2, single in 2, and associated with a PH-2 in one patient. The location of rPH
was lobar in 4 patients and in brainstem in one patient. rPH were symptomatic in
4 patients and asymptomatic in one. The neurologic worsening occurred 8, 14, 17
and 30 hours after rt-PA. The outcome was unfavourable in all patients, with 3
deaths.
Discussion: Remote parenchymal hemorrhage is an uncommon complication after
rt-PA (3%). It is usually lobar and symptomatic and has an unfavourable outcome.
18 Acute stroke: treatment concepts
A RETROSPECTIVE CLINICAL CASE-NOTE STUDY OF THE NUTRITIONAL
MANAGEMENT PRACTICES OF STROKE PATIENTS IN A SCOTTISH
POPULATION
S. Ray, B. Al Falasi, P. Rana, M.A. Haleem, M. Rajput, S. Atkinson
University of Dundee, Dundee, United Kingdom
A Retrospective Clinical Case-note Study of the Nutritional Management Practices
of Stroke Patients in a Scottish Population
Background: Stroke is a leading cause of death and adult disability. Feeding in
stroke remains important as a number of stroke patients are undernourished on
admission and nutritional status declines during hospital stay, with increased mor-
bidity and mortality. The “Scottish Intercollegiate Guidelines Network”, “Quality
Improvement Scotland” and “Council of Europe” provide guidance for nutritional
management of patients with dysphagia. This study aimed to assess the impact of
guidelines on the nutritional management of stroke patients.
Methods: Retrospective case note analysis was done for ischemic strokes admitted
to Ninewells Hospital, Dundee. This audit-type study looked at a 3-month period
prior to the establishment of guidelines and compared with 3 months post guideline.
Results: There were 126 and 204 suspected cases of stroke in Periods 1 and 2
respectively. The corresponding number of CT diagnosed strokes was 78 and 107
respectively. Out of these, 33 records were retrieved for patients in Period 1 and 43
in Period 2. The weight recording rates were 27% in Period 1 vs. 35% in Period 2.
One- fifth of those weighed were monitored in Period 1 compared to one-third in
Period 2.
Discussion: There appear to be specific barriers to the implementation of guidelines
in daily practice. A continuing clinical nutrition education programme as an adjunct
to guidelines for stroke carers may help to overcome these limitations.
19 Acute stroke: treatment concepts
IS REMOTE TELE RT-PA TREATMENT SAFE? THE EXPERIENCE OF THE
EMERGENCY NEUROLOGY NETWORK IN FRANCHE-COMTE (RUN)
E. Vidry, E. Medeiros, E. Revenco, F. Vuillier, P. Decavel, T. Moulin
University Hospital Besançon, Besançon, France
Background: The only validated treatment for acute ischemic stroke is thromboly-
sis with intravenous alteplase (rt-PA) performed in a stroke unit (SU). Its efficiency
is strongly time-dependent. Our aim was to evaluate the efficiency and safety of
Poster Session
Acute stroke: treatment concepts
rt-PA administered in distant hospitals using telemedicine tools imlemented in the
RUN, compared to that of patients treated directly in the Besançon SU.
Method: All patients admitted to the SU who were treated with rt-PA for ischemic
stroke since 2005 were included. Patients were either treated in the SU after
admission or were transferred to the SU after receiving rt-PA in a distant hospital.
The decision to administer rt-PA in distant hospitals was made by the SU neurology
team using “tele rt-PA” with telemedicine tools (video/imaging transfers). The
thrombolysis decision respected contra-indication and followed the usual criteria
for patients admitted within 3 hours or was guided by MRI findings (after 3
hours). NIHSS scores were measured on admission, modified Rankin scores (mRS)
were determined after treatment and at discharge as well as stroke causes and
haemorrhagic transformations (HT).
Results: Of 34 patients treated by rt-PA, 16 were in distant hospitals and 18 in
the SU. Median treatment times were 3hrs in the SU (4hrs25 for those transferred
there) and 2hrs30 in distant hospitals. Following rt-PA, 7/34 (20%) of patients
developed HT, which was symptomatic in only 3 (8.8%), 1/3 of whom were treated
in distant hospitals. mRS distribution was not statistically different between the
2 patient groups: mRS 0-1 in 6/34 (18%), of which 4/6 (66%) were in a distant
hospital, mRS (2-3) in 9/34 (26%), of which 4/9 (44%) were in a distant hospital,
mRS (4-5) in 16/34 (47%) of which 8/16 (50%) were in a distant hospital, and 3/34
(8%) of patients died, all of whom were treated in the SU.
Discussion: No significant difference was found concerning outcome or haemor-
rhagic complications between patients treated in the SU and distant hospitals. The
study shows that “tele rt-PA” is safe and can improve patient outcome.
20 Acute stroke: treatment concepts
DIURNAL FLUCTUATIONS IN THE EFFICACY OF RT-PA IN ACUTE
ISCHEMIC STROKE
J. Gracia, S. Martinez-Ramirez, A. Ayo, D. Cocho, J. Martí-Fabregas, T. Segura
Department of Neurology, University Hospital of Albacete, Albacete, Spain
Background: several studies have demonstrated that a circadian pattern of efficacy
exists in myocardial acute infarction, with a greater efficacy in the evening. This
fact has been explained for the presence of different levels of plasminogen-activator
inhibitors and probably other haemostatic factors. There are not published data
communicating this fact in intravenous thrombolytic therapy in stroke patients
Objetives: to investigate possible diurnal fluctuations in the efficacy of intravenous
thrombolysis in ischemic stroke patients
Methods: one hundred forty-eight patients with acute stroke treated with intra-
venous rt-PA were prospective enrolled in this study, conducted in two different
hospitals between January 05 and May 06. Efficacy of thrombolysis was deter-
mined according to accepted clinical criteria: neurological response was assessed
by NIHSS scale performed at 2 and 24 h after therapy, and long term functional
outcome was evaluated by modified Rankin scale at three months. We compared
the results dividing patients into 2 different groups, day (08-20 h.) and evening
(20-08am) and again dividing into 4 intervals of 6 hours: 0-06am, 06-noon, noon-06
pm and 06-00.
Results: The study population consists of 85 males and 63 females, age range 24-82
years (mean 68.47, SD 11.2). There were no demographic or clinical differences
between the two cohorts from the different hospitals (74 patients every one) or
among the pre-specified groups of time of thrombolysis. In the whole group,
median NIHSS before treatment was 16 and median NIHSS at 2 h and 24 h were
11 and 9 respectively. There was no significant relationship between the clinical or
functional result of thrombolysis and the time of the treatment.
Conclusions: Our results do not support the hypothesis that exist circadian
variations in the response to thrombolytic therapy in ischemic stroke.
21 Acute stroke: treatment concepts
NO PREVIOUS EXPERIENCE WITH INTRAVENOUS THROMBOLYSIS FOR
ACUTE ISCHAEMIC STROKE DOES NOT INFLUENCE THE PROPORTION
OF PATIENTS TREATED
A. Kobayashi, M. Skowronska, T. Litwin, A. Czlonkowska
Institute of Psychiatry and Neurology, Medical University of Warsaw, Warsaw,
Poland
To determine the eligibility of ischaemic stroke patients admitted to the 2nd De-
partment of Neurology for intravenous thrombolysis, identify the major exclusions
and assess if changes of the in-hospital pathway and informative campaign in the
local community and medical services can increase the number treated. To establish
if lack of previous experience with thrombolytic treatment or trials is predictive of
a low proportion of patients treated.
A survey of the database of stroke patients admitted during the first 30 months
Cerebrovasc Dis 2007;23(suppl 2):1–147 109
following introduction of intravenous thrombolysis for acute ischaemic stroke in
order to identify eligible patients. This included patients admitted within 2 hours
of symptom onset (assuming a 1-hour door-to-needle time), age < 80 years,
National Institute of Health Stroke Scale (NIHSS) score from 5 to 22, seizures
at onset, platelet count >100,000 per ml, glycaemia from 50 to 400 mg per dl
and international normalized ratio (INR) <1.6. We have compared the number of
patients eligible with the number treated.
745 patients with acute ischaemic stroke were admitted. 18.4% were admitted
within 2 hours of onset, 71.0% were aged under 80, 55.4% had an NIHSS score
between 5 and 22. 96.1% had INR < 1.6, 98.9% had a platelet count higher than
100,000 per ml, 99.4 had blood glucose between 50 to 400 mg per dl and 97.4%
had no seizures at onset. After adjusting for all inclusion criteria 7.1% of patients
were found potentially eligible and 8.7% were actually treated (p=0.250). Out of
the 65 treated patients 63.1% were independent after 3 months, 16.9% had died
and none had a symptomatic intracranial haemorrhage.
The proportion of ischaemic stroke patients treated with intravenous thrombolysis
in a previously inexperienced centre is not lower than in other centres and countries
were this treatment is provided for a longer period of time. The number of patients
treated is higher than estimated mainly due to organizational changes introduced in
our centre.
22 Acute stroke: treatment concepts
NEUROPROTECTIVE EFFECT OF XG-102 ALONE OR IN COMBINATION
WITH TISSUE PLASMINOGEN ACTIVATOR
K. Wiegler, C. Bonny, D. Coquoz, L. Hirt
Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
Background: XG-102 (formerly D-JNKI1), a TAT-coupled dextrogyre peptide
which inhibits the c-jun N-terminal kinase (JNK), is a powerful neuroprotective
drug in rodent models of cerebral ischemia (Borsello et al., Nat Med, 2003; Hirt et
al., Stroke, 2004) when administered by intra-cerebro-ventricular injection (i.c.v.).
We studied the feasibility of systemic administration. We also evaluated in vitro
the effect of combined administration of XG-102 and tissue plasminogen activator
(TPA), known to exacerbate excitotoxicity.
Methods: Young adult male ICR-CD1 mice were subjected to 30 min transient
suture MCAo. XG-102 was administered intravenously (i.v.) 6 or 9 hours after
ischemia. Neurological outcome was evaluated by neurological scores and rotarod
tests. Rat organotypic hippocampal slice cultures subjected to oxygen (5%) and
glucose deprivation (OGD) for 30 minutes.
Results: XG-102 administered i.v. 6 hours after ischemia onset significantly
reduced the infarct volume at 48 hours. The lowest dose with maximal neuroprotec-
tion, was 0.3 μg/kg, which reduced the infarct volume from 62±19mm3 (n=18) for
the vehicle-treated group to 18±9mm3 (P<0.001, n=5). Administration of XG-102
(1mg/kg) 9 hours after MCAo did not significantly reduce the infarct volume. The
behavioural outcome after transient MCAo was also considerably improved. In
organotypic slices, TPA alone (0.9 μg/ml) administered immediately after OGD,
increased cell death. XG-102 (12 nM), 6 hours after OGD onset, induced a strong
reduction (P<0.001) of cell death compared in the presence of TPA (49±19%,
n=20 vs 12±14%, n=24).
Conclusion: XG-102 is a powerful neuroprotectant in our mouse stroke model,
and can be administered i.v. up to 6 hours after MCAo. In vitro XG-102 can induce
neuroprotection also in presence of TPA.
Funding: CTI #7057.2
23 Acute stroke: treatment concepts
EFFECTS OF ASPIRIN PLUS CILOSTAZOL TO REDUCE THE PLATELET
ACTIVATION IN ACUTE ISCHEMIC STROKE
J.-K. Cha, S.S. Kim, H.W. Jeon, Jk Cha
College of Medicine, Dong-A University Hospital, Busan, South Korea
Background: Aspirin has been still considered to be the most evidenced therapeutic
regimen to prevent the recurrence of ischemic events in acute ischemic stroke.
Recently, Cilostazol, a Phosphodiesterase III inhibitor, has been known as useful
antiplatelet agents to curb the progression of atherosclerotic ischemic stroke. In this
study, we investigated the usefulness of cilostazol on the top of aspirin to regulate
the expression of P-selectin and PAC-1 on activated platelet in acute ischemic stroke.
Methods: We analyzed seventy-seven patients with acute ischemic stroke (<72
hrs). Among them, 50 patients were prescribed aspirin 100 mg per day and another
27 aspirin 100 mg plus cilostazol 200 mg per day. All patients were serially
valuated the expression P-selectin and PAC-1 on activated platelets at admission
day and 5 days later. We also serially measured clinical progression by using NIH
stroke scale at same time period.
110 Cerebrovasc Dis 2007;23(suppl 2):1–147
Results: After 5 days of using aspirin plus cilostazol, the extent of PAC-1 (58.5
± 19.2%, P<0.005) on activated platelet was significantly reduced compared with
the baseline (71.0 ± 12.1%). But there was no any difference (34.1 ± 13.3 vs 30.9
± 10.5%) in aspirin only. In case of P-selectin, both aspirin and cilostazol group
showed any differences of their expressions after 5 days of initiating treatment.
Compared clinical progression between two groups, there were no any significant
changes of NIHSS in the observation period.
Conclusions: In this study, we showed that the combined regimen of aspirin and
cilostazol had beneficial effect to reduced PAC-1 activity on activated platelets
in acute ischemic stroke. However, this regimen did not showed better clinical
outcome than aspirin only. Therefore, we need the more detailed future study about
the clinical benefit of cilostazol in acute ischemic stroke.
24 Acute stroke: treatment concepts
CARDIO-PROTECTION IN ACUTE STROKE: HYPOTHESIS FOR
INTERVENTION FOR MORTALITY REDUCTION
J.C. Sharma, I.N. Ross, M. Vassallo
Kings Mill Hospital, United Kingdom
Background: Measures of damage limitation for acute stroke have not produced
substantial benefit to reduce stroke mortality. Search continues for measures to
reduce stroke mortality.
Methods: Literature review for influence of cardiovascular factors, specifically the
value of NT proBNP (a sensitive index of cardiac impairment) for stroke mortality,
Results: Cardiovascular factors, in particular cardiac failure, adversely influence
acute stroke mortality. Recent studies reveal that Troponin and NT-proBNP are
elevated in acute stroke patients, in response to the activated Renin-Angiotensin-
Aldosterone-System and other neurohumoral changes, as a protective mechanism
for sympatho-inhibitory activity. Elevated NT-proBNP has been reported to be
associated with higher short and long term mortality. In one study all patients
who died at 4 months had NT-proBNP levels above the median, no patient with
NT-proBNP below the median value died. Two studies revealed that NT-proBNP is
more significant than clinical stroke severity for stroke mortality. Raised Troponin
indicates myocardial injury, raised NT-proBNP indicates occult cardiac impairment
in acute stroke patients. Protection of myocardium in stroke patients may be
possible by the use of drugs such as beta-blockers and the drugs acting on RAAS.
Reduction of mortality in studies of candesartan (ACCESS) and prior betablockers
is one such example.
Conclusion: Some stroke patients die due to occult cardiac impairment in acute
phase due to common risk factors. This relationship between brain and heart needs
evaluation. Protection of heart with currently available or new drugs in acute strokes
is worth investigating since this intervention could be applied to a large proportion
of acute stroke patients over a wide time window.
25 Acute stroke: treatment concepts
A NEW DEVICE FOR THE TREATMENT OF THROMBO-EMBOLIC
STROKES
G. Pearce, N.D. Perkinson, J.H. Patrick
ORLAU, RJAH Hospital Oswestry, United Kingdom
Each year in the UK 130,000 strokes occur (Arnold 2006), and it remains a heavy
burden on hospital and social service provision. We have invented a clot extraction
device for use in the acute situation-to reduce the continuing neuronal cell death in
the penumbral area, (the “GP” Clot Removal Device). This device was invented by
Pearce and Perkinson (2005) has recently been published as a international patent
(W0206120464). The unique interior surface of this device facilitates controlled
removal of blood clots in arteries that block during thrombo-embolic strokes. Our
device has an inner surface that generates a helical vortex which actually removes
the clot. It has advantages are (i) it has no moving parts and (ii) it does not make
intimate contact with the blood clot or arterial wall. Complications should be lower.
In-vitro experimental results (Pearce et al 2006a, 2006b, 2006c, 2006d, 2007) show
differences between fluid flow patterns when fluid is sucked through the device
(mounted within the catheter) compared to fluid sucking through a simple catheter.
We have also established that the device removes clots quicker and with less
volume of blood being removed, than with simple catheter being use. Methylene
blue dye has been used to effectively demonstrate the mechanism of the device.
Pearce and Perkinson, 2007 have also undertaken radial flow rates within the “GP”
clot removal device.
We have used both artificial clots and actual blood clots (abattoir sourced) to
show clot removal in plastic tubes and porcine abattoir arteries. At vacuum suction
pressures of 66 KPa, when using the “GP” clot removal device (of internal diameter
2.5 mm) occlusive clots of about 1cm long are removed.
16th European Stroke Conference
 26 Acute stroke: treatment concepts
RAPID ALTERNATE DAY DOSE TITRATION OF DIPYRIDAMOLE IS WELL
TOLERATED IN PATIENTS WITH ISCHEMIC STROKE
J.L. Pascual, H.M. Chang, M.C. Wong, C.P. Chen
National Neuroscience Institute, Singapore General Hospital Campus,
Singapore, Singapore
Background: The combination of aspirin (ASA) and dipyridamole (DIP) has been
shown to be efficacious in the secondary prevention of acute ischemic stroke
of arterial origin. However, DIP-induced headache is common and may affect
compliance. We aimed to determine the feasibility and tolerability of rapid dose
titration of DIP in Singaporean acute ischemic stroke patients.
Method: Observational study of non-aphasic ischemic stroke patients requiring
anti-thrombotic therapy and without hypersensitivity or contraindication to DIP.
Patients were allocated to either open label DIP starting at 25mg tds followed
by75mg tds and finally 150mg tds in either every other day(EOD) or week (EOW)
titration regimes at the choice of the attending physician. Follow-up was at 1 month
and occurrence of headache or other adverse effects, as well as any reason for
stopping the drug were documented.
Results: 188 acute ischemic stroke patients were started on ASA + DIP over
a 6-month period. There were 113 patients on EOD and 75 on EOW titration
schemes. No significant differences in baseline characteristics between treatment
groups were seen. The EOW regimen was associated with more adverse events
(22% vs. 9%, p < 0.05), predominantly headaches (72%), leading to more drug
discontinuations(12% vs 5%, p < 0.05). The majority of headaches in the EOD
group (70%) occurred at 25 mg tds, while in the EOW group, patients had
headache at 75mg tds or higher (88%). Discontinuation rates were similar for both
groups(13% vs 9%, p = 0.19).
Discussions: Rapid titration of DIP is well tolerated. These findings need further
confirmation with randomized trials but may form the basis of a treatment regime
to be considered in acute stroke trials.
27 Acute stroke: treatment concepts
COMBINED IV ABCIXIMAB/IA TPA TREATMENT OF ACUTE BASILAR
ARTERY OCCLUSION
U. Becker, G. Urban, R. von Kummer, G. Gahn
University Hospital Dresden, Dresden, Germany
Background: Acute basilar artery occlusion (ABAO) is a disease with high
mortality and morbidity. The optimal therapeutic approach remains still unclear.
We intended to analyze the rate of recanalization, complications and outcome in
patients with combined IV Abciximab/IA tPA treatment.
Methods: Following a prospective protocol, patients, with ABAO received an IV
bolus of Abciximab (0,25 mg/kg bodyweight), followed by a 12 hours infusion of
Abciximab (0,125 mg/kg bodyweight). Immediately after the bolus, we performed
DSA and administered tPA locally (up to 40 mg or until recanalization was
achieved). We investigated the rate of recanalization, complications and the clinical
course by standardized telephone interview after 6 months. Good outcome was
defined as a mRS < 3.
Results: Since 2003, we included 16 patients with ABAO, mean age was 60.9
years, 5 female, 11 male. Mean GCS ad admission was 9.4 (4-15), mean time
window 8.2 hours (3-25).
Recanalization was achieved in 13 patients (87%), symptomatic hemorrhage oc-
curred in 2 patiens (12%). Survival after 6 months was achieved in 7 out of 16
patients (44%), 3 of them had a good outcome (19%).
Discussion: Regarding survival and good outcome we observed similar results
compared to other treatment regimes, however, the rate of recanalization was higher.
We are encouraged to treat more patients with the combination of Abciximab and
tPa to find out whether morbidity can be reduced.
28 Acute stroke: treatment concepts
DYNAMICS OF MARKERS OF FIBRINOLYSIS AND ENDOTHELIAL
FUNCTION IN PATIENTS WITH ISCHEMIC STROKE TREATED WITH
INTRAVENOUS RT-PA
N.A. Shamalov, A.S. Kireev, N.A. Pryanikova, G.R. Ramazanov,
A.G. Kobylyansky, I.A. Grivennikov, V.I. Skvortsova
Federal Stroke Institute, Moscow, Russian Federation
Background: The aim of this study was to assess the dynamics of the markers of
fibrinolysis and endothelial function in patients with ischemic stroke (IS) treated
with intravenous (IV) rt-PA.
Poster Session
Acute stroke: treatment concepts
Methods: We prospectively included 14 patients treated with IV rt-PA within
3 hours after stroke onset (mean age 62.9±12.2 years, 10 (71%) male, mean
NIHSS score at admission was 12±5.8). A blood sample were obtained before
and immediately after thrombolysis, in 24 hours, in 3 and 7 days after IS onset
to measure markers of fibrinolysis [Plasminogen Activator Inhibitor-1 – PAI-1
(IU/ml), normal value 1-7] and endothelial function [Matrix Metalloproteinase-9 –
MMP-9 (ng/ml), normal value 169-705].
Results: Before thrombolysis increased plasma level of PAI-1 (14.1±17.9) and
decreased level of MMP-9 (102.9±106.8) was observed. After thrombolysis we
revealed the tendency towards decreasing PAI-1 (6.8±11.2) and increasing MMP-9
(136±166.1). In 24 hours, 3 and 7 days after IS onset level of PAI-1 insignificantly
increased (7.2±5.1; 10.3±18.1 and 10.6±11.6 respectively) and MMP-9 level
decreased (67.9±98.7; 35.1±7.5 and 54.3±26.6 respectively).
Conclusion: IV rt-PA therapy in stroke patients may reduce the activity antifibri-
nolytic system and cause short-term increase MMP-9 level.
29 Acute stroke: treatment concepts
ANCROD IN A SIX HOUR TIME WINDOW? EVIDENCE FOR AND AGAINST
EFFICACY
D.G. Sherman, D.E. Levy
University of Texas Health Science Center at San Antonio, San Antonio, TX,
USA
The publication in Lancet (2006;368:1871-78) of the unsuccessful European ancrod
trial (ESTAT), where the treatment began up to 6 hours after stroke onset, concluded
that compared with the positive results of STAT (JAMA 2000;283:2395-2403) with
its 3-hour window, ESTAT’s results suggested that ancrod was ineffective if started
later 3 hours. Although not published, ancrod’s efficacy was marginally better than
placebo’s at 3-6 hours (43.2% vs. 42.3%) but was substantially worse at 0-3 hours
(33.3% vs. 43.3%), inconsistent with attributing ESTAT’s poor results to its later
time window.
Pooled analysis of the North American data from STAT and an earlier 6-hour study
(Stroke 2004:25:291-97) shows that efficacy vs. placebo is virtually identical in 0-3
hour (43.0% ancrod vs. 36.1% placebo) and 3-6 hour patients (43.4% vs. 34.1%)
with no significant interaction of time-to-treat on ancrod response (p=0.69).
Therefore, explanations other than enrollment beyond 3 hours must underlie the
unfavorable ESTAT results. These include the fact that higher blood pressures
were permitted in ESTAT (up to 220/120) than STAT (185/105). Symptomatic
intracranial hemorrhages occurred in 10.1% of ESTAT patients with systolic BPs
of 185-220 vs. 6.9% of those with lower pressures. The ESTAT publication states
that deaths rarely occurred in patients with symptomatic ICH (4/44 ancrod vs. 2/9
placebo), but the actual data for 90-day mortality are 26/44 ancrod and 4/9 placebo.
Other explanations for the unsuccessful ESTAT results include age imbalance (69.3
ancrod vs. 67.6 placebo, p<0.03) and a 23% higher mean patient ancrod dose in
ESTAT than STAT.
The final answer on ancrod’s efficacy beyond 3 hours awaits conclusion of the two
currently-enrolling trials with 6-hour windows.
30 Acute stroke: treatment concepts
PERFUSION-CT GUIDED INTRAVENOUS THROMBOLYSIS AT 3 TO 6
HOURS: FEASIBILITY AND SAFETY STUDY IN 15 PATIENTS
P. Michel, M. Wintermark, M.D. Reichhart, F. Vingerhoets, P. Maeder,
R.M. Meuli, J. Bogousslavsky
Centre Hospitalier Universitaire Vaudois, Switzerland
Objective: To show the feasibility, safety and possible effectiveness of applying
perfusion-CT (PCT) for patient selection for intravenous thrombolysis with rtPA 3
to 6 hours after onset of acute ischemic stroke.
Methods: Between 9/2002 and 1/2006, patients aged 18-80 with a NIHSS of 6-22
arriving too late in our stroke center for treatment within 3 hours were eligible for
treatment. They had to have a minimal penumbra size for a given infarct (core) size
in the MCA-territory on PCT, according to a linear progressive cut-off table. This
model was designed for maximal potential benefit: the smaller the core size is, the
smaller the lower limit of the penumbra needs to be for inclusion. The maximal
upper size for inclusion is a core of 30% of the MCA territory. The primary
outcomes were symptomatic intracranial haemorrhage (ICH) and mortality at 90
days. Secondary outcomes were independence at 3 months (modified Rankin scale
0-2) and recanalisation rates at 24 hours measured by CT-angiography. The patients
were compared to 75 consecutive patients thrombolyzed in our center within 3
hours based on NINDS-criteria (independently of their PCT results).
Results (median ± standard deviation): 15 patients fulfilled the clinical and PCT-
criteria. Age and NIHSS were similar in both groups. Median time to thrombolysis
Cerebrovasc Dis 2007;23(suppl 2):1–147 111
was 255 (± 45) min. in the 3-6 hour group and 152 (±34) min. in the comparison
group. Symptomatic intracranial hemorrage was similar (6.7% vs. 6.7%) and
90-day mortality (6.7% vs. 10.7%) were similar. Good outcome was seen in 60%
and 52% respectively (non-significant), and 24 hour recanalisation rates were 60%
and 50% (non-significant).
Conclusion: The time window for intravenous rtPA can safely be extended from 3
to 6 hours if perfusion-CT shows salvageable tissue and no extensive core volume.
Clinical outcome and recanalisation rates are comparable to 0-3 hour thrombolysis
based on plain CT.
31 Acute stroke: treatment concepts
SYSTEMIC THROMBOLYSIS WITH ABCIXIMAB IN ACUTE ISCHEMIC
STROKE DUE TO ANTERIOR CIRCULATION INFARCTION BEYOND THE
3-HOUR TIME WINDOW
K. Barlinn, U. Becker, G. Gahn
University of Dresden, Dresden, Germany
Background: Intra-arterial treatment of ischemic stroke using pro-urokinase is
the only recommended therapy within 6 h of onset of symptoms in patients
with occlusion of the middle cerebral artery (MCA). Results from other trials
suggested that the glycoprotein IIb/IIIa antagonist Abciximab might also be useful
in treatment of ischemic stroke in patients without MCA occlusion beyond the 3 h
time window. We aim to evaluate the safety and efficacy of Abciximab at standard
dose in patients with acute ischemic stroke without MCA occlusion beyond the 3 h
time window.
Methods: From May 2002 to January 2005, we retrospectively studied 7 patients
with acute ischemic stroke attributed to the anterior circulation without MCA
occlusion who were treated with Abciximab (0.25mg/kg bolus, followed by 0.125
μg/kg/min x 12h) beyond 3 hours from onset of symptoms. All patients had
whether a progression or a fluctuation of focal neurological symptoms. MCA
occlusion was excluded by computed tomography angiography (CTA). Intracranial
bleeding complications were evaluated by CCT at day 1. National Institutes of
Health Stroke Scale (NIHSS) was assessed at baseline and at discharge, modified
Rankin Scale (mRS) was obtained at discharge.
Results: Mean onset to treatment time was 9 (range 4,5-48) hrs. No symptomatic
intracranial haemorrhage occurred. There were no cases of extracranial bleeding
complications. One patient had myocardial ischemia diagnosed. All patients (100%)
improved clinically from mean NIHSS 7 (range 2-15) to 2 (range 0-10). The rate
of favorable outcome (mRS 0-2) at discharge was 57% (4 of 7 patients).
Discussion: Regarding clinical outcome, the absence of symptomatic ICH and
other bleeding complications, Abciximab seems promising in late thrombolysis of
acute ischemic stroke in selected patients without MCA occlusion and progres-
sion or fluctuation of symptoms. Nevertheless further prospective clinical trials are
necessary to select patients who benefit from treatment beyond the 3 h time window.
32 Acute stroke: treatment concepts
SETIS - SERBIAN EXPERIENCE WITH THROMBOLYSIS IN ISCHEMIC
STROKE
D.R. Jovanovic, Lj. Beslac-Bumbaširevic, G. Toncev, M. Živkovic, for SETIS
Group
Institute of Neurology, Clinical Center of Serbia, Belgrade, Yugoslavia
Background: First intravenous thrombolysis in IS in Serbia was carried out in
February 2006. We present our preliminary one year experience with intravenous
thrombolysis in treating IS patients.
Methods: All patients with IS treated with intravenous thrombolysis in Serbia were
included in the study. The time of stroke onset, first neurological exam, CT exam
and beginning of therapy were recorded. The early CT signs of ischemia were
graded by the ASPECTS score. Neurological deficit was assessed with NIHSS
score and functional outcome with modified Rankin Scale (mRS).
Results: During one-year period 24 patients with IS were treated with intravenous
thrombolysis in three tertiary care centers. Average age of patients was 50.5 years,
ranging 18 to 78, with 62% of them younger than 55. Median time from symptom
onset to hospital door was 52.5 minutes, median time door-to-CT was 37.5 minutes,
and time from symptom onset to treatment was 165 minutes. Early CT signs of
ischemia were present in 62% of patients with median ASPECTS score 9. Median
initial NIHSS score was 14 with its decline during first 24 hours for at least 4
points in 50% of patients. Symptomatic intracerebral hemorrhage was present in
two patients. After 30 days of follow-up, 33% of patients had favorable outcome
(mRS < 1), 29% of patients had poor outcome (mRS 4-5) and two patients died,
one with malignant MCA infarction with symptomatic parenchymal hemathoma,
and the other patient with signs of heart insufficiency.
112 Cerebrovasc Dis 2007;23(suppl 2):1–147
Conclusion: Based on our initial experience, we confirm that intravenous throm-
bolysis carry a substantial benefit for the patients with acute IS. However, we also
uphold that one should strictly follow the thrombolysis protocol in order to avoid
possible complications.
33 Acute stroke: treatment concepts
INTRA-ARTERIAL THROMBOLYSIS IN ACUTE STROKE DUE TO MCA
OCCLUSION
I. Henriques, A. Calado, R. Roque, A. Bandeira, I. Fragta, C. Ribeiro,
J. Candido, J. Reis
Centro Hospitalar de Lisboa - Zona Central, Lisboa, Portugal
Background: Standard treatment for acute ischemic stroke in eligible patients is
intravenous (ev) thrombolysis, but efficacy is limited by low rates of recanalization.
Intra-arterial (IA) thrombolysis, combined transcranial ultrasound, or clot retrieval
devices are being evaluated to improve thrombolysis efficacy. We prospectively
studied consecutive patients with acute MCA occlusion submitted to IA rt-PA
thrombolysis in the first 6 hours after symptoms onset.
Methods: We included patients not eligible for ev thrombolysis according to
ECASS criteria. We excluded patients with vertebrobasilar stroke and with previous
concomitant ev thrombolysis. Symptomatic cerebral hemorrhage was considered if
associated with clinical deterioration. Major neurological improvement was defined
as a reduction of more than 7 points in NIHSS after procedure. Excellent or good
outcome was considered if modified Rankin scale was 2 or less. We studied 15
consecutive patients referred to our stroke unit (5 male) with median age of 72 (43–
78) years.
Results: Median NIHSS at admission was 19 (15-25), and 12 at discharge (2-25).
MCA recanalization was total in 33% (TIMI grade 3) and partial (TIMI grade2)
in 67%. In five patients, recanalization was achieved together with a mechanical
thrombectomy device. Hemorrhagic transformation was present in 7 patients (46%),
and symptomatic in 5 (33%). Three patients died (20%) in the first 72h and none
after. At discharge, excellent or good outcome was observed in 27% of the patients.
Discussion: In this group of large MCA infarcts not eligible for ev thrombolysis,
total recanalization was achieved in 33% and partial in 67%. Mechanical thrombec-
tomy device was used together with IA rt-PA thrombolysis in 33% of our patients.
Independency was achieved in 27% at discharge. Since patients not eligible for
ev thrombolysis with large MCA infarcts have a very high rate of disability and
mortality, IA thrombolysis alone or together with mechanical device can be an
alternative to current treatment. Randomized trials may confirm safety and efficacy
in larger series.
34 Acute stroke: treatment concepts
ARE POLYAMINE LEVELS USEFUL IN PREDICTING OUTCOME
FOLLOWING ACUTE STROKE?
M.J. Macleod, P. Mahendra, M. Bruce, H.M. Wallace
University of Aberdeen, Aberdeen, United Kingdom
Background: It is difficult to predict stroke outcome on infarct size and stroke
severity alone. There is therefore interest in markers which might predict outcome
following acute stroke. The endogenous polyamines, putrescine, spermidine, and
spermine, are found in high concentrations in the brain and have a regulatory
role in apoptosis. When neuronal cells are damaged polyamines are ’mopped up’
by erythrocytes. One small clinical study in acute stroke has suggested red cell
polyamine levels may correlate with infarct size and severity. The aim of this study
was to replicate and extend these findings in a group of patients admitted with
an acute cortical infarct of less than 48 hours duration. Patients with significant
comorbidity or unable to give consent were excluded.
Methods: Bloods and clinical assessment including NIHSS were performed at
admission, 12, 24 and 48 hours (depending on time of admission after onset of
symptoms), 72 hours, 7 days, 14 days and 28 days. Samples were also available
for 8 control subjects. Erythrocytes were separated and washed with isotonic
NaCl, haemolysed with distilled water and extracted with HClO4. The extract was
neutralised with KOH and frozen at -40 oC. Analysis of polyamines was performed
using reverse phase HPLC and quantification by fluorescence detection.
Results: Data from 10 patients is presented (6M/4F). Average age was 71.6 years
(±8.9). Polyamine levels vary considerably between patients, but in all but one
patient (who had a normal CT scan) were higher than normal control subjects at 7
days (p<0.008). Patients had a significant rise in polyamine levels between baseline
(mean 8.7±5.4) and 7 days (mean 22.3±8.3), p<0.032. There was a correlation
between total polyamine levels and NIH SS at day 7 post stroke (r=0.654, p=0.04).
Discussion: These findings confirm that polyamine levels are elevated after an
ischaemic cortical stroke, and peak at 7-14 days. If the correlation with NIHSS is
16th European Stroke Conference
confirmed in larger studies, polyamines may be a useful prognostic indicator after
an ischaemic stroke.
Long-term outcome of stroke
1 Long-term outcome of stroke
TIME SPENT AT HOME POST STROKE: “HOME-TIME” – A MEANINGFUL
AND ROBUST OUTCOME MEASURE FOR STROKE TRIALS
J. Dawson, T.J. Quinn, J.S. Lees, T.-P. Chang, M.R. Walters, K.R. Lees
Gardiner Institute of Cardiovascular and Medical Sciences, University of
Glasgow, Glasgow, United Kingdom
Background: Assessment of stroke outcome requires a measure of functional re-
covery eg. modified Rankin scale. Such instruments are prone to bias and variation
in clinical application. Approaches to improve rigour often increase complexity
without similar increases in clinical utility. Length of stay in hospital and nursing
homes is strongly related to incremental increases in mRs score but is weakened
as an outcome measure because fatal outcomes tend to shorten stay. We examined
duration of stay in the patient’s own home or chosen environment – “Home-time”
- as an alternative outcome more likely to show a graded response with less
confounding by survival issues.
Methods: We examined prospectively collected resource use data from the GAIN
International trial. We assumed Home-time if patients returned to their own or
relative’s home after stroke, restricting analysis to the first 90 days and using
ANOVA with Bonferroni contrasts of adjacent mRS categories.
Results: We had full outcome data from 1717 of 1788 intent to treat patients. Mean
age ±SD was 70 ±12 years; 737 were female. Mean initial NIHSS was 13±6 and
321 had primary intracerebral haemorrhage. Increasing Home time was associated
with significantly improved mRs scores (p<0.0001; table).
mRs 0 mRs 1 mRs 2 mRs 3 mRs 4 mRs 5
N 197 268 205 214 366 143
Home-time duration
(mean) 72.6 64.1 45.9 31.5 11.2 9.1
– * * * * p=0.37
95% CI 69.9–75.5 61.3–67.0 41.8–49.9 27.5–35.6 8.9–13.4 5.5–12.8
Home time = days spent living electively in existing setting, within the first 90d. *p<0.0001 compared
to preceding column
Conclusion: Recording of Home time offers a robust, useful and easily validated
outcome measure for stroke, particularly across better recovery levels.
2 Long-term outcome of stroke
THE IMPACT OF OBESITY ON SHORT AND LONG-TERM OUTCOME
AFTER FIRST EVER ACUTE STROKE. THE STROKE OBESITY PARADOX?
S. Scalidi, K. Xynos, T. Pappa, J. Zafeiriou, N. Mentis, N. Kokolakis,
K. Vemmos
Acute Stroke Unit, Dept. of Therapeutics, Univ. of Athens Med. School,
Alexandra Hosp., Halandri, Greece
Background: Obesity has long been implicated as a higher morbidity and mortality
risk factor for cardiovascular disease. However, its potential role and pathophysio-
logical significance on the outcome of patients after an acute stroke has not been
yet established. Our aim was to assess short and long term survival as well as
recurrence rate of obese patients suffering an acute stroke, compared to that of the
non-obese population.
Methods: We prospectively studied 1998 patients with first-ever acute stroke. Apart
from the stroke risk factors and body mass index (BMI), we scored consciousness
level and neurological deficit on admission by means of the Glasgow Coma Scale
(GCS) and the Scandinavian Stroke Scale (SSS). Cox regression and Kaplan-Meier
method was used in order to estimate the impact of obesity on survival and
recurrence.
Results: In our study population, 473 patients (23.7%) were classified as obese
(BMI>30) and 1525 (76.3%) as non-obese (BMI<30). Obese patients had higher
proportion of hypertension, diabetes and cholesterol. No significant difference in
age, GCS and SSS was observed between groups. After adjustment for age, sex,
risk factors and stroke severity, obesity was an independent prognostic factor for
survival Hazard Ratio=0.637 (95%CI 0.527-0.770), p=0.0001. Cumulative survival
for obese and non-obese patients was: after 1 month 0.895 (95%CI 0,864-0.921)
Poster Session
Long-term outcome of stroke
and 0.831 (95%CI 0.812-0.850), and in the end of follow up at 10 years 0.464
(95%CI 0.410 to 0.518) and 0.290 (95%CI 0.259 to 0.321) respectively, (log rank
test=24.23, p=0.0001). No differences were seen in recurrence rates (log rank
test=0.17, p=0.68).
Conclusion: Obesity in patients with acute stroke is associated with better short and
long-term survival. The mechanisms involved in obesity-related neuroprotection in
acute stroke demand further investigation.
3 Long-term outcome of stroke
BIOCHEMISTRY VERSUS CLINICAL SEVERITY OF ACUTE STROKE:
SIGNIFICANCE OF NT PROBNP TO PREDICT ONE YEAR MORTALITY
J.C. Sharma, I.N. Ross
Kings Mill Hospital, United Kingdom
Background: We have investigated the value of biochemical measurements to
predict stroke mortality.
Methods: Logistic regression was used to investigate significant variables of the
biochemical and clinical parameters in 125 previously independent (mRS <4) acute
stroke patients for mortality at one year.
Results: Age range 40 to 95, mean 73±12, Female:Male 63:62. 20 patients had
died at one year. Results are given for means ± SD between dead and alive patients
using Student’s t test. There was no significant difference in mean creatinine
111±32 vs 101±41, p=0.32, eGFR 54 vs 62, p=0.08; oxygen saturation–97.0 vs
97.0, p=0.60; HbA1C 6.01±0.7 vs 6.3±1.3, p=0.38; glucose 6.6±1.4 vs 7.0±2.8,
p=0.53; serum osmolality 306±11 vs 303±18, p=0.52; cholesterol 4.5±1.1 vs
4.9±1.2, p=0.16 and HDL 1.4±0.7 vs 1.5±0.7, p=0.42. There was a significant
difference in urea 10.1±4.6 vs 7.5±4.4, p=0.01; ALT 133.3±459 vs 30±33,
p=0.02; alk phosphatase 140±116 vs 91.6±45, p=0.002; NT proBNP 980±1249
vs 125±244, p<0.001; Barthel Index 2.2±2.5 vs 7.1±4.9, p<0.001; Scandinavian
stroke scale (SSS) 22±14 vs 35±12, p<0.001 and NT proBNP log 6±1.7 vs
3.5±1.7, p<0.001.
Logistic regression analysis using the significant variables from univariate analysis
revealed that NT proBNP was the most significant variable to predict mortality
mRs 6 (death) – Wald 17.9, p<0.001 followed by SSS – wald 5.7, p=0.02. Other biochemical
324 variables and Barthel Index were not significant to predict mortality.
Conclusion: NT proBNP, a measure of cardiac impairment, is the only significant
1.0 biochemical variable to predict one year mortality, more significant than the
p=0.0003 measures of clinical stroke severity. This provides an opportunity for intervention
0.3–1.6 to reduce stroke mortality.
4 Long-term outcome of stroke
INFLUENCE OF STROKE SECONDARY PREVENTION DRUGS ON
MOLECULAR MARKERS OF INFLAMMATION. THE MITICO STUDY
J. Vivancos, J. Alvarez-Sabín, A. López-Farré, E. Martínez-Vila, J. Montaner,
T. Sobrino, J. Castillo, on behalf of The MITICO Study investigators
Hospital Universitario de La Princesa, Stroke Unit, Neurology Service, Madrid,
Spain
Background: The MITICO study primary objective is to determine the prognostic
value of inflammation molecular markers (IMM) in vascular recurrence risk.
As a secondary objective, we studied the influence of antiplatelet, statins and
antihypertensive drugs on IMM profile.
Methods: Multicenter prospective observational study, including non-anticoagulated
ischemic stroke patients (within 1 to 3 months of stroke onset), with no inflam-
matory processes. Four visits were performed during the one-year of follow-up to
identify vascular death (VD) or vascular event (VE). Blood samples were obtained
at baseline visit for further determination of fibrinogen, high-sensitive C-reactive
protein, IL-6, IL-10, ICAM-1, VCAM-1, MMP-9 and cellular fibronectin.
Results: From 965 included patients (recruited in 59 hospitals), 780 subjects
(67.5±11.2 years, 33.6% female) were valid for the main analysis. One-hundred
and three patients (13.2%) showed a new VE and 116 patients (14.9%) either a VE
or VD (66.4% stroke, 21.5% coronary and 12.1% peripheral).
Only 21 patients were not taken antiplatelet drugs. Statins treatment was associated
with reduction of VE and VD (47.4% vs 28.2%. p=0.001). None of them modified
the one-year functional outcome. There were significant changes between baseline
and final plasma levels of IL6, MMP-9 and cellular fibronectin in statins-treated
patients in comparison with non-treated patients (IL6: 0.9 [-1.5, 6.5] vs 0.3
[-1.9,1.4] p<0.0001; MMP-9: 23.5 [-27.6, 119.5] vs -2.3 [-48.1, 34.4] p<0.0001;
cFn: 4.4 [-4.8, 14.7] vs -6.1 [-10.8, 3.6] p<0.0001).
Discussion: Statins treatment is associated with a significant reduction of VE and
VD. Statins treatment influences IMM by lowering IL6, MMP-9 and cFn plasma
levels along follow-up period.
Cerebrovasc Dis 2007;23(suppl 2):1–147 113
 5 Long-term outcome of stroke
MORTALITY AND VASCULAR MORBIDITY AFTER ISCHEMIC STROKE AT
A YOUNG AGE. A CROSS-SECTIONAL STUDY IN WESTERN NORWAY
U. Waje-Andreassen, H. Naess, L. Thomassen, G.E. Eide, C.A. Vedeler
Haukeland University Hospital, Bergen, Norway
Background: The aims of this population-based long-term follow-up study were to
obtain data on cardiovascular mortality and recurrent stroke, coronary disease (CD)
and peripheral artery disease (PAD) for long-term survivors of ischemic stroke and
controls.
Methods: After a median observation time of 11.1 years we evaluated all 232
patients aged 15-49 years with first-ever cerebral infarction in 1988-1997 and 453
birthday- and sex-matched controls for causes of death. We used information from
the Norwegian national death register, from hospital records and autopsy reports
when available. Among long-term survivors we evaluated 144 patients and 167
controls for cardiovascular events by questionnaires, hospital records and clinical
examination including an electrocardiogram (ECG) for patients.
Results: 45/232 (19%) patients and 9/453 (2%) controls died during follow-up
(p < 0.0005). Causes of death among patients were: stroke (9), acute myocardial
infarction (9), other heart disease (4), sudden death (5), unknown (5), cancer (7) and
others (7). One patient had 2 causes of death by autopsy. Controls died from acute
myocardial infarction (1), cancer (6) and others (2). Among long-term survivors
recurrent stroke was registered for 38 (26.4%) patients versus stroke in 5 (3%)
controls (p < 0.0005), CD occurred in 19 (13.2%) patients versus 9 (5.4%) controls
(p = 0.018) and PAD occurred in 17 (11.8%) patients versus 2 (1.2%) controls (p
< 0.0005).
Discussion: Mortality is increased after ischemic stroke at a young age and
cardiovascular death is dominating among patients. Cardiovascular morbidity is
higher on cerebral, coronary and peripheral level in long-term surviving patients
compared with controls.
Key-words: stroke, mortality, cardiovascular morbidity.
6 Long-term outcome of stroke
EFFECTIVENESS OF THROMBOLYTIC THERAPY ON OUTCOME WITHIN
3 MONTHS AFTER ISCHEMIC STROKE: THE TELEMEDICAL PILOT
PROJECT FOR INTEGRATIVE STROKE CARE (TEMPIS)
A.M. Toschke, P.U. Heuschmann, J. Schenkel, H. Audebert
King’s College London, London, United Kingdom
Background: Randomized trials showed a benefit of intravenous application of
tissue-type plasminogen activator (tPA) for ischemic stroke patients after three
months. Observational studies reported inconsistent results regarding effective-
ness of this treatment in terms of early mortality. Data on mortality after tPA
administration after 3m outcome from unselected community hospitals are scarce.
Methods: Data were collected from the Telemedical Pilot Project for Integrative
Stroke Care (TEMPiS) in Southern Germany including comprehensive stroke
centres and community hospitals. Patients were followed three months after
stroke onset. Propensity score analysis was used for adjusting differences in
sociodemographics, clinical characteristic, stroke severity, and comorbidities by
tPA treatment.
Results: Between July 2003 and March 2005 1710 patients after ischemic stroke
were observed with a mean age of 74y (SE 0.3y); 48% were male. 76 (4.4%)
patients were treated with tPA. Patients receiving tPA were younger, more often
male, had less often recurrent strokes; prevalence of diabetes, atrial fibrillation,
dyslipidemia and hypertension did not differ compared to non-tPA patients. The
proportion of tPA patients who died in-hospital or after 3 month was similar
(7.9% or 14.5%) compared to patients not receiving tPA (6.4% or 15.4%; p=0.61
and p=0.83). After adjusting for baseline differences by propensity score, patients
receiving tPA tended to have a lower probability of death in hospital (odds ratio
(OR) 0.58, 95%CI 0.21-1.63) and at 3 months (OR 0.69; 95%CI 0.32 to 1.50).
Conclusions: The tPA treatment within the TEMPiS community hospitals had no
adverse effect on in-hospital and 3months mortality after stroke.
114 Cerebrovasc Dis 2007;23(suppl 2):1–147
7 Long-term outcome of stroke
LONG-TERM PROGNOSIS OF STROKE IN YOUNG ADULTS: RESULTS
FROM THE FIRST 227 CONSECUTIVE CASES ENROLLED DURING
5-YEARS IN THE “ATHENIAN REGISTRY OF STROKE IN YOUNG ADULTS-
ARSYA”
K. Spengos, S. Vassilopoulou, M. Papadopoulou, A. Papapostolou,
G. Papadimas, E. Manios, G. Tsivgoulis
Eginition Hospital, University of Athens, Athens, Greece
Background: California- and ABCD-scores reliably predict short-term risk of
stroke after TIA. Both scores contain similar components. However, diabetes
mellitus (DM) is only included in the California Score. Aim of the present study
was to evaluate the potential relationship of DM with the early risk of stroke in a
cohort of hospitalised TIA patients.
Methods: All patients hospitalised in our Department with definite TIA during
a 5-year period were identified and their medical charts as well as their Emer-
gency Room records were retrospectively reviewed by two investigators blinded
to follow-up. Patients with previous history of stroke and those who missed their
follow-up evaluations at the outpatient clinic of our Department at 1 month after
admission were excluded. DM was specified as fasting serum glucose 7.0 mmol/L,
nonfasting serum glucose 11.1 mmol/L, or use of oral blood sugar-lowering drugs
or insulin. The outcome events of interest in all TIA patients were subsequent
strokes during the 1-month follow-up period. Statistical analyses were performed
using the Kaplan-Meier product-limit method and stepwise Cox’s proportional
hazards model.
Results: The 30-day risk of stroke in the present case series (n=226) was 9.7%
(95%CI:5.8-13.6%; 22 events). The 30-day risk of stroke was higher in patients with
DM (17.3%; 95%CI:7.6-27.0%) than in non-diabetic patients [(7.1%; 95%CI:3.2-
11.0%); log-rank test=5.20; df=1; p=0.0225]. After adjustment for demographic
characteristics, stroke risk factors, history and number of prior TIAs, duration and
symptoms of TIAs, as well as secondary prevention treatment strategies during
hospitalisation, DM was independently (p=0.015) associated with a three-fold
greater 30-day risk of stroke (HR:2.98; 95%CI:1.28-6.94).
Discussion: DM is an independent predictor of subsequent stroke in patients
presenting with TIA. It should be taken into account by prognostic scores that
stratify the risk of early stroke in TIA patients.
8 Long-term outcome of stroke
LONG-TERM SURVIVAL AFTER FIRST-EVER STROKE IN THE BESANÇON
STROKE REGISTRY: IMPACT OF STROKE UNIT ORGANISATION
P. Decavel, E. Medeiros, E. Vidry, F. Vuillier, E. Revenco, M. Pellicier,
T. Moulin
University Hospital Besançon, Besançon, France
Background: Development of stroke management over a number of years has
changed the vital and functional prognosis of patients. The aim was to test the
influence of stroke management on the long-term survival of patients admitted with
first-ever stroke in the Besançon stroke registry.
Method: To test long-term outcome of patients with first-ever stroke over 3
different periods (period 1: 1987-1994; period 2: 1998-2002; period 3: 2003-2006)
corresponding respectively to “basic stroke unit” period, stroke unit organisation
period and network organisation period in 3 cohorts of unselected stroke patients.
Results were statistically adjusted according to age, gender and stroke character-
istics. During the different periods, all patients with a first-ever stroke (infarction,
haematoma and TIA) admitted to the Besançon university hospital were registered
prospectively and assessed according to standardised diagnostic criteria. Patients
were followed up over several years and the outcome was analysed during the first
year.
Results: There were 6103 patients (55% male) which included 4250 (70%) infarc-
tions, 678 (11%) haematoma and 1175 (19%) TIA. The median age of the cohorts
was 71 years. The cohorts were different for each period in terms of recruitment
(gender - p = 0.035 - and age - p < 0.000) and stroke subtypes (p < 0.000). In the
first year after stroke, the overall survival rate was 75% (period 1), 80% (period 2)
and 82% (period 3). Although there was no difference in survival rates for patients
with TIA in any period, there was continuous improvement in survival rates for
patients with haematoma (p = 0,041) or infarction (p = 0,022). Adjustments to age
and gender amplified these results.
Conclusion: This study shows the strong impact of stroke management organisation
on long-term patient outcome in the Besançon area.
16th European Stroke Conference
 9 Long-term outcome of stroke
DOES ADMISSION C-REACTIVE PROTEIN PREDICT OUTCOME IN
STROKE PATIENTS UNDERGOING THROMBOLYSIS?
R. Topakian, A.M. Strasak, H.-P. Haring, K. Nussbaumer, F.T. Aichner
Academic Teaching Hospital Wagner-Jauregg, Linz, Austria
Objective: After acute stroke, increased levels of C-reactive protein (CRP) mea-
sured at discharge are associated with unfavourable outcome. We tested the
hypothesis that admission CRP may predict outcome in stroke patients undergoing
intravenous thrombolysis treatment (IVT).
Methods: From January 2003 to June 2006, 129 patients underwent IVT for acute
ischemic stroke in our centre. 111 patients were valid for analyses after exclusion
of those with stroke involving a territory other than the middle cerebral artery’s and
those probably infected (admission CRP >6 mg/dl). Patient data were collected
in a prospective local registry. CRP was measured by turbidimetry (Cobas Integra
700, Roche).
Results: 52 (46.8%) patients were independent after 3 months, defined by a modi-
fied Rankin Scale (mRS) score <3. Admission CRP levels were non-significantly
higher in 1) patients independent after 3 months compared to patients with mRS
>2 [median (range): 0.4 (0-5.7) mg/dl vs. 0.3 (0-5.9) mg/dl, p=0.131], 2) patients
who survived (87.4%) vs. patients who died within 3 months [median (range):
0.4 (0-5.9) mg/dl vs. 0.2 (0.1-1.5) mg/dl, p=0.275], and 3) patients who did
not deteriorate neurologically within 24 hours (91.9%) vs. those who developed
deterioration defined by an increase of the National Institute of Health Stroke Scale
(NIHSS) score of at least 4 points compared to baseline [median (range): 0.4 (0-5.9)
mg/dl vs. 0.2 (0.1-0.7) mg/dl, p=0.091]. In multivariate logistic regression analyses,
baseline NIHSS was the only variable significantly associated with independency
after 3 months (OR 1.235, 95%CI 1.118-1.363, p<0.001).
Conclusion: Our findings suggest that admission C-reactive protein is not useful in
predicting outcome in stroke patients with thrombolysis treatment.
10 Long-term outcome of stroke
INITIAL EXPERIENCE WITH VIDEO BASED MODIFIED RANKIN
ASSESSMENT
T.J. Quinn, J. Dawson, M.R. Walters, K.R. Lees
Gardiner Institute of Cardiovascular and Medical Sciences, Glasgow, United
Kingdom
Introduction: Modified Rankin Scale (mRs) is the preferred outcome measure in
stroke trials. Despite availability of training and structured interview interobserver
variability remains apparent - kappa=0.75 among UK SAINT trial investigators.
We hypothesised that “off-line” assessment of video recorded interviews would
offer the means to improve reliability.
Methods: 102 consenting patients were graded independently by two assessors.
Patients were randomised to undergo of structured interview or standard assess-
ment. One assessment from each pair was further randomised to video recording.
Videos were assessed by four experienced researchers, blind to interviewer’s and
other panellists’ gradings.
Results: 100 videos were of technical quality to allow assessment. A range of ages
(median:70 range:30-96) and stroke subtypes (Cortical 44; Lacunar 41; Posterior
9) representative of a trial population were included. Initial mRs scores agreed
in 66.7% of cases. Use of the structured interview did not significantly improve
reliability. At video assessment there was consensus amongst scorers for 55%
of cases (kappa 0.70). Greatest variability was seen for mRs grades 2 and 4
(kappa=0.60, 0.65).
Paired mRs Assessment Total Structured (n=49) Standard (n=53)
Agreement 68 30 38
Disagree = 1 mRs grade 29 14 15
Disagree > 1 mRs grade 5 5 0
Video Assessment (4 reviewers) Total Structured (n=48) Standard (n=51)
Consensus 54 24 30
3/4 Agree 32 17 15
2/4 Agree 13 7 6
Discussion: We have shown that “off-line” assessment of mRs is possible in a mock
clinical trial setting. Video assessment did not alter interobserver variability but
offers potential for central endpoint committee review with resultant improvements
in precision: pilot work to assess effect on reproducibility is now underway.
Poster Session
Long-term outcome of stroke
11 Long-term outcome of stroke
CHANGES IN QUALITY OF LIFE FROM ONE TO SIX MONTHS
FOLLOWING ACUTE STROKE AND ITS DETERMINANTS
O.M. Ronning, K. Stavem
Stroke Unit, Akershus University Hospital., Lørenskog, Norway
Background: There is little information available about change in health-related
quality of life (HRQoL) during the first few months following acute stroke, and
whether baseline variables can predict who will have the largest improvement
in HRQoL. This study assessed the change in HRQoL from one to six months
following acute stroke and the determinants of these changes.
Methods: Patients > 60 years of age, who experienced an acute stroke and were
admitted to hospital within 24 hours of onset, were followed prospectively. HRQoL
was measured with the SF-36 health status questionnaire.
Results: Of the 550 eligible patients, 315 fulfilled the inclusion criteria and
were alive after 30 days. At one month 174 responded to the questionnaire of
whom 140 also completed the second questionnaire. The changes in HRQoL were
statistically significant on all the SF-36 scales (Physical functioning: p<0.001,
Role physical: p<0.001, Vitality: p<0.001, Social functioning: p<0.001, Role
emotional: p<0.001, Bodily pain: p=0.016, General health: p=0.002, mental health
p=0.02). Mean scores for the two summary scales, physical component summary
(PCS) and mental component summary (MCS), increased from one to six months
from 36 to 42 (p < 0.001) and 43 to 53 (p < 0.001). Higher baseline scores at
one month were associated with lower changes in PCS and MCS in multivariate
analysis. Less severe stroke related to large improvement in PCS. Treatment in
stroke unit was associated with a larger improvement in MCS.
Discussion: In the present study we show a marked improvement in HRQoL from
one to six months. There was a favourable change in all domains assessed.
12 Long-term outcome of stroke
LONG TERM SURVIVAL OF STROKE PATIENTS FOLLOWING AN
INPATIENT REHABILITATION ADMISSSION
C.E. Connolly, J. Estell, F. Kohler, R. Renton
Braeside Hospital, Prairiewood, NSW, Australia
Objective: Patients admitted for stroke rehabilitation generally have numerous
comorbidities and a significantly increased mortality rate compared to the rest
of the population. The pioneers of Rehabilitation medicine demonstrated that
rehabilitation improved quality of life and minimised dependency. Limited research
has however been done to determine the survival period of patients after inpatient
rehabilitation for stroke. The aim of this study is to determine the survival period
of stroke patients following an episode of rehabilitation in our unit.
Method: All patients admitted to the Braeside Rehabilitation Unit (NSW Australia)
for stroke rehabilitation in the two years from 1st January 1997 to 31st December
1998 were identified. The hospital databases were checked to determine; the last
date of patient contact with a health service, or any indication that the patient had
died, and if so, the date of death. If there was no recent contact or confirmed
date of death a search was performed on the National Death Register kept by the
Australian Institute of Health and Welfare to establish if death had occurred
Results: 253 patients were admitted for stroke rehabilitation during the reference
period. Of these 7 patients died within 28 days of discharge, 20 patients died within
1 year and 30 within 2 years of discharge. By the end of eight years 72 patients had
died.
Discussion: The study shows that 71.5% of patients who were discharged following
inpatient stroke rehabilitation remained alive 8 years later. Given the age of this
population and presence of multiple comorbidities this survival rate is high and
underlines the importance of maximising patient function and outcomes for this
patient group. Further investigation with regards the survival periods in different
stroke subtypes is warranted.
13 Long-term outcome of stroke
ASSESSMENT OF QUALITY OF LIFE IN STROKE PATIENTS CAREGIVERS.
HOW TO PREDICT CAREGIVERS AT RISK
E. Marco, E. Duarte, M. Tejero, J.M. Muniesa, R. Belmonte, A. Aguirrezabal,
M. Pou, C.B. Samitier, F. Escalada
Physical Medicine and Rehabilitation Department, Hospital de l’Esperança,
Barcelona, Spain
Background: The increased proportion of stroke survivors has led to more impaired
and disabled subjects. The patient disability condition and the provision of care
have negative consequences for caregivers. Objectives: To detect the most affected
Cerebrovasc Dis 2007;23(suppl 2):1–147 115
dimensions in quality of life of stroke patients caregivers, and predict caregivers at
risk of presenting a worse health-related quality of life.
Methods: Cross-sectional study of 215 family caregivers of stroke patients. Main
variables were assessed with: the Short Form 36 (SF-36), the Geriatric Depression
Scale and the FIM-instrument. Statistical tests: Chi-squared and Fisher test, Student
“t” test, ANOVA, Mann-Whitney “U” test and Spearman correlation.
Results: The SF-36 subscales of vitality, social function, emotional role and mental
health are the most affected. There is a positive correlation between caregivers
health perception and patients health perception in these subscales. Motor disability
and assistence time required are the patient characteristic with a major influence
in caregiver health perception. The presence of depression and osteoarthritis in
caregivers have a significant effect on their perception of health. A model to be
used to detect the caregiver at risk of presenting a bad perception of health status
is constructed. This predictive model contemplates 8 different probability groups
ranging from 8.1 to 88.4%.
Discussion: Health-related quality of life of caregivers is affected in different
dimensions. To detect which caregivers are at most risk of presenting a bad
perception might be useful to provide resources and services to help caregivers in
charge of stroke patients.
14 Long-term outcome of stroke
POSTSTROKE EPILEPSY IN PATIENTS TREATED WITH SYSTEMIC
THROMBOLYSIS
B. Dimitrijeski, A. Villringer, A. Hartmann
Charité-Campus Benjamin Franklin, Berlin, Germany
Objectives: Poststroke Epilepsy (PSE) is an important complication after ischemic
stroke. We aimed to asses the occurrence of poststroke epilepsy, and to identify
possible predictors in patients with ischemic stroke treated systemically with
thrombolysis.
Methods: Patients with supratentorial stroke treated between 1998 and 2003
systemically with rt-PA according to the NINDS trial-protocol were followed
prospectively. Neurological status was measured at admission, discharge, 3-
months-follow-up and long-term follow-up. Occurrence of poststroke epilepsy was
noted. Predictors for PSE were identified using univariate analysis.
Results: A total of 134 Patients were treated. Long-term follow-up (mean follow-
up–time for the survivors was 39 months, range 14-66 months) was completed for
132 patients, 2 patients were lost to follow-up. Good clinical outcome (Rankin<2)
and mortality at 3 months was 50% and 13%, and at long-term follow-up 45% and
28% respectively.
Poststroke epilepsy occurred in 14 patients (11%). Factors univariately associated
with poststroke epilepsy were NIH at discharge (p= 0.001), cardio-embolic stroke
(p=0.018) and increasing infarct size (p=0.003).
Conclusions: The prevalence of poststroke epilepsy in patients treated with sys-
temic thrombolysis after a mean follow-up of 39 months was 11%. NIH-Score at
discharge, cardioembolic stroke and increasing infarct size are associated with a
higher risk for developing PSE.
15 Long-term outcome of stroke
INCIDENCE OF ASPIRATION PNEUMONIA AFTER SYSTEMATIC
APPLICATION OF AN EXPERT BEDSIDE SWALLOWING EVALUATION AND
FEEDING PROCEDURE IN A STROKE UNIT
V. Palumbo, S. Centorrino, P. Nencini, G. Pracucci, D. Inzitari
University of Florence, Florence, Italy
Background: Aspiration pneumonia is one of the most common and severe
complications of stroke-related dysphagia. We aimed to evaluate the variation over
time of the incidence of pneumonia in acute stroke patients admitted to a Stroke
Unit, who underwent an expert swallowing assessment and standardized feeding
procedures.
Methods: We evaluated after 2 years a second sample of 102 patients with
acute stroke (83% ischemic, 17% hemorrhagic) admitted consecutively in a Stroke
Unit over 6 months. All patients were systematically screened for dysphagia on
admission using the Standardized Bedside Swallowing Assessment, which involves
three stages: general evaluation (level of consciousness, postural control, voluntary
cough, voice quality and ability to swallow saliva), sipping water from a spoon,
and, if safe, proceeding to drink water from a glass. If difficulty on swallowing was
present, non-oral nutrition was considered, and the patient was referred to a speech
therapist for expert assessment.
Results: Median NIHSS of the cohort was 9, mean age 66.2 years, 63% of patients
were male.
Dysphagia was diagnosed in 18 (17.6%) patients; 6 (5.8%) patients developed
116 Cerebrovasc Dis 2007;23(suppl 2):1–147
pneumonia during hospitalization. Data from a sample of 100 patients examined 2
years before showed similar rates (dysphagia 27.0%, pneumonia 6.0%). Predictors
of increased risk of pneumonia were stroke severity, hemorrhagic (rather than
ischemic) stroke, and the presence of a total anterior circulation syndrome.
Discussion: The low incidence of aspiration pneumonia in our Institution supports
the effectiveness of a standardized swallowing assessment and feeding procedure,
and continuous training of the nursing staff. The incidence of pneumonia remains
in fact persistently low over time. However, there is a small group of patients at
higher risk of developing pneumonia. These patients, who are likely to have an
hemorrhagic stroke, severe symptoms and larger lesions, could benefit of more
selected strategies, to be eventually tested in this particular stroke subgroup.
16 Long-term outcome of stroke
QUALITY OF LIFE AND LONG-TERM FUNCTIONAL OUTCOME IN YOUNG
PATIENTS AFTER AN ISCHEMIC STROKE
A.A. Gongora, C. Mader, J.P. Arroyo, R. Garcia, A. Leyva
Institute National of Neurology and Neurosurgery, Mexico City, Mexico
Background and purpose: The purpose was to evaluate quality of life and long-
term functional outcome in patients under 45 years, after ischemic stroke to identify
variables that will accurately predict quality of life and long-term functional
outcome.
Methods: This was a cross-sectional, descriptive correlational design. The modified
Rankin scale, Barthel index and Short From -36 (SF 36) were administered to 192
stroke patients under 45 years. Subjects were interviewed 1 to 5 years after the
stroke. Independent variables were age, sex, comorbidity, cause, and location of
stroke. Multiple regression analysis was used to predict quality of life.
Results: 192 patients with a previous history of ischemic stroke <45 years of age
were included. The cause of the stroke was cardioembolism 20%, major blood
vessel atherosclerosis 9%, arterial dissection 28%, hypercoagulable state 15%, and
not determined 28%.
The most important risk factors associated with the cause of the stroke were
hypertension and major blood vessel atherosclerosis with 82% (p < 0.0005),
diabetes mellitus and major blood vessel atherosclerosis 47% (p < 0.0005). The
mean Barthel index was 95 with Barthel > 85 in 98% of cases. Rankin score was <
2 in 48%. (Rankin 3 – 4 = 52%). There was no significant difference between the
cause of the stroke and the SF – 36 profile category results. The SF – 36 category
which was affected the most, was emotional role with over 30% of patients with an
average value of less than 33.
Conclusions: There seems to be no difference between the long term functional
outcome and quality of life and the cause of the ischemic stroke. The identification
of alterations in the emotional role of patients furthers the need for support
programs.
17 Long-term outcome of stroke
PROGNOSIS IN FIRST-EVER ISCHEMIC STROKE/TRANSIENT ISCHEMIC
ATTACK PATIENTS WITH SIGNIFICANT EXTRACRANIAL CAROTID
ARTERY DISEASE
H.J. Lin, P.S. Yeh
Chi-Mei Medical Center, Yong Kang, Tainan, Taiwan
Background: The impact of significant extracranial carotid artery disease on the
prognosis in patients with ischemic stroke or transient ischemic attack (TIA) is
unclear in Taiwanese people, who have lower prevalence of such artery disease
than Western people.
Methods: From a prospective hospital-based registry of patients with first-ever
ischemic stroke or TIA, we investigated the outcomes among those with newly
found extracranial carotid artery disease > 50% stenosis. Data were collected
according to predetermined evaluation systems and diagnostic criteria, and the
subjects received regular follow-up. The composite outcome endpoint was subse-
quent stroke, myocardial infarction, or vascular death after the index event. The
Kaplan-Meier product-limit method was used to estimate the cumulative risk of the
endpoint, and the Cox regression model for evaluating prognostic factors.
Results: We enrolled 109 patients with a mean age of 69 years and 72% of men. The
mechanisms of the ischemic events included 64% of large artery atherosclerosis,
13% of small vessel disease, 9% of cardioembolism, and 12% of undetermined
etiology. All patients received medical treatments only. After a median follow-up
duration of 21.1 months, 33 events developed, including 14 strokes, 2 acute
myocardial infarcts, and 17 vascular deaths. The cumulative risks of the endpoint
were 7% in 1 month, 24% in 1 year, and 31% in 2 years. The Cox model analyses
revealed prior ischemic heart disease as a significant prognostic factor (hazard ratio,
2.6; 95% confidence interval, 1.0-6.8)
16th European Stroke Conference
Conclusions: Patients with first-ever ischemic stroke/TIA and newly found sig-
nificant extracranial artery disease are predisposed to grave vascular outcomes, in
particular those with concomitant ischemic heart disease.
18 Long-term outcome of stroke
PLASMA GLUTAMATE LEVELS PREDICT FATIGUE AFTER TIA AND
MINOR STROKE
A.B. Syed, L.M. Castell, A. Ng, C. Winward, P.M. Rothwell
Stroke Prevention Research Unit, Department of Clinical Neurology, University
of Oxford, Oxford, United Kingdom
Background: Post-stroke fatigue (PSF) is common and can be severe, even after
minor cerebral ischaemic events, but the mechanism(s) are poorly understood. High
levels of plasma glutamate are associated with fatigue in multiple sclerosis and in
chronic fatigue syndrome. We aimed to determine whether plasma glutamate and
glutamine levels predicted PSF after transient ischaemic attack (TIA) and minor
stroke.
Methods: We studied consecutive patients with TIA and minor stroke from the
Oxford Vascular Study (OXVASC). Participants were excluded if they had a Barthel
Score less than 18/20, a Rivermead Mobility Index (RMI) of less than 10/15, or
Mini Mental State Examination (MMSE) less than 23/30. Blood samples were
taken within one week of the presenting event and fatigue was assessed at home by
a research nurse (blind to all biochemical analyses) 6 months after the event with
the Chalder Fatigue Scale. Enzymatic spectrophotometric techniques were used to
assay plasma glutamine and glutamate levels.
Results: Among 38 patients (28 stroke, 10 TIA, 15 male, mean age 74 yrs), 64%
of stroke patients and 25% of TIA patients reported PSF. PSF was independent
of age, sex, depression, smoking, medication and (among stroke patients) residual
neurological deficit. However, there was a negative correlation between plasma
glutamine/glutamate ratio and PSF (r=-0.38. p=0.02). Plasma glutamate correlated
positively with PSF (r=0.35, p=0.02). Discussion: Plasma glutamate and the glu-
tamine/glutamate ratio appear to predict PSF 6 months after TIA or minor stroke.
Further research is warranted to confirm the predictive value of these tests and to
determine whether the relationship is causal.
Brain imaging -- new developments
1 Brain imaging – new developments
THE USE OF [11C]-(R)-PK11195 LIGAND AND POSITRON EMISSION
TOMOGRAPHY IN ACUTE ISCHAEMIC STROKE: INSIGHTS INTO THE
INFLAMMATORY PROCESS
J.A. Zavala, M.N. Perera, H.H. Ma, G. O’Keefe, H. Tochon-Danguy,
U. Akermann, J. Ly, D. Reutens, C. Rowe, G.A. Donnan
National Stroke Research Institute, Australia; Centre for PET Austin Health,
Australia
Inflammation after an ischaemic insult to brain tissue may have a key role in
the survival of viable hypoperfused tissue. Microglial and other inflammatory
cells are rapidly activated (within hours) after pathological insults to the CNS.
Macrophages accumulate after a period of days. Peripheral benzodiazepine binding
sites (PBBS) are mitochondrial membrane receptors in microglia and macrophages.
(R)-PK11195 is a ligand that binds to PBBS. [11C] PET scan can be used as a
non-invasive method of inflammatory response imaging. In this study we aimed
to understand the spatial and temporal changes of inflammatory response after
ischaemic stroke. We hypothesized that [11C]-(R)-PK11195 uptake levels increase
not only within the core of the ischaemic lesion but also in hypoperfused regions.
Methods: We studied ischaemic stroke patients within 1 month of onset. Imaging
was performed including CT, CT perfusion or MRI/A. [11C]-(R)-PK11195 was
given intravenously followed by 3-dimendional dynamic acquisition (PET) over 60
minutes. Distribution volume ratio maps were created using ipsilateral cerebellum
as reference tissue. The PET images were then coregistered to DWI and perfusion
maps.
Results: Fourteen patients were studied (median age 72 years, range 52 to 89
years). PET scans were performed from 48 hours to 20 days after stroke onset. Nine
patients had corresponding perfusion scans. There was no [11C]-(R)-PK11195
uptake within the first 5 days (5 patients) but increased uptake in 7 of 9 scans
performed from day 6 to day 20 after stroke onset. Increased uptake was found at
least as frequently beyond the infarct as within its core. For patients submitted to
perfusion scans, there was little uptake in chronically hypoperfused areas compared
to elsewhere outside the infarct core.
Poster Session
Brain imaging – new developments
Conclusions: More likely, [11C]-(R)-PK11195 uptake relates to macrophage (late
inflammatory response) rather than microglial activity. Because the uptake was
higher in the normally perfused rather than chronically hyposperfused areas it may
be that reperfusion promotes the inflammatory response.
2 Brain imaging – new developments
TC PERFUSION PREDICTS EARLY CLINICAL RESPONSE TO
INTRAVENOUS THROMBOLYTIC THERAPY OF ISCHEMIC STROKE IN
THE FIRST 3 HOURS
M. Revilla, E. Palacio, F. González, C. Ramón, P. Sánchez-Juan,
A. González-Mandly, E. Marco de Lucas, A. Gutiérrez, M. Rebollo, J. Berciano
Hospital Universitario Marqués de Valdecilla, Santander, Spain
Background and purpose: CT perfusion (CTP) and CT angiography (CTA) imag-
ing techniques identify tissue in penumbra and intravascular thrombus in acute
ischemic stroke, but their utility in the stroke therapy in the first three hours has
not been defined. We evaluated if CTP and CTA findings conditioned early clinical
response to intravenous (iv) thrombolytic therapy in the first three hours.
Methods: Forty-seven consecutive patients were treated with iv tPA according to
SITS criteria. Additionally, 33 of them were studied with CTP+/-CTA before tPA
administration. We evaluated cerebral blood flow (CBF), mean transit time (MTT)
and cerebral blood volume (CBV) images, CBF/CBV mismatch and arterial oc-
clusion. Early recanalization was detected with control CTA+/-transcranial doppler
examination. Early clinical response was measured by NIHSS at 0, 1, 24 and 72
hours post-treatment.
Results: Clinical evolution of patients by mean NIHSS was 13.5 (0 h), 10.8 (1 h),
9.4 (24h) and 7.6 (72 h). Between 0 and 72 hours NIHSS differences, measured by
mean rank, were as follows: 16.4 vs 19.4 if there was CBF abnormality (n=26);
14.2 vs 19.3 if there was CBV abnormality (n=15); 15.2 vs 6.2 if there was
CBF/CBV mismatching (n=21) (p=0.01, Mann-Whitney U); 12.9 vs 8.5 if there
was arterial occlusion (n=15); and 13.2 vs 4.5 if there was early recanalization
(n=12) (p=0.001, Mann-Whitney U).
Conclusion: Findings of mismatch and early recanalization of arterial occlusion
in CTP/CTA images predict a better early clinical response and may help in the
selection of patients for iv thrombolysis of stroke in the first three hours.
3 Brain imaging – new developments
INTRAPLAQUE HAEMORRHAGE IS ASSOCIATED WITH MULTIPLE
DIFFUSION WEIGHTED IMAGING LESIONS IN SYMPTOMATIC PATIENTS
WITH HIGH GRADE CAROTID STENOSIS
N. Altaf, S. Goode, P.S. Goode, J.R. Gladman, S.T. MacSweeney, D.P. Auer
University of Nottingham, Nottingham, United Kingdom
Introduction: Magnetic Resonance Imaging sensitively detects carotid intraplaque
haemorrhage (IPH) that is increasingly accepted as surrogate marker of plaque
instability. The aim of this study was to investigate an association between IPH and
the presence, pattern and extent of cerebral acute and sub-acute ischaemic lesions
identified by diffusion weighted imaging (DWI).
Methods: 46 patients (18 females, mean age 71.5 years ± 10.7) with high grade
carotid stenosis (>70% stenosis) presenting with stroke, TIA or amaurosis fugax
were prospectively recruited. All patients underwent MRI assessment of IPH in
the carotid artery and DWI of the brain. The presence, extent and pattern of DWI
hyperintense lesions were compared with the IPH status of the presenting carotid
artery.
Results: 32 (69.6%) patients had evidence of IPH in the presenting carotid artery
and 26 (56.5%) had DWI lesions. The mean delay from the presenting symptom
to MRI was 21.8 ± 18.5 days. Patients with carotid IPH were more likely to
have ipsilateral DWI lesions than those without IPH (22/32 [69%] vs. 4/14 [29%],
P<0.05); had more lesions (mean 2.8 ± 3.3 vs. 0.7 ± 1.2, P<0.05); multiple lesions
were strongly associated with IPH (17/32 vs. 1/14), whereas the DWI hyperintense
lesion volume was similar (mean 2.1 ± 3.4 ml vs. 1.7 ± 4.0 ml, P=0.6).
18/32 (56.3%) of patients with IPH had multiple DWI lesions and 3/14 (21.4%)
patients without IPH had multiple lesions (P<0.05).
The association between carotid IPH and the presence of DWI lesions was
marginally significant (Odds ratio = 3.8; 95% C.I. 0.8 – 18.2, P=0.09) after
controlling for stroke and time between symptom and MRI.
Conclusion: Intraplaque haemorrhage in the presenting carotid artery is moder-
ately associated with DWI ischaemic lesions and strongly with multiple lesions
supporting a thromboembolic pattern.
Cerebrovasc Dis 2007;23(suppl 2):1–147 117
 4 Brain imaging – new developments
TISSUE SWELLING WITHOUT HYPOATTENUATION ON NON-CONTRAST
CT IS RARE BUT POTENTIALLY REVERSIBLE IN ACUTE ISCHEMIC
STROKE
I. Dzialowski, S. Subramaniam, V. Puetz, A. Krol, J.M. Boulanger, P.A. Barber,
M.D. Hill, S.B. Coutts, T. Watson, A.M. Demchuk, for the Calgary CTA Study
Group
University of Dresden, Dresden, Germany
Background: Early ischemic changes (EIC) on non-contrast CT (NCCT) can
represent tissue hypoattenuation or cortical swelling and are both scored tradi-
tionally in the Alberta Stroke Program Early CT Score (ASPECTS). However,
only hypoattenuated brain tissue seems to be specific for ischemic core whereas
isolated cortical swelling (ICS) might be reversible. We sought to assess ASPECTS
ignoring isolated cortical swelling (ASPECTS - ISC) and compare the incidence of
deviation from classic ASPECTS.
Methods: We studied ischemic stroke patients from 04/2002-07/2005 presenting
within 24 hrs of onset in whom a NCCT was performed. We prospectively applied
ASPECTS to all baseline NCCT scans by 3-reader consensus scoring any EIC.
A normal scan scores 10, a complete middle cerebral artery infarction 0. In the
same session, we interpreted ASPECTS - ISC. We independently assessed follow-
up ASPECTS at day 1-7. We determined the incidence of differences between
ASPECTS-ICS and ASPECTS and proportion of reversibility at follow-up.
Results: We identified 335 patients with a mean age of 67 years, mean onset-to-
NCCT-time of 286 min, median baseline NIHSS score of 7 and median ASPECTS
of 10. We found ASPECTS - ICS > ASPECT scores in 7/335 (2.1%) of patients.
In this group, mean onset–to-NCCT-time was 399 min and median ASPECTS-
difference was 2 (range 1-4). In 5/7 patients follow-up imaging was available
and 2/5 (40%) showed higher final ASPECTS (> 1-point increase) than baseline
classic ASPECTS consistent with reversibility. In the population without baseline
ASPECTS difference, 16/247 (6%) of available follow-up images showed higher
final ASPECTS than baseline classic ASPECTS.
Conclusion: In our study, isolated tissue swelling was rare but likely to reverse.
ASPECTS interpretation should ignore isolated cortical swelling to better represent
irreversible ischemic core.
5 Brain imaging – new developments
LACTATE DOES NOT PREDICT INFARCT GROWTH
V. Cvoro, J.M. Wardlaw, S. Muñoz Maniega, I. Marshall, P.A. Armitage,
C.S. Rivers, M.S. Dennis
Division of Clinical Neurosciences, University of Edinburgh, Edinburgh, United
Kingdom
Background: In patients with acute ischaemic stroke, the mismatch between mag-
netic resonance (MR) diffusion- and perfusion weighted imaging (DWI and PWI)
was initially thought to predict infarct growth, but recent studies have questioned the
strength of this association. Lactate is a marker of early ischaemia and is elevated
in acute stroke lesions. N acetyl aspartate (NAA) which represents neuronal loss
falls more gradually. We examined whether elevated lactate or decreased NAA in
mismatch tissue predicted infarct expansion.
Methods: Patients with acute ischaemic stroke underwent diffusion tensor imaging
(DTI), dynamic susceptibility contrast PWI, T2W and MR spectroscopic imaging
(SI) at admission, days 5 and 14, and 1 and 3 months. A 0.5 cm diam. voxel grid
was superimposed on the baseline DTI and metabolite data were extracted from the
normal, mismatch and DTI lesion tissue. Infarcts were categorized into those with
or without lesion growth.
Results: 21 patients had DTI/PWI mismatch; 7 developed infarct expansion, 10 did
not (4 patients did not have follow up scans, and could not be included). Mean age
was 77 years (range 37-95), NIHSS 16 (range 7-29); 30% were first imaged <6
hrs, 40% from 6-12 hrs and 30% from 12-24 hrs. Lactate (34.4±21.2 vs 18.9±9.7
p<0.01) but not NAA (122.1±23.9 vs 115±30.6 p=NS) was elevated in mismatch
tissue compared with normal brain. However, there was no difference in mismatch
tissue at baseline in lactate or NAA between infarcts that expanded versus those that
did not (lactate 39.3±20.5 vs. 23.9±27.3, p=NS; NAA 118.7±23.4 vs. 137±18,
p=NS respectively). Furthermore there was no difference in mismatch tissue over
the first five days in lactate or NAA between lesions that grew and not.
Summary: Lactate may be a marker of ischaemia, but its presence in mismatch
tissue does not predict infarct growth. Infarct growth must be related to other
individual factors.
118 Cerebrovasc Dis 2007;23(suppl 2):1–147
6 Brain imaging – new developments
MRI ON DAY 1 IDENTIFIES PATIENTS AT RISK FOR DELAYED STROKE
PROGRESSION AFTER I.V. THROMBOLYSIS
R. Kern, K. Szabo, S. Bukow, M. Griebe, A. Förster, M.G. Hennerici, A. Gass
Universitätsklinikum Mannheim, University of Heidelberg, Mannheim,
Germany
Objective: Deterioration of clinical status after treatment with tPA for acute stroke
is a possible outcome but difficult to predict on an individual basis. Besides an
early malignant course a delayed symptom progression can occur. In an approach to
characterize the stability in the post-tPA phase we performed systematic follow-up
MRI in this patient group.
Methods: MRI (T2w, T1w, T2*w, DWI, TOF-MRA, PWI) was performed in 45
acute stroke patients on the first day after CT-based tPA therapy (3h time-window).
8/45 patients had an early malignant course and in 12/45 there was marked clinical
improvement with MRI demonstrating successful therapy on day 1 and no further
MRI was performed. In 25/45 patients MRI on the 1st and 7th day were compared.
MRI findings on day 7 were either considered “improved” (= vessel recanalisation;
resolution of hypoperfusion), “stable” (= no progress of infarct size, of hemorrhagic
transformation [HT], or of vessel pathology) or “progressive” (= progression of
infarcted or hypoperfused tissue size, HT or vessel pathology).
Results: In 19/25 (76%) MRI was stable or improved on day 7, whereas 6/25
(24%) were progressive: 6 patients showed new DWI lesions - 4 in the same, 2 in a
different vascular territory. One patient developed HT between day 1 and 7. 67% of
patients with persistent vascular obstruction and persistent hypoperfusion on day 1
had progressive MRI findings on day 7 and did not improve clinically.
Fig. 1. MRI performed on day 1 and day 7 of a 68-year-old patient who underwent intravenous
thrombolysis 2.5 hours after symptom onset DWI on day 7 showed multiple new acute lesions in the
right PCA territory with a persistent perfusion deficit on TTP maps. On MRA, vascular obstruction of
the left PCA even became more prominent. MRI characteristics were considered progressive.
Discussion: MRI on day 1 can identify those patients with a persisting unstable
situation at risk for stroke progression as indicated by hypoperfusion due to
incomplete vessel recanalisation after thrombolysis. Identifying these patients is
important for clinical management with close monitoring and blood pressure
management.
7 Brain imaging – new developments
TRANSCRANIAL SONOGRAPHIC DELINEATION OF INTRACEREBRAL
HEMORRHAGE –A PROSPECTIVE MULTICENTER STUDY
K. Meyer-Wiethe, R. Kern, S. Meairs, G. Seidel
University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
Background: A prospective study was performed in patients suffering from acute
intracerebral hemorrhage (ICH) in two German stroke centers to determine sensi-
tivity, extent of midline shift (MLS) and lesion volume determined by transcranial
ultrasound (US).
Materials and methods: US was performed with two systems (Philips SONOS
5500 and HDI 5000) via the temporal acoustic bone window. We used sector trans-
ducers at 2 MHz obtaining axial and coronary imaging planes. The sonographers
were blinded to the results of computed tomography (CT) performed in each patient
as a reference.
Results: 33 consecutive patients suffering from acute ICH (mean age 65 years,
range 37 -84, median NIHSS 8/34) were investigated within 48h of symptom onset.
16th European Stroke Conference
There was no difference in baseline characteristics between the patients from the
different centres. The localisations of the lesions were as follows: 23 basal ganglia,
2 frontal, 5 parietal, 2 temporal, 1 occipital lobe. In 30 of 33 patients (91%), US
identified the lesion correctly. In three patients ICH could not be detected due to
inadequate insonation conditions. Both US and CT showed no case of significant
midline shift of > 2 mm. CT depicted ventricular hemorrhage in 12 patients (US: 7
patients – sensitivity 0.58, specificity 1.0). There was a close correlation between
blood clot volume measured in CT and US (r = 0.85, P < 0.001, n = 30).
Conclusions: In this prospective multicenter study US correctly diagnosed, lo-
calized and measured intracerebral hemorrhage in patients with adequate bone
windows. In contrast, US depiction of ventricular hemorrhage showed high
specificity, but low sensitivity.
This study is part of the UMEDS project (Ultrasonographic Monitoring and Early
Diagnosis of Stroke) funded by the European Commission (QLG1-CT-2002-01518).
8 Brain imaging – new developments
DIAGNOSTIC VALUE OF COMBINED ANALYSIS OF T2-WEIGHTED
GRADIENT ECHO IMAGING AND POSTCONTRAST TIME-OF-FLIGHT MR
ANGIOGRAPHY IN HYPERACUTE ISCHEMIC STROKE
S.I. Sohn, C.H. Sohn, H.W. Chang, S.H. Choi, S.R. Kim, H.C. Park
Keimyung University, DongKang Hospital, Andong General Hospital, Daegu,
South Korea
Background: Identifying the composition and the length of clot may be important
in choosing the optimal treatment on acute thrombolysis. We assessed the diagnos-
tic value of combined analysis of T2-weighted gradient echo imaging (GRE) and
postcontrast MR angiography (PC-MRA) in patients with acute middle cerebral
artery (MCA) occlusion.
Methods: From May 2004 and December 2006, consecutive 49 patients with
occlusion of the MCA M1 segment within the first 6 hours from the onset of
symptoms admitted to our emergency department were enrolled. Then all patients
were imaged using acute stroke MR protocol included GRE for susceptibility
vessel sign (SVS) and pc-MRA for the length of occlusion and had conventional
angiography. We classified into 4 groups as the visibility and length of GRE SVS
and the signal gap of PC-MRA: longer clot length of GRE SVS than the signal gap
of PC-MRA (group A), longer signal gap of PC-MRA then the length of GRE SVS
(group B), the signal gap of PC-MRA without GRE SVS (group C), non-visible of
the signal gap of PC-MRA and negative GRE SVS (group D). MR findings were
compared with findings of conventional angiography.
Results: Among 49 patients, 42 (85.7%) patients with good MR imaging were
selected (23 men, mean age: 66.5). Group A was the most common type. The
difference of the length and the gap in group A and B may be associated with the
shape of thrombus. Long difference assumed oval shape clot and short difference
tended to be barrel shape clot. Group C showed focal occlusion of the MCA M1
segment by atherosclerosis. Group D had poor collateral circulation on conventional
angiography.
Conclusions: Compared to independent analysis of GRE SVS or PC-MRA in
patients with acute arterial occlusion, combined analysis was showed more accurate
information for the clot property and occlusion status.
9 Brain imaging – new developments
GLOBAL CHANGES ON DIFFUSION WEIGHTED IMAGING (DWI) AND
MAGNETIZATION TRANSFER (MT) IN RELATION TO WHITE MATTER
HYPERINTENSITIES: THE LADIS STUDY
S. Ropele, A. Seewann, W. van der Flier, L. Pantoni, E. Rostrup, T. Erkinjuntti,
L.-O. Wahlund, R. Schmidt, F. Barkhof, F. Fazekas
Medical University Graz, Graz, Austria
Objective: DWI and MT imaging should improve the detection and quantification
of cerebral tissue changes associated with white matter hyperintensities (WMH).
Supportive data come mostly from single centres which studied only one modality
in small and selective groups of individuals. We therefore aimed to investigate
and compare the sensitivity of these techniques for describing changes in normal
appearing brain tissue (NABT) and WMH in a multi-centre setting.
Subjects and methods: Within the LADIS study investigating the impact of WMH
on 65 to 85 year olds without prior disability we obtained DWI and MT in 9
centres with 1.5T whole body systems from different manufacturers. Lesions were
delineated on the FLAIR images; apparent diffusion coefficient (ADC) and MT
ratio (MTR) maps were calculated, co-registered and the respective values assessed
globally for WMH and NABT by means of histogram analysis. The mean value,
the peak position (PP), and the relative peak height (rPH) were related to subjects’
age and WHM severity.
Poster Session
Brain imaging – new developments
Results: We analyzed 340 DWI and 177 MT scans and both modalities in 124
subjects. ADC and MTR values showed a significant inter-site variation which was
stronger for the MTR. After z-score transformation multiple regression analysis
showed WMH severity and age as significant predictors for all ADC and MTR
histogram metrics of NABT. Only lesional ADC was increasing with WMH severity
while such correlation was not seen with MTR.
Conclusions: Despite some variation from a multi-centric collection of ADC and
MTR data both modalities appear sensitive for changes in NABT which appear
to occur with ageing and increase with the severity of WMH. However, the ADC
was more sensitive for discerning tissue changes within WMH and their relation to
lesion size.
10 Brain imaging – new developments
CHANGES IN BRAIN VOLUME 2 YEARS AFTER EC-IC BYPASS SURGERY:
A PRELIMINARY SUBANALYSIS OF THE JAPANESE EC-IC BYPASS TRIAL
J. Jinnouchi, K. Toyoda, T. Inoue, S. Fujimoto, S. Gotoh, K. Yasumori,
S. Ibayashi, M. Iida, Y. Okada
National Hospital Organization Kyushu Medical Center, Nippon Steel Yawata
Memorial Hospital, Kitakyushu, Japan
Background: Changes in cerebral blood flow (CBF) may be associated with brain
atrophy, especially in patients with cerebral artery occlusive disease. However,
previous studies have failed to find a significant relationship between CBF and
brain atrophy. Recently, Japanese extracranial-intracranial (EC-IC) bypass trial
(JET) revealed that EC-IC bypass was effective for stroke prevention. JET is a
multicenter, randomized, prospective study of patients with hemodynamic brain
ischemia due to cerebral artery occlusive disease. Here, we compared the changes
in brain volume and cerebral hemodynamics in patients with and without EC-IC
bypass surgery.
Methods: We registered 10 Japanese patients with mild ischemic stroke for the
JET. Six patients successfully underwent EC-IC bypass surgery and 4 were treated
medically. We studied changes in brain volume on magnetic resonance imaging.
We also examined the association of cerebral hemodynamics on single photon
emission computed tomography with the changes in brain volume. The differences
between patients with and without EC-IC bypass were investigated.
Results: The affected/unaffected ratio of the % brain volume declined in patients
without EC-IC bypass surgery (p<0.02, n=4), and the affected/unaffected % rCBF
ratio increased in patients with the surgery (p<0.03, n=6). Acetazolamide reactivity
increased in the affected hemisphere of patients with surgery (p<0.01). Two-year
increase (decrease) in acetazolamide reactivity of the affected hemisphere showed
a significant positive correlation with 2-year changes in the affected/unaffected %
brain volume ratio (R2 = 0.737, p=0.0007).
Conclusions: Change in acetazolamide reactivity might be a good predictor for
brain atrophy in cerebral artery occlusive disease.
11 Brain imaging – new developments
PERFUSION PATTERNS IN PATIENTS WITH SEVERE INTERNAL CAROTID
ARTERY DISEASE USING PERFUSION-CT
M.G. Delgado, V. Mateos, S. Calleja, R.L. Roger, P. Vega, C.H. Lahoz
Hospital Universitario Central de Asturias, Oviedo, Spain
Introduction: Cerebral perfusion profile of patients with chronic internal carotid
artery disease has not been well studied.
Material/Methods: Between January 2006 and January 2007, we studied consec-
utive patients with severe internal carotid artery (ICA) disease by CT-Angiography
and Perfusion-CT. Hypoperfusion was defined as increased MTT, decreased CBF
and CBV.
Five perfusion patterns are described: cerebral hemisphere hypoperfusion (type 1),
middle and anterior cerebral arteries territory (MCA and ACA) hypoperfusion (type
2), MCA territory hypoperfusion (type 3), watershed territory hypoperfusion (type
4) and normal pattern (type 5).
Results: We identified 26 patients, 24 males and 2 females. 73% of patients had
critical ICA stenosis and 27% of patients had ICA occlusion. Perfusion patterns
were: 38% type 1, 31% type 2, 15% type 3, 8% type 4, 11% type 5. In ICA
occlusion we only found 3 patterns: 43% type 1, 43% type 2 and 14% type 3.
In critical ICA stenosis we found: 37% type 1, 21% type 2, 16% type 3, 10%
type 4 and 3 patients (16%) had a normal perfusion study (type 5) with anterior
collateral circulation preserved and ipsilateral posterior communicating cerebral
artery absence. Six patients (26%) with abnormal perfusion study had a complete
circle of Willis.
Conclusions: The majority of patients with critical ICA stenosis or occlusion had
cerebral perfusion deficit. There were more patients with critical ICA stenosis than
Cerebrovasc Dis 2007;23(suppl 2):1–147 119
occlusion with cerebral hemisphere perfusion deficit (type 1). A normal perfusion
study can be found in symptomatic patients.
12 Brain imaging – new developments
INTER-OBSERVER AGREEMENT ABOUT THE PRESENCE AND
DISTRIBUTION OF BRAIN MICROBLEEDS IN ADULTS WITH STROKE
C. Cordonnier, G. Potter, C. Jackson, C.L.M. Sudlow, J.M. Wardlaw,
R. Al-Shahi Salman
Division of Clinical Neurosciences, University of Edinburgh, Edinburgh, United
Kingdom
Background: The increasing use of haem-sensitive gradient echo (GRE, T2*)
sequences in magnetic resonance (MR) imaging of stroke has lead to frequent
detection of brain microbleeds (BMBs). If BMBs are found to be of diagnostic
or prognostic significance, and are used for these purposes in clinical practice,
observer variation in their assessment must be known.
Methods: Two doctors assessed the MR imaging of 264 adults with stroke.
BMBs were defined as small, homogeneous, round foci of low signal intensity on
T2*-weighted images of less than 10 mm in diameter. Reviewers were blinded,
and quantified BMBs on each side of the brain in the following locations: lobar
(cortex, grey-white junction, deep white matter), deep (basal ganglia grey matter,
internal capsule, external capsule, and thalamus), and posterior fossa (brainstem
and cerebellum).
Results: Thirty percent (95% confidence interval [CI] 26-34) of patients had 1
BMB or more. Agreement about the presence/absence of BMBs at any location was
moderate (75%, 95% CI 70 to 80; kappa 0.44, 95% CI 0.32 to 0.56). Agreement
was worse in lobar locations (81%, 95% CI 76 to 85; kappa 0.44, 95% CI 0.30 to
0.58) than in deep locations (90%, 95% CI 86 to 93; kappa 0.62, 95% CI 0.48 to
0.76) or the posterior fossa (95%, 95% CI 92 to 97; kappa 0.66, 95% CI 0.47 to
0.84).
Discussion: This study provides insight into one of the reasons why inter-observer
agreement about the presence of BMBs is only moderate. Agreement was moderate
in lobar locations, but substantial in deep areas and the posterior fossa. This may be
due to the existence of BMB mimics in lobar locations, especially vessel flow voids.
We will explore agreement about BMB size and number, and ways of increasing
agreement about lobar BMBs, in an effort to develop a BMB grading scale.
13 Brain imaging – new developments
STUDIED ON BROCA’S APHASIA BY DIFFUSION TENSOR IMAGING
Y. Zhang, S. Wang, C. Wang, X. Zhao, Y. Wang
Beijing Tiantan Hospital, affiliated with Capital University of Medical Sciences,
Beijing, China
Background and purposes: Diffusion tensor imaging (DTI) is sensitive to the rate
and direction of water diffusion, The fibers distributing of language functional
areas exhibit that extensive and complicated relationship between language areas
and other areas. We studied Broca’s aphasia cases by the technique in order to
comprehend clinic symptom of the aphasia type.
Methods: DTI in axial covering the entire brain volume were obtained in thirty
volunteers and thirty Broca’s aphasia patients who suffered from left hemisphere
damaged after stroke. Used SIEMENS DTI software to post process and to measure
fractional anisotropy (FA) value and display the course of Broca’s area and the
mirror side.
Results: The results showed that the left Broca’s area FA of volunteers was 0.3081
± 0.0325, the mirror side was 0.3069 ± 0.0630, and there were no significant
between them (p>0.05). On the other hand, the left Broca’s area FA of Broca’s
aphasia patients was 0.2578 ± 0.05260, right corresponding area was 0.3063 ±
0.0562, there were significant between them (p<0.05).
Conclusions: The Broca’s area fibers of Broca’s aphsia were damaged. and using
DTI can analyse the fibers distributing of language functional areas, offer anatomy
information for clinic and explain the baffling of neurology of widen activating
signal language areas on cortex. Key words: DTI, Broca’s Aphasia, Broca’s area
120 Cerebrovasc Dis 2007;23(suppl 2):1–147
14 Brain imaging – new developments
CT PERFUSION IN ASSESSMENT OF BRAIN CIRCULATION IN PATIENTS
WITH STENOSIS OR OCCLUSION OF INTERNAL CAROTID ARTERY
G. Witkowski, P. Richter, A. Rozenfeld, R. Poniatowska, A. Dowzenko,
H. Jarosz, D. Ryglewicz
Institute of Psychiatry and Neurology, Warsaw, Poland
Background and purpose: The risk of stroke due to severe stenosis or occlusion
of internal carotid artery (ICA) is higher in patients with insufficient collateral
brain circulation. Transcranial Doppler Ultrasonography (TCD) is routinely applied
for assessment of collateral circulation. Computer tomography perfusion (CTP)
imaging is used in the clinical practice especially in the evaluation of brain blood
flow during acute stroke, transient ischemic attacks (TIA), in epileptogenic foci and
differential diagnosis of brain tumors. CTP also can be applied in assessment of
brain circulation in patients with unilateral stenosis of ICA.
The aim of the present study was to correlate the signs of collateral circulation in
TCD with the results of CTP in patient with symptomatic carotid arterial occlusion
or stenosis.
Methods: 17 patients hospitalized in First Department of Neurology, Institute of
Psychiatry and Neurology with TIA due to stenosis or occlusion of ICA were
introduced to the study. 4 patients were previously treated with the intravas-
cular occlusion (Gold Baloon) because of carotid cavernous fistula and brain
aneurysm. In Doppler examination blood flow through ophthalmic artery and
anterior communicant artery was estimated. CTP was routinely applied in all cases.
Results: Unilateral cerebral hypoperfusion was more pronounced in case of insuffi-
cient cerebral collateral circulation. In these patients Mean Transit Time parameter
(MTT) was prolonged for about 30-40%.
Conclusion: CT perfusion can be considered as a complementary method to TCD.
This examination helps to estimate the influence of arterial stenosis or occlusion
on cerebral blood flow. It can also predict the increased risk of ischemic stroke in
patients with carotid stenosis.
Interesting cases
1 Interesting cases
MULTIPLE LOCALISED CERVICOCRANIAL ARTERY DISSECTIONS
DEVELOPING AFTER AORTIC ARCH DISSECTION
A. Lovrencic-Huzjan, V. Vukovic, S. Antic, I. Galinovic, V. Demarin
University Hospital, Zagreb, Croatia
A 56-year old male without vascular risk factors, presented with syncope, shock
and encephalopathy afterwards. The diagnosis of aortic arch dissection was set.
Aortic arch was operated, aortic valve was replaced and warfarin was introduced.
During the first year of follow up, he was symptom-free. However carotid color
Doppler (CCD) showed a newly developed localized distal right common carotid
and proximal internal carotid artery dissection. During the second year of follow
up, he was ten months symptom-free. Afterwards, he had two attacks of vertigo
and nausea, without vomiting. No other neurological symptoms or signs developed.
He started complaining on the pain in the right shoulder. CCD confirmed persistent
right carotid dissection, and a new right subclavian artery dissection was displayed.
This is the first report of a previously healthy patient who developed consecutive
localized carotid and subclavian dissections during two-year follow-up of aortic
arch dissection.
2 Interesting cases
BILATERAL ISCHAEMIC STROKES IN A 33 YEAR OLD WOMAN WITHIN A
FEW MONTHS OF PITUITARY IRRADIATION
G. Beamond, K. Murray, P. Keston, C. Sudlow
University of Edinburgh, Edinburgh, United Kingdom
Cranial irradiation is associated with increased stroke risk, usually years after
exposure. We describe a 33 year old female with recurrent ischaemic strokes,
starting only 4 months after cranial irradiation.
She presented initially with acromegaly and a pituitary macroadenoma on MR
brain scan. After transphenoidal hypophysectomy, she received octreotide and
45Gy of radiotherapy to the pituitary bed in 25 fractions over 5 weeks. Subsequent
hypopituitarism was treated with DDAVP, hydrocortisone, thyroxine and the oral
contraceptive.
4 months later she developed sudden onset apraxia, agnosia, acalculia and agraphia,
16th European Stroke Conference
transient episodes of right arm jerking, right-sided weakness and dysphasia. MR
brain scan, MR angiography and CT angiography showed bilateral hemispheric
watershed infarction, complete occlusion of the cavernous sinus portion of the right
internal carotid artery (ICA) and severe stenosis of the intracavernous left ICA. She
had no vascular risk factors, and investigations for causes other than radiotherapy
were negative. She received aspirin and then warfarin. Her neurological deficit
almost completely resolved over the next few weeks, and subsequent CT perfusion
scan showed good perfusion bilaterally. 11 months after her initial strokes, warfarin
was discontinued and aspirin re-started. She re-presented 2 weeks later with further
left hemisphere ischaemic strokes and radiological evidence of complete occlusion
of both intracavernous ICAs. Warfarin was re-started. Several months later she had
residual language difficulties and mild right upper limb dysfunction.
We assume that her recurrent strokes are due to large artery radiation-induced arteri-
tis with associated thromboembolism. Such early development of this complication
has not been described previously.
3 Interesting cases
HEAD POSITION DEPENDENT VERTEBROBASILAR TIA’S
A.A. Weck, H. Hungerbühler, A. Mironov, G. Schwegler
Cantonal Hospital of Aarau, Aarau, Switzerland
Based on studies using duplex ultrasonography mechanical compression of the
extracranial vertebral artery (VA) during rotation of the head is not very rare, but
hardly ever symptomatic with signs of vertebrobasilar ischemia. As a general rule, to
become symptomatic prearranged anatomical conditions in the vertebrobasilar cir-
culation must be present: flow restriction in the contralateral VA (occlusion/severe
stenosis/hypoplasia) and lack of functioning posterior communicating arteries.
We report a 62 years old man who suffered from blurred vision after head rotation
to the right side. Back in the neutral position his visual symptoms resolved rapidly.
Driving car was a major problem for him due to impaired sight by turning his head
to watch the traffic on the right side.
Ultrasonography showed a normal right VA and a severe hypoplasia of the left VA
(1.2 mm diameter). Both posterior communicating arteries were absent. Transcra-
nial colour coded sonography documented a massive decrease of flow velocities in
the posterior cerebral artery during head turning to the right reproducing his typical
symptoms (video demonstration) and a transient reactive hyperemia of BFV above
baseline values by return to the neutral position. Angiography of the right VA was
normal in neutral position. By turning the head to the right, the VA became stenotic
at level C6-C7 (V2 entrance zone). After maximal head rotation the bloodflow
distal of the C6/7 segment stopped due to mechanical occlusion at that level. The
cervical spine CT revealed no relevant osteophyte formation at C5/6 and C6-C7.
We suggest a rotational obstruction due to extraluminal cervical fascial bands of
the longus coli muscle. Surgical evaluation is planned.
The TCCD monitoring of the posterior cerebral artery is a reliable and reproducible
method to detect cases of vertebrobasilar insufficiency dependent on head rotation
and mechanical compression.
4 Interesting cases
INTERNAL CAROTID ARTERY OCCLUSION DUE TO WEGENER’S
GRANULOMATOSIS
T. Das, W. Sunman, R.H. Harwood, J. Beavan, S. Munshi
Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
A 44 year-old male presented to the Emergency Department (ED) with profuse
epistaxis. Three months previously he was seen by otorhinolanrygologists for
left sided otalgia, tinnitus and hearing loss. They noted left middle ear effusion
and a polyp in the post-nasal space. Computed Tomography (CT) of the neck
demonstrated an ulcerated pharyngeal mass. A nasopharyngeal biopsy showed
a granulomatous lesion with central necrosis. A diagnosis of tuberculosis was
considered as he had severe ankylosing spondylitis and was being assessed for
anti-TNF therapy. He had no vascular risk factors.
In the ED, he developed sudden-onset aphasia and right hemiplegia, with a left
Horner’s syndrome. CT head scan showed a hyperdense left middle cerebral artery
and early signs of cerebral infarction. He had greatly raised inflammatory markers,
a mild anaemia and normal renal function. Electrocardiography, urinalysis and
chest X-ray were normal. His cANCA (PR3) level was high and indicative of
Wegener’s granulomatosis.
Magnetic Resonance Imaging showed a nasopharyngeal mass involving the hor-
izontal petrous carotid canal and occlusion of the left internal carotid artery
from its origin to the middle cerebral artery M1 segment. Catheter angiogram
showed no evidence of pseudoaneurysms in external carotid artery branches as the
cause of his epistaxis. He was treated with intravenous methylprednisolone and
Poster Session
Interesting cases
cyclophosphamide. However his aphasia and weakness persisted. Retrospective
analysis of his initial CT neck scan showed signs of inflammation within the left
carotid sheath.
Wegener’s Granulomatosis is a rare cause of central nervous system infarction,
usually due to small vessel vasculitis. We present a case of carotid artery thrombosis
related to extravascular granulomatous involvement of a large vessel. There is no
reported association between ankylosing spondylitis and Wegener’s granulomatosis.
5 Interesting cases
CLINICAL PRESENTATION OF INTERNAL CAROTID ARTERY
DISSECTION: REPORT OF 10 CASES
I. Divjak, M. Jovicevic, A. Jovanovic
Institute of Neurology, Clinical Centre Novi Sad, University of Novi Sad, Novi
Sad, Yugoslavia
Background: Internal carotid artery dissection (ICAD) is a recognized cause of
stroke, particularly in young adults. It may occur spontaneously or result from local
trauma. Clinical diagnosis may be difficult and the classical triad of symptoms is
uncommon. Imaging plays a pivotal role in the diagnosis of ICAD. The aim was to
analyze the spectrum of clinical presentation in 10 ICAD patients, with a special
emphasis put on a patient presenting with Horner’s syndrome and facial and neck
pain as the only symptoms of ICAD.
Methods: Ten patients with ICAD aged 35-45 (mean age 42.1 years) were
evaluated in the period January 2001 – December 2006. The ICAD diagnosis was
established using MRI, MRA and duplex sonography in all cases. In one case CT
angiography was additionally performed.
Results: Four patients presented with facial pain, Horner’s syndrome and con-
tralateral sensorimotor deficit. One patient presented with facial and neck pain and
Horner’s syndrome only. Five patients presented with contralateral sensorimotor
deficit, with or without speech impairment. Two patients had traumatic ICAD (one
while unloading sacks of corn and the other after sudden head turning) and other
eight patients had spontaneous ICAD. MRI revealed infarction in 9 patients, while
in the patient presenting with facial and neck pain and Horner’s syndrome diffusion
MRI did not show evidence of infarction. Good outcome (defined as modified
Rankin score of 0-2) was seen in all patients. Complete recanalization of ICAD
was associated with favorable prognosis.
Discussion: The spectrum of clinical presentation of ICAD is variable. ICAD is
not necessarily accompanied by infarction on diffusion MRI.
6 Interesting cases
BILATERAL SPONTANEOUS CAROTID ARTERY DISSECTION
H. Weitenberg, M. Uyttenboogaart, J. De Keyser, G.J. Luijckx
University Medical Centre Groningen, Groningen, The Netherlands
Background: Spontaneous carotid artery dissection is a cause of ischemic stroke
in the young. In this case we report a patient with spontaneous bilateral carotid
artery dissection.
Case: A previous healthy 40 year old man presented with an isolated Horner
syndrome on the right side. Several weeks before patient had an upper airway
infection. This was followed by a period of right sided headache. Besides the
Horner syndrome neurological examination was normal. MR angiography (MRA)
revealed a dissection of the right carotid artery from bifurcation to skull base with
a fresh trombus and a dissection with a double lumen of the left carotid artery.
To prevent tromboembolic complications patient was treated with antiplatelet
therapy for a year. Control MRA showed normalisation of the right and a slight
pseudo-aneurysm of the left carotid artery.
Discussion: The pathogenesis of spontaneous carotid dissection is at present
uncertain. If multiple vessels are involved fibromuscular dysplasia, Ehlers-Danlos,
Marfan syndrome, osteogenesis imperfecta and alpha-1-antitrypsin deficiency
should be considered. These conditions were ruled out in this patient. Recently
an association between spontaneous carotid artery dissection and upper airway
infection has been reported. Suggested pathophysiological mechanisms are local
infection of the arteries, or mechanical by sneezing. The higher incidence of carotid
artery dissections in autumn is an argument for the possible relationship with
upper airway infection. This case demonstrates that after excluding an underlying
connective-tissue disorder upper airway infection should be considered as a cause
of spontaneous bilateral carotid artery dissection.
Cerebrovasc Dis 2007;23(suppl 2):1–147 121
 7 Interesting cases
TRANSIENT ISCHEMIC ATTACK AND LIVEDO RACEMOSA –
ANTIPHOSPHOLIPID SYNDROME
L. Valdemar, A. Marinho, G. Lopes
Dept. Neurology, Hospital Geral de Santo António, Porto, Portugal
Background: The Antiphospholipid Syndrome (APS) is an autoimmune disor-
der characterized by persistently elevated titters of antiphospholipid antibodies,
associated to thrombotic events, without vasculitis, typically affecting females
(82%). Ischemic stroke is reported in 30% of the patients with APS, with transient
ischemic attacks (TIA) representing one third of them, but only 7% at disease
onset. Livedo Racemosa (LR) is a rare pathologic skin condition occurring in some
immunologic disorders. When associated to cerebrovascular disease it is called
Sneddon’s Syndrome (SS).
Case presentation: A fifty three years old male patient, with hypertension,
suddenly became nauseated, vomited, and had vertigo and disequilibrium. The
neurological examination showed dysarthria, right dysmetria and ataxic gait. He
also had an exuberant LR. He completely recovered from all symptoms and
signs in less than 24 hours. The cerebral MRI showed bihemispheric ischemic
leukoencephalopathy and no signs of acute ischemia with diffusion technique. High
and persistent titters of autoantibodies were found (anticardiolipin, antiB2GPI and
lupus anticoagulant). AngioMRI, transcranial Doppler, ultrasonography of cervical
and renal arteries, ECG, transesophagic echocardiogram and serologic studies were
normal. Anticoagulation was started.
Discussion: This patient, with a cerebellar TIA, presented as a SS and fulfils
clinical, imagiological and laboratorial criteria for APS with LR. Ischemic cere-
brovascular disease can be a manifestation of APS, but its association with LR is
rare. This clinical presentation, in a male patient, is even less frequent. Relationship
between SS and APS with LR is not clear, as these two entities are clinically
indistinguishable and classified as a continuous spectrum of a disease.
8 Interesting cases
AN UNRECOGNIZED CAUSE OF THUNDERCLAP HEADACHE:
REVERSIBLE CEREBRAL VASOCONTRICTION SYNDROME
K. Koopman, M. Uyttenboogaart, G.J. Luijckx, J. De Keyser, P.C. Vroomen
University Medical Centre Groningen, Groningen, The Netherlands
Background: An unrecognized cause of thunderclap headache (TCH) is Reversible
Cerebral Vasoconstriction Syndrome (RCVS). We describe 3 patients with RCVS.
Cases: Three women, aged between 40-55 yrs, presented with TCH. One patient
had a history of migraine with sumatriptan abuse and one had an exacerbation
of Crohn’s disease. SAH was ruled out by CT scan and CSF examination. MR
venography was normal. Brain MRI in 2 patients showed infarction in the posterior
regions. Cerebral angiography (DSA) showed diffuse beading in one patient. She
was suspected of having primary angiitis of CNS (PACNS) but did not respond to
treatment with immunosuppressants. All had increased velocities on TCD. RCVS
was diagnosed and they were treated with calcium channel inhibitors. This led to
clinical improvement and normalisation of TCD within weeks.
Discussion: RCVS is characterised by a reversible segmental vasoconstriction of
the cerebral vessels, most commonly occurring in women aged 20-50 yrs. It is asso-
ciated with conditions such as migraine, certain drugs and pregnancy. The striking
presenting feature is TCH, with or without focal signs. CSF is (near) normal, in
contrast to PACNS and SAH. Brain imaging findings vary between normal and
infarction, particularly in the posterior circulation. Segmental vasoconstriction on
DSA does not differentiate between vasculitis and RCVS. One of the hallmarks of
RCVS is the complete reversibility of vasoconstriction on TCD. Treatment is with
calcium channel blockers, in severe cases combined with prednisone.
These patient cases underline that (1) TCH, normal CSF, and MRI or angiographic
abnormalities may point to RCVS, (2) TCD is helpful in diagnosing RCVS and (3)
proper diagnosis of RCVS has important therapeutic consequences.
9 Interesting cases
BROCA’S APHASIA ELICITED BY WERNICKE’S AREA DAMAGED
Y. Zhang, N. Wie, H. Chen, N. Zhang, Y. Wang
Beijing Tiantan Hospital, affiliated with Capital University of Medical Sciences,
Beijing, China
Aphasia is one of the common symptoms in acute and chronic stroke patients, many
postmortem and radiologic studies have documented the pattern of associations
between brain lesions and aphasic syndromes, such as Broca’s aphasia is mainly
due to a lesion damaged of the left inferior frontal area, namely Broca’s area,
122 Cerebrovasc Dis 2007;23(suppl 2):1–147
Wernicke’s aphasia is usually associated with a lesion of the posterior part of the
lateral temporal areas, namely Wernicke’s area, conduction aphasia is associated
with lesion of the left arcuate fasciculus or of the left supramarginal gyrus, and so
on. However, we found that not all aphasia types met with the pattern.
A fifty-six man suffered from aphasia after stroke, he understanded what words
mean, but had trouble performing the motor or output aspects of speech, and he
couldn’t communicate through writing. The results of Western Aphasia Battery
showed he was Broca’s aphasia, but we found the damaged lesion was Wernicke’s
area instead of Broca’s area. On the other hand, we studied regional blood volume
(rCBV) and regional cerebral blood flow (rCBF), mean transit time (MTT), and
time to peak (TTP) of Broca’s area of the patient by perfusion-weighted imag-
ing, and compared with that of the contralateral hemisphere, we also measured
the metabolic rate of N-acetylaspartate (NAA), choline (Cho), and creatine (Cr)
by magnetic resonance spectroscopy, and compared the results with that of the
contralateral hemisphere. We found the Broca’s area were in a hypoperfusion and
hypometabolism state compared with the contralateral hemisphere, maybe this can
explain why the type of this case was Broca’s aphasia while damaged lesion was
Wernicke’s area. The aphasia case challenged the anatomy of aphasia theory.
10 Interesting cases
RECURRENT TRANSIENT ATAXIC HEMIPARESIS REVEALING A
HYPOGLYCAEMIC PARANEOPLASIC SYNDROME
P. Olivier, J. Zapf, P. Michel
Centre Hospitalier Universitaire Vaudois, Switzerland
Aim: We describe a patient presenting with recurrent ataxic hemiparesis as a
consequence of hypoglycaemia due to a benign pleural fibrous tumour.
Case description: A 80 year old hypertensive women with a history of a pleural
tumor resected 11 years earlier presented four episodes of mild transient right
hemiparesis and mild confusion upon awakening on four consecutive mornings.
On admission, mild right ataxic hemiparesis was present. At the end of her first
night in the stroke unit, worsening of the right ataxic hemiparesis and decreased
vigilance occurred.
Investigations: Head CT and CT-angiography were performed. Blood sugar, in-
suline, cortisol, C-peptide, insuline-like growth factor-I (IGF-I) and IGF-II were
measured. Thoraco-abdominal CT and PET were done.
Results: Cerebral CT with angiographic sequences didn’t reveal any abnormality.
Hypoglycemia of 1.2 mmol/l was detected during worsening and neurological status
normalized promptly with treatment. Recurrent hypoinsulinemic hypoglycaemia
(glycemia 1.0-2.2 mmol/L; insulin <2mUl/l (5.0-18.0); C-peptide < 0.30 ugL
(0.7-3.0)) was documented and required continuous glucose perfusion. Cortisol and
IGF-I were normal. IGF-II (740ng/ml) and "big IGF-II” fraction (212 ng/ml; 28.7%
of total IGF-II, N<15%) were elevated. An extrapulmonary tumor occupying most
of the right hemithorax was found, consistent with a benign pleural tumor on
PET. Thoracotomy revealed a benign pleural fibrous tumor of the fuso-cillary type,
identical to the one resected 11 years earlier. After complete resection, no more
symptoms occurred, and IGF-II and its fractions normalized.
Conclusion: This elderly lady presented with recurrent ataxic hemiparesis sug-
gestive of a lacunar warning syndrome. Demonstration of severe hypoglycaemia
during these episodes led to the detection of a fuso-cillary pleural tumor. This
stroke-imitating paraneoplastic syndrome was related to hypersecretion of a fraction
of IGF-II, and was completely cured by resection of the tumor.
11 Interesting cases
THREE CASES OF CEREBRAL PEDUNCULAR INFARCTION WITH PURE
DYSARTHRIA
G.S. Kim, J.H. Lee, S.A. Choi, J.H. Cho
NHIC Ilsan Hospital, Goyang Shi, Kyungki Do, South Korea
Background: Pure dysarthria can be seen in patients with stroke involving the
corticobulbar tract, usually at the lenticulocapsular, pontine base, or cortical areas.
Infarction of cerebral peduncle is rare. Its manifestation is dysarthria-clumbsy
hand or dysarthria-one arm weakness. Pure dysarthria due to cerebral peduncular
infarction is extremely rare. We experienced three cases of cerebral peduncular
infarction with pure dysarthria.
Cases: All cases showed inaccurate articulation in the labial sound than palatal or
lingual sound. One with left cerebral peduncular infarction showed slight impair
of right sided hopping in neurologic examination. The others with right cerebral
peduncular infarction showed dysarthria only. There is no severe stenosis of relevant
arterial system in magnetic resonance angiography. In short follow-up period, they
showed full recovery of symptoms.
Discussion: Dysarthria of infratentorial origin has been described in infarctions of
16th European Stroke Conference
the basis pontis and cerebellum. We also observed pure dysarthria in patients with
an infarction of the cerebral peduncle. Focal injury to corticobulbar tract within
cerebral peduncle seemed to be a possible cause of pure dysarthria.
12 Interesting cases
CEREBRAL INFARCTION IN ACUTE (MYELOMONOCYTIC) LEUCEMIA
AT INITIAL PRESENTATION
S. Koskina, A. Tavernarakis, I. Xydakis, E. Mamouzelos, E. Koutra, N. Matikas
Evangelismos Hospita, Athens, Greece
Acute leukemia (A.L) is a rare cause of stroke in young adults. We present the case
of a patient in whom stroke was the first manifestation of the disease.
The patient, a 48 years old woman,was admitted to the hospital to investigate
unremitting fever. Few days later, she suffered a stroke (left hemiplegia),and then a
second one (right hemiparesis and aphasia), and developped thrombosis of the left
superficial femoral vein. The patient didn’t have any known risk factors other than
a mild hypertension. Successive computerized tomography scans showed mainly a
hypodense area in the right temporo-parietal region.
Blood tests were performed, that revealed evidence of disseminated intravascular
coagulation (D.I.C.) and positive lupus anticoagulant,while other ancillary inves-
tigations, including lumbar puncture, thoracic and oesophageal cardiac ultrasound
and carotid artery triplex were normal.
Finally,the patient was diagnosed from a bone marrow biopsy,as having acute
myelomonocytic leukemia. Treatment was initiated, but the patient died two
months later from multiorgan failure and sepsis.
There are several mechanisms causing thrombotic episodes in acute leukemias.
D.I.C.,positive lupus anticoagulant or antiphospholipid antibody in serum, leucosta-
sis syndrome in leukemias with leukocytosis, or direct viral damage to endothelial
cells in virus induced leukemias are mechanisms encountered in the literature. The
particularity of the present case is the fact that stroke, probably caused by D.I.C.,
was the first manifestation of A.L.
Thus, it is of the utmost importance that young adults presenting with stroke, be
investigated thoroughly to diagnose any underlying hematologic malignancy and
initiate, as soon as possible,the apropriate treatment.
13 Interesting cases
ARTERIAL OCCLUSION AND STROKE AFTER CISPLATIN
CHEMOTHERAPY
K.A. Pasco, P. Hart
St George’s Hospital, London, United Kingdom
Background: Malignancy as a risk factor for cerebrovascular disorders and as a
thromboembolic risk is well described. Cisplatin, used alone or in combination,
has become standard treatment for various solid tumours. Side effects of cisplatin
include neurotoxicity and Goldhirsch et al first described the association of acute
stroke with cisplatin use in 1983, suggesting this agent increases ones risk of stroke
above that of the tumour alone.
Case reports: We describe three cases of acute ischaemic stroke post cisplatin
chemotherapy, all supported by clinical and radiological evidence. The cases are
aged 17, 36 and 44 years, two female; one male and each with different tumour
subtypes (neuroendocrine, cervical adenocarcinoma and medulloblastoma). All
received cisplatin based chemotherapy in conjunction with other treatment. All had
Middle Cerebral Artery (MCA) territory infarction 2-10 days post cisplatin therapy.
All had received more than two treatment cycles. In two cases arterial occlusion
was confirmed, in the third it was found to be highly likely.
Discussion: Cisplatin regimes are implicated in acute stroke and the mechanisms
may be multi-factorial. Our cases could be explained by direct cisplatin endothe-
lial toxicity and enhanced platelet aggregation thus leading to arterial thrombus
formation. Work also suggests that cisplatin predisposes to a hypercoagulable
state through an acquired protein C deficiency or increased von willebrand factor.
Other reports suggest cisplatin induced vasospasm through hypomagnesaemia. Ad-
ditionally, our cases demonstrate the close temporal relationship between cisplatin
administration and acute stroke onset in the absence of other cardiovascular risk
factors and support the suggestion that stroke tends to occur after several treatment
cycles. A review in 2006 identifying cisplatin use as a stroke risk factor, more
so than other chemotherapeutic agents, also found the MCA territory most often
affected, which lends further weight to our own case findings.
Poster Session
Interesting cases
14 Interesting cases
PRIMARY ANGITIS OF CENTRAL NERVOUS SYSTEM IN A PATIENT OF
ACQUIRED DEFICIENCY SYNDROME (AIDS), A CASE REPORT
A. Al Memar, N. Akhtar, A. Trip
Atkinson Morley Wing at St George’s Hospital London, London, United
Kingdom
Background: Cerebral vasculitis in patients infected with human immunodefi-
ciency virus (HIV) is usually secondary to infectious agents rather then HIV
itself. It is extremely rare to have cerebral vasculitis where no other cause can be
found and role of HIV is postulated in genesis of cerebral vasculitis. This is a
case report of 44-year-old, was diagnosed to have HIV in January 2005, when he
presented with features of fever headaches, night sweating and hairy leukoplakia.
He presented to us in December 2005 with the features of, personality change was
hemi paresis and cortical blindness. He had mild leukopenia of 3.7 ANA, ANCA
and other antibodies of vasculitic screen were negative. MRI- was suggestive of
gross abnormality involving left occipital lobe. Occipital lobe biopsy was consistent
with clear-cut vasculitis.
Methods: We compared the clinical and biopsy results between our case and
previously published cases.
Result: PCR and histological findings looking into the possibilities of HSV 1+2,
CMV, Adeno virus, VZV, JC virus and HIV were negative there was no evidence
of cerebral lymphoma. In the view of negative specific viral staining, and absences
of antibodies of vasculitic screen suggest the diagnosis of primary angitis of the
central nervous system in a patient infected with HIV.
Discussion: To our knowledge only eight cases are reported in literature in which
primary angitis of central nervous system was suspected to be associated with HIV.
This case Illustrates a rarity of condition but does raise the strong hypothetical
link between HIV and primary vasculitis. In our case histological studies were
compatible with a diagnosis of primary angitis of the central nervous system, but
the pathogenic role of HIV in the genesis of the vasculitic process cannot be
elucidated.
15 Interesting cases
FAMILIAL SNEDDON’S SYNDROME
S. Llufriu, A. Cervera, S. Amaro, A. Chamorro
Stroke Unit, Hospital Clinic, Barcelona, Spain
Background: Sneddon’s syndrome is a non inflammatory arteriopathy character-
ized by livedo reticularis and cerebrovascular disease. It is an uncommon cause
of stroke in young people and it has been associated to the Antiphospholipid
syndrome. It mainly occurs sporadically, although few familial cases have been
reported. In familial cases the most common pattern of inheritance is autosomal
dominant, although the gene responsible is not known.
Case report: A 34 year-old woman with right hemiparesis, progressive ataxia
since early childhood and frequent migraine attacks. In the last year, she had
experienced episodes of dizziness, and dysphagia. The neurological exam dis-
closed mild cognitive impairment, right hemiparesis, horizontal nystagmus and left
cerebellar signs. On clinical exam, prominent skin lesions -mainly in the thighs-
were consistent with livedo reticularis. Global atrophy, multiple and confluent
subcortical ischemic strokes and abundant microbleeds were found on brain MRI,
whereas angio-MRI, carotid ultrasonography and transesophageal echocardiogram
were normal. Prothrombotic states and antiphospholipid antibodies were ruled out
as appropriate. A skin biopsy was non specific. Two sisters and one brother had
livedo reticularis and a history of early-onset stroke (neuroimaging available). The
remainder sister had 2 abortions and livedo reticularis but not neurological deficits.
Her father died from a myocardial infarction at the age of 54.
Discussion: Sneddon’s syndrome is a devastating cause of stroke in the young with
few cases reported in the literature. We add a new family of this entity which its
main clinical findings, imaging and immunological traits are reviewed.
16 Interesting cases
INTRACRANIAL PRESSURE AND CEREBRAL BLOOD FLOW
CORRELATION
I. Voznjuk, M. Odinak, S. Golokhvastov, N. Tsygan
Military Medical Academy, Russian Federation
Background: Current imaging methods are unable to differentiate neuroinflamma-
tory processes such as endothelial activation. We imaged activated endothelium in
a mouse model of acute stroke using a novel iron oxide nanoparticle MRI contrast
agent - MNP-Psel - targeted to the adhesion molecule P-selectin.
Cerebrovasc Dis 2007;23(suppl 2):1–147 123
Methods: MNP-Psel was compared to the non-targeted iron oxide MRI contrast
agent Feridex. In ten C57 Black 6 mice the left middle cerebral artery was
transiently occluded for 30 minutes while a body temperature of 36.5 ± 0.5 C was
maintained throughout and after the procedure. 24 hours after reperfusion, six mice
were injected with MNP-Psel and four with Feridex at a dose of 2.8 mg Fe/kg.
MRI scans (T1, T2, and T2*) were obtained at 9.4 T, and infarct was identified
from T2 maps. Subtraction images (pre-contrast – post-contrast) from T1 maps, T2
maps and T2* were obtained at 1, 36, 72 and 108 minutes after contrast injection.
Changes in T1 and T2 values in the contralateral hemisphere were subtracted from
the stroke hemisphere to reveal the infarct tissue-specific contrast accumulation
effect. After imaging, the mice were euthanized and brain sections through the
cortex and striatum were taken for iron histochemical staining by the Prussian blue
method.
Results: MNP-Psel and Feridex had similar T1 effects. T2* images demonstrated
a peri-infarct prolonged contrast effect with MNP-Psel but not Feridex. T2 sub-
traction maps revealed a prolonged MNP-Psel infarct-specific contrast effect not
seen with Feridex. Iron staining on vessel walls in the infarct hemisphere indicated
endothelial localization of the MNP-Psel contrast agent.
Discussion: Injection of MNP-Psel, but not Feridex, resulted in a prolonged infarct-
specific iron oxide contrast effect associated with endothelial iron accumulation.
This suggests that MNP-Psel accumulated in infarct and peri-infarct areas via
P-selectin-binding on activated endothelium. This demonstrates the feasibility of
using MRI to image specific neuroinflammatory processes that contribute to the
evolution of stroke injury.
17 Interesting cases
“PERIPHERAL” VERTIGO OF “CARDIAC” ORIGIN. TWO CASES OF
CARDIOEMBOLIC PICA INFARCTS, ASSOCIATED WITH PFO,
PRESENTING AS A MISLEADING ISOLATED VERTIGO
S. Beretta, P. Santoro, C. Ferrarese
University of Milano-Bicocca, Monza, Monza (MI), Italy
Background: Isolated vertigo as a manifestation of acute cerebellar infarct in the
posterior inferior cerebellar artery (PICA) territory was first reported by about 25
years ago. Nonetheless, this presentation of cerebellar strokes still represents a
clinical challenge, especially in young patients.
Results: We report two cases (man, age 48; woman, age 59) presenting with
stereotyped-rotatory dizziness, nausea, vomiting, inability to stand unaided and
nystagmus, which were evaluated in the ER by a ENT and a neurologist and were
admitted to the ENT department with the diagnosis of “peripheral vertigo”. Such
initial manifestation was followed by delayed neurologic signs within 2 days after
the onset. An acute, large inferior cerebellar ischemic stroke due to occlusion of
the right PICA was demonstrated by CT scan in both cases. Both patients were
admitted to the acute stroke unit and received treatment with antiplatelet agents and
osmotic diuretics. Both cases demonstrated no evidence of atherothrombosis in the
cerebral arteries, normal heart rhythm and morphology, except from a significant
patent foramen ovale (PFO). Both patients recovered completely within 3 months
and underwent a successful percutaneous closure of PFO.
Discussion: Early diagnosis of cerebellar infarction simulating vestibular neuritis
is difficult and these patients are likely to be excluded from rtPA therapy. Carefully
looking for subtle neurological signs and the eventual use of diffusion weighted
MRI may overcome this problem in selected patients. Finally, PFO needs to be
investigated as a potential cause of this disorder in young patients.
18 Interesting cases
CARDIAC AMYLOIDOSIS - A RARE CAUSE OF TRANSIENT ISCHAEMIC
ATTACK (TIA)
D.M. Collas
Watford General Hospital, Watford, Hertfordshire, United Kingdom
Introduction: A 41-year old male with a TIA is presented.
Method: After an initial 30 minute episode of motor and sensory loss in the right
arm and leg the patient re-presented within 24 hours with a stroke involving face,
arm and leg. Limb weakness resolved within 1 hour and facial weakness within
1 day, mild dysarthria persisting. There had been right amaurosis 6 weeks before,
and 1 week of mild confusion, 1 month of lethargy, knee pain, and weight loss
and urticarial rash over a 5 month period. He had a cholesterol of 6 but no other
common risk factors for stroke, being a normotensive non-smoker.
Results: Computed tomography (CT) revealed a left striato-capsular infarct with
mild mass effect confirmed on magnetic resonance imaging (MRI), with signal
increase on diffusion weighting, and normal carotids on duplex scan and MR
angiography. Erythrocyte sedimentation rate (ESR) was 40 but C-reactive protein
124 Cerebrovasc Dis 2007;23(suppl 2):1–147
(CRP) less than 3 and tests for vasculitis and thrombophilia were negative.
Electrocardiogram (ECG) showed sinus rhythm with right bundle branch block
and echocardiogram a hyperechoic myocardium with restricted filling. Cardiac
MRI showed global wall thickening, oedema suggesting an inflammatory process,
global subendocardial late enhancement characteristic of amyloid [1], and impaired
diastolic function. There was an IgG lambda paraproteinaemia with partial immune
paresis and 20% plasma cells in bone marrow. Serum amyloid protein scan showed
no visceral deposition and rectal biopsy was inconclusive.
Discussion: Systemic symptoms preceding amaurosis and a contralateral TIA and
an abnormal echocardiogram gave a clue to a rare cause of cardio-embolic stroke,
primary amyloidosis. This was confirmed by cardiac MRI, bone marrow and serum
electrophoresis. Anticoagulation is indicated despite sinus rhythm in view of a 33%
risk of cerebral embolism [2] due to impaired cardiac function
References: [1] Maceira AM et al. Circulation. 2005;111:186-93. [2] Hausfater P
et al. Scand J Rheumatol. 2005;34:315-9.
19 Interesting cases
POSTERIOR INFERIOR CEREBELLAR ARTERY DISSECTION CAUSING
ANEURYSM AND TRANSIENT ISCHEMIC ATTACK: ANEURYSM
DISAPPEARANCE AND PREVENTION OF RECURRENT BRAIN ISCHEMIA
WITH CONSERVATIVE TREATMENT. A CASE REPORT
D. Muentener, A. Mironov, A. Valavanis, R.W. Baumgartner, H. Hungerbuehler
University Hospital of Zurich, Zurich, Switzerland
Isolated spontaneous dissection of the posterior inferior cerebellar artery (PICA)
causing aneurysm formation is rare. Up to 70% present with subarachnoid
hemorrhage and remaining cases with ischemic events.
We present a 49 year old man with vertebro-basilar transient ischemic attack (TIA).
Magnetic resonance imaging showed two cerebellar DWI lesions in the territory
of left PICA with a normal MR angiography (MRA). Transforaminal duplex
sonography revealed a stenotic signal, but identification of the affected artery was
not possible. Digital subtraction angiography (DSA) performed 2 days after MRA
showed a stenosis and a fusiform aneurysm of the proximal left PICA likely due to
dissection.
The patient was treated with oral aspirin. One month later another vertebro-basilar
TIA occurred. Aspirin was replaced by oral anticoagulation. No further ischemic
event was observed in the next 12 months. DSA performed 6 months after symp-
toms onset showed complete resolution of the aneurysm, which retrospectively
confirmed the diagnosis of PICA dissection. Anticoagulation was discontinued.
We conclude that dissecting aneurysms of the PICA can resolve spontaneously.
Anticoagulation may be an efficient and safe treatment in patients with PICA
dissection causing TIA and aneurysm.
20 Interesting cases
ISCHEMIC STROKE AFTER CHEMOTHERAPY WITH CISPLATIN,
ETOPOSIDE AND BLEOMYCIN FOR A TESTICULAR NON-SEMINOMA
CARCINOMA: A CASE REPORT
M. Vikelis, M. Xifaras, A. Basta, G. Gekas
General Hospital of Nikea, Nikea, Greece
Background: Vascular toxicity associated with cisplatin-containing chemotherapy
for testicular cancer is a side effect that its frequency has not been described
precisely. Nevertheless, major vascular complications such as stroke, myocardial
infarction and pulmonary embolism seem to occur infrequently.
Case report: We present the case of a 37-year-old man that was treated with
a combination of cisplatin, bleomycin and etoposide (BEP) for a testicular non-
seminoma carcinoma. Two days after the first course of BEP he experienced
sudden-onset right hemiplegia with involvement of the lower facial muscles and
right homonymous hemianopia. A MRI-scan of the brain revealed an extended
infarction in the vascular territory of the right middle cerebral artery. Angiography
of the head and neck arteries revealed a completely thrombotic right internal carotid
artery. There was no evidence of coagulopathy, vascular, or endocardial disease that
may have led to a cerebrovascular accident and the patient had no known vascular
risk factor except for smoking. The time sequence between the chemotherapy
and the stroke clearly suggest a causal relationship between them in our patient.
Particularly, a cisplatin-related cause is probable, since such adverse effects are
unknown with bleomycin or etoposide.
Conclusion: Whereas a cause and effect relationship is probable for some vas-
cular events following chemotherapy, some cases may represent coincidence or
may be disease related. Several factors appear to be responsible for cisplatin
vascular toxicity, such as an increased thrombogenicity and vascular spasm due to
hypomagnesaemia. Potential late vascular toxicity has also to be taken into account.
16th European Stroke Conference
 21 Interesting cases
CEREBRAL LIPIODOL EMBOLISM WITHOUT PULMONARY
INVOLVEMENT DURING TRANSCATHETER ARTERIAL
CHEMOEMBOLIZATION
B.G. Yoo, J.K. Kim, J.H. Ko, E.G. Kim
Kosin University College of Medicine, Busan, South Korea
Background: Use of lipiodol in transcatheter arterial chemoembolization (TACE)
for hepatocellular carcinoma (HCC) treatment has been found to be associated with
a number of complications. However, cerebral lipiodol embolism has been rarely
reported. All of the reported cases of cerebral lipiodol embolism have pulmonary
involvement.
Case report: A 68- year-old woman with advanced HCC underwent a second
course of TACE at the hepatic artery using a mixture of 30 mL lipiodol. During
the procedure he had dysarthria and deteriorated consciousness, followed by status
epilepticus and semicoma. There was no breathing difficulty, and skin examination
was normal. Two hours later, MRI showed restricted diffusion in the cortex and
cortical-subcortical junction, both cerebral and cerebellar hemispheres. Two days
later, a follow-up MRI showed multiple cerebellar and cerebral infarcts with hem-
orrhagic transformation. A transcranial doppler with a bubble study demonstrated
a right-to-left shunt.
Conclusion: We report a patient with cerebral lipiodol embolism without pul-
monary involvement during TACE of HCC. TACE is not an innocent procedure
and clinicians must be alert to complications such as right-to-left shunt. To reduce
the risk of lipiodol embolism, a smaller lipiodol dose and survey for detection of
intracardiac shunt before the procedure can be considered.
22 Interesting cases
CROSSED CONDUCTION APHASIA: A CASE REPORT
Y. Zhang, Y. Liu, X. Zhao, C. Wang, Y. Wang
Beijing Tiantan Hospital, affiliated with Capital University of Medical Sciences,
Beijing, China
Conduction aphasia is known as a disconnection syndrome, and characterized by a
comparatively reduced ability to repeat spoken language and well comprehension.
According to Geschwind, conduction aphasia results from damage to the arcuate
fasciculus, one major pathways connects Broca’s and Wernicke’s areas. Both
Broca’s and Wernicke’s areas are left intact. We found that not all conduction
aphasia cases met with these standards.
A 50 year-old highly educated, right-handed man suffered from aphasia after stroke.
And he had fluent paraphasic expression, severe impairment of repetition and poor
comprehension without motor impairment. Western Aphasia Battery showed that
he was conduction aphasia, and the damaged lesion was right hemisphere, thereby,
he was crossed conduction aphasia case. We found that he had severe deficits
in repeating no-words and short memory capacity, although he failed to show
cognitive limitation in phonological output tasks.
By diffusion tensor imaging, we found that the fractional anisotropy (FA) values
of right arcuate fasciculus were smaller than that of the mirror side, that were
to say the right major pathways connects Broca’s and Wernicke’s areas were
damaged. On the other hand, we also found that the FA values of right Wernicke’s
area were smaller than that of mirror area, that means the Wernicke’s area was
also damaged, maybe this damaged can explain why the case had fluent output
and poor comprehension and his language disorders liked Wernicke’s aphasia,
that were to say he was “Wernicke-like” crossed conduction aphasia. The case
proved that three supposes of conduction aphasia:Wernicke-Geschwind’s theory
of disconnection, the defect pattern of auditory-speech shorten memory and the
Bidirectional pattern.
23 Interesting cases
STROKE IN THE PUERPERIUM AND PERI-PARTUM PERIOD
K.M. Tan, A. Carroll
National Rehabilitation Hospital, Rochestown Avenue, Dun Laoghaire, Co.
Dublin, County Dublin, Ireland
Stroke in the puerperium and peri-partum period, although rare, causes devastating
consequences. The following are 3 cases.
Case 1: A 28 year old woman with an acute right frontal headache developed
left sided weakness 10 days post caesarean section. CT brain showed right basal
ganglia, internal capsule and parietal infarcts. CT angiogram showed right carotid
dissection. Intravenous heparin was commenced followed by warfarin.
Case 2: A 32 year old woman had a severe headache, nausea and vomiting in
Poster Session
Interesting cases
the second stage of labour. Three hours post delivery she developed left sided
weakness, left homonymous hemianopia and a GCS of 11/15. CT Brain showed a
large intracranial haemorrhage in the right basal ganglia.
Case 3: A 39 year old woman with a severe headache and systolic blood
pressure of 200mmHg eight days post-partum, developed left sided weakness.
CT Brain showed infarction in the right middle cerebral artery territory. CT
angiogram showed bilateral carotid dissection. Intravenous heparin was started and
subsequently warfarin.
Five weeks later she had a new headache in her right temple. MR angiogram showed
further occlusion of the right vertebral artery. Intravenous methylprednisolone was
started followed by oral prednisolone in view of possible recurrent inflammatory
process.
All 3 women improved. Each patient could walk independently with residual
weakness to varying degrees. None had speech or swallow difficulties. One patient
had mild cognitive impairment not evident in everyday function.
The challenges in rehabilitation include strategies to cope with infant care, de-
pression in not participating fully in nursing and a fear of not being able to bond
with the newborn if hospitalised for a long period. It is vital that patients receive
rehabilitation as soon as possible.
24 Interesting cases
IRON DEFICIENCY ANAEMIA AND STROKE
J.C. Wöhrle, M. Silomon, M. Kaspers, R. Werner
Katholisches Klinikum Koblenz, Koblenz, Germany
Background: Stroke is a rare complication of iron deficiency anaemia that may
be related to reactive thrombocytosis with thrombophilia or to impaired oxygen
delivery.
Case report: A 45 year-old woman had a severe right-sided hemiparesis upon
awakening resolving within 30 minutes. Subsequently, symptoms recurred and
progressed to hemiplegia and global aphasia on arrival in our stroke unit. She was a
cigarette smoker and had felt weak for the last 3 months; she had hypermenorrhagia.
Immediate cranial computed tomography showed early signs of infarction in the
territory of the left middle cerebral artery (MCA). In the presence of ubiquitous
high blood flow velocities, transcranial ultrasound revealed a significant reduction
in the left MCA (systolic/diastolic velocities 89/34 cm/s left vs. 193/77 cm/s
right). There were small hypoechogenic plaques in both proximal internal carotid
arteries. Thrombolysis was withheld because of severe microcytic anaemia with
haemoglobin 5.9 mg/dl and thrombocytosis (698.000/μl). We found iron deficiency
(iron 22 ug/ml, ferritin 4 ng/ml). Screening for thrombophilic factors and cardiac
embolism was negative. The patient received blood transfusions, low dose heparin,
and aspirin. Within days, sonography and MR angiography revealed normalized
flow patterns in both MCAs. Hypermenorrhagia remained the only cause of
anaemia. She became ambulatory, but had persistent Broca’s aphasia and a severe
spastic brachial paresis.
Discussion: While extracranial artery thrombosis is recognized as sequelae of
severe iron deficiency anaemia (e.g. Caplan et al. Neurology 1984), isolated
intracranial artery occlusion is exceedingly rare. Intracranial artery obstruction may
have been caused by embolism from proximal sites with complete resolution of the
original thrombus or by local MCA thrombosis.
25 Interesting cases
ISCHEMIC STROKE OR MULTIPLE SCLEROSIS RELAPSE AFTER 44
YEARS OF REMISSION?
Y.-M. Huang, O. Nordmark, M. Lee, H. Naver
Uppsala University Hospital, Uppsala, Sweden
Background: MS and stroke differ in many ways but share a final common
path with neuronal and axonal loss. It is not known how these diseases influence
each other, nor their coincidence or best strategy concerning therapy and stroke
prevention.
Here we report a patient with 60 years history of MS, complete neurological
remission for >40 years and progressive gait and balance problems with spasticity
for the last 5 years.
Case presentation: Woman born 1923, had at age 24, 27 and 29 right-sided optic
neuritis, at age 31, 32 and 33 episodes of vertigo and diplopia, and at age 33
an episode of slight left leg weakness and spasticity with minor sequelae. CSF
at age 31 and 33 showed slight mononuclear pleocytosis, normal protein and
glucose. ACTH courses given at age 31 and 33 had beneficial effect. After 1956,
she remained healthy till 2001 when gait and balance problems and left-sided
spasticity developed insidiously, making unaided walk difficult but she did not
consult physician.
Cerebrovasc Dis 2007;23(suppl 2):1–147 125

Fig. 1. Brain CT: slight bilateral signal changes in capsula externa.
In May 2005, she was seen in emergency room because of sudden expressive
dysphasia and confusion. Symptoms disappeared after 45 min. BP 170/80. When
83 and having UTI, she had head trauma after fall in Febr, 2006, followed by
increase left-sided hemiparesis. Brain CT: unchanged. CSF: >2 oligoclonal IgG
bands in CSF absent in serum. MRI showed on T2 multiple pericallosal lesions
(Fig. 1, A), on T1 no gadolinium enhancement (B) and no fresh ischemic lesions
at apparent diffusion coefficient image (C) but leucoaraoisis. After UTI treatment,
she was mentally intact but had severe gait and balance problems and spasticity
persistent at 10 m follow-up.
Questions:
1. Did the patient have stroke in 2001? TIA in May 2005?
2. Cause of left-sided hemiparesis in February 2006, stroke or MS relapse?
3. Best available management both from medical and social aspects?
4. How can imaging help in diagnosis?
26 Interesting cases
THROMBOLYSIS IN CAPSULAR WARNING SYNDROME (CWS): FOUR
CASE-REPORTED
R.M. Vivanco, A. Rodriguez-Campello, A. Ois, M. Gomis, C. Pont,
E. Cuadrado, J. Roquer
Stroke Unit, Hospital del Mar, Barcelona, Spain
Background: CWS, first described by Donnan in 1993, is characterized by
stereotyped episodes of motor or sensory deficit (usually more than 3 episodes
in 24 hours). It is associated with a high risk of imminent lacunar infarction
with permanent deficits resembling those of CWS in more than 40% of patients.
Pathophysiology of CWS has not been well characterized. Ischemia mechanism is
probably due to small vessel penetrating disease and hemodynamic factors associ-
ated as well as molecular mechanisms. Diffusion-weighted imaging (DWI) shows
acute lesions in majority of cases. There are no proven therapies for preventing
completed stroke in this unstable situation. The use of thrombolytic treatment was
not described previously in these cases. We report four cases of CWS treated with
fibrinolysis
Patients and methods: Four patients were evaluated between February 2005 and
December 2006 (0.5% of ischemic stroke). 3 of them were male (75%). Mean age
was 67.5 years. Hypertension was the main vascular risk factor. Stroke symptoms
were compatible with lacunar syndrome (motor pure or sensitive-motor), with mean
NIHSS 10. Number of episodes varied between 3 and 6 (mean 4). All patients were
treated with rtPA in the first three hours since last episode.
Results: 3 patients remained asymptomatic after treatment (mRS 0) and did not
present any other episode. One patient presented a new episode after the rtPA
with left hemiplegia (mRS 4). Blood pressure was monitored in all patients during
episodes and no decrease coinciding with the clinical worsening was observed.
In all patients laboratory tests, CT scan, non-invasive studies for carotid and
intracranial artery disease were normal. Atrial fibrillation was found in one patient.
126 Cerebrovasc Dis 2007;23(suppl 2):1–147
DWI was performed in three patients. The two asymptomatic patients with DWI did
not show any acute lesion. The other one showed acute lesion in AChA territory.
Conclusion: We suggest that fibrinolysis is a therapy to take into account in CWS.
DWI was normal in treated patients who recovered.
27 Interesting cases
MIGRAINE WITH AURA AS AN ISOLATED PRESENTING SYMPTOM OF
CEREBRAL VENOUS THROMBOSIS
R.E. Petrea, J.R. Romero, S. Seshadri, J. Viereck, V. Babikian, C.S. Kase
Boston University School of Medicine, Boston, MA, USA
Background: Headache is the most common presenting symptom of cerebral
venous thrombosis. In the majority of cases headache is a non-specific symptom
accompanied by other neurological signs.
Methods: Case report. A 27 year old right handed man presented to the emer-
gency department (ED) with a 30 minute headache with visual aura and sensory
symptoms. He reported a generalized, excruciating throbbing headache followed by
bright lights in front of both eyes lasting about 15 minutes. A tingling march from
the right side of his face down to his right upper and lower limbs progressed over
another 15 minutes. All deficits resolved completely in 30 minutes. He had a total
of four episodes only with visual aura and headache, the first one 2 months prior to
the ED presentation. Two of these episodes were evaluated by head CT (computer
tomography) and lumbar puncture both of which were normal. His neurological
examination was entirely normal.
Results: MRI (magnetic resonance imaging) of the brain revealed a hyperintense
signal on T1 and FLAIR sequences in the superior sagittal sinus suggesting
thrombosis. Tiny venous infarcts were seen in the parietal cortex bilaterally. MRV
(magnetic resonance venography) confirmed lack of flow in the superior sagittal,
left transverse and sigmoid sinuses, extending to the jugular bulb. Laboratory
work-up revealed a nephritic syndrome and an abnormal activated protein C
resistance. He was treated with anticoagulation with no recurrence of his headache.
Conclusions: New onset recurrent migraines with aura can be an isolated pre-
senting symptom of cerebral venous thrombosis. Any headache that progresses
in an unusual fashion should also prompt the consideration of cerebral venous
thrombosis and the appropriate imaging for diagnosis.
28 Interesting cases
EOSINOPHILIC VASCULITIS: A RARE CAUSE OF DOLICHOECTASIA OF
THE CAROTID AND INTRACRANIAL ARTERIES
M. Labuda, S. Lanthier
Université de Montréal, Faculty of Medicine; CHUM-Hôpital Notre-Dame,
Montreal, Canada
Background: Present in 12% of strokes, intracranial arterial dolichoectasia (IADE)
is associated with atherosclerosis and elastic tissue diseases, and attributed to
internal elastic lamina disruption. Goals: To clarify pathogenesis of IADE and to
stress the diagnostic challenge of eosinophilic vasculitis (EV).
Methods: Case report.
Results: A 46-year-old man presented in 2005 with <2-minute episodes of aphasia
and right limb tremor and weakness without altered vigilance. In 1999, similar
episodes were attributed to carotid and IADE and treated with warfarin for 6 months
followed by aspirin. He denied allergies and other neurological, constitutional or
systemic symptoms, except pruritus since 2003; investigation had shown skin
infiltration by lymphocytes and idiopathic blood eosinophilia. Physical exam was
normal, as well as brain MRI and 24-hour EEG witnessing episodes. Selective
brain angiography revealed progression of carotid and IADE and no arterial
stenosis. Temporal artery biopsy revealed trans-mural non-necrotic infiltration by
lymphocytes and eosinophils, multinucleated cells, and histiocytes forming a single
granuloma. Blood tests showed increased white cell count (14.8 x 109/l; 37%
eosinophils) and IgE level, negative HIV, aspergillus and hepatitis serologies, and
normal inflammatory, prothrombotic and vitamin B12 workups. Echocardiography,
thoraco-abdominal CT, abdominal CT-angiography, and stool exam were normal.
Skin tests indicated pollen and cat hypersensitivity. On bone marrow biopsy, cells
(50% eosinophils) had no chromosomal abnormalities. His neurologic symptoms,
pruritus and eosinophilia resolved with prednisone (1mg/kg/d for 4 months, tapered
over 3 more months). We did not find previous reports of EV with IADE.
Discussion: EV can cause IADE by disrupting the internal elastic lamina. In this
case, idiopathic blood and tissue eosinophilia is consistent with hypereosinophilic
syndrome, but vasculitis as the sole organ infiltrated by eosinophils is unexpected.
Differential diagnosis includes atypical Churg-Strauss syndrome.
16th European Stroke Conference
 29 Interesting cases
MYOCARDIAL INFARCTION DURING STROKE THROMBOLYSIS: A CASE
REPORT
M. Herrera, M.E. Erro, J. Gállego, R. Muñoz, B. Zandio, J.A. Villanueva
Hospital de Navarra. Pamplona, Pamplona, Spain
Background: One potential harm of thrombolytic therapy for brain infarction is
thrombolytic-induced breakup of thrombi (mostly in the heart or aorta) leading to
new strokes, myocardial damage or limb ischemia.
Methods: We report a patient who presented a myocardial infarction during stroke
thrombolysis.
Case report: A 78-year-old man was admitted to the neurology stroke care unit for
sudden aphasia and right hemiparesis. The NIH Stroke Scale (NIHSS) score was
15. Brain CT scan was normal. A transcranial doppler revealed left proximal ACM
oclussion.The ECG showed an atrial fibrilation with normal repolarization pattern.
The patient was started on tPA therapy 150 minutes after stroke onset. During drug
infusion, he developed hypotension, oxygen desaturation and bradycardia. He also
suffered neurological deterioration with somnolence, complete right hemiplegia
and left forced gaze deviation. An anaphylactic adverse reaction was suspected and
tPA infusion was stopped. A new CT scan ruled out brain hemorrhage. An ECG
was perfomed with signs of anterior acute miocardial damage. A thoracic CT scan
ruled out an arterial ascending aortic dissection. A coronary angiography confirmed
occlusion in distal territories of left anterior descending and circumflex arteries
and mechanical recanalization was unsuccessfully tried. Two days later a trans-
esophageal echocardiogram revealed an anterolateral myocardial infarction,dense
left atrial spontaneous echo contrast, non complicated atheromatosis in the aortic
arch, and no intracardiac thrombus.
Discussion: This patient had an ischemic stroke of a likely embolic origin from
an intraauricular thrombi; tPA therapy could have favoured the fragmentation of
this thrombi and thus facilitated a second-step coronary embolism. A shock during
fibrinolytic therapy should raise the possibility of this rare complication, confirmed
by a simple electrocardiographic recording.
30 Interesting cases
LEFT VENTRICLE NONCOMPACTION, MYOPATHY, DYSMORPHIC
FEATURES AND STROKE IN A YOUNG WOMAN
A. Mendes, F. Silveira, M. Garcia, E. Azevedo
Hospital S. João, University of Porto, Porto, Portugal
Background: Left ventricle noncompaction is a rare congenital cardiomyopathy
characterized by numerous prominent trabeculations and intratrabecular recesses
in the ventricles. Heart failure is the most common presenting condition. Other
manifestations include arrhythmia and thromboembolic events. We present a case
of stroke associated to noncompaction of left ventricle, unspecific myopathy and
some dysmorphic features.
Case report: A 20 years old woman was referred to our department for investi-
gation after having a left middle cerebral artery ischemic stroke with aphasia and
right hemiparesis. At 5 months of age she was diagnosed with a hypertrophic
cardiomyopathy. Since her 15 years she complained with limbs fatigue and muscle
spasms, and an unspecific myopathy was diagnosed after investigation including
electromyography and skeletal muscle biopsy. There was no relevant familial
history. She presented some dysmorphic features such as short stature, webbed
neck, low hairline at the nape of the neck and bilateral cubitus valgus. The
patient had a good mental state and recovered from the aphasia and most of
the right hemiparesis. There was evidence of a distal muscular atrophy in lower
limbs. Stroke investigation disclosed a left internal carotid artery (ICA) occlusion.
Ecocardiography and cardiac catheterism identified left ventricle noncompaction.
Blood investigations were negative, including for serologic, immunologic and
prothrombotic changes, as well as for muscle enzymes. Cariotype was 46, XX. She
started anticoagulation. Six months later she remained clinically stable, and there
was no recanalization of left ICA.
Discussion: Cardioembolism was the probable cause of stroke. Although left
ventricle noncompaction may be associated with neuromuscular involvement, like
in Barth syndrome, it doesn’t usually affect women. Her dysmorphic features
resemble Turner or Noonan syndromes, which could not be confirmed in this
case. To our knowledge, there is no description in the literature of the congenital
associations found in this patient.
Poster Session
Interesting cases
31 Interesting cases
POST-PARTUM CEREBRAL ANGIOPATHY: REPORT OF THREE CASES
J. Willeit, M. Furtner, M. Knoflach, T. Gotwald, S. Kiechl
Dept. of Neurology, Innsbruck, Austria
Background: The post-partum angiopathy (PPA) is a rare disease of unknown
etiology characterized by segmental vasoconstriction of medium-sized and large
cerebral arteries. No standard management has been established.
Methods: We report 3 cases with PPA, in whom serial magnetic resonance
tomography (MRT) and MR angiography were performed.
Results: All three women delivered a healthy child after an unremarkable preg-
nancy. They received dopamin agonists to suppress lactation. After hospital
discharge the patients complained of severe headache. Two developed seizures,
hemianopsia and hemiparesis. Blood pressure monitoring showed intermittent and
severe hypertension. The cerebral MRT demonstrated high signal intensity lesions
in the occipito-parietal/frontal region on T2-weighted and diffusion-weighted imag-
ing. Most of the lesions showed high signal intensity on ADC maps compatible
with vasogenic edema, and MRA showed narrowing of large and medium-sized
cerebral arteries. The results of extensive tests for cerebral vasculitis were negative.
In two of the patients, lowering of blood pressure was accompanied by complete
recovery of the neurological deficits and normalization of imaging findings. In the
last patient, blood pressure lowering was without any clinical effect. Aggressive
medical therapy including high-dose methylprednisolon and nimodipin resulted in
a gradual improvement.
Conclusion: These cases provide evidence that apart from hypertension, ergot
derivates might act as a trigger of PPA. PPA can be complicated by both va-
sogenic edema and ischemic stroke. The clinical course is highly heterogenous,
ranging from self-limited and fully reversible to vasculitis-like progressive forms.
Apart from blood pressure-lowering therapy some patients may require high dose
corticosteroids.
32 Interesting cases
DISSECTING FUSIFORM VERTEBRAL ANEURYSM IN AN ADOLESCENT:
ENDOVASCULAR TREATMENT
C. Semedo, M. Manita, J. Reis, P. Raimundo, P. Esperança, J.M. Cândido
Centro Hospitalar de Lisboa - Zona Central, Lisboa, Portugal
Introduction: Intracranial aneurysms are rare below 18 years old, corresponding
to less than 1% of all the treated aneurysms. Most centres handle no more than 1
case a year. Moreover, dissecting fusiform aneurysms of posterior circulation have
a difficult approach and have been traditionally treated by parent vessel occlusion.
Nowadays aneurysmatic stent placement, with or without coiling, has become a
valuable treatment option.
Case report: 15 years-old female patient with a right sided cervical and occipital
severe headache, thunderclapping, with nausea and dizziness, holding on for a
month in spite of oral analgesiae. The patient had no history of previous trauma
and had been otherwise healthy. Neurological examination was normal. The CT
revealed an isodense, calcified lesion in the right lateral-cistern and the MRI showed
to be probably a displasic aneurysm partially thrombosed with 13mm of diameter,
with light mass effect over the adjacent medullary side, continuous with the RVA
(right vertebral artery). The cerebral angiogram revealed a displasic/dissecting
fusiform aneurismatic formation of the distal RVA (V4), with PICA (posterior
inferior cerebellar artery) originating directly from the aneurismatic sac. A Leo
“stent” (4,5mmx20mm) was placed in VA between the two extremities, through all
the aneurism length, and after that partial occlusion of the remaining aneurismatic
sac was excluded with coils, with the purpose to induce the progressive thrombotic
occlusion of the residual sac, in order to protect PICA and allow collateral circula-
tion. The control angiogram, 2 days after, confirmed the complete exclusion of the
aneurysm, with the main vessel patency. The patient was discharged asymptomatic.
Clinical and transcranial doppler revaluation was normal 3 months after.
Conclusions: This is an interesting case combining an aneurysm in an early
age with an fusiform aneurysm difficult approach, turning it into a therapeutic
challenge. In these situations endovascular stent placement and embolization can
be an effective and safe method.
Cerebrovasc Dis 2007;23(suppl 2):1–147 127
 33 Interesting cases
LEFT VENTRICULAR PAPILLARY FIBROELASTOMA, A RARE CAUSE OF
POSTERIOR CIRCULATION INFARCTION
J. Damásio, R. Almeida, A. Furtado, L. Caiado, A. Tuna
Hospital Geral de Santo António, Oporto, Portugal
Background: Papillary fibroelastoma compromise approximately 7.9% of benign
cardiac tumours. They are most commonly detected on the cardiac valves, being
the intra-ventricular localization very rare. Although mostly asymptomatic, their
clinical manifestations may be sudden death, myocardial infarction or cerebral in-
farction of cardiogenic embolic source. The embolic mechanism may be explained
by one of two mechanisms: dislodgment of tumoral fragments or embolization of
fibrin thrombi that arise on the papillary surface.
Case report: A 68-year-old male, hypertensive, presented with sudden dysphagia,
dysarthria, gait disequilibrium, vertigo, nausea and vomiting. On neurologic exami-
nation he had rotatory nystagmus on lateral gaze; decreased right palatal excursion;
broad based stance and gait with right side deviation. Cranial computed tomography
(CT) revealed recent infarct on the right cerebellar hemisphere. The diagnostic
studies were normal except the transthoracic echocardiogram that disclosed an
ectopic, mobile mass with the stalk attached deeply in the left ventricular wall.
The patient started anticoagulation. A month later he was submitted to surgical
resection of the tumour. The histology revealed a papillary fibroelastoma. One year
later he was symptoms free, had a normal neurologic examination. There was no
evidence of recurrence of the tumour on control echocardiography.
Discussion: We report a case of posterior circulation stroke of cardiogenic embolic
origin as a first manifestation of very rare and treatable intra-ventricular papillary
fibroelastoma.
34 Interesting cases
ISOLATED INFERIOR SAGITTAL SINUS THROMBOSIS (ISST)
N. Tran, J. Silva
Hamilton General Hospital, McMaster University, Hamilton, ON, Canada
Background and purpose: The inferior sagittal sinus (ISS) is the rarest affected
area of cerebral vein thrombosis. Only one previous case of isolated inferior sagittal
sinus thrombosis (ISST) has been reported. We describe a new case of isolated
ISST.
Methods: A 70 year-old man presents with a four day history of decreased appetite,
global weakness followed by decreased level of consciousness. He had a witnessed
right sided focal motor seizure with secondary generalization. He was found with
right sided weakness, right facial droop, right sided hyperreflexia, drowsiness,
disorientation to time and was febrile (39.9 C). He also had features of frontal
lobe dysfunction including apathy, decreased insight and volitional activity. His
condition did not change despite empiric treatment with acyclovir, cefotaxime,
ciprofloxacin and levofloxacin.
Results: Initial CT-head showed frontal paramedian hypodensities. CSF demon-
strated elevated protein and pleocytosis, primarily lymphocytes. Auto-immune and
coagulation work-up were negative. Peripheral blood cell count showed leuko-
cytosis, mostly neutrophils, which improved spontaneously. No obvious systemic
malignancy was detected by imaging. MRI Head demonstrated high signal in
the superior and medial areas of the frontal lobes in the distribution of the ISS.
MR-Venogram showed attenuation of the ISS only. After anticoagulation treatment
the patient improved and managed to go home with some residual frontal lobes
dysfunction. Follow-up MRI showed improved ischemic area and incomplete
recanalization of the ISS.
Conclusion: Primary isolated ISST can present as a febrile non-infectious en-
cephalopathy. In our case, we were unable to demonstrate any particular etiology.
35 Interesting cases
STROKE AND EPIGASTRIC PAIN: CONSIDER AORTIC DISSECTION
S. Mavinamane, H.G. M Shetty, M. Robinson, K.R. Davis
University Hospital Wales, Cardiff, United Kingdom
Aortic dissection may rarely present with stroke and the diagnosis can be difficult
with atypical symptoms. Thrombolysing such stroke patients can be disastrous. We
report a patient with Aortic dissection who presented initially with an epigastric
pain and stroke.
A 73 year old hypertensive man, presented with a left hemiparesis and dysarthria
for 3 hours. He had epigastric pain for 2 weeks, which worsened significantly on the
day of admission. Examination revealed epigastric tenderness, dysarthria, and left
hemiparesis. The hemiparesis and dysarthria resolved completely by the following
128 Cerebrovasc Dis 2007;23(suppl 2):1–147
day. Investigations revealed anaemia (Hb-9.7) and deranged liver function tests
(Bilirubin-29, AST-99, Alkaline phosphatase-388). Initial chest radiograph, abdom-
inal ultrasound and CT brain were normal. The epigastrc pain persisted and he
developed headache, sweating and nausea, whilst his liver function tests gradually
deteriorated. On the tenth day as an inpatient, he suffered a brief episode of
syncope. A repeat ultrasound showed mild intrahepatic duct dilatation. A magnetic
resonance cholangiopancreatogram was performed which suggested a dissection of
the abdominal aorta. Subsequent CT angiogram confirmed type A dissection of
aorta extending from the aortic root to both common carotid arteries and down to
the right common iliac artery. He was commenced on beta blockers and surgical
repair was undertaken.
Aortic dissection can present deceptively and delay in diagnosis can be catastrophic
especially if thrombolytic treatment is given for treatment of the associated stroke.
Such an incident has been previously reported. Our case illustrates the need for a
high degree of suspicion in all stroke patients.
Recovery and rehabilitation
1 Recovery and rehabilitation
OPTIMISING REHABILITATION OUTCOMES FOR APHASIA FOLLOWING
STROKE THROUGH NEW LEARNING
H. McGrane
Queen Margaret University College, Speech and Language Sciences,
Edinburgh, United Kingdom
Many people with aphasia retain residual language impairments to varying degrees
of severity following rehabilitation. Currently there is no theory of rehabilitation
that explains the therapeutic process involved in the restoration of a damaged
language system. Therefore it is not possible to discern what approaches/tasks
would be most successful at restoring particular language functions. Does rehabili-
tation facilitate the accessing of the damaged language system or could it involve
new learning resulting in the creation of new language representations? The main
objective of this study was to investigate whether adults with aphasia could learn
new vocabulary. The methodology incorporated procedures based on evidence from
the literature in order to facilitate and promote optimum learning. The novel stimuli
(20 new words) were taught to 12 adults (<65 years) who presented with varying
degrees of severity of aphasia. The training procedure incorporated learning theory
and a cognitive neuropsychological model of language. The immediate and delayed
recall of this vocabulary was investigated using a range of assessments to facilitate
the capture of new learning which was measured not only in terms of the accurate
production of the stimuli but also the recognition and knowledge of the word
forms and meanings. Overall findings of this investigation with the presentation
of select case studies demonstrate the ability of people to learn new language
representations despite severe language impairment. The findings, which strongly
suggest that language rehabilitation could incorporate the process of new learning,
have significant clinical relevance in terms of developing a theory of rehabilitation
and to the procedures employed in speech and language therapy.
2 Recovery and rehabilitation
EFFECT OF RHYTHMIC AUDITORY CUES ON GAIT OF STROKE PATIENTS
S.I. Lin
National Cheng Kung University, Tainan, Taiwan
Introduction: Sensory regulation is a feature of bipedal locomotion control. For
patients with chronic sensory loss, it is not clear if the way sensory inputs are
used for locomotion control would be altered. This study examined if the use of
rhythmic auditory cue (RAC) for locomotion control was affected by the residual
proprioceptive function in patients with chronic stroke.
Methods: Fourteen chronic stroke patients went through a joint repositioning test
of the knee and ankle, and were classified into intact and impaired joint position
sense (JPS) groups. EMG activity and peak joint angular acceleration of the
affected leg during two walking conditions, normal and with RAC, were recorded
and compared. In RC, subjects were asked to match their foot-floor-contact with a
beeping tone delivered by a metronome.
Results: Walking speeds did not differ significantly between the two conditions
or the two patient groups. Compared to normal condition, RAC had shorter EMG
activation time in patients with impaired JPS, but not in patients with intact JPS.
Stride characteristics did not differ significantly between walking conditions or the
two patient groups.
Discussion: Chronic stroke patients were found to use RAC to regulate locomotion.
16th European Stroke Conference
However, the effect of RAC was not equal between patients with intact and
impaired lower extremity JPS: walking with cues lead to shorter EMG activation
time in patients with impaired JPS, but not in patients with intact JPS, compared to
walking without cues. These findings imply that after chronic sensory loss, changes
in sensorimotor processing for locomotion might have occurred and affected the
use of augmented sensory cues. Thus clinically, instead of using augmented sensory
inputs routinely, their use should be planned and effects carefully monitored.
3 Recovery and rehabilitation
THE EFFECTS OF TYPE AND INTENSITY OF PHYSIOTHERAPY ON
LOWER LIMB STRENGTH AND FUNCTION AFTER STROKE
E.V. Cooke, R.C. Tallis, S. Miller, V.M. Pomeroy
St. George’s University of London, London, United Kingdom
Background: Stroke survivors often have permanent residual motor impairment.
This may be due to a sub-optimal dose of conventional physical therapy (CPT) and
the discouragement of strength training. However, experimental evidence suggests
that strength training might be beneficial. Hypothesis: adding functional strength
training (FST) to CPT improves muscle function, gait and functional mobility more
than either CPT alone or CPT plus “neuro-facilitation” (NF).
Methods: Multi-centred randomised controlled observer-blind trial. Subjects were
within 3 months of stroke with the ability to voluntarily move their paretic lower
limb. A power calculation estimated sample size as 102. Subjects underwent
baseline measurements before being allocated randomly to; CPT; or CPT + NF;
or CPT+FST for 6-weeks. All additional therapy was provided up to1-hour/day,
4 times/week. Outcome measures were made at 6 weeks after baseline. Measure-
ment battery included: muscle strength; walking speed; and functional mobility
(Rivermead). Analysis followed the intention to treat principle. Data, outcome
minus baseline, was tested for differences between groups using the Kruskal-Wallis
test. Results: 109 subjects were recruited. Mean age was 68.3 (SD12.03) years.
The attrition rate was 8.3%. Only Rivermead data is reported here. Median (IQR)
change in Rivermead score following intervention was 5.0 (9.7) for control, 6.5
(14.3) for NF and 7.0 (13.7) for FST. The Kruskal-Wallis statistic was 1.06
(p = 0.59). Discussion: Immediately after intervention no statistically significant
differences were found between groups for functional mobility, however there was
a trend towards CPT + FST. Muscle strength (for which the trial was powered) and
gait data are currently undergoing analysis.
4 Recovery and rehabilitation
MOTOR NETWORK CHANGES AND FUNCTIONAL RECOVERY IN STROKE
PATIENTS TREATED WITH VERY EARLY MOBILISATION IN AN ACUTE
STROKE UNIT. A LONGITUDINAL FUNCTIONAL MRI STUDY
T. Askim, B. Indredavik, S. Mørkved, O. Haraldseth, A. Håberg
Norwegian University of Science and Technology, Trondheim University
Hospital, Trondheim, Norway
Background: Functional MRI (fMRI) might elucidate mechanisms of brain plas-
ticity. The aim of this study was to investigate the relationship between functional
recovery and brain activation patterns after an acute stroke.
Methods: 14 patients (62-75 years) with first ever ischemic stroke and unilateral
hand paresis, but intact language were included. 16 age and gender matched
controls were also investigated. All patients were treated in an acute stroke unit
with very early mobilisation and early supported discharge. They underwent MRI,
fMRI and functional tests 4-8 days from onset and after three months. fMRI
paradigms were 1 Hz and self-paced (SP) index finger tapping.
Results: No patients had infarction involving primary motor cortex (M1). There
was significantly improved hand function as measured by all functional tests. 1 Hz
task: Patients in the acute phase activated more prefrontal regions than the controls.
There was increased activation in contralateral thalamus, anterior cingulate cortex
and ipsilateral prefrontal cortex for patients in the chronic compared to the acute
phase. SP task: Controls had significantly larger activation in contralateral M1
and ipsilateral cerebellum than patients in the acute phase. In the chronic phase
patients had increased bilateral M1 activity compared to the controls. There was
increased activity in contralateral M1 for patients in the chronic compared to the
acute phase. Discussion: For the 1 Hz task the difference in activation between the
chronic and the acute phases did not involve increased activation in motor areas,
but encompassed other cortical regions. This was at great variance to the results
from the SP task. These findings indicate that the injured brain adapts to different
motor task demands using different networks.
Poster Session
Recovery and rehabilitation
5 Recovery and rehabilitation
FACTORS PREDICTING EARLY HOSPITAL DISCHARGE FOLLOWING
ADMISSION FOR ACUTE STROKE
J. White, L. Dacey, R. Navaratnasingam, M. Wani
Morriston Hospital, Swansea, Cardiff, United Kingdom
Background: Reducing hospital length of stay following admission for acute stroke
has economic benefits for the healthcare provider. However, identifying patients
suitable for a reduced length of stay with early supported discharge is difficult at
the time of admission. This study explored the relationship between clinical and
social characteristics at the time of admission, with length of hospital stay for acute
stroke inpatients to predict a safe early discharge.
Methods: A retrospective case control study of all patients admitted with acute
stroke to a UK hospital, over a 3 year period. Patients were categorised into two
groups, those requiring a 10 day or less hospital admission and those requiring
longer. 23 separate clinical and social characteristics were assessed to evaluate their
impact on length of hospital admission.
Results: 359 patients, mean age 76.2 years, mean length of stay 54 days (median
24 days), mean Barthel Score on admission 10.8.
Ten factors, on admission, were independently associated with a reduced length
of stay: CT brain scan showing no sign of haemorrhage, (odds ratio (OR) 11.07
(95% confidence interval (CI) 1.87 to 65.11)); no receptive dysphasia (OR 7.59 (CI
1.98 to 29.03)); no sensory deficit on admission (OR infinite (CI 5.49 to infinite));
no hemi neglect (OR infinite (CI 5.72 to infinite)); sinus rhythm (OR 2.72 (CI
1.35 to 5.49)); living with support prior to admission (OR 2.52 (CI 1.49 to 4.26));
Functional Ambulation Categories (FAC) score ≥4 (OR 10.68 (CI 6.23 to 18.31));
Barthel Score ≥19 (OR 12.32 (CI 6.63 to 22.88)); and urinary continence (OR
11.98 (CI 5.66 to 25.29)).
Discussion: This study has identified 10 clinical and social factors present at
admission that may help identify patients who could be potentially discharged early
from hospital, allowing prompt referral to early supported discharge teams and
other intermediate care services.
6 Recovery and rehabilitation
DIFFERENCES IN VISUAL ATTENTION BETWEEN HEMIPLEGIC SIDES IN
POSTSTROKE PATIENTS
S. Shimizu, M. Maeda, Y. Ikeda, H. Nagasawa
Faculty of Rehabilitation, School of Allied Health Sciences, Kitasato
University, Kanagawa, Japan
Background and purpose: We previously reported that visual attention in the
circumferential field in healthy persons was greater in the left lower field than in
the right upper field. The present study investigated differences in visual attention
between left and right hemiplegic sides based on simple reaction times (RTs) to
visual stimuli.
Methods: Participants were 10 stroke patients with right hemiplegia (RH group),
10 stroke patients with left hemiplegia (LH group), and 20 normal control subjects.
RTs were recorded using RT estimation software on a personal computer. Fixation
point and reaction stimuli were presented on a screen. Stimuli were presented at
one of 16 sites located on circles with radii of 1 cm or 11 cm; visual angles (VA)
were 2 degrees (VA2) or 20 degrees (VA20). Stimuli were randomly presented five
times at each site for a total of 80 trials, and the delay from presentation to the
subject pressing a key was recorded as RT. Stroke patients used their unaffected
hand to press the key, while half of the control subjects used their right hand (CR
group) and the other half used their left hand (CL group).
Results and discussion: In the comparison of the LH and CR groups, RTs for the
LH group were slower; however, no significant differences were observed between
stimuli positions. In contrast, the comparison of the RH and CL groups showed no
significant difference in RTs. For the RH and CL groups, RTs to left lower field
stimuli were significantly shorter than RTs to upper field stimuli. These results
indicate that patients with left hemiplegia may have decreased attention in all visual
fields compared to patients with right hemiplegia.
7 Recovery and rehabilitation
DEPRESSION IN CAREGIVERS OF LONG-TERM STROKE SURVIVORS
D. Varga, E. Boros, J. Kenez, Z. Nagy
National Institute for Neurology and Psychiatry, Budapest, Hungary
Objective: Caregivers of stroke patients’ may experience high levels of burden,
that can result in deterioration of the caregivers’ mental and/or physical health. Our
aim was to examine the prevalance of depression among caregivers.
Cerebrovasc Dis 2007;23(suppl 2):1–147 129
Methods: A sample of 87 stroke survivors and their informal caregivers was
studied. Caregiver burden was evaluated with Beck Depression Inventory and
Caregiver Strain Index. Patients’ functional, cognitive and behavioural status was
also assessed with a questionnaire yielding information pertinent to these items.
Results: 69% of caregivers of long-term stroke survivors suffered some kind
of depression. In 50% the patients’ serious residual functional status, in 77%
mental-behaviourial symptoms were mentioned as cause of depression. Presence
of both caused depression in 87% of caregivers. Patients generate high caregiver
burden are significantly older and had significantly higher volume of cerebral
infarction.
Conclusion: High percentage of caregivers suffer from depression. The level of
self-percepted burden was stronger associated to the patients’ mental-behaviourial
symptoms, than to the degree of their disability.
8 Recovery and rehabilitation
A PILOT STUDY INVESTIGATING THE COMPARISON BETWEEN
FAMILIAR AND UNFAMILIAR ENVIRONMENT ON PATIENT’S ABILITIES
TO COMPLETE AND PROCESS ACTIVITIES OF DAILY LIVING, POST
BRAIN INJURY
J. Scott
Hammersmith Hospitals NHS Trust, London, United Kingdom
Background: Cognitive impairment is common post-brain injury and is associated
with poor long-term outcomes. Environmental context is thought to impact on
cognitive processing, and it is possible that the venue where cognitive abilities are
assessed will influence the patients’ performance.
The Assessment of Motor and Process Skills (AMPS) is an observational tool used
to measure the quality of a person’s ability to perform activities of daily living,
based on normative data for age and injury.
Hypothesis: Patients’ will perform better in terms of cognitive ability, at home
compared to in hospital.
Objective: To compare the process abilities of patients with brain injury in hospital
and at home using the AMPS, with a same subject design.
Methods: Patients admitted with brain injury, who had cognitive impairment but
were orientated, were assessed in the hospital and at home within 48 hours using
AMPS. The scores for process skill (the skills needed to organize and adapt actions
to complete tasks) were compared at the end of the study.
Results: 7 out of the 8 patients assessed performed better within the hospital
context.
Median AMPS process score Interquartile range P
Home 0.16 0.2-0.54 0.05
Hospital 0.94 0.47-1.29
Discussion/Conclusion: The structure and lack of external stimuli may account
for the improved performance within the hospital context. Patients with cognitive
processing deficits performed better within the hospital setting. This implies that
the level of challenge therapists use to assess patients’ cognition through function
may need to be higher in hospital to ensure sufficient process ability at home.
9 Recovery and rehabilitation
THE EFFECTS OF CURRENT PHYSICAL THERAPY AND FUNCTIONAL
STRENGTH TRAINING ON UPPER LIMB FUNCTION AND
NEUROMUSCULAR WEAKNESS AFTER STROKE: A PILOT STUDY
C. Donaldson, R. Tallis, V. Pomeroy
St George’s, University of London, London, United Kingdom
Background: Scientific evidence suggests that functional strength training (FST)
might have a better effect than current physical therapy (CPT) on upper limb motor
recovery after stroke. Aim: to assess the feasibility and sample size for a clinical
trial to compare CPT and FST.
Methods: A randomized, single-blinded, clinical trial. Subjects were within 3
months of infarction (anterior circulation) with upper limb weakness. Subjects were
randomised into 3 groups. All received routine CPT. Control Group 1 received no
extra physical therapy (CPT), Group 2 received increased intensity (CPT+CPT),
Group 3 received CPT and FST. Intervention lasted 6 weeks. A treatment recording
form, developed by our team and validated in clinical practice, was used to stan-
dardise and record CPT. Measurements included: muscle strength, Action Research
Arm Test (ARAT) and 9-Hole Peg Test. Measurements were taken before treatment
began, after six weeks of intervention, and 12 weeks thereafter. Analysis: Attrition
130 Cerebrovasc Dis 2007;23(suppl 2):1–147
rate was calculated and differences between groups were analysed with descriptive
statistics. ARAT data was used to calculate the sample size for a Phase III trial.
Results: 30 subjects were recruited with an attrition rate=0%. No statistically
significant differences were found between groups, however there was a trend
for CPT+FST to produce greater improvement at a clinically relevant level: mean
ARAT change of +13 (CPT) and +22 (CPT+FST). The power calculation estimated
a sample size of 246 for a Phase III trial.
Discussion: Results of this pilot study suggest that increased intensity of CPT may
not further enhance motor recovery after stroke but adding FST to CPT might.
A Phase III trial is feasible using the methods of this study although a large
multicentre trial will be required.
10 Recovery and rehabilitation
MODIFIED OBSERVATIONAL PERSPECTIVE AND STROKE
REHABILITATION
L.M. Ewan, T. Haire, K. Kinmond, H. Chatterton, N. Smith, P. Holmes
Manchester Metropolitan University, Alsager, United Kingdom
Background and purpose: Motor imagery has been questioned as a neuropsy-
chological rehabilitation technique for stroke patients with structured observation
being proposed as a more valid approach (Holmes, 2006). Similar to imagery
however, observation conditions provide two spatial visual perspectives: first and
third person. Since there is evidence that the different perspectives are linked to
different brain activity, the use of each perspective may be moderated post-stroke.
The practical considerations of this change have not been examined experimentally.
This research explored observational visual perspective in individuals who had
experienced stroke to aid the development of observation-based rehabilitation
programmes.
Method: 21 individuals who had experienced stroke were matched against 19
individuals who had not had a stroke. Following ethical approval and full written
informed consent, a stroke and observation specific questionnaire was employed to
explore viewing experiences; specifically kinesthisis. Participants viewed DVDs of
activities of daily living from both visual perspectives.
Results: Non-parametric analysis indicated that individuals who had not had a
stroke showed a statistically greater preference for a first person visual perspective
and reported stronger kinesthisis with this perspective. In contrast, individuals
who had experienced stroke showed no preference for either perspective and were
generally unable to report kinesthisis with either the first or third person perspective.
Discussion: Stroke may lead to a change in preferred visual perspective and experi-
ence of observational kinesthisis as a consequence the lesion damage and functional
motor inactivity. Observation-based rehabilitation interventions may support neural
change. However, further research is required to investigate these changes linked
to individual differences in stroke aetiology. This study provides evidence that
visual perspective should be considered in all imagery and observation-based stroke
rehabilitation interventions.
11 Recovery and rehabilitation
FUNCTIONAL RECOVERY IN ISCHAEMIC STROKE PATIENTS YOUNGER
OR OLDER THAN 65 YEARS
J. Jansa, Z. Sicherl, K. Angleitner, A. Grad
University Medical centre Ljubljana,Ljubljana, Slovenia
Background: To compare duration of occupational therapy (OT), functional out-
come and quality of life in group of ischaemic stroke (IS) patients younger or older
than 65 years.
Methods: IS patients who were consecutively included into OT within early hospi-
tal stay and contacted three months after stroke; 24R-hemiplegia, 26L-hemiplegia;
31 males, 19 females. Assessment tools: Extended Barthel index (EBI), Canadian
Occupational Performance Measure (COPM) and EuroQol (EQ). They were done
during OT and at follow up.
Results: There were 25 patients younger than 65 years (mean 55 yrs, range 39-65)
and 25 were older than 65 yrs (mean 73 yrs, range 67-81). Mean duration of OT
in younger group was 15 days (range 4-54); mean duration of OT in older group
was 8 days (range 2-28). This difference was statistically important (p<0,007). The
EBI and EQ were assessed in the whole sample; we were able to follow client’s
priorities with COPM in 32 patients; 15 in younger group and 17 in older group.
Difference in EBI was statistically important from the first assessment to follow-up
in both groups (p<0,0001;p<0,0001);there were no statistically important differ-
ences among groups in initial or follow-up assessment (p=0.28; p=0.67). Difference
in EQ was statistically important in both groups (p<0,01;0,002);there were no
statistically important difference among groups (p=0,63;p=0,45). Regarding the use
of COPM; 32 patients (64%) of our sample expressed in total 87 activities. There
16th European Stroke Conference
were 15 patients from younger group and 17 patients from older group. 14 patients Management and economics
from each group named 58 activities (68%) of basic activities of daily living; 6
younger, 4 older expressed in total 14 (18%) issues of productivity and 5 from each
group named in total 14 (14%) leisure activities. 1 Management and economics
Discussion: Results showed that both groups need less help as measured by EBI.
Equally, the quality of life, as measured with EQ has improved. We were able COMPARISON OF BLOOD PRESSURE MANAGEMENT AFTER STROKE
to follow client functional priorities in both groups, although the younger group AND CORONARY EVENT. THE REDUCTION OF ATHEROTHROMBOSIS
received more OT. Further work is needed to clarify this issue. FOR CONTINUED HEALTH (REACH) REGISTRY
E. Touzé, J. Röther, D. Batt, F. Aichner, M. Alberts, M. Ohman, P. Durieux,
J. Coste, S. Goto, G. Steg
12 Recovery and rehabilitation Hôpital Sainte-Anne, Paris, France

A SERIES OF INVESTIGATIONS INTO SENSORY REHABILITATION POST
STROKE
S.L Hillier
University of South Australia, Adelaide, Australia
Background: Sensory loss post-stroke is well documented, however the role
sensation plays in the recovery of motor function is less understood. We have
conducted a series of clinical trials investigating different applications of sensory
input as part of rehabilitation post-stroke.
Methods: Firstly we have applied combinations of peripheral and central stimula-
tion to either the foot or hand in chronic and acute stroke rehabilitation participants.
The rationale is that such stimulation will excite the cortex and facilitate positive
neuroplastic responses to subsequent task specific training. The second series of
trials involved training awareness and appreciation of sensory input to the lower
limb post stroke. The rationale for these experiments was based more on a learning
or attention-training paradigm.
Results: Results from these trials offer some functional evidence that afferent input
is effective in driving recovery, however data from TMS investigations have been
less convincing. We found sensory appreciation could be improved via specific
training in chronic stroke participants but not as convincingly in acute. There
was also some preliminary indications that the increased sensory awareness led to
improved postural control in some participants.
Discussion: Our findings warrant further investigation and current studies are
exploring the relationship between sensory input in the lower limbs and functional
activity.
13 Recovery and rehabilitation
IS THE BIO-PSYCHOSOCIAL MODEL SUITABLE TO EXPLAIN THE
DEVELOPMENT OF DEPRESSION AFTER STROKE?
T.A. Barskova, G. Wilz
Technical University Berlin, Department of Clinical and Health Psychology,
Berlin, Germany
Background: Depression after stroke is common and increases morbidity and
mortality in the first years after stroke onset. Nevertheless little is known about the
role of psychosocial factors on the etiology of depression in early as well as in the
late poststroke stages. With reference to the bio-psychosocial model, the aim of
our study was to investigate the influence of stroke survivors’ mental impairment
as well as the quality of their social relationships on the development of poststroke
depression.
Method: The study used a longitudinal design. Eighty-one German stroke patients
were investigated twice, directly after discharge (on the average three month after
stroke onset) and one year later. Hierarchical regression analyses and cross-lagged
partial correlation analyses tested direct and indirect mediating effects of potential
predictors on poststroke depressive symptoms.
Results: Time 1 patients’ perceived cognitive and emotional functioning predicted
psychological depressive symptoms at time two. Quality of patients’ social rela-
tionships mediated the effect of the stroke-related emotional deficits on depression.
Discussion: In contrast to the previous research the study provided more evidence
for causal influence of different risk factors on PSD. Results support the biopsy-
chosocial model of poststroke depression. Early and late poststroke depression
seem are based on partially different etiological mechanisms.
Background: Management of blood pressure (BP) is not optimal in patients with
atherothrombotic diseases. We looked for differences in BP control and the use of
antihypertensive drugs in patients with cerebrovascular disease (CVD, including
stroke or TIA) and coronary artery disease (CAD).
Methods: 68,236 patients were enrolled in the REACH Registry, an international
(44 countries worldwide) prospective, observational study of patients with or ≥3
risk factors for atherothrombotic disease. Of these patients 12,153 had isolated
CVD and 33,611 had isolated CAD. At inclusion BP was measured and treatment
data were collected.
Results: There were no major differences in age, previous hypertension and other
risk factors between the CVD and CAD patient groups. However, CAD patients
experienced lower mean BP values, were more likely to have a BP<140/90 mmHg,
and to receive 3 or more antihypertensive drugs (34.2% vs. 22.7%, p<0.0001).
The use of 3 or more antihypertensive drugs was also more common in CAD
patients with elevated BP (≥140/90 mmHg) (39.4% vs. 26.2%, p<0.0001). After
adjustment for age, sex, other risk factors, and world regions, the CAD group
maintained significantly better control of BP (OR=1.4; 95%CI: 1.3-1.5, p<0.0001)
and the use of ≥3 drugs (OR=1.4; 95%CI: 1.3-1.5, p<0.0001). Similar trend was
observed across world regions.
CVD only (12,153) CAD only (33,611)
Mean age (SD) 68.9 (10.2) 67.8 (10.2)
Male, % 56.4 70.8
Previous hypertension, % 80.7 78.7
Mean systolic BP (SD) 140.2 (19.6) 134.5 (18.7)
All P values < 0.0001.
Conclusion: Blood pressure management is better after a coronary event than
after a cerebrovascular event. This result could be explained by the under use of
combination therapies in stroke patients compared to CAD patients.
2 Management and economics
US SURVEY OF STROKE NEUROLOGISTS AND
NEUROINTERVENTIONALISTS ON TREATMENT CHOICES FOR
INTRACRANIAL STENOSIS
T. Turan, M. Lynn, M. Chimowitz
Emory University School of Medicine, Atlanta, GA, USA
Background: We sought to determine the effect of an NIH-sponsored clinical trial
on treatment choices of physicians managing patients with intracranial stenosis.
Methods: Surveys of treatment choices were sent pre- and 1 year post-publication
of the Warfarin vs. Aspirin for Symptomatic Intracranial Disease (WASID) Trial
results. The pre-WASID survey was sent to neurologists and the post-WASID sur-
vey was sent to neurologists and neurointerventionalists. The post-WASID survey
included questions about the minimum benefit that physicians would require to
make stenting their treatment of choice. Data was analyzed using the chi-square test.
Results: There was a significant difference in the choice of antithrombotic agents
for the treatment of both anterior circulation (p<0.001) and posterior circulation
(p<0.001) stenoses after publication of WASID (see Table).
There was no significant difference in risk reductions required by neurologists
vs. neurointerventionalists for stenting to become their treatment of choice. For

Table 1. Antithrombotic choices before and after WASID

MCA or IC siphon % of MD % of MD Basilar or vertebral % of MD % of MD
pre-WASID post-WASID pre-WASID post-WASID
n=181 n=199 n=181 n=199
Warfarin 41 7 Warfarin 49 15
Antiplatelet 44 85 Antiplatelet 36 74
Combination 11 4 Combination 10 7
Other 4 4 Other 4 4

Poster Session Cerebrovasc Dis 2007;23(suppl 2):1–147 131

Management and economics
a primary endpoint rate of 20%/2 yrs in the medical arm (the rate in WASID
for high-risk patients with 70-99% stenosis), 33% of physicians required a 25%
reduction from stenting, 15% required a 33% reduction, 14% required a 40%
reduction, 21% required a 50% reduction, 13% required a 60% reduction, and 4%
would continue to use medical therapy regardless of the stenting rate.
Discussion: The results of WASID had a significant impact on physician treatment
practices. For high-risk patients with intracranial stenosis, 40% is the minimum
relative risk reduction required from intracranial stenting to make it the treatment
of choice for a clear majority (at least 60%) of physicians.
3 Management and economics
HOSPITAL DISCHARGE CODING UNDERESTIMATES BURDEN OF STROKE
M. Taylor, C. McAlpine, M. Walters
Stobhill Hospital, Glasgow and Western Infirmary, Glasgow, United Kingdom
Background: Hospital discharge coding is an important process which informs
health resource planning. During an audit project we noted a discrepancy between
the information services division (ISD) of the Scottish Executive numbers for
stroke disease workload and the numbers recorded by the local stroke consultants.
Methods: 280 stroke service discharges were reviewed from 2 different stroke units
during different time periods within the health board division. One doctor coded
them according to ICD10. The actual coding was then reviewed and compared to
this.
Results: 219 out of the 280 (78%) stroke service discharges had a final diagnosis
of stroke when coded by the doctor. Of those 219 only 166 (76%) of patients were
recorded as stroke by hospital coding. In particular, of those diagnosed as a lacunar
stroke (43 patients) only 23 (53%) were coded as stroke on discharge. Of the 61
diagnosed as “not stroke” by the doctor 19 had a “false positive” coding of stroke
by coders on discharge.
Discussion: There are several potential sources of error in the coding process. This
has major implications for both national stroke statistics and local stroke service
planning and resources. Urgent further work is required to identify the extent to
which “false positive” stroke codes are generated and whether this pattern of “false
negative” stroke coding is reproduced elsewhere.
4 Management and economics
FIRST IRISH NATIONAL AUDIT OF STROKE CARE
F. Horgan, A. Hickey, S. Murphy, M. Wiley, R. Conroy, H. McGee, D. O’Neill,
on behalf of the Irish National Audit of Stroke Care
Trinity College Dublin, Dublin, Ireland
Improving services for people with stroke represents a global challenge, espe-
cially in the light of the proven efficacy of many treatment modalities. The UK
National Sentinel Stroke Audit was a pioneer in developing a national profile of
hospital services for stroke. We report on the design of a project which builds
on this methodology, but which also profiles nation-wide preventive, community
rehabilitation and long-term care services for people with stroke.
The Irish Heart Foundation, in association with the Irish Department of Health
and Children, commissioned a national audit of stroke services in March 2006.
The project involves hospital audits, and community-based surveys of general
practitioners (GP), allied healthcare practitioners (AHPs), patients and carers, and
nursing homes.
All 37 public hospitals (100%) providing acute services to stroke patients are
participating in the.Organisational and Clinical Audit Proformas of the UK Na-
tional Sentinel Stroke Audit 2004. A random sample of 484 GPs were surveyed
by post and 46% responded. The AHP survey, involved interviews with regional,
disciplinary and nursing managers, and frontline staff, with 85% response. 200
people with stroke and a family member will be interviewed one year after
discharge using a questionnaire on health status and service needs and utilization,
as well as 200 people with stroke who have been discharged to nursing homes, and
a family member. Final results are due in September 2007.
This audit is of interest for two main reasons: it provides evidence of the feasibility
of using the UK National Sentinel Audit in another jurisdiction, but also provides
a methodology which allows for the measurement of availability of the full range
of services for people with stroke across the modalities of primary and secondary
prevention, acute treatment, rehabilitation and long term care. This global overview
is vital to the delivery of services across the full spectrum of stroke prevention and
care.
132 Cerebrovasc Dis 2007;23(suppl 2):1–147
5 Management and economics
PRIMARY CARE MEDICINE AND STROKE: THE IRISH NATIONAL AUDIT
OF STROKE CARE
D. O’Neill, D. Whitford, F. Horgan, M. Wiley, R. Conroy, S. Murphy,
H. McGee, D. O’Neill, on behalf of the Irish National Audit of Stroke Care
Trinity College Dublin, Dublin, Ireland
Primary care services have a key role in the prevention and management of stroke.
As part of the Irish National Audit of Stroke Care, a survey of general practitioners
(GPs) was performed to document the availability of evidence-based structures for
supporting stroke care and prevention in general practice and to profile the views,
experiences, and needs of Irish GPs in this context. In a cross-sectional study of
randomly selected GPs practising in the Republic of Ireland was surveyed by postal
survey.
Of the target sample of 484 GPs, 36 were ineligible and 204 responded (response
rate = 46%). Regarding the acute management of stroke, nearly a fifth of GPs (17%)
reported initially managing at least a substantial minority (20%) of their patients
at home. The majority of GPs viewed existing rehabilitation services for their
stroke population as inadequate. Overall, general practice showed little structured
organisation for long-term follow-up of stroke patients.
There was little or no organised system of care for the primary prevention of stroke
within primary care in Ireland. Three quarters of GPs believed there were barriers
to implementing secondary prevention strategies in their practiceJust over 60%
reported time as a barrier, 57% of reported staffing issues and almost a third (33%)
funding as barriers. Other barriers listed included lack of protocols/guidelines
(17%) and lack of space (almost 10%). The main barriers listed for secondary
prevention were very similar to those recorded for primary prevention.
There was little or no organised system of care for the prevention and management
of stroke within primary care in Ireland. However, there were encouraging signs of
development. GPs in practices involved in a national cardiac prevention programme
and those with good or excellent access to practice nurses were more likely to
engage in evidence-based activities to manage stroke.
6 Management and economics
EDUCATIONAL MULTIMEDIA CAMPAIGNS HAVE DIFFERENTIAL
EFFECTS ON PUBLIC STROKE KNOWLEDGE AND AWARENESS OF
INDIVIDUAL STROKE RISK
J.J, Marx, M. Nedelmann, B. Haertle, M. Dieterich, B.M. Eicke
Johannes Gutenberg-University Mainz, Mainz, Germany
Background: Aim of the study was to evaluate the educational effects of different
media in a multimodal educational program on public knowledge of risk factors
and warning signs of stroke.
Methods: Computer-assisted telephone surveys were conducted among an average
sample of 500 members of the general public, before and immediately after an
intense three months educational campaign in a German area of 400.000 inhabi-
tants. The multimodal educational program comprised of 400 poster advertisements
on billboards, busses, local emergency transport cars etc. Print media included
flyers dispensed in pharmacies and at the doctors’ office and mail circular to all
households. Slogans, stroke interest stories and interviews appeared regularly in
local newspapers, on television and radio, and several public events focussed on the
subject.
Results: Before the educational intervention stroke knowledge was generally low,
especially in men and elderly individuals. General knowledge of the nature of
stroke (65.7% correct answers before versus 84.9% after the campaign, p<0.01)
and the awareness of being at risk of stroke (32.7% vs. 41.9%, p<0.01) significantly
increased due to the campaign, especially in respondents of lower educational
Background: In contrast, there was hardly any effect on detailed knowledge of
specific stroke warning signs or different risk factors. Mass media were most fre-
quently reported as the main information source (66.5%). Information flyers were
also remembered by a high proportion of respondents (59.0%), while widespread
poster advertisements received far less attention (26.7%).
Discussion: Our data indicate that educational programs are effective in increasing
general knowledge of stroke in the public. They improve awareness of individual
stroke risk and this may influence behavior in acute stroke. Especially in indi-
viduals of lower educational background repeated information using short-tailored
messages presented in mass media proved to be effective. It is difficult, however, to
transfer detailed information by means of a large educational campaign.
16th European Stroke Conference
 7 Management and economics
THROMBOLYTIC THERAPY IN ACUTE ISCHEMIC STROKE IN TAIWAN
M. Tseng, K. Chang, J. Liu
National Sun Yat-Sen University, Kaohsiung, Kaohsiung, Taiwan
Background and purpose: Starting Jan 1, 2004, the use of intravenous recom-
binant tissue plasminogen activator (rtPA) in patients with acute stroke becomes
available for reimbursement from the National Health Insurance (NHI) Program
in Taiwan. The purpose of this study was to study the frequency of intravenous
rtPA for stroke treatment in Taiwan the first year after the reimbursement, and to
examine the characteristics regarding the usages in the health care system.
Methods: We studied the administrative claims data of NHI beneficiaries of 2004.
The compulsory and universal NHI covers more than 96% of the total population of
Taiwan since the implementation in March 1995. We identified patients treated with
rtPA by searching the database of Details of Inpatient Orders with the rtPA-specific
order code. The associated data of Inpatient Expenditures by Admissions were
examined.
Results: Among 90,550 admissions with cerebrovascular diseases in 2004, there
were 93 patients treated with rtPA. The mean age was 64.0 ± 11.0 years (range 35.5
to 82.4). Fifty-nine or 63% of patients were men, 69% had a Charlson comorbidity
index of 0, 27% 1, and 4% 2. Neurologists were admitting physicians for 66.7% of
patients. About one-forth of patients were treated in medical centers, 57% regional
hospitals, and 17% district hospitals. Median length-of-stay (LOS) was 10 days
(range 1 -136), and in-hospital death were found in one case (1.1%). Patients cared
for by neurologists as compared to non-neurologists had significantly lower median
LOS (8.5 versus 19 days, P = 0.016). Patients admitted into medical centers had
longer median LOS (16 days), as compared to regional hospitals (12) or district
hospitals (6) (Kruskal-Wallis test, P = 0.002).
Discussion: Intravenous rtPA was not widely applied within the first year following
reimbursement from NHI in Taiwan. Because the analysis was based on NHI
claims data, some important patient-level data, particularly initial stroke severity
and functional outcomes, were not available.
8 Management and economics
COST OF STROKE FOR SOCIETY IN YOUNGER PERSONS RECEIVING
REHABILITATION
A.K.S. Sunnerhagen, A.A. Björkdahl
Göteborg University, Göteborg, Sweden
Background and purpose: In recent years a number of costs of stroke studies have
been conducted based on incidence or prevalence estimating costs a given time.
As there still is a need for a deeper understanding of factors influencing the cost
the aim of this study was to calculate the direct and indirect costs for society in
a “younger” (<65) sample of stroke patients and to explore factors affecting the
costs.
Methods: 58 patients, included in a study home rehabilitation, were followed 1
year and interviewed about use of health care services, assistance, medicine and
assistive devices. Costs were calculated. A linear regression of cost and variables
of functioning, ability, community integration and health-related quality of life was
undertaken.
Result: Inpatient care contributed substantially to the direct cost with a mean length
of stay of 92 days. Rehabilitation during the first year constituted of in average 28
days in day clinic, 38 physiotherapy sessions and 20 occupational therapy sessions.
Total direct mean cost was 33 604 Euro and indirect cost 32 129 Euro. The direct
costs were influenced by the process skill (the ability to plan and perform a given
task and to adapt when needed) and presence of aphasia. Indirect cost for informal
caregiving increased for patients less health-related quality of life scoring low on
home integration.
Conclusion: Costs are high in this group compared to other studies partly due to
length of stay as well as loss of productivity.
9 Management and economics
DOES ORGANISATION OF STROKE CARE CORRELATE WITH RESEARCH
ACTIVITY IN STROKE?
D.F. Jenkinson, G.A. Ford, A.R. Rudd, A. Hoffman, G.D. Lowe
UK Stroke Research Network, Leazes Building, Royal Victoria Infirmary,
Newcastle upon Tyne, London, United Kingdom
Background: It is unclear whether participation of stroke services in research leads
to improved patient care, or conversely whether better organized stroke services
facilitate greater participation in research. We determined the association between
Poster Session
Management and economics
quality of organization of stroke care and research activity in stroke services in
England.
Methods: The 2006 National Sentinel Audit of Stroke assessed by questionnaire
the quality of stroke service infrastructure and included two questions on research
activity: (A) “How many stroke research studies are you involved in?”, and (B)
“How many Whole Time Equivalent staff are employed in stroke research?”. Data
were collected by local staff from 235 sites in England in April/May 2006.
Data analysis was performed using SPSS. As research activity formed part of the
total score for Organisation of Care, we did not compare with the total score. We
examined the association between responses to the 2 questions on research activity
with each of the other 9 domains of Organisation of Care.
Results: Correlation was shown at the 0.01 level (2-tailed) between responses to
the 2 questions research and the following 6 domains: acute care organisation,
organisation of care, interdisciplinary services (overall service), TIA/neurovascular
services, team working – agreed assessment measures and communication with
patients and carers. The strongest correlation was with acute care organisation
(Spearman’s rho 0.381 for research question (A) and 0.387 for question (B)). No
significant correlation was found with the domains interdisciplinary services (stroke
unit), team working (records) and team working – team meetings.
Discussion:
The significant correlation between quality of organization of stroke care and
research activity suggests that well organized stroke care facilitates stroke patient
participation in research and/or that participation of stroke services in research
facilitates improved services.
10 Management and economics
COST EFFECTIVENESS OF STROKE UNIT (SU) CARE FOLLOWED BY
EARLY SUPPORTED DISCHARGE (ESD)
Ö. Saka, V. Serra, Y. Samyshkin, S. Merkur, A.J. Mcguire, C. Wolfe
Kings College, London, Division of Health and Social Care Research, London,
United Kingdom
Introduction: Stroke is the second leading cause of death in England and Wales
and the leading cause of adult disability. Annual cost of stroke care in the UK
government is over £7bn including. SUs provide improved outcomes for stroke
patients with respect to non-stroke specialised hospital units. In addition to that
another trend has been ESD of some stroke patients. This allows inpatient beds to
be available for the care of stroke patients faster, decreases the necessary number
of expensive hospital beds to be maintained whilst providing further rehabilitation
care to stroke patients at home. We assessed the cost effectiveness (CE) of SU care
followed up by ESD (SUESD).
Methods: Data from the South London Stroke Register, and local ESD were
utilised for clinical and resource use data. The cost effectiveness of SUESD was
compared with with SU without ESD (SUNESD) and general medical ward care
without ESD (GWNESD). We used a Markov model to simulate the care process
for 10 years. Societal perspective was used for costing and included direct care
costs as well as informal care costs and productivity losses due to mortality and
morbidity.
Results: SUESD option leads to better outcomes, although it increases total
care costs. We found that it costs £9,200 per additional quality adjusted life
years (QALY) when SUESD was compared with GWNESD and £8,600 when
compared with SUNESD. The incremental cost effectiveness ratio (ICER stayed
within accepted limits of £30,000 per QALY gained. The multi-way (+10%) and
probabilistic sensitivity analyses did not have a significant impact on the results.
Discussion: This is the only study to date looking at the CE of SU followed by ESD,
comparing it with other treatment options. The results of the study suggests that
treatment in stroke unit followed by early discharge of patients with an enhanced
outpatient care policy (SUESD) offers the best results in terms of effectiveness,
with an additional cost within accepted reasonable CE levels. GWNESD, although
cheaper than the other two, appeared the least effective strategy.
11 Management and economics
STROKE OCCURRENCE AND DISEASE CLASSIFICATION IN GERMANY- A
NATIONWIDE ANALYSIS BASED ON THE GERMAN DRG REPORT 2004
P.L. Kolominsky-Rabas, B. Griewing, J. Rüthemann
Dep. of Health Economics, Institute for Quality and Efficiency in Health Care
(IQWiG), Cologne, Germany
Background: Data are limited regarding the number of stroke patients and their
fraction in each ICD-10 (International classification of diseases) and DRG (Di-
agnosis Related Groups) category in German hospitals since so far data are only
available from cohort studies and stroke registers with a limited number of patients.
Cerebrovasc Dis 2007;23(suppl 2):1–147 133
Methods: Based on the analysis of more than 1.780 German hospitals transferring
their DRG (B70 A- D) and ICD-10 data to InEK (Institut für Entgeltsystem im
Krankenhaus) we compiled a detailed overview of stroke occurrence and disease
classification of all German inpatient strokes in 2004.
Results: 235.097 stroke patients were reported for 2004. 5.658 (2%) thereof died
within 3 days after admission (B70 C), 189.403 (81%) had a non-hemorrhagic
stroke (DRG B70 B), 20.929 (9%) had a hemorrhagic stroke (B70 A), and 19.107
(8%) stayed in hospital for one day only (B70 D). As categorised with the ICD-10
coding system there were 11.500 (4%) patients with subarachnoid haemorrhage
(SAH, I60), 33.075 (12%) with intracerebral haemorrhage (ICH, I61), 6.482 (2%)
with other non-traumatic intracranial bleeding (I62), 180.863 (66%) with ischaemic
stroke (I63), and 40.882 (15%) with stroke neither defined as haemorrhagic nor
ischaemic (I64). This implied an overall ratio of 19% haemorrhagic (I60,61,62) and
81% non-haemorrhagic (I63,64) strokes for Germany in 2004.
Conclusions: This nationwide analysis based on the German DRG report 2004
gives a detailed overview of stroke occurrence and disease classification in Ger-
many. Numbers revealed are higher than previous assumptions made by assessing
data available from cohort studies and stroke registers containing a limited sample
of patients.
12 Management and economics
A NEW METHOD OF ESTIMATING THE TIME USED BY HEALTH CARE
PROFESSIONALS (HCP) FOR ACUTE STROKE CARE IN EUROPE,
EUROPEAN REGISTERS OF STROKE (EROS) COLLABORATION
Ö. Saka, A.J. Mcguire, P. Heuschmann, A. Rudd, C. Wolfe
Kings College London, Division of Health and Social Care Research, London,
United Kingdom
Intro: The EROS project is assessing the provision of stroke care in 8 European
centres. As stroke is a labour intensive disease, time spent by the HCP make up a
major part in the resources used. The purpose of our study was to analyse the time
spent by HCP.
Methods: A questionnaire was developed, piloted and used in 7 of the participating
centres to the EROS project. The forms included the description of 5 case scenarios
with different severities (case 1 the least, case 5 the most severe according to NIH
scores). In the forms HCP were asked to define the activities they would carry out
daily, weekly, on admission and on discharge for each case scenario. The answers
were recorded in minutes (mins). We analysed the mean and the median time spent
by HCP groups (classified as nurses, doctors and therapists which included speech
and language therapists, physiotherapists, occupational therapists) for different case
scenarios. We used Kruskall Wallis test to test the correlation between the times
spent by HCP in different countries.
Results: 145 interviews with HCP were included. The nurses spent more time
with patients than the other HCP (mean total daily time; for nurses 25-305 mins,
for doctors 5-55 mins, for therapists 0-66 mins). For all of the specialists groups
there was a tendency to spend more time with mid range severity cases (cases 2 &
3), total time spent increasing steadily from mild to moderate and declining from
moderate to severe. There was statistically significant correlation between the time
spent by the nurses and the doctors (p values between 0.0001 and 0.05) but not for
the therapists.
Conclusion: The HCP time use questionnaire helped gather data when the forms
were filled through an interview with the HCP. Although this tool mainly will be
used in costing the stroke service provision we found strong correlation between
the time spent by doctors and nurses in different countries. The lack of such a
correlation in the case of therapists can be explained by the differences in the way
the function of therapists are defined in EROS centres.
13 Management and economics
IMPORTANCE OF THERAPEUTIC INERTIA IN SECONDARY STROKE
PREVENTION: IMPLEMENTATION OF PREVENTION AFTER A
CEREBROVASCULAR EVENT (IMPACT) STUDY
E. Touzé, M. Voicu, J. Kansao, R. Masmoudi, B. Doumenc, A. Ferreira,
P. Durieux, J. Coste, J.-L. Mas
Hôpital Sainte-Anne, Paris, France
Background: Many patients do not receive prevention according to recommen-
dations after stroke, but the relative importance of patient- and physicians-related
factors is uncertain.
Methods: We prospectively assessed individual factors associated with blood
pressure (BP)<140/90 mmHg and LDL-cholesterol<1g/L in a cohort of 240
consecutive stroke/TIA patients (Rankin<4; ≤80 years; no major comorbidity)
from a stroke unit and 3 emergency departments. A standardized assessment of risk
134 Cerebrovasc Dis 2007;23(suppl 2):1–147
factors was performed 6 and 12 months after the initial event by an investigator not
involved in the usual follow-up of patients.
Results: At 6 months, 41% of patients with diagnosed hypertension at inclusion
had BP<140/90 mmHg and 55% of those with diagnosed hypercholesterolemia had
LDL<1g/L. Compliance to treatment was excellent in 81% of patients. In univariate
and multivariate analyses, initiation or reinforcement of appropriate treatments was
the main factor associated with BP<140/90 mmHg (OR=2.2; 95%CI: 1.0-4.5)
and LDL<1g/L (OR=3.3; 1.3-8.7) or with decrease in BP (p<0.0001) and LDL
(p<0.0001). Patients’ characteristics including sociodemographic characteristics,
education, income, and knowledge of disease and risk factors were not associated
with control of BP or LDL. Among patients with BP≥140/90 mmHg, about 40%
received either no treatment or only one drug, and treatment was reinforced in only
20% of them. Results were similar at 12 months with no improvement in the rate
of control of risk factors.
Conclusion: In-hospital initiation of secondary stroke prevention could influence
the long term quality of secondary prevention. Therapeutic inertia is an important
impediment to achieve the BP and LDL control goals after stroke, even in relatively
motivated/compliant patients.
14 Management and economics
LONGER TERM STROKE CARE: HOW SHOULD SERVICES BE
DEVELOPED IN THE POST-ACUTE PHASE?
A.M. Cox, L. Kalra, A.G. Rudd, C.D.A. Wolfe, C. McKevitt
King’s College London, Division of Health and Social Care Research, London,
United Kingdom
Background: Organised stroke care, such as inpatient stroke units and early
supported discharge, improves outcomes for patients. There is less evidence for
the optimal organisation and delivery of stroke care in the longer term. Following
the MRC Framework for developing complex interventions, we undertook Phase
1 work to identify the potential components of an intervention to improve longer
term stroke care.
Methods: In-depth interviews with a purposive sample of health professionals
(n=25) working in stroke. Participants were asked to describe existing services for
patients in the post-acute phase, identify successes and shortcomings and propose
ways to improve service provision. Interviews were recorded, transcribed and
analysed using framework analysis.
Results: Participants highlighted gaps in the available evidence base regarding the
optimal setting, timing, intensity and focus of therapy delivery.
There are theoretical questions that need to be resolved to improve post-acute
services. These include whether specialist care is necessary and what specialism
means in this context, the nature of multi-disciplinary working, and how to
overcome the structural and professional divisions that currently influence service
provision.
Problems relating to the delivery of services include transfer of care between ser-
vices, lack of psychology support, capacity to provide intensive therapy, inadequate
service provision for the cognitively and perceptually impaired.
Conclusion: This interview study identified gaps in the evidence base, theoretical
questions that underpin the organisation of services as well as practical problems in
care delivery. These will need to be addressed in formulating an improved model
of post-acute stroke care.
15 Management and economics
IMPACT OF CHANGES TO THE DRG CLASSIFICATION ON ACUTE
ISCHAEMIC STROKE CARE IN GERMANY
P.L. Kolominsky-Rabas, V. Ziegler, J. Rüthemann
Dep. of Health Economics, Institute for Quality and Efficiency in Health Care
(IQWIG), Cologne, Germany
Background: In 2005, the German Diagnosis Related Groups (DRG) classification
was modified to allow, for the first time, differentiation between different forms of
acute ischaemic stroke (AIS) care.
Prior to this, the German DRG system consisted of only one classification for
AIS: B70B. The new classification distinguishes between complex (B70B) and
non-complex (B70E) neurological treatments for AIS. The advanced category of
complex neurological treatment (OPS 8-981) comprises specific diagnostic and
treatment features including potential thrombolysis commonly provided in stroke
units (SU).
Methods: To assess the influence of the changes made to the DRG system in
2005 on patient disease management, we analyzed the data, from more than 250
of the 1.750 German hospitals, sent to the InEK (Institut für Entgeltsystem im
Krankenhaus) for the years 2004-2006.
16th European Stroke Conference
Results: Prior to the changes in the DRG classification (2004), 6.480 (34%)
patients received either plain or contrast MRI (Magnetic Resonance Imaging) as
part of their stroke care. After changes made to the DRG system, 1.112 (59%) AIS
patients in the B70B group and 5.971 (34%) patients in the B70E group underwent
MRI in 2005. The corresponding figures for 2006 were 1.180 (71%) patients in
the B70B group and 4.613 (27%) patients in the B70E group. Concurrently, the
percentage of thrombolytic treatment given to patients increased in the complex
treatment group from 15% in 2005 to 33% in 2006.
Conclusions: Distinguishing between complex and non-complex AIS care is rele-
vant and more accurately reflects patient disease management. Thus, the changes
to the DRG system improve the frequency of appropriate MRI imaging and
thrombolytic treatment in hospitals providing complex neurological treatment.
16 Management and economics
THE APPLICATION OF TELEMEDICINE FOR STROKE IN THE BALEARIC
ISLANDS
S. Tur, I. Legarda, M.J. Torres, C. Jimenez
Son Dureta Hospital, Palma de Mallorca, Spain
Background and purpose: Systemic thrombolysis for acute ischemic stroke is
administered only in Son Dureta University Hospital (SDUH) in the island of
Mallorca. It is impossible to move a patient from Ibiza or Menorca to Mallorca
in time to treat. Our main aim is to extend the use of this treatment to the other
Balearic Islands (Menorca, Ibiza) through telemedic support.
Methods: The Department of Neurology of SDUH has Stroke Unit, neurologist
on duty 24 hours per day and experience in thrombolytic treatment. Our hospitals
are connected by a video conference system (red ATM). All hospitals have specific
equipment (Tandberg MXP) to allow us to explore a patient at a distance and a CT
image transferer.
After a first phone contact, emergency physicians consult stroke neurologists
via a two-way video conference system. Medical history, neurologic examination
according to National Institute of Health Stroke Scale (NIHSS) and head CT scan
are reviewed to select a candidate patient for t PA treatment.
Can Misses Hospital in the island of Ibiza has organized a stroke team. There is
a specific stroke bed in the Intensive Medical Care Unit and we share the same
stroke protocol. Both doctors and nurses have been trained. This activity began in
the island of Ibiza in July 2006. Verge del Toro Hospital in the island of Menorca
is developing its own assistance process.
Results: We are registering clinical data, number of contacts, number of thrombol-
yses, onset to contact and to treatment time, complications, mortality, neurological
deficits and disability at admission, discharge and after 3 months (NIHSS and
modified Rankin Scale) and no treatment reasons.
Conclusions: Telemedicine allows us to extend specialized assistance and throm-
bolytic treatment to underserved areas.
17 Management and economics
COSTS OF STROKE BORNE BY INDIVIDUALS AND FAMILIES: USER-LED
DEVELOPMENT OF A PATIENT BASED COST MEASURE
C. McKevitt, N. Fudge, A. Sriskantharajah, C. Coshall, C. Wolfe, KCL Stroke
Research Patients & Family Group
King’s College London, London, United Kingdom
Background: The high costs to the state/health service associated with stroke care
are documented in several economic analyses. These provide little information
about the costs borne by families/individuals. Our Stroke Research Patients and
Family Group (PFG) identified personal costs resulting from stroke as a research
priority but methods to assess these costs are not well developed. We report a
user-led study to adapt an existing generic, but untested, cost questionnaire for
completion by stroke patients.
Method: PFG discussions and 5 individual qualitative interviews were held to
identify preferred research methods and specific cost items. These were used to
develop a topic guide for a novel qualitative method, “guided conversations”,
between 10 stroke survivors/carers. These were recorded, transcribed and analysed
to finalise items for the cost measure. The existing generic questionnaire was
adapted to incorporate stroke specific items, and reviewed by the PFG to ensure all
topics were covered and approve wording.
Results: User-led qualitative methods led to identification of items to include in
a questionnaire. These include: payment for adaptations, medications, alternative
therapies, diabetic/organic food, nutritional supplements, clothing suitable for dis-
ability, transport; direct and indirect loss of family income. The cost measure was
incorporated into a structured interview questionnaire with content validity, for use
in a pilot study.
Poster Session
Experimental studies
Conclusion: The PFG identified an under-researched area that they regard as
important to understanding the consequences of stroke. Their participation led to
the development of a cost measure relevant to the population under study. The
measure is currently being piloted with people recruited to the South London Stroke
Register.
18 Management and economics
MARKET SHARE OF INPATIENT CARE STROKE UNITS FROM THE TOTAL
HOSPITAL CARE MEASURED BY THE DIAGNOSIS RELATED GROUPS
(DRG) SYSTEM
I. Boncz, A. Sebestyén, J. Betlehem, L. Gulácsi
Department of Health Economics, Policy and Management, University of Pécs,
Pécs, Hungary
Aim: In the early 1990s, a Diagnosis Related Groups-like financing system was
introduced in Hungary including all the Hungarian acute care hospitals. The aim
of the study is to analyse the market share of acute stroke units according to DRG
system.
Data and methods: Data were derived from the financial database of the National
Health Insurance Fund Administration, the only health care financing agency in
Hungary (1996-2005). All the acute care stroke units were involved into the study.
The following indicators were used for the analysis: number of cases, the number
of DRG cost-weights, hospital days. Regression lines and Pearson coefficients (R2)
were calculated.
Results: Although it was no significant changes in the number of stroke cases
(18.000-20.000 patients/year), the market share of stroke care within in-patients
care – measured by the number of cases – decreased continuously from 1,07%
(1996) to 0,77% (2005). The market share of stroke care within in-patients care
measured by the number of DRG cost-weights has been also decreased from 1,06%
(1996) to 0,84% (2005). The market share of stroke care from the total in-patients
care hospital days has been also decreased from 1,41% (1996) to 1,01% (2005).
The market share of acute stroke care in 2005 compared to 1996 felt to 72,3% in
the number of cases, 79,3% in DRG cost-weights and 71,6% in hospitals days. The
Pearson coefficients (R2) for number of cases, DRG cost-weights and hospitals
days are 0,74, 0,72 and 0,55 respectively.
Conclusion: The market share and health insurance financial conditions of acute
stroke care units varied significantly between 1996-2005. The overall financial
effect of DRG system on the Hungarian stroke care seems to be relatively good or
neutral, but not disadvantageous.
Experimental studies
1 Experimental studies
AN EXTENDED WINDOW OF OPPORTUNITY FOR
GRANULOCYTE-COLONY STIMULATING FACTOR TREATMENT IN RAT
FOCAL CEREBRAL ISCHEMIA
J. Minnerup, R. Wysocki, R. Laage, A. Schneider, W.R. Schäbitz
University of Münster, Münster, United Kingdom
Background: Granulocyte-Colony Stimulating Factor (G-CSF) is known as a
regulator of white blood cell proliferation and differentiation. We and others have
shown that G-CSF is effective in treating cerebral ischemia in rodents, both relating
to infarct size as well as functional recovery. We assessed the hypothesis that
G-CSF has acute neuroprotective effects and long-term recovery effects in rat focal
cerebral ischemia after delayed treatment onset.
Methods: Wistar rats (n=24/group) underwent middle cerebral artery occlusion
(MCAO) for 90 min. Four hours after onset of occlusion animals received 60
μg/kg G-CSF i.v. over 20 min or vehicle. Infarct volumes were determined by TTC
staining. For evaluation of long-term functional outcome photothrombotic ischemia
was induced in the parietal cortex. For treatment, animals (n=10/group) were given
vehicle or 10 μg G-CSF/kg i.v. starting 24 or 72 hours after induction of ischemia
and daily repeated for 10 days. Rotarod testing was performed at 1, 2, 3, 4, 5
and 6 weeks after ischemia. Brain sections were immunostained for anti-BrdU and
NeuN.
Results: After MCAO we observed a infarct volume reduction by 33% in the total
infarct volume as compared to vehicle-treated rats (334.0 ± 31.5 mm3 vs. 223.3 ±
27.3 mm3 , p < 0.05). G-CSF treated rats in both the 24 h and 72 h time-window
performed significantly better in the rotarod test than vehicle-treated animals. The
number of newly generated neurons (BrdU+/NeuN+) in the dentate gyrus was
increased (p < 0.01) by G-CSF treatment.
Cerebrovasc Dis 2007;23(suppl 2):1–147 135
Discussion: In Conclusion we demonstrate an infarct reducing effect of a 4 h
treatment delay with G-CSF in a severe hemispheric stroke model (MCAO). In
the photothrombotic model we have shown that the time window for initiation of
poststroke functional recovery by G-CSF is at least 72 h. This effect correlated with
a profound induction of neurogenesis. G-CSF is therefore thought to activate dual
mechanisms within the brain such as the previously shown neuroprotective effect
plus a substantial recovery/neurogenesis inducing function.
2 Experimental studies
EFFECTS OF THE TP RECEPTOR ANTAGONIST S 18886 IN A RAT MODEL
OF MIDDLE CEREBRAL ARTERY PHOTOTHROMBOTIC OCCLUSION
T. Hirvonen, V. Blanc-Guillemaud, L. Lerond, J. Jolkkonen
CNServices, Kuopio, Finland
Background: Platelet activation represents the major source of increase in TXA2
biosynthesis after a cerebro-vascular event and plays an essential role in the
pathogenesis of thrombotic stroke.
S 18886, a TXA2 and prostaglandin endoperoxide (TP) receptor antagonist is being
developed as an anti-atherothrombotic agent and is expected to be effective in
cerebral artery thrombosis. The aim of this study was to investigate the effects of
S 18886 in comparison to aspirin and clopidogrel, in a rat middle cerebral artery
(MCA) model of focal thrombosis induced by photochemical reaction.
Methods: S 18886 (10 mg/kg), aspirin (100 mg/kg) and clopidogrel (30 mg/kg)
were orally administered to male Wistar rats (n=10-16/group) 2 hours before
thrombosis induction. A group receiving the vehicle served as control. Blood flow
in the distal MCA was monitored by a laser Doppler flowmeter for a 70-min period.
Time to occlusion (TO) and total patency time (TPT), expressed as a percentage of
observation period, were measured.
Results: There were no statistical differences in time to occlusion between treat-
ment groups. However S 18886 and clopidogrel prevented MCA occlusion in 2/10
and 2/11 animals, respectively. S 18886 significantly increased the incidence of re-
opening (87.5% versus 25% in control group; p<0.05) and the TPT measured when
MCA blood flow was above 70% of baseline (67.9 ± 8.3% versus 20.9 ± 4.2%
in control group, p<0.001). The increases in the incidence of reopening (55.5%)
and the TPT (41.1 ± 12.4%), observed with Clopidogrel were not statistically
significant. Aspirin had no effect on these parameters.
Conclusion: The present study demonstrates that single oral administration of
S 18886 increases incidence of MCA reperfusion and improves MCA blood
flow during reperfusion. The findings suggest that anti-platelet therapy with the
TP receptor antagonist S 18886 can be potentially beneficial in cerebro-vascular
diseases
3 Experimental studies
HYPERBARIC OXYGEN TREATMENT COMBINED WITH THROMBOLYTIC
THERAPY REDUCES INFARCTION SIZE IN EXPERIMENTAL ISCHEMIC
STROKE
L. Küppers-Tiedt, A. Manaenko, A. Günther, D. Michalski, A. Wagner,
D. Schneider
Klinik und Poliklinik für Neurologie; Universität Leipzig, Leipzig, Germany
Background: In acute ischemic stroke effective treatment is still limited. The only
approved therapy is thrombolysis with rtPA within the first three hours, but this
therapy is only an option for a small number of patients due to the time window
and the risk of hemorrhage. This study investigated the effects of thrombolysis in
combination with hyperbaric oxygen therapy (HBOT) in acute ischemic stroke in
rats.
Methods: In 22 male Wistar-Rats an ischemic stroke was induced by embolic
occlusion of the middle cerebral artery using clots of 20 mm length. After stroke
induction the animals were randomized to one of three groups: 1) Control (room air
and placebo), 2) Thrombolysis (room air and rtPA), 3) HBOT (hyperbaric oxygena-
tion (2.5 ATA) and rtPA). rtPA was given intravenously two hours after the embolic
stroke. The animals were exposed to room air/HBOT before or during thrombolysis
for one hour. 6 hours after the stroke the animals were sacrificed and brain slices
stained with Triphenyltetrazoliumchloride to calculate the infarct volume.
Results: The ischemic infarctions calculated 6 hours after the embolic stroke
extended to 50% of the hemisphere. Thrombolysis alone did not reduce the
infarction size (about 43% of the hemisphere), but the combination of throm-
bolysis and HBOT lead to a significant decrease of infarction size to about
20% of the hemisphere (HBOT before rtPA p=0.01; HBOT during rtPA p=0.02,
Student-Newman-Keul-Test).
Discussion: In this study we could demonstrate a significant reduction of infarction
size in an embolic stroke model in rats by combining thrombolytic and hyperbaric
136 Cerebrovasc Dis 2007;23(suppl 2):1–147
oxygen therapy. These effects were observed 6 hours after the ischemic stroke.
Hence further studies are needed to investigate the long term effects of the
combination therapy.
4 Experimental studies
BLOOD-BRAIN BARRIER (BBB) OPENING AFTER TRANSIENT FOCAL
CEREBRAL ISCHEMIA IN RATS
I. Marinkovic, A. Durukan, U.A. Ramadan, D. Strbian, M. Pitkonen,
E. Pedrono, L. Soinne, T. Tatlisumak
Biomedicum Helsinki, Helsinki, Finland
Background: It is widely believed that BBB breakdown after transient focal
cerebral ischemia occurs in a biphasic pattern. The aim of this study was to evaluate
quantitatively the pattern of BBB damage after transient focal cerebral ischemia and
its correlation with the size of the ischemic lesion by the use of contrast-enhanced
magnetic resonance imaging (MRI).
Methods:
Adult male Wistar rats (n=10) were underwent 90 minutes of transient focal
cerebral ischemia with the suture occlusion method and imaged with MRI at 4.7
Tesla at 2, 24, 48, 72 hr and 1 week after reperfusion. Diffusion weighted imaging,
FLAIR (fluid attenuated inversion recovery), and T1-weighted (with and without
contrast agent gadolinium) sequences were acquired. After calculating lesion area
and contrast-enhanced areas, their ratio was obtained. The gadolinium permeability
(by calculating Ki values via the Patlak plot approach) was estimated for all
imaging time points.
Results: In all post contrast images, gadolinium enhancement occurred in a similar
spatial pattern with ischemic lesion and there was no statistically significant differ-
ence between ratios (mean ratio was 0.94 for T1-weighted sequence, p=0.06 and
0.91 for FLAIR, p=0.6). The Ki values of ischemia regions (cortex and subcortex)
for all groups were statistically significant (p<0.01) compared with the identical
regions in the contralateral brain hemisphere. The difference in Ki between different
time points was not statistically significant (p=0.38).
Discussion: Our results showed that BBB leakage to gadolinium (molecular weight
590 Da) occurs in a monophasic pattern during the period of 2 hr to 1 week after
transient focal cerebral ischemia in rats and BBB damaged brain area is highly
similar to the ischemic area depicted on DWI.
5 Experimental studies
EFFECT OF HIGH-DOSE OESTROGEN THERAPY ON CEREBRAL
PLASTICITYAFTER TRANSIENT FOREBRAIN ISCHAEMIA IN GERBIL
E.A. Wappler, A. Gal, G. Szilagyi, J. Vajda, J. Skopal, K. Felszeghy, C. Nyakas,
Z. Nagy
National Institute of Psychiatry and Neurology, National Stroke Center,
Budapest, Hungary
Background: After ischaemic injury repair mechanisms in the brain tissue reduce
the functional deficit. Neuroprotective effect of oestrogen is well documented,
however its effect on repair mechanisms are still not elucidated. In our work
we focused on the expression of plasticity genes and functional recovery after
oestrogen treatment in transient ischaemic model.
Methods: 3 month-old ovariectomized femail gerbils (n=40) were subjected to 10
min transient forebrain ischaemia or sham procedure. Half of the ischemic animals
were pre-treated i.p. with 4 mg/kg body weight oestrogen 20 min previous to
surgery. From one series of animals brain samples were collected on postoperative
day 4 for histological and molecular biological examinations. Paraffin-embedded
brain slices were stained with TUNNEL-caspase double labelling fluorescent anti-
sera. Marker mRNA levels were determined with real-time PCR. Gene expression
levels were assessed by ddCT method using TaqMan gene expression assays. On
other series of animals attention and learning behaviour were tested in spontaneous
alternation, novel object recognition and spatial learning paradigms beginning from
postoperative day 7.
Results: Oestrogen significantly decreased the number of apoptotic and necrotic
cells in CA1 region. Oestrogen treatment resulted in a significant increase in
Bcl-XL, nestin and GAP-43 mRNA expression. In ischaemic insult inpaired atten-
tion and working memory in all behavioural tests, while oestrogen pre-treatment
improved attention and prevent or decreased memory deficit.
Discussion: Our novel finding is that oestrogen is not just neuroprotective in our
model, but augmented the expression of plasticity genes and these correlate well to
better outcome in behaviour tests.
This work was supported by OTKA T037887, GVOP-3.1.1.-2004-05-0389/3.0.
16th European Stroke Conference
 6 Experimental studies
S 18886, A THROMBOXANE A2 RECEPTOR ANTAGONIST, PREVENTS
OCCURRENCE OF SPONTANEOUS BRAIN DAMAGE IN STROKE-PRONE
RATS VIA ANTI-INFLAMMATORY ACTIVITIES
P. Gelosa, E. Nobili, A. Gianella, V. Blanc-Guillemaud, L. Lerond, U. Guerrini,
E. Tremoli, L. Sironi
Dept. Pharmacol. Science, Univ. Milan; Italy; Inst. Recherches Internationales
Servier, Courbevoie, Milan, Italy
Background and aim: Spontaneously Hypertensive Stroke-prone rats (SHR-SP)
are an established model of human cerebrovascular disease. In this rat strain, the
development of hypertension and inflammation precedes the appearance of brain
abnormalities. The aim of the present investigation was to assess the efficacy of S
18886, an orally active antagonist of TP-receptors (the receptors for thromboxane
A2), in protecting the brain of SHRSP and whether this effect was related to its
anti-inflammatory properties.
Methods and results: Male SHR-SP (n=10 per group), fed with a high-salt diet,
received by gavage vehicle or S 18886 (3 or 30 mg/kg/day). In vehicle-treated
animals, brain lesions, as detected by magnetic resonance imaging, developed spon-
taneously after 40 ± 2 days (mean ± SEM). Treatment with S 18886 had no effect
on arterial blood pressure, significantly delayed the appearance of brain damage,
at the dose of 30 mg/kg/d (p<0.001), and increased survival, in a dose dependent
manner (p<0.001 and p<0.0001 at the dose of 3 and 30 mg/kg/d respectively).
In comparison with vehicle-treated SHRSP, treatment with S 18886 (30 mg/kg/d;
n=5), preserved brain tissue by preventing macrophage infiltration (ED1 positive
cells) (p<0.05), and reduced the accumulation of perivascular macrophages (ED2
positive cells) and lymphocytes T helper (CD4+ positive cells) as assessed by
immunohistochemistry. Furthermore, S 18886 attenuated the transcription of the
pro-inflammatory cytokines IL-1beta, TNF-alpha, IL-6, and MCP-1, as assessed by
RT-PCR.
Conclusion: These data indicate that S 18886 prevents the occurrence of sponta-
neous brain damage in SHRSP by reducing inflammation, suggesting that S 18886
may exert a beneficial anti-inflammatory effect in cerebrovascular disease.
7 Experimental studies
CDP-CHOLINE INCREASES EAAT2 ASSOCIATION TO LIPID RAFTS AND
AFFORDS NEUROPROTECTION IN EXPERIMENTAL STROKE
I. Lizasoain, O. Hurtado, J.M. Pradillo, D. Fernández-López, T. Sobrino,
T. Gasull, M. Castellanos, F. Nombela, J. Castillo, M.A. Moro
Facultad de Medicina, Universidad Complutense Madrid, Madrid, Spain
Background: EAAT2 is responsible for up to 90% of all glutamate transport
and has been reported to be associated to lipid rafts. In this context, we have
recently shown that CDP-choline induces membrane translocation of EAAT2. Since
CDP-choline preserves membrane stability by recovering sphingomyelin levels a
glycosphingolipid present in lipid rafts, we have decided to investigate whether
CDP-choline increases association of EAAT2 transporter to lipid rafts.
Methods and results: For lipid rafts isolation, brain homogenates from each group
were subjected to a discontinous sucrose gradient in the presence of Brij-58 and 8
fractions were collected. Flotillin-1 was used as a marker of lipid rafts due to its
known association to these microdomains. We have found that flotillin-1 was found
mainly in fractions 2 and 3 and their levels were similar in all the groups studied.
EAAT2 protein was predominantly found colocalised with flotillin-1 in the fraction
2, and CDP-choline increased EAAT2 levels in fraction 2 at both times examined
(3 and 6 hours after 1g/Kg CDP-choline administration). Furthermore, exposure to
middle cerebral artery occlusion also increased EAAT2 levels, an effect which was
further enhanced in those animals receiving 2 g/Kg CDP-choline 4 hours after the
occlusion. Infarct volume measured at 48 h after ischemia showed a reduction in
the group treated with CDP-choline 4 h after the ischemic occlusion.
Conclusions: We have demonstrated that CDP-choline induces a re-localisation
of EAAT2 into lipid raft microdomains in rat brain. This effect is also found
after experimental stroke, when CDP-choline is administered 4h after the ischemic
occlusion. We have also shown that this delayed post-ischaemic administration of
CDP-choline induces a potent neuroprotection.
Poster Session
Experimental studies
8 Experimental studies
ULTRASOULD-THROMBOLYSIS WITH 488KHZ - SAFETY-STUDIES WITH
AN MRI-BASED RAT STROKE MODEL
M. Walberer, M. Nedelmann, D. Schiel, K. Volk, P. Reuter, M. Kaps,
T. Saguchi, G. Bachmann, H. Furuhata, T. Gerriets
University Giessen, Germany; Kerckhoff-Clinic Bad Nauheim; Jikei University
Tokyo, Giessen, Germany
Objective: Ultrasound can enhance the effect of i.v.-thrombolysis in acute stroke.
First clinical trials with 2MHz-ultrasound revealed an improved recanalisation rate
but yet no convincing clinical benefit. Lower ultrasound frequencies might be
more effective. However, clinical trials as well as animal experiments have shown
severe side-effects. Safety of new therapeutic ultrasound devices thus needs to be
determined.
Methods: Male Wistar rats were subjected to middle cerebral artery-occlusion
for 90 minutes followed by reperfusion (suture technique). Rt-PA (Actilyse® ) was
injected intravenously thereafter. Then transcranial ultrasound treatment (488kHz;
sweep: 10%; 0.7W/cm2 ; continuous wave) was started and continued for 60
minutes. Sham treated animals were used as controls. Intracerebral temperature
was recorded during ultrasound application in a sub-study.
MRI (Bruker PharmaScan, 7.0 Tesla) was performed after 24h. Ischemic lesion
volume (T2-WI and DWI) and vasogenic brain edema (T2-relaxation time) were
quantified. T2*-WI was used to determine hemorrhagic complications.
Results: 488kHz-ultrasound treatment did not noteworthy affect brain temperature.
Ultrasound did not increase lesion volume or edema formation. No hemorrhagic
complications could be detected on T2*-weighted imaging.
Conclusion: The 488kHz-device did not exert any side-effects in our MRI-based
rat stroke model. Further safety- and efficiency-studies are required prior first
clinical applications.
9 Experimental studies
GW3965, AN AGONIST OF THE LXR NUCLEAR RECEPTORS, IS
NEUROPROTECTIVE IN EXPERIMENTAL STROKE
M.A Moro, J.R Morales, M.P. Pereira, J.R. Caso, O. Moldes, J. Vivancos,
C. Gubern, J. Serena, A. Davalos, I. Lizasoain
Facultad de Medicina, Universidad Complutense Madrid, Madrid, Spain
Background and purpose: Liver X receptors alpha (LXR-alpha) and beta (LXR-
beta), also known as NR1H3 and NR1H2, respectively, are ligand-activated
transcription factors that belong to the superfamily of nuclear receptors. Apart from
their role in the regulation of cholesterol homeostasis and fatty acid metabolism,
LXR receptors have been described to inhibit the expression of inflammatory medi-
ators such as inducible nitric oxide synthase (iNOS), cyclooxygenase-2 (COX-2) or
matrix metaloproteinase-9 (MMP9). Since these anti-inflammatory actions might
be useful in stroke, we have investigated the effects of the LXR agonist GW3965
on stroke outcome in a rodent model of cerebral ischaemia by permanent occlusion
of the middle cerebral artery (MCAO).
Methods: Male Fischer rats were used. Infarct size: 48 after MCAO, animals
were sacrificed with an overdose of pentobarbitone and a serial of 2 mm thick
coronal slices were made and stained with 2,3,5-triphenyltetrazolium chloride 1%
in 0.2 phosphate buffer. Infarct size was determined using a computer image
analysis system. Experimental groups were control, permanent middle cerebral
artery occlusion (MCAO), and MCAO+GW3965 (20mg/kg). GW3965 or vehicle
(DMSO) were administered i.p. 10 min after MCAO. Stroke outcome was assessed
by measurement of infarct size. Protein expression of iNOS, COX-2 and MMP9
in cerebral cortex were studied by Western blot and data were expressed as % of
densitometry of bands in the MCAO group.
Results: The administration of the LXR agonist GW3965 reduced infarct volume
(180.4 ± 7.7 mm3 vs. 150.2 ± 5.5 mm3 in MCAO and MCAO+GW3965,
respectively, n=6-10, p<0.05). Furthermore, GW3965 reduced MCAO-induced
expression of iNOS (41 ± 1% of MCAO, n=4, p<0.05), COX-2 (43 ± 3% of
MCAO, n=4, p<0.05) and MMP-9 (43 ±1% of MCAO, n=4, p<0.05) was reduced
in animals treated with GW3965.
Conclusions: Activation of LXR receptors induce neuroprotection in experimental
stroke, very likely due to anti-inflammatory mechanisms.
Cerebrovasc Dis 2007;23(suppl 2):1–147 137
 10 Experimental studies
ENHANCEMENT OF SENSORIMOTOR RECOVERY UNDER
CEREBROLYSIN TREATMENT IN A RAT MODEL OF FOCAL CEREBRAL
INFARCTION
M. Hitzl, J.M. Ren, D. Sietsma, S.M. Qiu, H. Moessler, S.P. Finklestein
EBEWE Pharma GmbH Nfg.KG, R&D Neuro Products, Unterach, Austria
Background: Many efforts have been made to find drug products having the po-
tential to reduce infarct volume and/or promote neurological recovery after stroke.
Cerebrolysin a unique drug product composed of neurotrophic and neuroprotective
peptides from biological origin seems to fit perfectly into this specification. It has
therefore been tested in an rodent model of stroke.
Methods: Focal cerebral infarction was produced in mature male Sprague-Dawley
rats by occlusion of the proximal right middle cerebral artery. Animals have
subsequently been treated with Cerebrolysin at a daily dose of 1.0, 2.5, or 5.0 ml/kg
body weight starting 24, 48 or 72 hours after stroke onset for 21 days. Behavioral
assays were performed before and during Cerebrolysin treatment (forelimb and
hindlimb placing and body swing tests). At the end of Cerebrolysin treatment the
infarct volume has been determined using a computer-interfaced imaging system.
Results: Cerebrolysin treatment of rats after focal cerebral infarction resulted
in enhanced recovery of sensorimotor function compared to vehicle-treated ani-
mals. Enhancement of sensorimotor recovery has been found when Cerebrolysin
treatment at a dose of 2.5 ml/kg was started 24 or 48 hours after stroke onset.
Discussion: These findings clearly demonstrate that administration of Cerebrolysin
after stroke can enhance neurological recovery.
11 Experimental studies
RHEOENCEPHALOGRAPHY: A NON-INVASIVE METHOD TO ASSESS THE
ELECTRICAL IMPEDANCE CHANGES RELATED TO THE PULSATILITY OF
THE CEREBRAL BLOOD FLOW
J.M. Pons, J.J. Pérez, P. Ortiz, E. Guijarro, A. Navarré, J. Sancho
1
Consorcio Hospital General Universitario Valencia; 2 Centro de investigación e
innovación en bioingeniería Universidad Politécnica de Valencia, Valencia,
Spain
Objective: Rheoencephalography (REG) measures the electrical impedance
changes of the head caused by the pulsatility of the cerebral blood flow (CBF).
However, the use of REG in the clinical practice is limited because signal is buried
by the extracranial component. Our research group has formulated a mathematical
algorithm that allows the extraction of the intracranial component from the REG
signal. The main goal of this work is to validate the separation method. For this
purpose, an experimental model that arrests mechanically the extracranial blood
flow is used.
Material and methods: REG signal was acquired in healthy volunteers in two
conditions: (i) normal and (ii) during the arrest of the scalp blood flow by means the
scalp compression with a pneumatic cuff. Subsequently, the intracranial component
extracted with our algorithm was statistically compared with the REG traces
recorded in scalp compression condition.
Results: Intracranial component extracted by our algorithm matches well with
the REG trace recorded in scalp compression condition. Additionally, the mor-
phology of the extracted intracranial component agrees with the intraparenchymal
impedance traces previously described in the literature.
Conclusions: Our results suggest that the intracranial REG component can be
reliably extracted from the raw REG signal by cancelling the scalp blood artifact.
This method could provide a new non-invasive technique to assess the cerebral
blood flow. Nevertheless, additional works would be necessary to check and to
assess the diagnostic capability of our REG technique.
This work was supported by grant PI04/0303 from the Instituto de Salud Carlos
III (Fondo de Investigación Sanitaria) in the framework of the “Plan Nacional de
Investigación Científica, Desarrollo e Innovación Tecnológica (I+D+I)”.
12 Experimental studies
FIRST EXAMINATIONS WITH AN AUTOMATICALLY OPTIMIZED
COMPUTER MODEL FOR INDIVIDUAL SIMULATIONS OF CEREBRAL
HEMODYNAMICS
F.C. Roessler, V. Metzler, R. Grebe, G. Siegel
Clinic for Neurology, UK-SH, Campus Lübeck, Lübeck, Germany
Background: During the medical treatment of some cerebrovascular diseases it
is necessary to occlude brain supplying arteries. Sometimes these interventions
cause a cerebral ischemia and the patient will suffer from strokes. Until now this
138 Cerebrovasc Dis 2007;23(suppl 2):1–147
risk can only be estimated by invasive diagnostics, which themselves bare the risk
of cerebrovascular accidents. Therefore we searched for a reliable non-invasive
diagnostic tool for preoperative risk estimation.
Methods: A computer model of the brain supplying arteries was designed, whose
parameters can be determined by non-invasive measurements and picture-giving
procedures to fit the model to the individual physiological state of the patient.
Comparing time series generated by the model with those measured at the patient
the model can be evaluated and in the case of insufficient results its parameters can
be changed by an optimization process based on evolutionary algorithms.
Results: The patient adapted models behaved physiologically and showed good
agreement between the modelled data and those recorded from the subjects. The
reaction of individual cerebrovascular systems in critical situations similar to the
occlusion of the internal carotid artery was investigated by special scenarios. Even
though in this first step of examination the optimization process was only related
to a few parameters, it became obvious that evolutionary algorithms are suitable
provided that some physiological laws are considered.
Discussion: Although some difficulties remain concerning the parameter estimation
and optimization we hope, that this flexible, time saving, cheap and non-invasive
method makes a valuable contribution to avoid complications of induced vessel
occlusion during medical treatment by an improved operation planning.
13 Experimental studies
NATURAL REGULATORY CD4+CD25+FOXP3+ T-LYMPHOCYTES (TREG)
PREVENT DELAYED INFARCT GROWTH BY AN INTERLEUKIN-10
DEPENDENT MECHANISM
R. Veltkamp, E. Suri-Payer, C. Sommer, C. Veltkamp, H. Doerr, T. Giese,
A. Liesz
University Heidelberg, Heidelberg, Germany
Background and aims: Inflammatory cascades contribute to secondary ischemic
brain damage. Tregs are important anti-inflammatory modulators in various inflam-
matory diseases. We studied the role of Tregs in ischemic stroke.
Methods: Focal ischemia was induced by transtemporal MCAO. Tregs were
eliminated either by preischemic depletion with mAb (clone PC61) in C57Bl/6
mice or by adoptive transfer of CD4+CD25- into rag2-/- mice. Infarct volume and
cerebral cytokine expression (RT-PCR) were measured at various time points after
MCAO. Effect of IL-10 was tested by intraventricular injection or by transfer of
Tregs from IL -10 -/- mice.
Results: Treg depletion had no effect 24h after MCAO, but Treg-depleted
mice had significantly larger infarct volumes 7d after MCAO (control: 7.4mm3 ;
antibody-treated: 12.1mm3 ). Correspondingly, transfer of CD4+25- T cells into
lymphocyte-deficient rag2-/- mice resulted in larger infarcts (12.9mm3 ) than trans-
fer of CD4+ cells (6.8mm3 ; p<0.05). Intraventricular IL-10 reversed this effect.
Treg derived IL-10 was particularly important as adoptive transfer of CD4+CD25+
cells derived from IL-10 -/- failed to prevent infarct growth. In mice lacking
Tregs, RNA levels of proinflammatory cytokines were significantly more elevated
in ischemic hemisphere compared to control (6h after MCAO: TNFa 4x; IL-1b 2x;
72h after MCAO: IFNg: 5x). Cerebral invasion of Tregs became first detectable
72h after MCAO by FACS and immunohistochemistry.
Conclusions: Tregs are master anti-inflammatory modulators in ischemic stroke
which reduce secondary infarct progression by downregulating proinflammatory
cytokine –induced cell death. Based on our findings, this effect is probably mediated
by early humoral IL-10 signalling and by delayed Treg invasion.
14 Experimental studies
NONLINEAR ANALYSIS OF BRAIN SPIROGRAPHY SIGNALS - THE WAY TO
A NEW NON-INVASIVE DIAGNOSTIC TOOL (A PILOT STUDY)
M. Swierkocka-Miastkowska, G. Osinski
Department of Neurology for Adults, Medical University of Gdansk, Gdansk,
Poland
Background: Ischaemic stroke is associated with disturbances of respiration
rhythm. The purpose of this study was to analyze breathing patterns of acute phase
stroke patients in comparison to healthy subjects.
Methods: Brain spirography (BSG) as a new method of experimental clinical
breath research was deviced and tested in Medical University of Gdansk. It has a
detecting system coupled with pressure sensors. Signals from the sensors through
the analog-digital converter are transferred to the computer for making visual
representation of respiration activity on a screen. Data from 55 patients with
first-ever supratentorial ischaemic stroke and a control study of 25 volunteers were
obtained. In patients the respiration curves were measured 3 times during first
5 days of hospitalization. All patients were assessed with the National Health
16th European Stroke Conference
Institues Stroke Scale and (if needed)Glasgow Coma Scale. The curves were
analyzed with 3 nonlinear methods: Return Map Plot (RMP), calculation of Fractal
Dimension (FD) with Higutchi algorithm and graphical representatiom of Visual
Map Plot (VMP).
Results: We analyzed 25 physiological and 165 pathological data sets. As a result
we obtained average values of FD for both groups: in the group of volunteers
FD=1.599 ±0.072, in stroke patients FD=1.873±0.076. The values analyzed with
ANOVA test are significantly different (p<0.003).
Discussion: As a number of stroke patients is instantly high, it is very important
to develop quick, easy-to-use and non-invasive methods to monitor acute phase of
stroke. A set of graphical interpretation of RMP and VRP together with value of
FD and estimation of trends in groups of signals could give us clinically important
information by visual representation of the analysis of dynamic status of respiratory
pattern.
15 Experimental studies
MRI AND BEHAVIOR EFFECTS OF EARLY INTRAVENOUS DELIVERY OF
MESENCHYMAL STEM CELLS AT EXPERIMENTAL CEREBRAL INFARCT
IN RATS
L. Gubskiy, K. Yarygin, O. Povarova, Yu. Pirogov, R. Tairova, A. Dubina,
I. Cheblakov, D. Kupriyanov, V. Skvortsova
Fundamental and Clinical Neurology Department, Russian State Medical
University, Moscow, Russian Federation
Background: To measure the effect of early intravenous delivery of mesenchymal
stem cells (MSCs) on neurological and neurobehavioral functional deficits and
MRT volume of experimental cerebral infarct in rats.
Methods: 3-month-old 19 male Wistar rats (weight 180 to 250 g) were subjected to
focal ischemia in the region of MCA by electrocoagulation before bifurcation into
frontal and parietal branches under intraperitoneal anesthesia by chloral hydrate
(300 mg/kg). The rats were randomized into three groups: sham (3), control (8)
and experimental (8 animals with intravenous delivery of 6 million of MSCs on the
1 - 2nd days after operation). MRT was performed on 1-2 and 7 days at BioSpec
70/30, neurological and behavior functional tests (elevated cross - maze, open-field
tests) also where performed.
Results: Neurological severity scores in experimental and control groups on 1, 7
and 14 days after operation were equal but lower than those in the sham-operated
group. At open-field test the horizontal activity of control rats was higher than
experimental animals. There were no significant differences between control and
MSC groups on the cross-maze on 10 but not 20 day. Before delivery of MSCs
volumes of cerebral infarct (at T2-weighted imaging) were without significant
difference between control and experimental groups. There was significant decrease
of the volumes in both groups on 7 day.
Discussion: Early intravenous delivery of MSCs did not change the rate of decrease
of the volume of cerebral infarct at the first 7 days of experimental cerebral infarct
in rats. There were no difference between groups at neurological and behavior
functional tests except for more high activity of control rats at open field test.
16 Experimental studies
OXYGEN-GLUCOSE DEPRIVATION-INDUCED CELLULAR CHANGES IN
ORGANOTYPIC SLICE CULTURES OF THE HIPPOCAMPUS: PROTECTIVE
EFFECT OF (-)DEPRENYL
B. Bali, Z. Nagy, K.J. Kovács
Semmelweis University, Budapest, Hungary
Background: (-)Deprenyl is an irreversible inhibitor of type B monoamine oxidase
(MAO-B), which is now used as a neruoprotective compound for treatment of
Parkinson’s or Alzheimer’s diseases. Evidence suggests that the therapeutic efficacy
of deprenyl may not be related exclusively to the inhibition of the enzyme MAO-B,
however the cellular mechanisms underlying its neuroprotective effect remained
unknown.
Methods: To test the impact of deprenyl on ischemia-induced changes in vitro, we
followed the time course of propidium iodide (PI) uptake as an indicator of neuronal
cell death in organotypic hippocampal slice cultures exposed to oxygen-glucose
deprivation (OGD) for 45 min. The expression of apoptotic factors (Bcl-2, Bcl-xl
and Bax) as well as of the proinflammatory citokine interleukin-1 (IL-1) was
measured by polymerase chain reaction (PCR)
Results: The first signs of neuronal death were detected 2 hours after OGD and
were extended to all subfields of the hippocampus by 24 hours post-injury. Presence
of deprenyl (10-9 M) significantly delayed the cell death induced by the insult.
Exposure of control cultures to deprenyl significantly increased the abundance of
Bcl-2 and Bcl-xl mRNAs as revealed by RT-PCR. OGD resulted in an elevation of
Poster Session
Experimental studies
anti-apoptotic factors and IL-1, while the expression pro-apoptotic bax remained
unchanged.
Discussion: These data suggest that deprenyl is neuroprotective in an in vitro
model of ischemia. Although deprenyl upregulates the expression of Bcl-2 under
basal conditions, its effect on anti-apoptotic factors is not significantly manifested
during OGD.
17 Experimental studies
BCL-2 AND BCL-XL GENES THERAPY INCREASES PLASTICITY AND
CELL CYCLE GENES EXPRESSION AFTER HYPOXIA IN PC12 CELLS
A. Gal, G. Szilagyi, E. Wappler, Z. Bori, J. Vajda, J. Skopal, Z. Nagy
National Institute of Psychiatry and Neurology, National Stroke Center,
Budapest, Hungary
Introduction: Hypoxia induces cell necrosis and/or apoptosis. Antiapoptotic gene
therapy could be an option to prevent the cell death and activate the repair mecha-
nisms. In this study we measured the expression of plasticity and pro/antiapoptosis
genes (Bcl-2, Bcl-XL, Bax, synapsin-1, nestin and c-fos) in PC12 cell culture
system after adenovirus containing Bcl-2 or Bcl-XL gene delivery. We found pre-
viously that the gene transfer has a cytoprotective effect, protects the mitochondrial
function and augmented repair protein GAP-43 expression after hypoxic insults.
Materials and methods: The cells were treated by Argon gas (1 hr) for induction
hypoxic cell injury followed by 24 hrs of restored oxygen. The cells were infected
with adenovirus constructs contaning Bcl-2 or Bcl-XL gene utilized before or
after hypoxia. We examined the selected mRNA levels with real-time PCR. The
gene expression levels were determinated by ddCT method using TaqMan gene
expression assays.
Results: Hypoxia and reoxygenization increased the pro-apoptotic Bax gene ex-
pression while the c-fos mRNA level was decreased. Gene transfers of Bcl-2 or
Bcl-XL resulted in a significant increase of Bcl-2, Bcl-XL, synapsin-1, nestin and
c-fos mRNA expression levels after hypoxic insults.
Conclusions: In our in vitro model, Bcl-2 or Bcl-XL anti-apoptotic gene delivery
was not only cytoprotective but it augments repair genes expressions after hypoxic
insults. The double actions of these genes appear to be beneficial in preventing
hypoxic cell injury. However, the link between the augmented anti-apoptotic and
repair mRNA expression is not clear at the moment.
Keywords: PC12, hypoxia, Bcl-2, Bcl-XL gene transfer, plasticity genes
18 Experimental studies
(-) DEPRENYL-N-OXID IS NEUROPROTECTIVE AFTER TRANSIENT
HIPPOCAMPUS ISCHEMIA IN GERBILS
G. Szilágyi, K. Magyar, Z. Nagy
National Stroke Centre, Budapest, Hungary
Introduction: As we reported previously, (-)deprenyl-N-oxid (DNO) has signifi-
cant cytoprotective effects in PC12 cell culture. Decreased cell death and reactive
species production and increased mitochondria trans-membrane potential were
demonstrated after hypoxic injury. In this paper we tested the neuroprotective effect
of DNO on hippocampus in a model of transient, bilateral common carotid artery
occlusion in Gerbils.
Methods: We performed transient, bilateral carotid artery occlusions for 10 min-
utes. The treated group was injected 0.4 mg/kg/day of N-oxid-deprenyl intra
peritoneal for 4 days. The control rats were injected with the vehicle only. The
gerbils were killed after 4 days. On the formaldehyde fixed sections TUNEL and
caspase-3 immuno-histochemistry were performed and NIKON/BIORAD confocal
microscope was used for analysis. Consecutive images were taken from the hip-
pocampus. The TUNEL and caspase-3 positive cells were counted automatically
with Image J 1.37 software (NIH, USA).
Results: All the caspase-3 positive cells were TUNEL positive too. In the CA2
regions we found significantly less caspase positive neurons az there were found in
the controls. Similarly in the same region significant decrease in number of TUNEL
positive cells were counted.
Discussion: In our previous study we demonstrated the neuroprotective effect of
deprenyl. This drug decreased significantly the TUNEL labelled and TUNEL-
caspase-3 double labelled neurons in the penumbra region after permanent MCA
occlusion in rat. In the present experiment one of the deprenyl metabolite DNO
decreased similarly the number of TUNEL positive cells in the CA2 hippocampus
region. DNO cytoprotective effect was previously documented in PC12 cell culture.
The neuroprotective effect of the highly polar molecule in the in vivo model could
be related the transient opening of BBB in this model.
Grant: OTKA T037887.
Cerebrovasc Dis 2007;23(suppl 2):1–147 139
Vascular surgery and neurosurgery/Interventinal
neuroradiology
1 Vascular surgery and neurosurgery/Interventinal
neuroradiology
INTRA-ARTERIAL AND INTRAVENOUS THROMBOLYSIS IN ACUTE
ISCHEMIC STROKE FROM CAROTID “T” OCCLUSION
P. Nencini, S. Mangiafico, M. Nesi, I. Romani, G. Cagliarelli, M. Pratesi,
V. Palumbo, M. Cellerini, A. Rosselli, D. Inzitari
Careggi Hospital, Florence, Italy
Background: Outcome in acute ischemic stroke from internal carotid artery oc-
clusion is poor with high mortality or severe long-term disability. We evaluated if
intra-arterial (IAT) or intravenous thrombolysis (IVT) may influence outcome.
Methods: From February 2004 to August 2006, twenty-nine patients with acute
internal carotid artery “T” occlusion were admitted to two Hospitals in Florence,
Italy. All patients underwent screening for IVT (SITS-MOST protocol), colour
duplex sonography or cerebral angiograph, and had a 3-month follow-up with
mRankin scale (mRS).
Results: Eleven patients (male 64%, mean age 66 years, mean NIHSS 20) were
treated with IATwithin 6 hours from symptom onset; 11 patients (male 27%, mean
age 72 years, mean NIHSS 18) with IVT within 3 hours from symptom onset; and
7 patients (male 86%, mean age 64 years, mean NIHSS 18) had standard treatment.
Recanalization was achieved in 8/29 (27.6%) patients (6 TIMI 3 and 2 TIMI 2), all
treated with IAT. Four out of 11 (27.3%) IAT patients had a 3-month good (mRS
0-2) outcome compared with no patients in both the IVT and standard treatment
group. The 3-month mortality rate was 36% in IAT, 27% in IVT, and 43% in
the standard group, respectively. Symptomatic haemorrhage occurred only in IAT
group (27% of patients).
Conclusions: The prognosis of ischemic stroke due to internal carotid artery
“T” occlusion remains severe. Our data may suggest a favourable effect on the
intra-arterial approach. More data are needed to confirm this hypothesis.
2 Vascular surgery and neurosurgery/Interventinal
neuroradiology
RETROSPECTIVE VALIDATION OF THE ABCD SCORE IN PATIENTS
PRESENTING WITH TRANSIENT ISCHAEMIC ATTACKS UNDERGOING
CAROTID ENDARTERECTOMY
S. Shaikh, J. Brittenden, E. MacAulay, M.J. Macleod
University of Aberdeen, Aberdeen, United Kingdom
Introduction: Patients who have experienced a transient ischaemic attack are at
risk of developing a stroke especially within the first two weeks after a TIA. The
ABCD score aims to predict an individual patient’s risk, thus facilitating the ability
to fast-track investigation and treatment of the high-risk group who have a score of
5 or 6. We aimed to assess the ABCD score of patients who had undergone carotid
endarterectomy.
Method: 194 of patients who underwent CEA between January 2001 and December
2005 were identified from a prospectively collected database.
Results: 90 (46.4%) patients undergoing CEA presented with a TIA. The remaining
operations were performed for cerebrovascular accident (n=59), amaurosis fugax
(n=36) and asymptomatic carotid disease (n=9). All patients had an ipsilateral
high-grade internal carotid artery stenosis (>70%). Of the 89 patients with TIAs
(case-notes of 1 patient were destroyed), the median age was 71years (range
45-83) with a male to female ratio of 1.6:1. Post-operative complications included
2/89 (2.22%) TIAs, 2/89 (2.24%) lingual nerve paraesthesia, and 4/89 (4.5%)
haematomas none of which required drainage. The ABCD scores were as follows:
1, n=4 (4.49%); 2, n=15 (16.85%); 3, n=19 (21.34%); 4 n=22 (24.71%); 5 n=17
(19.10%); 6 n =12 (13.48%).
Conclusions: All patients undergoing CEA for TIAs were treated as per the
recommendations of the European carotid trial, yet according to the ABCD score
two thirds of these patients would be considered to be at low risk of a subsequent
neurological event. These patients would not have been fast-tracked for treatment
and thus further validation of this score is urgently required.
140 Cerebrovasc Dis 2007;23(suppl 2):1–147
3 Vascular surgery and neurosurgery/Interventinal
neuroradiology
CAROTID ENDARTERECTOMY: COMPLICATIONS AND CLINICAL
OUTCOME
R. Martinez, Y. Silva, J.A. Amado, O. Andres, J. Puig, S. Pedraza,
M. Castellanos, J. Serena
Hospital Universitari Dr. Josep Trueta, Girona, Spain
Background: To investigate the rate of perioperative complications and the clinical
outcome of endarterectomy in patients with symptomatic carotid-artery stenosis of
at least 70% in daily clinical practice. High risk patients were included.
Method: Ninety-five patients consecutively diagnosed as having symptomatic
carotid stenosis >70% were included over a 4 year period up to 2006. The
therapeutic decision was taken collectively by a multidisciplinary team from the
neurology, neurosurgery and neuroradiology departments. Vascular risk factors,
neurological examination, neuroimaging findings, carotid and transcranial colour
duplex study, intra- and post-operative complications (local and systemic), stroke
recurrence and mortality at 3 months were recorded. Patients were admitted to
the neurology department both on the occurrence of stroke and for immediate
postoperative attention.
Results: Seventy-six percent of patients were men, mean age 70±8.5 years. Hyper-
tension had a frequency of 72.6%; hypercholesterolemia, 51.6%; diabetes, 31.6%;
smoking, 29.5%; and ischaemic cardiac heart disease, 23.2%. Sixty percent had suf-
fered a stroke and 40% a TIA. Forty percent of patients had a symptomatic stenosis
>90% and 24% had a contralateral asymptomatic stenosis >70% or occlusion.
The occurrence of stroke or death within 3 months of carotid endarterectomy was
4.2%. Two patients died perioperatively (2.1%), one as a result of a hyperperfusion
syndrome and the other due to a brain infarction. Two patients (2.1%) suffered
stroke recurrence.
Minor haemodynamic alterations were detected in 42.1% of patients during the
first days after endarterectomy (hyper or hypotension) and 43.2% had local
complications (XII or VII minor pareses).
Conclusions: Among patients with severe carotid-artery stenosis and coexisting
conditions, carotid endarterectomy in clinical practice, including high risk patients,
has a low perioperative risk although minor complications are frequent, which may
be attributable to the close neurological control.
4 Vascular surgery and neurosurgery/Interventinal
neuroradiology
CAROTID ENDARTERECTOMY AUDIT OF GREAT BRITAIN & IRELAND
A. Rudd, T. Lees, A. Halliday, P. Rothwell, A. Hoffman, D. Kamugasha
Royal College of Physicians, London, United Kingdom
Background: A prospective two-year audit involving all hospitals that offer
Carotid Endarterectomy (CEA), aiming to capture data on all CEA cases performed
between Dec 05 & Dec 07, to assess quality of process of care & outcomes against
the available evidence base. Main reporting spring 2008. A firm evidence base
supports the role of CEA & its urgency in the prevention of stroke. In the UK
110,000 patients per annum suffer first stroke & 30,000 suffer TIAs. 10%-15% of
the stroke patients should have CEA. The Healthcare Commission commissioned
the audit following a pilot funded by the Stroke Association.
Methods: All surgeons who undertake CEA are eligible to participate and un-
dertake to contribute to: Organisational Survey (2 rounds) describing individual
surgeon routine practice: investigations, case selection criteria, surgical technique
& post-operative assessment and Clinical Audit to collect patient level data
(indications, investigation, surgical technique & 30-day morbidity/mortality).
Results: Organisational Survey (Round 1): Median number of CEAs performed
per annum overall is 17 (IQR 10-25) - 90% of these done for symptomatic disease
Over 70% of surgeons say they are able to see patients referred by letter within 2
weeks
99% of surgeons would not operate on symptomatic carotid stenoses <50% and
53% would not operate <70%.
62% of surgeons would be prepared to undertake CEA within 2 weeks following
a non-disabling stroke if the CT scan showed no infarct and 39% if the CT scan
showed a small infarct
Vascular surgeons perform nearly all CEA but about one quarter of surgeons
perform fewer than 10 cases per year. There are significant variations across the
country in access to CEA services.
Discussion: Recruitment is still open. 86% of eligible surgeons have registered and
so far contributed 1300 cases for the Clinical Audit for which data collection will
continue until end of December 2007. The first round of the Organisational Survey
completed May 2006 and the second is currently Round 2 is underway will report
April 2006
16th European Stroke Conference
Venous diseases
1 Venous diseases
DEVELOPMENT OF A RISK SCORE TO PREDICT THE PROGNOSIS OF
CEREBRAL VEIN AND DURAL SINUS THROMBOSIS (CVT)
J.M. Ferro, T. Rodrigues, L. Bacelar-Nicolau, H. Bacelar-Nicolau, P. Canhão,
I. Crassard, A. Dutra, A. Massaro, M.A. Mackowiak-Cordiolani, D. Leys, J.
Fontes
Department of Neurosciences, Hospital de Santa Maria, Lisboa, Portugal
Background: Although cerebral vein and dural sinus thrombosis (CVT) has an
overall favourable prognosis, a variable proportion of patients die or became
dependent after CVT. It is relevant to identify such high-risk patients.
Method: We used the ISCVT sample (624 patients) with a median follow-up time
of 478 days to develop a Cox proportional hazards regression model. Because of
non proportional hazards, the used model was stratified by the median age of 37
years. A treatment of influential observations (dfbeta analysis) led us to not include
9 outlier subjects. The model was tested in the whole ISCVT sample and in two
validation samples 1) the VENOPORT (91 patients), 2) of 169 consecutive CVT
patients admitted to 5 ISCVT participating centres after the end of the ISCVT
recruitment period.
Results: In the ISCVT sample the model (HR - CNS infection 5.11; malignancy
3.96; deep system 3.32; coma 3.17; mental 2.25; haemorrhage 1.57; male 1.76)
accurately predicted 89% of good and 47% of bad outcomes (accuracy: 85%) at 6
months, for a cut-off of 83% in the estimated survival probability. Area under the
ROC curve was 0.79 (p=0.000). In the VENOPORT validation sample the model
accurately predicted 91% of good and 25% of bad outcomes (accuracy: 84%). Area
under the ROC curve was 0.69 (p=0.077). In the 5 ISCVT centres validation sample
the model accurately predicted 93% of good and 24% of bad outcomes (accuracy:
86%). Area under the ROC curve was 0.79 (p=0.000).
Conclusion: The prognostic model presents a good external validity. The model
accurately predicts the majority of favourable outcomes and 1/4 to 1/2 of un-
favourable outcomes. It can be used to avoid dangerous interventions in low-risk
patients and to select patients for intensive monitoring and aggressive interventions.
From hazard ratios a prognostic score and estimated survivor probability at 6
months can be computed.
2 Venous diseases
DURAL ARTERIOVENOUS FISTULAS AND PREMATURE
ANTICOAGULATION CESSATION AFTER CEREBRAL VENOUS
THROMBOSIS
P. Cardona, H. Quesada, P. Sanchez, M.A. Fong, A. Escrig
Bellvitge Hospital, Hospitalet de Llobregat, Barcelona, Spain
Dural arteriovenous fistulas (DAVF) rarely are associated with cerebral venous
thrombosis (CVT). We report five cases of symptomatic intracranial dural arteri-
ovenous fistulas during follow-up of CVT.
Methods: We retrospectively review forty patients with intracranial venous throm-
bosis between 1996-2006. In five cases DAVFs were developed during follow-up
period 1 year after anticoagulation stopping (after 6 -9 months of period treatment);
leptomeningeal drainage were present in all the cases.
Results: Symptoms as pulsatile tinnitus or headache appeared 3-12 months interval
after anticoagulation cessation. All five patients where the initial angiogram studies
had showed abnormalities of the venous transverse or sigmoid sinuses, persistent
abnormalities were seen on the later angio-MR previous to stopping oral anticoag-
ulant (6-12 months period) as occluded or filiforme sinus. Two of five patients had
factor V Leiden previously unknowned. Embolization of DAVF was performed in
three cases with good outcome.
Discusion: DAVF appeared over previous ocluded or filiforme transverse sinus
demonstrated in angio-MR. All fistulaes were on the transverse or sigmoid sinuses.It
was hypothesized that factor V Leiden and other inhereted deficiencies of coagula-
tion factors, might be involved in the pathogenesis of DAVFS secondary to venous
thrombosis predisposition over damaged venous wall. Also the anticoagulation
cessation may predispose to DAVF formation.
Conclusion: The longterm anticoagulant therapy in occluded or partial thrombosed
sinus might be important for prevention of thrombosis and DAVF formation
although patients were asymptomatic. Due to a potential risk of intracranial hemor-
rages, embolisation previous to prompt anticoagulation may be developed in these
cases.
Poster Session
Heart & brain
3 Venous diseases
INCIDENCE OF INHERITED THROMBOPHILIA IN GREEK PATIENTS
WITH CEREBRAL VENOUS THROMBOSIS
K. Lysitsas, I. Gravas, G. Papaioannou, P. Kyriakidis, E. Dermitzakis, J. Rudolf
Papageorgiou General Hospital, Thessaloniki, Greece
Background: Hereditary thrombophilia has been reported to be present in approx-
imately 30% of all patients with cerebral venous thrombosis (CVT). However, data
on the incidence of inherited thrombophilia in Greek CVT patients are scarce.
Methods: We report the results of the diagnostic work-up including a full throm-
bophilia screening in a consecutive case series of 27 patients (8 males, 19 females,
age range 17 – 59 years) with CVT from a Greek tertiary healthcare facility.
Results: Cephalalgia was the leading symptom in 85% of the patients (n=23),
focal neurological signs were present in 48% (n=13), and epileptic seizures in 22%
(n=6). Multiple thrombosis of cerebral sinus was a common finding in MRI and
MRV: Thrombosis of the superior sagittal sinus was found in 78% (n=21), of the
transverse sinus in 41% (n=11), the sigmoid sinus in 7% (n=2), of the sinus rectus
in 18% (n=5) and of the cavernous sinus in one patient only. Elevated D-dimers
were found in 48% (n=13, hyperhomocysteinaemia in 30% (n=8), heterozygous
mutation of the MTHFR gene in 44% (n=12) and homozygous MTHFR mutation
in 18% (n=5). Other hereditary thrombophilias (e.g. FV-Leiden mutation, n=1, or
the prothrombine G20210A mutation, n=2) were found in single cases only.
Conclusion: In this consecutive open case series of Greek patients with CVT, the
incidence of inherited thrombophilia was considerably higher than reported from
other comparable study populations.
Heart & brain
1 Heart & brain
DIAGNOSING PATENT FORAMEN OVALE(PFO) IN CRYPTOGENIC
STROKE:TRANSCRANIAL DOPPLER VS TRANS OESOPHAGEAL ECHO
S. Kumar, M.S. Randall, L.O.’ Toole, J.N. West, G.S. Venables
Sheffield Teaching Hospitals NHS Trust, Sheffield, United Kingdom
Background:
PFO is associated with cryptogenic stroke in young patients (<55 years). Trans
Oesophageal Echo (TOE) has been the standard for diagnosing PFO. Contrast en-
hanced Trans Cranial Doppler (TCD) is a simpler, easier & less invasive technique
that detects a right to left shunt (RLS).The aim of this study was to compare the
utility of the two techniques in the management of young patients with stroke.
Methods:
TCD & TOE were performed in 100 consecutive patients with ischaemic stroke
or TIA (< 55 years; mean age 40years). Statistical analysis was performed using
SPSS software.
Results:
51% of patients had RLS on TCD and only 41% on TOE. After a positive result
on ce TCD 2 patients who had a negative TOE on the first occasion were shown
to have a shunt on repeat TOE. Other structural abnormalities detected by TOE
were inter atrial septal aneurysm (19), aortic atheroma (7), atrial thrombus (2), left
ventricular hypertrophy (2) & mitral valve abnormalities (3). Using TOE as the
standard, TCD sensitivity was 90% and specificity was 76%.With the combination
of the two tests as the standard, the sensitivity of TCD & TOE was 93% & 75%
respectively. The negative predictive value of TCD was 92%,while that of TOE
was only 76%.McNemar’s test showed a significant difference between TCD &
TOE(P=0.03).
Discussion:
This study reveals the added value of TCD in combination with TOE. The higher
sensitivity and negative predictive value of ceTCD may be due to an extracardiac
shunt or inadequate valsalva during TOE. The size of the shunt on TCD may
assist in the risk assessment for stroke recurrence in young people with stroke.
TOE is useful to exclude other sources of cardiac emboli. TCD has been shown
to be reliable, more sensitive, less invasive and easy to use in a clinical setting
making it the ideal screening tool. All young cryptogenic stroke patients should
have both TCD & TOE; undergo risk stratification based on degree of shunt on
TCD, the presence of intra cardiac abnormalities and other concomitant risk factors
to facilitate appropriate management.
Cerebrovasc Dis 2007;23(suppl 2):1–147 141
 2 Heart & brain
MODERATE HYPOTHERMIA FOR ANOXIC ENCEPHALOPATHY AFTER
IN-HOSPITAL AND OUT-OF-HOSPITAL CARDIAC ARREST: RESULTS IN
ROUTINE CLINICAL PRACTICE
R.A. Bernstein, K. Dewan, A.M. Naidech, M.J. Alberts, D. Fintel, D. Bergman,
R. Oakley
Northwestern University, Chicago, IL, USA
Background and purpose: Randomized trials have shown that induced moderate
hypothermia (MH) improves neurological outcomes after out-of-hospital cardiac
arrests due to ventricular fibrillation/tachycardia (VF/VT). However, the effective-
ness and safety of this treatment for other arrhythmias or for in-hospital arrests is
less clear. In addition, the prognostic significance of early brainstem dysfunction
after hypothermia is unknown. We devised a standard protocol for MH in patients
with anoxic encephalopathy after cardiac arrest of any type, including both in
hospital and out-of hospital arrests.
Methods: For this retrospective case series, we collected demographic, clinical,
and outcome data on our first 21 consecutive patients treated with MH for anoxic
encephalopathy after cardiac arrest. Target temperature was 33o C for 24 hours
from start of cooling, with controlled re-warming over 8 hours. Neurological out-
comes were dichotomized based on discharge disposition as “good” (discharge to
home or rehabilitation) or “poor” (discharge to nursing home or death). Brainstem
dysfunction was defined as any of the following: pupillary non-reactivity, absent
caloric or oculocephalic reflexes, absent corneal reflexes, or absent gag reflex.
Results: Of the 21 patients who underwent MH after cardiac arrest, 62% were
male, and the mean age was 60 [range 35-88]. In hospital arrests (n=16, 76%) out-
numbered out-of-hospital arrests (n=5, 24%). Arrest arrhythmias included pulseless
electrical activity (44%), asystole (24%), VF/VT (19%), primary respiratory arrest
followed by cardiac arrest (10%) and unknown (5%). The mean time to return
of spontaneous circulation was 16 minutes [95% CI 9.7-22.7 min]. Discharge
dispositions were to home (10%), rehabilitation (19%), nursing home (14%) and
dead (57%). Good outcome (discharge to home or rehabilitation) occurred in 3 of
5 (60%) of out-of-hospital arrests, and 3 out of 16 (18%) of in hospital arrests.
Among patients surviving 3 or more days, all of those with brainstem dysfunction
had poor outcomes (n=8); of those without brainstem dysfunction on day 3, 6 out
of 7 (86%) had good outcomes.
Conclusions: Moderate hypothermia after cardiac arrest is feasible in routine clin-
ical practice. Good neurological outcome may be more common in out-of-hospital
arrests; only a randomized trial can determine if this therapy is effective for
in-hospital arrests. Consistent with experience in the pre-hypothermia era, patients
with brainstem dysfunction on or beyond day 3 have poor outcomes.
3 Heart & brain
IS HEART DISEASE A PROGNOSTIC FACTOR FOR ACUTE STROKE
OUTCOME? A PROSPECTIVE STUDY
I. Ybot, M.J. Abenza, B. Fuentes, B. San José, M.A. Ortega-Casarrubios,
P. Martínez, E. Díez-Tejedor
University Hospital La Paz, UAM, Madrid, Spain
Background: Heart disease in ischemic stroke (IS) may be the cause of stroke,
a coexistent illness, or even a consequence of stroke, but its presence means a
higher risk for vascular death. Objective: To analyse the presence of cardiopathy in
patients with acute IS and its impact on stroke outcome.
Methods: Prospective study with inclusion of consecutive IS patients in a 4-month
recruitment period. Previous or current cardiopathy, vascular risk factors, stroke
severity on admission, in-hospital complications and modified Rankin Scale (mRS)
at discharge were analysed.
Results: 91 patients included, 33% with known heart disease. Most frequent
entities were arrhythmia, including atrial fibrillation (AF) (53.3%) and ischemic
cardiopathy (36.7%). They were older (72 vs 63 years old; p<0.05), had greater
frequency of hypertension (80% vs 42%; p<0.05), hypercholesterolemia (60% vs
19%; p<0.05) and peripheral artery disease (20% vs 4,9%; p<0.05), had more
severe strokes on admission (p<0.05) and worse outcome at discharge (mRS>2:
48.1% vs 18.2%;p<0.05) than patients without previous history of heart disease.
It was diagnosed cardiopathy in 11 among 61 patients without known heart
disease (18%), being AF the most frecuently diagnosis (6 patients). In the logistic
regression analysis, the only independent factor of poor outcome was the stroke
severity on admission, without significant influence of heart disease.
Discussion: Although previous cardiopathy seems to be associated to higher stroke
severity on admission and worse recovery at discharge, when adjusting for other
prognostic factors it was not independently associated to poor outcome.
142 Cerebrovasc Dis 2007;23(suppl 2):1–147
4 Heart & brain
THE ROLE OF THE MORPHOLOGICAL CHARACTERISTICS OF PATENT
FORAMEN OVALE IN CRYPTOGENIC STROKE: AN MRI STUDY
C. Bonvin, K.O. Lovblad, H. Müller, R. Sztajzel
University Hospitals of Geneva, Genève, Switzerland
Background and purpose: Patent foramen ovale (PFO) is an established cause of
cryptogenic stroke in young patients. The aim of our study was to evaluate, in pa-
tients admitted for a cryptogenic stroke or transient ischemic attack (TIA), whether
the number and distribution of ischemic lesions on MRI differed according to the
morphological characteristics of the PFO including size and degree of interatrial
right-to-left shunting (RLS) and presence of atrial septal aneurysm (ASA).
Patients and methods: We included 220 consecutive patients less than 60 years old
admitted from 2000 to 2006 for a cryptogenic stroke or TIA (absence of any other
determined stroke etiology following TOAST criteria after complete diagnostic
workup). Hypercoagulable state was not an exclusion criterion, since it may play
a role in the paradoxical embolism. Demographic data have been analyzed from
the patients’ personal records. MRI scans and echocardiographies were evaluated
by independent experienced investigators, blinded to the patients’ history. Two
different methods were systematically assessed to diagnose PFO and ASA: contrast
transcranial Doppler (c TCD) and transesophageal echocardiography (TEE) as well
as transthoracic echocardiography (TTE) in most patients.
Results: Recruitment of patients is completed and neurologists, cardiologists and
neuroradiologists are currently working intensively on the data. We will especially
determine (i) the prevalence of PFO and ASA in cryptogenic strokes, (ii) compare
c-TCD, TEE and TTE methods in their ability to detect and quantify the PFO,
(iii) correlate the number and size of MRI lesions with size of PFO, ASA and
degree of RLS in univariate and multivariate analysis (logistic-regression model
and ANCOVA). To our knowledge, this study is the first to compare simultaneously
c-TCD, TEE and TTE findings with MRI lesions in patients with cryptogenic
stroke. This study may help to better assess the risk of stroke in these patients and
thus have critical impact on treatment options.
Large clinical trials (RCTs)
1 Large clinical trials (RCTs)
DELAYS IN TREATMENT FOR SYMPTOMATIC CAROTID STENOSIS AT
RESEARCH ACTIVE CENTRES
R.L Featherstone, J. Ederle, M.M. Brown
UCL Institute of Neurology, London, United Kingdom
Background: Treatment of symptomatic carotid artery stenosis is an effective
secondary prevention measure for stroke. The earlier endarterectomy is performed
after symptoms, the better the long-term outcome. We have used baseline data from
the International Carotid Stenting Study (ICSS), an ongoing multicentre study of
symptomatic patients randomized between carotid endarterectomy and stenting, to
assess delays in treatment.
Methods: The interval between the most recent TIA or non-disabling stroke,
recorded at randomization, and the date of procedure (carotid endarterectomy or
stenting) was calculated for all ICSS patients where data on the procedure was
returned by December 2006. Data came from 36 centres in the UK, Europe, North
America and Australia.
Results: The median delay between event and treatment was 55 days (n=854). Most
of the delay occurred before randomization, median delay between randomization
and treatment was 14 days. The three centres with the shortest average delay
between event and treatment were compared with the three that had the longest.
The median delay at the fastest centres was 14 days (N=42 patients) compared
to 123 days in the three slowest centres (N=72 patients), a significant difference
(p<0.001).
Discussion: Significant differences exist in treatment delays between centres. Even
the most efficient research active centres are failing to treat many patients with
symptomatic carotid stenosis within 2 weeks of the presenting symptoms, when
the benefit is greatest. Such treatment delays result in a substantial proportion of
patients being left at high risk of a recurrent event while awaiting investigation
and treatment. The results emphasise the need to reorganize stroke services to
investigate and treat carotid stenosis urgently.
16th European Stroke Conference
 2 Large clinical trials (RCTs)
THE SAFETY AND EFFICACY OF CLOPIDOGREL VERSUS TICLOPIDINE
IN JAPANESE STROKE PATIENTS — COMBINED RESULTS OF TWO PHASE
III MULTICENTRE RANDOMISED CLINICAL TRIALS
S. Uchiyama, T. Yamaguchi, Y. Fukuuchi
Tokyo Women’s University, Tokyo, Japan
Background: Compared with aspirin, both ticlopidine and clopidogrel have demon-
strated superior efficacy in preventing recurrent vascular events, but adverse drug
reactions (ADRs) are more common with ticlopidine. For the first time, the safety
and efficacy of these agents have been compared directly among Japanese stroke
patients in a combined analysis of 2 phase III randomised, controlled studies.
Methods: Patients aged 20–80 years with a history of noncardioembolic stroke
were randomised to receive clopidogrel 75 mg once daily (n=941) or ticlopidine
200 mg once daily (n=928) for 26 or 52 weeks. The primary endpoint was
safety (incidence of ADRs; n=1869). The major secondary endpoint was efficacy
(combined incidence of cerebral infarction, myocardial infarction, and vascular
death; n=1862).
Results: Baseline characteristics of each group were similar (mean age, 64.7
years; 71.3% males). The clopidogrel group had significantly fewer ADRs than the
ticlopidine group (35.0% vs 48.7%; p<0.0001) and a significantly lower incidence
of hepatic dysfunction (13.4% vs 25.6%; p<0.001). The frequency of hemorrhagic
ADRs was similar in the two treatment groups (clopidogrel group, 11.9%; ticlo-
pidine group 10.1%; p=0.612). Both drugs were equally effective in preventing
vascular events (clopidogrel group, 3.6%; ticlopidine group, 3.8%; p=0.510).
Conclusions: In Japanese patients with a history of noncardioembolic stroke, both
clopidogrel and ticlopidine are equally effective in the prevention of recurrent
vascular events.
However, clopidogrel is safer than ticlopidine. Now that clopidogrel is available
in Japan, it should be considered as the preferred treatment choice, as occurs for
Western patients.
3 Large clinical trials (RCTs)
ETHNICITY DOES NOT AFFECT THE HOMOCYSTEINE-LOWERING
EFFECT OF VITAMIN THERAPY IN SINGAPOREAN STROKE PATIENTS
K. Kasiman, J.W. Eikelboom, G.J. Hankey, H.M. Chang, M.C. Wong, C.P. Chen
National Neuroscience Insititute, Singapore General Hospital Campus,
Singapore
Background: Increased plasma total homocysteine (tHcy) levels are a risk factor
for stroke and can be reduced with vitamin therapy. However, data on the tHcy-
lowering effects of vitamins are limited largely to white populations. Thus, we
aimed to determine in Singaporean patients with recent stroke: (1) the efficacy
of vitamin therapy (folic acid, vitamin B12, and B6) on lowering tHcy, and (2)
whether efficacy is modified by ethnicity (Chinese, Malay & Indian).
Methods: A total of 506 eligible patients (420 Chinese, 41 Malays and 45 Indians)
were recruited after presenting with ischemic stroke within the past 7 months.
Patients were randomized to receive either placebo or vitamins as part of a
large multi-centre double-blinded clinical trial. Fasting blood samples collected at
baseline and at 1 year were assayed for levels of plasma tHcy.
Results: Mean baseline tHcy was similar in the 2 groups, At 1 year, mean tHcy
was significantly higher in the placebo group compared with the vitamin group.
Ethnicity was not an independent determinant of tHcy
levels at baseline. The magnitude of the reduction in tHcy levels at 1 year with
vitamin therapy was similar, irrespective of ethnicity: mean change in tHcy Chinese
(-3.2 vs 0.6 micromol/L); Malay (-3.5 vs 1.5 micromol/L) and Indians (-3.0 vs 0.2
micromol/L).
Discussion: Vitamin therapy reduces mean tHcy levels in the Singaporean stroke
population studied. Ethnicity did not impact on the tHcy-lowering effect of vitamins
used in this study, despite possible differences in dietary intake and genetic makeup.
This suggests the generalisability of vitamin therapy efficacy in lowering tHcy
across Asian populations.
Poster Session
Behavior and mood
Behavior and mood
1 Behavior and mood
SYMPTOMS AND DIAGNOSIS OF DEPRESSION IN APHASIC STROKE
PATIENTS
A.C. Laska, B. Mårtensson, T. Kahan, M. von Arbin, V. Murray
Karolinska Institutet, Department of Clinical Sciences, Stockholm, Sweden
Background: We investigated the feasibility of assessing depression, and symptom
occurrence, in patients with aphasia.
Methods: 89 acute stroke patients with aphasia of all types were followed for six
months. The diagnosis of depression was made in accordance with DSM-IV criteria
at baseline, 1, 3, and 6 months. A standard aphasia test was performed. A battery
of “yes and no” capability questions from the comprehension part of the aphasia
test were selected for depression diagnostic purposes.
Results: In 60 patients (67%) at baseline, and successively increasing to 100%
at six months, comprehension allowed reliable DSM-IV diagnosis. The possibility
to undertake a DSM-IV interview was related to the degree of aphasia (p<0.01),
and was least in patients with global and mixed non-fluent types of aphasia. A
comparison at one month between patients reliably fulfilling the criteria for a
depression (D) and those who did not (Non-D) revealed: none of the two cardinal
symptoms occurred among the Non-D. Of the other symptoms, weight loss (36% in
D, 16% in Non-D); insomnia (50% in D, 33% in Non-D); loss of energy (25% in D,
20% in Non-D); and impaired concentration (27% in D, 19% in Non-D) occurred
(all n.s.). At six months weight loss, insomnia, and loss of energy still occurred in
above 10% in Non-D. In all, criteria for depression were fulfilled in 24%.
Discussion: It is possible to verify the presence or absence of a depression accord-
ing to DSM-IV criteria in two thirds of aphasic stroke patients in the acute setting.
Some depression symptoms occur irrespective of depression diagnosis. Hence, if
a cardinal symptom is fulfilled depression may possibly be over-diagnosed in the
individual stroke patient with aphasia.
2 Behavior and mood
SYMPTOM PROFILES IN MAJOR AND MINOR POSTSTROKE DEPRESSION
V. Murray, P. Gustavsson, B. Mårtensson
Karolinska Institutet Danderyd Hospital, Dept. Clin. Sciences, Stockholm,
Sweden
Background: Findings on clinical profiles in poststroke depression are conflict-
ing. Meta-analysis is difficult due to different methodologies. Hence, new data
are needed. Symptom profiles in major and minor poststroke depression were
compared. For clarity, or basis for hypotheses, the symptom profiles of the major
depressed stroke patients were compared with those of major depressed psychiatric
patients.
Methods: Stroke patients fulfilling DSM-IV diagnostic criteria for major or minor
depression (n=127), and “psychiatric” in-patients with a major depression (n=40)
were assessed by the Montgomery-Åsberg Depression Rating Scale (MADRS).
Results: The MADRS profiles of major and minor depressed stroke patients were
similar, with lower scores in minor depression but for “inner tension”; “pessimistic
thoughts”; and “suicidal thoughts” where scoring was equally high. No basic
clinical or neuroradiology differences were identified. Stroke patients with lesions
Cerebrovasc Dis 2007;23(suppl 2):1–147 143
involving the cortex rated higher for “sadness”, while in those with a central lesion
only, “inner tension” (anxiety) was more pronounced. In the comparison of profiles
between major depressed stroke patients and “psychiatric” patients, the items on
“sadness” and “reduced sleep” were similarly pronounced.
Discussion: Given the similarity in “sadness” i.e. depressed mood, equivalent to
cardinal criterion 1 in the DSM classification of a depression, it is striking that
“inability to feel”, the equivalent of the DSM cardinal criterion 2, was much less
pronounced in stroke than among the “psychiatric” patients.
Conclusions: The difference between major and minor poststroke depression may
be more quantitative than qualitative, while the difference between poststroke and
“psychiatric” major depression could be more qualitative.
3 Behavior and mood
ENDOREACTIVE POST-STROKE DEPRESSIONS ARE ASSOCIATED WITH
POORER MOTOR RECOVERY
V. Kontzevoj, V. Skvortsova, M. Savina, E. Petrova
Russian Medical State University, Russian Federation
Background: The majority of recent studies showed that poststroke depression
(PSD) influence the recovery of neurological deficit and daily activities. However,
some studies didn’t take into account the clinical heterogeneity of PSD. Some of
PSD are known to have endogenic structure.
Objective: We hypothesized that PSD with different psychopathological structure
would influence differently on motor recovery.
Methods: 115 subjects with first stroke (57 males, 58 females, the mean age 65
years) were observed in fixed terms. Depression was diagnosed using criteria of
ICD-10. The elaborate psychopathological analysis of their clinical features was
made. The degree of neurological impairment was assessed by the Orgogoso Scale.
The recovery was assessed by criterion of Wilxoson.
Results: During first year after stoke depressions were observed in 38 patients
(33%). 6 cases with manifestation of depression before stroke were not included
in further analysis. In 21 patient were diagnosed reactive PSD. In 12 patients
were diagnosed endoreactive PSD that had both reactive and endogenic features
(vitalized affects, circadian rhythmus with worsening of depressive symptoms at
the morning etc.). In patients without PSD (n = 77) Orgogozo scale total score
changed significantly from 1–3 days to 2. week (p = 0,005), from 2. to 4. week (p
= 0,000), from 4. week to 3 month (p = 0,000) and from 3. month to 6. month (p
= 0,017); changes from 6 to 12 month after stroke were insignificant. In patients
with reactive PSD changes of Orgogozo scale total score were significant from 2.
to 4. week (p = 0,001) and from 4. week to 3. month (p = 0,002). In patients with
endoreactive PSD Orgogozo scale scores changed insignificantly in all defined time
intervals.
Conclusions: Endoreactive PSD compared with reactive ones are associated with
poorer motor recovery.
4 Behavior and mood
NEUROPSYCHIATRIC PROFILE OF ELDERLY ACUTE STROKE PATIENTS
C.O. Santos, L. Caeiro, J.M. Ferro, M.L. Figueira
Serviço de Neurologia e Serviço de Psiquiatria, Department of Neurosciences,
Hospital de Santa Maria, Lisboa, Portugal
Background: Neuropsychiatric disturbances after acute stroke are relatively fre-
quent. Elderly stroke patients have a high proportion of concomitant diseases, a
worse recovery and an aging brain. We aim to describe the neuropsychiatric profile
of a sample of elderly acute stroke patients.
Methods: Consecutive acute stroke patients (≤4 days after stroke onset) hospi-
talised in a Stroke Unit were assessed with a standardized protocol including:
MMSE, Delirium Rating Scale, Montgomery Asberg Depression Rating Scale, De-
nial of Illness Scale, Catastrophic Reaction Scale, Mania Rating Scale, Apathy Scale
and Apathy Evaluation Scale. Neuropsychiatric profile of patients aged </≥65
years old (younger vs elderly) was compared. Bivariate analysis was performed to
find associations between neuropsychiatric disturbances and demographic, clinical
and imaging data in the elderly patients.
Results: We studied 55 elderly patients (mean age of 72.5 years old), 13 (24%)
of them presenting an acute cognitive impairment, 7 (13%) delirium, 27 (49%)
acute depression, 27 (49%) denial, 8 (15%) catastrophic reaction, 1 (2%) mania,
9 (39%) were identified as clinically apathic and 8 (35%) considered themselves
as apathic. Elderly patients presented a higher frequency and severity of acute
cognitive impairment (p=.01), a higher severity of delirium (p=.04) and catastrophic
reaction (p=.02) and they considered themselves as more apathic (p=.02).
Discussion: Although the frequency of neuropsychiatric disturbances was similar
to that presented by younger patients, we found a higher severity of cognitive
144 Cerebrovasc Dis 2007;23(suppl 2):1–147
impairment, delirium, catastrophic reaction and self-referred apathy in elderly. The
identification of those neuropsychiatric disturbances is clinically relevant for their
functional state recovery.
Stroke and movements disorders
1 Stroke and movements disorders
MYOCLONUS AFTER ACUTE STROKE
L. Idrovo Freire, F. Vivancos Matellanos, M. Lara Lara, E. Diez-Tejedor
Hospital Universitario La Paz, Madrid-Spain
Introduction: Hyperkinetic abnormal movements during acute stroke are uncom-
mon, with an estimated prevalence of 1%. Myoclonus is a clinical manifestation
defined as a sudden, brief, involuntary and shock-like movements caused by
muscular contraction (positive) or inhibitions (negative).
Methods: We report 3 patients that on examination during the acute phase of
stroke showed hemi-asterixis (two of them) and a positive myoclonus in the other
(videos).
Results: The patients with asterixis had similar clinical features and both suffered
cardioembolic ischaemic infarcts of the posterior cerebral artery territory. The
patient showing a positive myoclonus had a thalamo-mesencephalic haemorrhage.
On all cases, neuroimaging studies revealed that the postero-lateral thalamus was
involved. The patients who showed asterixis, in addition to the thalamic compro-
mise, also had temporo-occipital lesions (one of them the cerebellar hemisphere was
also affected). On the other hand, in the patient with the haemorrhagic stroke the
rostral mesencephalus was also affected. In all cases, these abnormal movements
had a good outcome.
Discussion: Hyperkinetic abnormal movements during stroke are unusual neurolog-
ical manifestations and acute-onset hemi-asterixis is even less frequently reported.
Asterixis is usually associated with thalamic lesions (ventral and posterolateral)
though any lesion of the cerebellar-rubrothalamic-cortical pathway can enhance
myoclonic activity.
Intracranial aneurysms and vasospasm
1 Intracranial aneurysms and vasospasm
LOCAL LEVELS OF ENDOTHELIN-1 AND NITRIC OXIDE METABOLITES
IN BASILAR ARTERY AND CEREBROSPINAL FLUID AFTER
EXPERIMENTAL SUBARACHNOID HEMORRHAGE IN RABBITS
V. Neuschmelting, S. Marbacher, A.R. Fathi, R.W. Seiler, S. Jakob, J. Fandino
University Hospital Berne, Berne, Switzerland
Objective: The genesis of Endothelin-1 (ET-1) and Nitric Oxide (NO) as two
important mediators in the development of cerebral vasospasm (CVS) after sub-
arachnoid hemorrhage (SAH) is controversially discussed. The objective of this
study was to determine whether local levels of ET-1 and NO in cerebral arterial
plasma and/or in cerebrospinal fluid (CSF) are associated with the occurrence of
CVS after SAH.
Methods: CVS was induced using the one-hemorrhage-rabbit-model and confirmed
by digital subtraction angiography of the rabbits’ basilar artery (BA) on day 5. Prior
to sacrifice local samples of CSF and basilar arterial plasma (BAP) samples were
assessed by transclival approach to the BA in addition to systemic arterial plasma
(SAP). ET-1 levels were determined by an immunometric technique (in pg/ml ±
SEM) and total nitrate/nitrite level spectrophotometricly (in μmol/L ± SEM).
Results: Angiographically detectable CVS could be documented in animals with
induced SAH (n=12, p<0.05). The ET-1 level in CSF was significantly elevated by
27.3% to 0.84 ± 0.08 pg/ml in SAH animals (n=7) in comparison to control (0.66
± 0.04 pg/ml, n=7, p<0.05). There was no significant difference of ET-1 levels in
SAP and BAP samples of SAH animals compared to controls. Highly significant
lack of local NO metabolites could be documented in BAP of SAH animals (36.8
± 3.1 μmol/L, n=6) compared to controls (61.8 ± 6.2 μmol/L, n=6, p<0.01).
Decreasing tendency of local NO level remained insignificant in CSF and SAP
(n=6, p>0.05).
Conclusions: This study demonstrates elevated ET-1 level in CSF and local lack of
NO in BAP samples to be associated with CVS after experimental SAH. Possible
genesis of local changes of ET-1 and NO level after SAH are discussed in respect
to controversial data reported to date.
16th European Stroke Conference
 2 Intracranial aneurysms and vasospasm
SHARED EXPERIENCE IN THE ACUTE TREATMENT OF PATIENTS WITH
CEREBRAL ANEURYSM
M. Carvi y Nievas, J. Hattingen, H. Höllerhage, M. Müller-Schimpfle
Neurosurgery, Frankfurt am Main/Höchst, Germany
Objective: evaluation of our shared endovascular-microsurgical experience treating
cerebral aneurysms.
Method: An interventional neuroradiologist and a neurosurgeon administered
the emergent treatment of 97 consecutive SAH-patients harboring 108 cerebral
aneurysms. Decisions were based on the patient-clinical-condition, aneurysm mor-
phology and location, degree of ICP and on CBF distribution patterns. The benefits
of joined case-assessment were retrospectively analyzed evaluating the rate of
aneurysm occlusion, the employment of complementary treatments, the patient
clinical evolution and number of observed complications.
Results: Initially, 39 aneurysms in 34 patients were endovascular (EV) and 65
aneurysms in 63 patients were surgical (S) treated. Four non-ruptured aneurysms
remain under control. Three patients in the surgical group died without angio-
control. Complete radiological aneurysm occlusion was achieved in 35 (89.5%)
EV- and 60 (95.2%) S treated aneurysms. Complementary treatments included
24 CSF-drainages and 7 decompressive surgeries in the EV-group as well as 5
EV-procedures to treat severe vasospasm in the S-group. Four aneurysms-remnants
(2 EV and 2 S-treated) remain unchanged. One EV-treated-aneurysm grew and
was surgically occluded. Favorable evolution was observed in 27 (79.4%) EV and
52 (82.5%) S treated patients. CT-documented rebleedings (7 - 1), angiographic
vasospasm (3 - 5), occlusion of main vessels (1 - 2) were the method related
complications in EV and S-groups respectively.
Conclusion: After comparing literature data, shared decisions in the emergent
aneurysm-treatment increases the rate of aneurysm-occlusion, improves patient’s
evolution and allows appropriated complementary treatments reducing the number
of complications.
3 Intracranial aneurysms and vasospasm
NOREPINEPHRINE INDUCES DILATION IN THE RABBIT BASILAR
ARTERY DUE TO ALPHA ADRENOCEPTOR DEPENDENT MECHANISM
AFTER EXPERIMENTAL SUBARACHNOID HEMORRHAGE IN VIVO
V. Neuschmelting, A.R. Fathi, S. Marbacher, R.W. Seiler, S. Jakob, J. Fandino
University Hospital Berne, Berne, Switzerland
Objective: Norepinephrine (NE) is routinely administrated for prevention and
treatment of cerebral vasospasm (CVS) after subarachnoid hemorrhage (SAH).
The aim of this study was to determine mechanisms responsible for angiographic
dilation and hypertension observed during continuous NE infusion in the rabbit
basilar artery (BA) after SAH.
Methods: CVS was induced using the one-hemorrhage-model. On day 5 the
animals underwent control angiography prior to continuous intravenous adminis-
tration of NE. Alpha-1 adrenoceptor antagonist (prazosine) and alpha-2 antagonist
(rauwolscine) were added for partial inhibition. Changes in diameter of the BA
were digitally calculated in μm and expressed in percentages ± SEM. Prior to
sacrifice, local samples of cerebrospinal fluid (CSF) and BA blood were obtained
by transclival approach. Endothelin-1 (ET-1) and nitric oxide (NO) levels were
determined in random samples of both groups.
Results: SAH induced CVS in the BA (-13.9% ± 2.0, n=36, p<0.0001). NE
caused hypertension from 83.2 ± 0.8 mmHg to 170.3 ± 0.9 mmHg (p<0.001).
A dilation of 12.4% ± 2.6 (p<0.0001) of the BA during NE administration could
be documented. Alpha-2 adrenoceptor inhibition partially reversed NE-dependent
blood pressure plateau and significantly narrowed BA diameter by 11.3% ± 1.7
(n=12, p<0.05). Additional alpha-1 inhibition instead showed similar antihyper-
tensive effect while its narrowing effect on the dilated BA was less (-4.8% ±
0.9, n=12) and remained insignificant (p>0.05). ET-1 and NO levels in CSF, BA
and systemic plasma remained unchanged after NE administration and were not
affected by additional alpha antagonism (n=7 each, p>0.05).
Conclusion: This study demonstrates the novel finding that NE causes dilation of
the BA in the SAH rabbit model due to alpha adrenergic dependent mechanism,
independently, however, from ET-1 and NO system.
Poster Session
Intracranial aneurysms and vasospasm
4 Intracranial aneurysms and vasospasm
INTEREST OF PERFUSION AND DIFFUSION MR IMAGING TO FOLLOW
PATIENTS WITH CEREBRAL VASOSPASM AFTER ANEURYSMAL
SUBARACHNOID HEMORRHAGE
E. Le Bars, H. Brunel, M. Moynier, G. Boubotte, A. Bonafé
CHU Hôpital Gui de Chauliac, Montpellier, France
Objective: study the potentiality of Diffusion and Perfusion MRI to improve the
vasospasm diagnosis sensitivity in case of aneurysmal subarachnoid bleeding.
Methods: Thirty cases of aneurysmal SAH were evaluated with TCD, DWI and
PWI within the first three days and the following sixth and tenth day after the
bleeding. The fourth MRI examination is done at 6 months to evaluate brain
damages. For each patient, the apparent diffusion coefficient, the cerebral blood
volume, the cerebral blood flow, the tissue mean transit time, the Time to Peak
(TTP), the time inflow of contrast agent were evaluated for each exam. Two
methods for the evaluation of DWI and PWI analysis were carried out: a qualitative
analysis for the thirty cases; a longitudinal quantitative analysis of PWI based on
two groups of patients. The control group showed no modification of PWI during
the study. In the other group variations of PWI time data outside the ischemic area
were found.
Results: We found in two patients a complete reversibility in DWI anomalies.
Three patients showed PWI anomalies without DWI modification. The amplitude
of relative perfusion time data at the acute stage of vasospasm is statistically
significant between the two groups. The evolution of relative perfusion time data
for the group with altered perfusion is statistically significant compared to the
control group. The relative TTP evolution is correlated with the clinical symptoms
during the acute stage of vasospasm, MRI lesion and with the neurological deficits
at 6 months. The longitudinal analysis of the rTTP value was the most sensitive
parameters witch was correlated with the deficit and with a risk of a lesion at six
month.
Conclusion: The DWI and PWI appear to be sensitive imaging techniques for
cerebral vasospasm evaluation. According to these preliminary results, perfusion
appears to be an important tool for the evaluation of symptomatic or asymptomatic
vasospasm and for the follow up of those patients.
5 Intracranial aneurysms and vasospasm
PILOT STUDY OF NON-INVASIVE MEASURES OF ENDOTHELIAL
DYSFUNCTION IN ACUTE ISCHAEMIC STROKE
S.L. Soiza, I. Ford, H. Clark, M. Bruce, K.K. Kalal, D.J.P. Williams
University of Aberdeen, Aberdeen, United Kingdom
Introduction: Endothelial dysfunction (ED) is believed to be important in the
pathogenesis of ischaemic stroke. Studies show serum markers of endothelial
activation are acutely raised after stroke. A direct, non-invasive measure of global
ED has recently been developed.1 The method relies on pulse wave analysis
(PWA) before and after administration of endothelium-dependent (salbutamol) and
independent (glyceryl trinitrate (GTN)) vasodilators. We believe this is the first
study employing this technique in stroke patients.
Methods: 29 patients with recent ischaemic stroke, 21 controls matched for risk
factors, and 9 healthy controls underwent PWA at the right radial artery using
SphygmoCor. ED was assessed by the ratio of the change in augmentation index
after 400mcg inhaled salbutamol via spacer over the change after 400mcg of
sublingual GTN.1 Serum markers of ED (vonWillebrand factor, E-selectin and
sVCAM-1) were obtained simultaneously. One-way ANOVA was used to look for
significant differences between the groups.
Results: See Table 1. Correlation between the various measures of ED was poor.
Table 1. Mean values of measures of endothelial function
Healthy Controls Matched Controls Acute Stroke P
Augmentation Index (AIx), % 9.7 32.7 32.6 <0.001
AIx drop after Salb/GTN 0.57 0.23 0.30 0.02
vonWillebrand Factor, U/ml 0.91 1.01 1.30 0.05
E-selectin, ng/ml 36.2 50.9 49.9 0.43
sVCAM-1, ng/ml 274.2 361.7 353.4 0.40
Conclusions: Patients who have suffered an acute ischaemic stroke have evidence
of endothelial dysfunction, but this was not significantly different from that found
in a population matched for risk factors for stroke.
Reference: [1] Hayward et al. J Am Coll Cardiol 2002;40:521-528.
Cerebrovasc Dis 2007;23(suppl 2):1–147 145
Vascular biology
1 Vascular biology
POTENTIAL OF ERYTHROPOIETIN IN TREATMENT OF SPINAL CORD
INJURY AND VASCULAR FAILURE
I. Voznjuk, M. Odinak, N. Tsygan
Military Medical Academy, Russian Federation
Nowadays the use of cytokines that promote neuron survival and growth is a
promising trend in the treatment of spinal cord injury and vascular failure. One of
the few nerve growth factors which are used in clinical practice is erythropoietin.
The purpose of the study was to evaluate the potential of erythropoietin in the
treatment of spinal cord injury and vascular failure.
The experiment involved 48 male adult rats. The rats were subject to spine
compression at 20 N for 30 sec at level L3-L4. The animals were divided into
three groups: intact rats (8 animals); the rats that received sodium chloride (0.9%,
0.5 ml) intraperitoneally 10 min after the trauma (20 animals); the rats that
received erythropoietin (5,000 units/kg) intraperitoneally 10 min after the trauma
(20 animals). All the rats underwent daily neurological examination (the assessment
of hind limb and tail muscle strength, the pain sensitivity of the hind part of the
body, and pain reflexes of hind limb flexion and tail withdrawal). The results of the
examination were assigned numerical scores. Histological spinal cord examination
was carried out on the 1st and 21st day after the trauma.
The lifetime of the rats that received erythropoietin (4.63±1.69 days) was reliably
(p<0.05) higher than in rats that received sodium chloride (2.75±1.28 days). On the
11-16th day after the injury, the muscle strength in rats that received erythropoietin
was reliably (p<0.05) higher than in rats that received sodium chloride. The speed
of the recovery of the muscle strength was reliably (p<0.025) higher in rats that
received erythropoietin. Histological examination showed a smaller number of
damaged neurons and a smaller area of spinal hemorrhage in rats that received
erythropoietin.
The data proves that erythropoietin increases the lifetime, extent and rate of
neurologic recovery after spinal cord injury in rats. This may be due to the
neurotrophic and vascular-protective effect of erythropoietin. Thus, erythropoietin
may have high potential in the treatment of spinal cord injury and vascular failure.
2 Vascular biology
REDUCED ADAMTS-13 (VON WILLEBRAND FACTOR-CLEAVING
PROTEASE) ACTIVITY IN THE EARLY PHASE AFTER TIA OR ISCHAEMIC
STROKE
D.J.H. McCabe, R. Starke, P. Harrison, P.S. Sidhu, M.M. Brown, S.J. Machin,
I.J. Mackie
The Adelaide and Meath Hospital, Trinity College Dublin, Dublin, Ireland
Background: Reduced ADAMTS-13 (von Willebrand factor-cleaving protease)
enzyme activity is well described in patients with thrombotic thrombocytopenic
purpura (TTP), and may lead to the accumulation of very large von Willebrand
factor (VWF) multimers. Large VWF multimers may promote platelet activation
and thrombus formation in vivo and could exacerbate ischaemia or infarction in
patients with TIA or ischaemic stroke who do not have TTP.
Methods: Using a collagen binding assay, we performed a pilot study to measure
ADAMTS-13 activity in platelet poor plasma in 56 patients in the early phase (≤4
weeks) and 46 patients in the late phase (≥3 months) after a TIA or ischaemic
stroke while they were on treatment with aspirin (75-300 mg daily). We compared
these data with those obtained from 22 controls subjects who were not on aspirin.
The results were expressed in percentages relative to pooled normal plasma.
Results: Mean ADAMTS-13 activity was significantly lower in the early phase
(70.3%, P = 0.002) but not in the late phase (80.1%, P = 0.07) after TIA or stroke
compared with controls (94.5%).
Discussion: We have shown that ADAMTS-13 activity is significantly reduced in
the early phase after TIA or ischaemic stroke. Studies in larger cohorts of patients
are required to assess the importance of this finding, and further work is ongoing
to assess the impact of reduced ADAMTS-13 activity on platelet function ex vivo
under high shear stress conditions.
146 Cerebrovasc Dis 2007;23(suppl 2):1–147
3 Vascular biology
IMPAIRED FLOW MEDIATED DILATATION IS ASSOCIATED WITH POOR
OUTCOME IN ISCHEMIC STROKE
D. Santos, M. Blanco, N. Perez de la Ossa, S. Arias, J. Serena,
X. Rodriguez-Osorio, F. Nombela, M. Rodriguez-Yañez, R. Leira, A. Davalos
Hospital Clinico, University of Santiago de Compostela, Santiago de
Compostela, Spain
Background: Brachial arterial flow-mediated dilatation (FMD) reflects endothelium-
dependent vasodilator function. FMD is diminished in patients with atherosclerosis,
is a marker of low nitric oxide bioavailability, and is associated with an increased
risk of vascular or cardiac events. Our aim was to investigate the relationship
between FMD and outcome in patients with acute ischemic stroke.
Methods: In 120 consecutive patients (58.3% male, median age 73 years) with
acute ischemic stroke within the first 24 hours of evolution we measured FMD by
high-resolution ultrasonography. FMD was calculated as the relationship between
basal diameter of the brachial artery before (d1) and after (d2) transient vascular oc-
clusion (300 mmHg for 4 minutes) with a sphygmomanometer (FMD= d2 – d1/d1).
The intima-media thickness (IMT) >0.9 mm, extracranial carotid atherosclerosis,
stroke severity (NIHSS score) at baseline and discharge, and modified Rankin Scale
(mRS) at 3 months were also evaluated. Poor outcome was defined as mRS >2.
FMD was categorized according to ROC analysis.
Results: Median [quartiles] FMD was 8.9 [4.3, 13.9]. Median FMD values were
significantly lower in patients with IMT >0.9 mm (p<0.0001), and extracranial
carotid atherosclerosis (p<0.0001). FMD negatively correlated to stroke severity,
both at baseline (p=0.038) and discharge (p=0.034). Median FMD was significantly
lower (4.5 [2.3, 10.3] vs 9.4 [5.6, 15.1], p=0.003) in patients with poor outcome
(n=38). The adjusted odds ratio of poor outcome for FMD >4.5% was 9.69 (1.97,
47.68; p=0.005).
Conclusions: Impaired FMD in patients with acute ischemic stroke is associated
with poor outcome.
4 Vascular biology
A SYSTEMATIC ASSESSMENT OF THE GENETIC INFLUENCES ON
CAROTID INTIMA MEDIA THICKNESS (CIMT)
L. Paternoster, N. Martínez-González, M. Chung, R. Charleton, S. Lewis,
C. Sudlow
University of Edinburgh, Division of Clinical Neuroscience, Edinburgh, United
Kingdom
Background: CIMT is a measure of subclinical atherosclerosis, associated with
increased risk of stroke and myocardial infarction, and a heritability of around 50%.
It should be informative in studying the genetics of vascular disease, particularly
large artery ischaemic stroke.
Studies of the association between various genes and CIMT have produced con-
flicting results. We aimed to identify genes whose association with CIMT has been
studied in >5000 subjects, and to perform meta-analyses to evaluate reliably the
evidence for an association.
Methods: For each relevant study, we extracted information on subjects, methods
and mean (&SD) CIMT per genotype. We calculated study-specific and pooled
mean difference in CIMT between genotypes.
Results: 8 genes were studied in >5000 subjects: angiotensin converting enzyme
(ACE); apolipoprotein E (APOE); beta 2 adrenergic receptor; methylenetetrahy-
drofolate reductase; endothelial nitric oxide synthase; factor V; interleukin 6;
paraoxonase 1.
Several relevant studies (accounting for 19% of subjects studied across all genes)
had insufficient published data for inclusion.
2 genes (ACE and APOE) showed a significant association with CIMT. The DD
genotype of ACE had a mean CIMT 0.02mm greater than the II genotype. e4
allele-containing genotypes of APOE had a mean CIMT 0.07mm greater than e2
allele-containing genotypes. For both genes, we found larger associations among
smaller studies, Asian subjects and subjects at high vascular risk.
Discussion: We have identified 2 genes likely to influence CIMT, but methodolog-
ical issues such as small study bias and missing data make it difficult to estimate
the true size of the associations. To increase the reliability of our results, we are
seeking additional data from studies with insufficient published data.
16th European Stroke Conference
 5 Vascular biology
THE EFFECT OF ACUTE HYPERHOMOCYSTEINAEMIA ON CEREBRAL
BLOOD FLOW OF HEALTHY ELDERLY VOLUNTEERS
S.R. Hart, A.A. Mangoni, C. Swift, C. Deane, R. Sherwood, A. Wierzbicki,
S.H. Jackson
Div. of Clinical Neuroscience, University of Edinburgh, United Kingdom
Background: Mildly increased plasma homocysteine is an independent risk factor
for ischaemic stroke. However, the underlying fundamental causal arterial mecha-
nisms in vivo linking hyperhomocysteinaemia with cerebrovascular disease remain
unclear.
Objective: To test the hypothesis that acute increases in plasma homocysteine
produced by methionine are associated with an acute decrease in cerebral arterial
blood flow velocity (CABFV) measured by transcranial Doppler (TCD) ultrasound.
By contrast, the simultaneous response of peripheral arterial distensibility was
measured by pulse wave velocity (PWV) and digital volume pulse (DVP).
DESIGN: A double-blind, cross-over, placebo controlled design was used and
cerebral blood flow velocity and peripheral arterial distensibility and plasma homo-
cysteine concentrations were measured between 12 and 20 hours after methionine
loading or placebo.
Results: Between 13 and 16 hours after initial exposure to a methionine loading
test, mean CABFV showed a significant 5.1% decrease in mean blood flow velocity
(34.1±0.3 m/s vs 36.0±0.3 m/s, p <0.01) compared to placebo (Sample size = 8).
However, between 17 and 20 hours after methionine exposure, CABFV showed no
significant sustained change, compared to placebo (36.1±1.0 m/s vs 35.3±0.3 m/s,
p < 0.1). There was no significant change in peripheral arterial distensibility mea-
sured by PWV during hyperhomocysteinaemia compared to placebo (9.9±0.2m/s
vs 10.1±0.2m/s, p<0.5) and no difference in DVP, stiffness index (83.7±1.8% vs
83.7±1.6%, p<0.1).
Conclusion: In healthy elderly volunteers, acute hyperhomocysteinaemia resulted
in a significant initial decrease in CABFV but no sustained reduction in cerebral
blood flow velocity. There was no significant simultaneous change in periph-
eral arterial distensibility suggesting that elderly cerebral arterial response to
hyperhomocysteinaemia is different to that of peripheral arteries.
7 Vascular biology
ASSOCIATION BETWEEN STROKE SUB-TYPES AND INTERLEUKIN-1
GENE POLYMORPHISM WITHOUT SALIVA INTERLEUKIN-1 BETA
IMPLICATION
M. Caillier, Y. Bejot, G.V. Osseby, F. Contegal, D. Minier,
R.M. Gueant-Rodriguez, M. Giroud
Stroke registry of Dijon, Dijon, France
Background: Ischemia-induced inflammation is characterised by early infiltra-
tion of leucocytes in the ischaemic region and development of brain oedema.
Interleukin-1 (IL-1) is one of the key modulators of the inflammatory response.
The IL-1 gene cluster on chromosome 2q14 contains three related genes (IL-1
alpha, IL-1 beta and IL-1 receptor antagonist, IL-1 ra). Clinical studies suggest an
early intrathecal IL-1 beta production and IL-1 beta mRNA expression in blood
mononuclear cells during stroke. We aimed to investigate the association between
ischemic stroke sub-types and IL-1 gene polymorphism as well as production of
saliva IL-1 beta.
Methods: The -889C/T IL-1A, -511C/T IL-1B and IL-1RN (VNTR) polymorphism
was genotyped in patients with stroke due to large vessel disease (n=22), car-
dioembolism (n=33), lacunar stroke (n=24), other determined mechanism (n=17),
undetermined cause (n=21), transient ischemic attack (n=19) and in control group
(n=19) by PCR. IL-1 beta concentration was determined in saliva using ELISA.
Results: There was no significant rise in the concentration of salivary IL-1 beta
in acute stroke compared to the control group’s results. Studied polymorphisms
did not influence concentration levels. Genotypes frequency of IL-1A CT and TT
were significantly higher in lacunar stroke with respect to the control group (62,5%
and 31,6%, respectively; p=0,04), but not T allele. For IL-1RN (VNTR), IL-1RN
4-4 genotype frequency was higher in cardioembolic stroke than in control group
(85,7% and 46,2%, respectively; p=0,04). This result was also confirmed for the
allele 4 (35,4% and 21,1% respectively, p=0,02).
Discussion: This study suggests than IL-1A and IL-1RN gene polymorphism is
related with respectively lacunar and cardioembolic stroke onset.

6 Vascular biology
SUBMICROSCOPIC FEATURES OF SMALL VESSEL DISEASE IN SKIN
BIOPSIES OF PATIENTS WITH CHRONIC KIDNEY DISEASE AND
EARLY-ONSET (<50 YEARS) COGNITIVE IMPAIRMENT. PRELIMINARIES
RESULT
G. Arismendi-Morillo, M. Fernandez-Abreu, A. Castellano-Ramirez
Laboratory of Electron Microscopy, University of Zulia. Nephrology and
Pathology Department HGS, Maracaibo, Venezuela

Background and aims: Decline in cognitive function has been reported in patients
with advanced renal disease. In addition, end-stage renal disease has been associated
with accelerated vascular disease of the cerebral circulation. Cerebral small vessel
disease is frequent in patients with cognitive impairment. Skin biopsy is hire in the
study of leukoaraiosis since permit establish the responsible vascular pathology of
possible brain disease. The aim of this study was illustrate the small vessel disease
in skin biopsies of patients with chronic kidney disease and early-onset cognitive
impairment in Maracaibo city - Venezuela.
Patients and methods: Two female patients with chronic kidney disease and early-
onset (< 50 years) of cognitive impairment that showed signs of Leukoaraiosis were
studied. Punch skin biopsy was prepared for conventional transmission electron
microscopy study and for haematoxylin/eosin, PAS and Red Congo stain.
Results: Small vessels study by means electron microscope revealed an increase in
media-lumen ratio, endothelial cells with hyperplasic nucleus, clear cytoplasm and
scarce organelles, thickened and multilayered basal membrane with focal degener-
ative changes and deposition of amorphous and electron-dense materials as well
as proliferation of collagen fibers. Smooth muscular cells exhibited hypertrophy.
Pericytes showed phagocytoced material and residual bodies. In adventitia was
thickened with abundant collagen fibers, amorphous and electron-dense materials
and cell debris.
Conclusion: The morphological changes in subcutaneous small vessel correspond
to small vessel disease of type degenerative microangiopathy and, possibly corre-
spond to the microvascular pathology in the brain. Added patients with chronic
kidney disease and early-onset cognitive impairment are needed to establish a
complete characterization of small vessel disease.

Poster Session Cerebrovasc Dis 2007;23(suppl 2):1–147 147

Vascular biology