XVII

XVII. European Stroke Conference
Nice, France

Poster Session: Acute stroke: treatment concepts

Session: Poster Session II
Date: Thursday 15 May 2008
Time: 12:30 - 14:00
Room: Agora 3


Gender Differences in Thrombolytic Treatment for Ischemic Stroke The SITS-MOST patients
A. Falcou    A. Niaz    S. Lorenzano     E. Puca     N. Wahlgren    M. Prencipe     D. Toni

Unità di Trattamento Neurovascolare Università La Sapienza Rome Italy

ITALY

Background The natural history of stroke shows that women have a worse outcome than men, whereas they could benefit from a better response to thrombolytic treatment with higher recanalization rate and better functional outcome. The hypotheses to explain this apparent influence of sex are multiple (size arteries, hormonal and coagulative factors). We analyzed the cohort of the Safe Implementation of Thrombolysis in Stroke Monitoring Study (SITS-MOST) in order to determine whether gender has an influence on response to intravenous rt-PA treatment for acute ischemic stroke. Methods We conducted comparisons between genders through univariate analyses of baseline characteristics (age, previous mRS, vascular risk factors, glycemia, NIHSS, blood pressure), time intervals to treatment, and outcome parameters (mRS, death, SICH, cause of death), obtained in the SITS-MOST patients. Results From December 2002 to April 2006, 3.902 men and 2.581 women have been included in the trial. The analysis of baseline characteristics shows statistically significant differences for median age (64,9 for men, 66,64 for women; p = 0,0000), diastolic blood pressure (83,4 in men, 81,1 in women; p = 0,0000), and NIHSS (12,5 in men, 13 in women; p = 0,001). As regard risk factors, there were significant differences in hypertension (p = 0,002) and AF (p = 0,0000), more frequent in women, and in smoke (p = 0,0000) and hyperlipidemia (p = 0,0000), more frequent in men. Outcome parameters revealed a significantly better functional prognosis in men (mRS 0-2: 56,2% vs. 52,8%; p = 0,008), not due to mortality nor hemorrhagic complications. Discussion These analyses confirm data learned in literature: stroke women are older, have a more severe deficit, and suffer more often from atrial fibrillation. Moreover, our study demonstrates that functional outcome after thrombolysis is better in men, following the natural history. The very large sample size can reasonably exclude the role of chance in these results. We conclude that there is no difference to thrombolysis response between genders.

Session: Poster Session II
Date: Thursday 15 May 2008
Time: 12:30 - 14:00
Room: Agora 3


Safe Implementation of Thrombolysis in Stroke- Monitoring Study (SITS-MOST) in Italy
S. Lorenzano    N. Ahmed    E. Puca     N. Wahlgren     M. Prencipe    D. Toni

Unità di Trattamento Neurovascolare, Department of Neurology, University "La Sapienza", Rome

ITALY

Background. The SITS-MOST study was the observational safety study required by the European Evaluation of Medicines Agency (EMEA) to investigate whether the safety of i.v. alteplase given within 3 h of ischemic stroke reported in randomised controlled trials (RCTs) could be replicated in clinical practice. In Italy, only few centers were expert in thrombolysis before the SITS-MOST and hence this was an unique opportunity to test safety and efficacy of i.v. thrombolysis in the “real world” outside the setting of clinical trials. Methods. In Italy to participate in the study the clinical centers had to possess organisational and structural characteristics that had to be certified by Regional Health Authorities and confirmed by local Ethics Committee. Results. Seventy-one centers were activated of which 56 (79%) treated patients. Of these 41 (73%) had never used thrombolysis before the study. Globally, 586 patients were included. Baseline median NIHSS of Italian patients was 13 vs 12 in other european centers (p .0001). SICH as per the NINDS/Cochrane definition occurred in 6.7% of italian patients (39/584; 95% CI 4.8-9.1) compared with 7.3% (429/5854; 95% CI 6.7-8.0) in the european patients (p 0.56) and 8.6% of the pooled RCTs (40/65; 95% CI 6.3-11.6). Mortality and independence (mRS 0-2) rates at 3 months in Italian patients were 11.6% (68/583; 95% CI 9.2-14.6) and 51.6% (300/582; 95% CI 47.4-55.7) compared respectively with 11.2% (633/5635; 95% CI 10.4-12.1) (p 0.75) and 55.1% (3062/5554; 95% CI 53.8-56.4) (p 0.09) in the other european patients and 17.3% (83/479; 95% CI 14.1-21.1) and 49% (227/463; 95% CI 44.4-53.6) in the RCTs. There were no statistical differences in the proportion of SICH (p 0.955), mortality (p 0.395) and independence (mRS 0-2) (p 0.790) at 3 months between experienced and new italian centers. Discussion. The SITS-MOST study showed that in Italy i.v. alteplase is safe and effective in routine clinical use as in the other european centers, even in centers with little previous experience of thrombolytic therapy.

Session: Poster Session II
Date: Thursday 15 May 2008
Time: 12:30 - 14:00
Room: Agora 3


INTRAVENOUS AND INTRA-ARTERIAL INTERVENTIONAL APPROACHES IN ACUTE ISCHEMIC STROKE DUE TO CERVICAL ARTERY DISSECTION.
M. Nesi    D. Barale    G. Orlandi     I. Santilli     M. Melis    C. Marini     D. Inzitari     M. Cavazzuti    P. Nencini

Neurological and Psychiatric Sciences, University of Florence

ITALY

Background: Cervical artery dissection (CAD) accounts for 10% of strokes in young people and may cause disabling stroke. Acute treatment with intravenous rtPA (IVT) or intra-arterial intervention (IAT) may improve stroke outcome, although, thrombolysis could enlarge parietal haematoma, and mechanical revascularization could aggravate vessel wall damage. Methods: From February 2002 to December 2007, 28 patients presenting with ischemic stroke due to CAD underwent acute stroke treatment in 6 Italian hospitals. Diagnosis of dissection was based on colour duplex ultrasound examination, MRI or digital angiography. Results: 24 patients had an internal carotid artery dissection, 2 had vertebral artery dissection, complicated by basilar artery occlusion in other 2 patients. 11 (82% males, mean age 41±13 years, mean NIHSS 11±4 were treated with IVT within 3 hours from symptoms onset, whereas 17 patients (82 % males, mean age 43±10 years, mean NIHSS 18±6) underwent IAT including thrombolysis (urokinase or rtPA) with or without mechanical manoeuvres or stenting. A good outcome (Rankin≤2) was achieved in 7 (53%) of the 11 patients treated with IVT, and in 6/17 (35%) of patients treated with IAT. No complication occurred in IVT patients and in the IAT group 6 patients (35%) experienced intracerebral hemorrhage that was symptomatic in 3 cases. In this group 3 patients died. Conclusions: in our series IVT proved safe and effective in over 50% of cases. IAT achieved good results in 1/3 of cases, but these cases had a more severe stroke. The best approach (acute intervention or not, type of intervention) of patients with acute stroke due to CAD remains undetermined, especially in severe cases. Randomized controlled trials comparing the different approaches and techniques are warranted.

Session: Poster Session II
Date: Thursday 15 May 2008
Time: 12:30 - 14:00
Room: Agora 3


UA reduces the early activation of MMP-9 in acute stroke patients receiving tPA.
S. Amaro    M. Gomez-Choco    X. Urra     A. Cervera     V. Obach    AM. Planas     A. Chamorro

Functional Unit of Cerebrovascular Diseases. Hospital Clinic. Barcelona.

SPAIN

Background. Matrix Metalloproteinase 9 (MMP-9) is rapidly up regulated after acute human cerebral ischemia and is related to bad clinical outcomes, such as hemorrage. In human stroke the combined treatment with tPA and uric acid (UA) is safe and decreases the lipid peroxidation. The aim of this study was to evaluate the effect of the antioxidant agent UA in the temporal profile of total and active MMP-9 levels in acute stroke patients receiving tPA. Methods. Patients were part of a phase-II trial of intravenous administration of UA in 24 acute stroke patients treated with tPA within 3 hours of stroke onset. At the end of tPA infusion patients received 500mg (n=8) or 1000 mg of UA (n=8), or vehicle alone (n=8). The levels of total (tMMP-9) and active (aMMP-9) MMP-9 were assessed at baseline (T0), after UA/vehicle treatment (T1) and at 48 hours (T2). Disability was evaluated with the Rankin Scale (RS). Results. Good RS (<2) at day 90 was related to lower aMMP-9 levels at T0 and at T1 (p=0.028 and p=0.022 respectively, t-test). tMMP-9 levels increased significantly from T0 to T1 (p=0.016, paired t-test); no effect of UA was observed in the temporal profile of tMMP-9 levels. Contrarily, patients allocated to vehicle alone showed higher aMMP-9 levels at T1 (28.8+/-11.7 ng/ml) respect to those allocated to UA (1000 mg: 22.2+/-8.75, 500mg 22.5+/-9.5 ng/ml); p=0.047, ANCOVA adjusted to T0 aMMP-9 levels. Discussion. Early activation of MMP-9 is related to bad clinical outcome in acute stroke patients receiving tPA. UA administration inmediately after tPA appears to prevent the hyperacute activation of MMP-9. These findinds support the role of oxidative stress in in-vivo regulation of MMP-9 and the potential clinical utility of combined treatment with tPA and antioxidants in acute stroke.

Session: Poster Session II
Date: Thursday 15 May 2008
Time: 12:30 - 14:00
Room: Agora 3


Intra-venous (iv.) t-PA for cerebral ischemia: baseline characteristics and 3-month outcome in patients treated at non-working time.
D. LEYS    C. LEFEBVRE    S. DEBETTE     C. CORDONNIER     F. DUMONT    C. LUCAS     M. GIROT     M.A.MACKOWIAK    D. DEVOS   H. HENON

Lille University Hospital

FRANCE

Background: at non-working time (NWT) neurologists are more tired, sometimes less experienced in the stroke field, and have less possibilities to share decisions with colleagues. These conditions may influence the selection of patients treated with iv. t-PA, and outcomes. Objective: to compare baseline characteristics and 3-month outcome of patients treated with iv. t-PA at NWT, with those of patients treated at working time (WT). Methods: we compared baseline characteristics, protocol violations, and 3-month outcome, between patients treated by iv. t-PA for cerebral ischaemia at NWT and at NWT. All patients were treated by a senior neurologist in a stroke unit. Results: 100 consecutive patients (mean age 66 years; 57 men; median NIHSS score 15) were recruited. We observed 18 protocol violations, 13 being onset-to-needle times between 3h and 3h30. Fifty patients (50%) were treated at NTW. Their baseline characteristics differed only by a shorter door-to-imaging time (median delay 14 min vs. 21 min; p=0.047), but not for demographic characteristics, medical history, stroke severity (NIHSS) and subtype (TOAST classification), biological features, vital signs, and onset-to-needle time. They had more protocol violations (15/50 vs. 3/50; p=0.02), and asymptomatic intracerebral haemorrhages (ICH) (10/50 vs. 1/50; p=0.009), but not symptomatic ICH (4/50 vs. 3/50; p=0.548). They did not differ at month-3 for the proportion of patients with mRS 0-1 (18/50 vs. 19/50; p=0.836), mRS 0-2 (27/50 vs. 24/50; p=0.548), or death (7/50 vs. 9/50; p=0.585). At NWT protocol violations did not differ between neurologists who are stroke specialists and neurologists who are not. Conclusion: protocol violations and asymptomatic ICH were more frequent in patients treated at NWT, but they did not influence the 3-month outcome. Working at NWT might be more important than being a neurologist not specialised in the stroke field to explain the excess of protocol violations. However, the small sample size is a limitation to this study which needs to be confirmed in a larger group.

Session: Poster Session II
Date: Thursday 15 May 2008
Time: 12:30 - 14:00
Room: Agora 3


Responder Analysis of Outcome in MRI-selected Patients for Thrombolytic Treatment in the 3 Hour Time Window
C. Sølling    N. Hjort    M. Ashkanian     L. Østergaard     G. Andersen

Aarhus University Hospital

DENMARK

Introduction The use of magnetic resonance imaging (MRI) may alter the target population thrombolytic treatment relative to conventional computerized tomography (CT). With altered selection, it remains crucial to demonstrate safety and efficacy of thrombolytic therapy for the overall population, as well as in sub-populations hypothesized to benefit from MRI. Outcome according to initial stroke severity (responder analysis) in the 0-3 hour window is reported and compared to data from the randomized CT-based National Institute of Neurological Disorders and Stroke (NINDS) trial. Materials and methods Clinical outcome and incidence of symptomatic intracerebral hemorrhage (ICH) was recorded in 112 consecutive patients treated with intravenous Alteplase (0-3hours) with MRI as first choice imaging modality. Baseline stroke severity was assessed on the National Institute of Health Stroke Scale (NIHSS) and outcome on the modified Rankin Scale (mRS). According to the responder analysis, favorable outcome was defined separately for mild (NIHSS<8; mRS 0), moderate (NIHSS 8-14; mRS 0-1) and severe (NIHSS>14; mRS 0-2) stroke. Results 83 patients were treated with Alteplase after MRI, and 29 after CT. Adjusted for baseline severity, 42% of all patients had a favorable outcome, compared to 37% in the NINDS trial. Among patients with severe stroke, MR-selected patients (n=31) showed a good outcome in 52% of patients compared to 29% in NINDS (p<0.05). Symptomatic ICH occurred in 2 patients (1.9 %), and 7 patients died during hospitalization (6.3%). Conclusion MRI based thrombolytic treatment is safe and efficacious. Our data support the hypothesized benefit of MRI in patients with severe stroke.

Session: Poster Session II
Date: Thursday 15 May 2008
Time: 12:30 - 14:00
Room: Agora 3


Relationship between blood pressure and recanalisation in cerebral arterial occlusion treated with intravenous thrombolysis: Results from SITS Thrombolysis Register (SITS-ISTR)
T. Kharitonova    N. Ahmed    N. Wahlgren
for SITS-ISTR collaborators
Karolinska University

SWEDEN

Background. An inverse association between systolic blood pressure (SBP) and vessel recanalisation after stroke thrombolysis has been reported in a previous study, although other studies showed contradictory results. We aimed to compare the course of blood pressure in recanalised and non-recanalised patients treated with intravenous thrombolysis after ischaemic stroke. Methods. In the Safe Implementation of Treatment in Stroke- International Stroke Thrombolysis Register (SITS-ISTR) data on vessel occlusion at baseline and 22-36h follow up imaging scans were recorded for 1980 patients. Of these, 428 were recruited by CT/MR angiography and 1552 by hyperdense middle cerebral artery sign (HMCAS) on CT scan. Blood pressure was recorded at baseline, 2h and 24h after the thrombolysis. Recanalisation was defined by either absence of vessel occlusion on CT/MR angiography or resolution of HMCAS on follow-up imaging scans. Blood pressure change was calculated as difference from baseline to follow up values. Results. Recanalisation occurred in 1038 patients (52.4%) after intravenous thrombolysis. Median SBP was similar (150 mm Hg) in recanalised and occluded groups (mean baseline SBP was lower in recanalised compared to occluded group, 147 vs. 149, p=0.09), at 2h was 143 vs. 147, p=0.07 and at 24h was 140 vs 144, p<0.001. No statistically significant difference was found for DBP at all time points. Median SBP decline at 2h in recanalised group was 3 vs. 2 (p=0.90), in the occluded group and at 24h was 7 vs. 5 (p=0.10). Conclusion. In ischaemic stroke patients treated with intravenous thrombolysis, recanalisation seemed to be associated with additional decrease of systolic, but not diastolic blood pressure from baseline to 24h level.

Session: Poster Session II
Date: Thursday 15 May 2008
Time: 12:30 - 14:00
Room: Agora 3


Single loading doses of Clopidogrel are well tolerated in ischemic stroke up to 24 hours from onset
M.M.Awadh    S.A.Ragab    M.A.Sherif     H.M.Afify     H.M.Aref    R.R.Moustafa     M.O.Abdulghani

Ain Shams University, Cairo, Egypt

UNITED KINGDOM

Background: Few ischemic stroke patients are candidate for IV r-TPA thrombolysis. Single loading doses of Clopidogrel up to 900 mg are approved in per-cutaneous coronary interventions as a pre-procedural prophylaxis against thrombotic events. A useful role might exist in management of acute ischemic stroke, yet safety profiles remain the major concern. Methods: 39 consecutive patients ineligible for IV thrombolysis and presented within 24 hours were recruited for this pilot study, excluding lacunar infarctions.15 patients received 600 mg (group 1) and 10 received 900 mg (group 2) of Clopidogrel then maintained on a daily 75 mg, and 150-300 mg daily aspirin was prescribed to 14 sex and age matched controls. According to risk factors, low or full doses of low molecular weight heparin (LMWH) started a day later. NIH-SS was recorded on admission, second and seventh days. Follow-up imaging (full MRI & MRA, CT on demand) was done within a week. Results: No significant differences exist among 3 groups in mean age, sex and stroke subtypes. Mean NIH-SS scores at admission, 2 & 7 days were: 12.9, 11.3 & 8.4 respectively in group 1, and 17.3, 11.9 & 6.7 in group 2 and 10.9, 9.1 & 7.6 in the control group. Significant difference in improvement (P value < 0.05) exists only between group 2 and either group 1 and controls. 3 patients in group 1 and a patient in group 2 had hemorrhagic transformations, but none in the control group. All 4 patients had received full-dose LMWH, with only a single clinically manifest hemorrhage in group 1, developed beyond the half life of loading Clopidogrel. Discussion: Single oral high doses of Clopidogrel appear to be safe in acute ischemic stroke unless combined with full-dose anti-coagulation, providing a probable clinical improvement in larger doses.

Session: Poster Session II
Date: Thursday 15 May 2008
Time: 12:30 - 14:00
Room: Agora 3


Evaluation of an intravenous (IV) insulin infusion associated with 0.9% NaCl perfusion in acute ischemic stroke
M. Bruandet    S. Deltour    S. Crozier     M. Lejeune     M. Zuber    Y. Samson

Urgences cérébro-vasculaires, groupe hospitalier Pitié-Salpétrière

FRANCE

Background and purpose: Early hyperglycemia is associated with poor outcome of stroke. We report the safety and biological efficacy of a predefined IV insulin protocol for acute ischemic stroke patients. Methods: Fifty-four consecutive patients with middle cerebral artery infarct admitted in stroke critical care unit within 6 hours of stroke onset were treated between April 2003 and May 2004 by insulin IV infusion. Infusion started as soon as possible after NIHSS, blood sampling, MRI, and the beginning of tPA infusion, if ever done. Insulin was infused in 0.9 % saline with an electric pump during 24 hours with hourly adjustment to capillary glucose level (CBG), according to a normogram starting at 1 UI/h above 100 mg/dl, up to 4 UI/h above 310 mg/dl. Results: The 54 patients had a median age of 59 years (IQR: 48-70) and the median baseline NIHSS was 16 (IQR: 12-20). Six patients (11%) were previously identified as diabetics. Thirty five patients (65%) were thrombolysed. Insulin protocol was started with a median delay of 195 minutes (IQR: 150-255) after stroke onset. The median initial CBG was 117 mg/dl (IQR: 104-138), and decreased to 111 mg/dl (IQR: 98-123) at 3 hours. Only one asymptomatic hypoglycemia below 67 mg/dl was observed. Three variables were independent predictors of mRs at 3 months: initial NIHSS (p<0.0001), recanalization status (p=0.0111) and mean CBG level between the fourth and sixth hours (CBG 4-6) (p<0.0001). A discriminant analysis showed that good outcome (mRs 0-2) was significantly more frequent when GBC 4-6 was ≤ 111 mg/dl (72 vs 19% of patients, p<0.0001). The 111 mg/dl threshold was achieved for the 4-6 hour slot in 67% of patients, but in only 2% of those with known diabetes. Conclusion: These preliminary data suggest an acceptable safety profile of this IV insulin protocol, when used in a dedicated critical care stroke unit. The toxicity threshold of glucose levels may be close to normoglycemia (111 mg/dl), and this goal was achieved at the 4-6 hour slot with the current protocol in 67% of consecutive acute MCA infarct patients.

Session: Poster Session II
Date: Thursday 15 May 2008
Time: 12:30 - 14:00
Room: Agora 3


The Impact of Nurse led Assessment on the Management of TIA patients in an acute stroke Unit. The RASS project.
C.K.Ritchie    L.N.Smith    J. Dawson     A. Hill     L. Craig

NHSGreater Glasow and Clyde & Universtity of Glasgow

UNITED KINGDOM

Background. 15% of TIA patients are at a high risk of stroke, with 35% having a full blow event within 7 days.Early, effective management of TIA is essential to reduce mortality.To reduce TIA assessment waiting times,we explored the use of stroke nurses to assess and investigate our TIA patients to implement evidence into practice and achieve clinical and service performance targets. Aims. 1.To achieve >95% diagnostic accuracy from trained stroke nurses for acute cerebrovascular events. 2. To increase the proportion of TIA patients completing investigation from <20% within 1 week of assessment to >50%. 3. To develop a scoring system for nurses/refering practioners to use. Method. A training package for nurses was developed by a Clinical Research Fellow to enhance their assessment skills. The protocol driven nurse led assessment service started in Janauary 2006.Data collection and analysis included patient demographics, management, and waiting times. Diagnostsic accuracy of nurses decisions was conducted by medical review and compared to doctor accuracy. Interviews with nursing staff and medical staff documented the change process Results. 25 RASS clinics were completed over a 7 month period, 4 nurses were trained as per protocol. 57 patients were reviewed during this period with nurse/doctors agreement on diagnosis for 74% of patients. Nurses achieved 74% diagnositic accuracy with a tendency to over diagnosis of CVA/TIA. Conclusions. The limited number of nurses trained for this role with staffing resources issues within the nursing unit meant it was difficult to sustain the skills. Waiting times from GP referral to assessment were reduced. While nurses demonstrated they could achieve these competencies,a larger cohort is required to prove sustainable service improvement. .

Session: Poster Session II
Date: Thursday 15 May 2008
Time: 12:30 - 14:00
Room: Agora 3


CDP-CHOLINE ENHANCES THE INCREMENT OF ENDOTHELIAL PROGENITOR CELLS IN PATIENTS TREATED WITH tPA.
T. Sobrino    D. Brea    O. Moldes     J. Agulla     R. Rodríguez-González    I. Cristobo     P. Ramos-Cabrer     O. Hurtado    M. Rodríguez-Yáñez   J. Castillo

Clinical Neuroscience Research Lab, Hospital Clínico Universitario. Santiago de Compostela

SPAIN

BACKGROUND: Previous studies by our group have demonstrated that an increase of the circulating concentration of EPCs was associated with a better outcome in patients with acute ischemic stroke. CDP-choline (citicoline) protects the stability of the cellular membranes and increases neuronal plasticity after experimental stroke. Therefore, we study if an administration of citicoline could increase the EPC concentration after ischemic stroke. METHODS: Forty-eight patients (24 males, average 70.7 (10) years) with acute ischemic stroke, <12 hours (h) from onset, were included in the study and classified according treatment or non-treatment with citicoline (2 g/day) from acute phase of ischemic stroke. Likewise, 15 patients were treated with t-PA within 3 hours from symptom onset following the SITS-MOST criteria. EPC colonies were quantified as early outgrowth colony forming unit - endothelial cell (CFU-EC) at admission (previous to citicoline or tPA treatment) day 7, and at 3 months. We defined the EPC Increment during the first week as the difference in the number of CFU-EC between day 7 and admission. RESULTS: CFU-EC were similar at baseline between patients treated and non-treated with citicoline (7.7 (6.1) vs. 9.1 (7.3) CFU-EC, p=0.819). However, patients treated with citicoline and tPA showed a higher CFU-EC absolute increment compared to patients treated only with citicoline or non-treated (35.4 (15.9) vs. 8.4 (8.1) vs. 0.9 (10.2) CFU-EC, p <0.0001). On the other hand, and EPC Increment ≥4 CFU-EC during the first week was associated with a good functional outcome at 3 months (OR, 75.2; CI95%, 1.1-386.6; p=0.047). In a logistic model, co-treatment with citicoline and tPA was independently associated with an EPC Increment ≥4 CFU-EC (OR, 108.5; CI95%, 2.9-4094.2, p=0.001) after adjustment for ischemic volume, time from stroke onset and citicoline treatment. CONCLUSION: Co-administration of citicoline and tPA increases EPC concentration and improves functional outcome in acute ischemic stroke.

Session: Poster Session II
Date: Thursday 15 May 2008
Time: 12:30 - 14:00
Room: Agora 3


Aspirin Resistance is Prevalent in Patients with Acute Ischaemic Stroke
S. Halawani    I. Ford    M. Greaves     J. Webster     D.J.Williams

University of Aberdeen and NHS Grampian

UNITED KINGDOM

Aspirin is the most commonly used anti-platelet drug in the secondary prevention of ischaemic stroke. Biochemical aspirin resistance may be defined as failure of aspirin to inhibit platelet thromboxane A2 production, whereas clinical aspirin resistance (also known as aspirin treatment failure) is diagnosed following the occurrence of an atherothrombotic event in patients receiving a therapeutic dose of aspirin. We have determined the prevalence and nature of aspirin resistance in 44 adults admitted with a diagnosis of suspected ischaemic stroke and already taking prescribed 75-150 mg daily aspirin. Within 48h of admission with acute stroke, platelet function was measured by optical aggregometry in platelet-rich plasma, after stimulation with arachidonic acid (AA), ADP and collagen. Urinary 11-dehydro-thromboxane B2 metabolite was measured by immunoassay. Haemorrhagic stroke was excluded by CT scan. Compliance was assessed by interviewing patients and relatives, and through pharmacy records. Platelet function was tested again 24h after administration of 150mg aspirin on the ward. On the first test, we found residual AA-stimulated platelet aggregation (>=10%) indicating a poor response to aspirin, in 18 patients (41%). Of these, 10 remained poorly responsive after aspirin dosing in hospital, suggesting causes other than poor compliance in 23%. In vitro, platelet aggregation could be inhibited further by addition of acetylsalicylic acid in only 3 of these subjects, indicating true biochemical aspirin resistance in 16%. However, urinary 11-dehydro-TxB2 was not significantly different between good and poor responders to aspirin (median (iqr) 77.0 (38.9-156.8) vs. 86.2(50.0-261.2) ng/mmol of creatinine). These data suggest that in a significant proportion of patients with acute stroke, platelet activity is not adequately inhibited despite apparent compliance with aspirin therapy. Biochemical aspirin resistance and poor compliance with therapy each contribute to aspirin responsiveness in patients with acute stroke.

Session: Poster Session II
Date: Thursday 15 May 2008
Time: 12:30 - 14:00
Room: Agora 3


Abolition of Micro Embolic Signals in Symptomatic Carotid Stenosis Using Dual Antiplatelet therapy
F. Khan    M. Saqqur    C. Stephenson     E. Stewart     J. Roy    J.M.Boulanger     A.M.Demchuk

Calgary Stroke Program University of Calgary

CANADA

Background: Microembolic signals (MES) detected by Transcranial Doppler (TCD) in symptomatic carotid stenosis (CS) is considered a marker of subsequent stroke risk and so strategies to abolish the MES are important. We aimed to investigate the role of antiplatelet and antithrombotic agents in abolishing the MES in recently symptomatic CS. Methods: Transient ischemic attack/stroke patients with 50% CS or unstable carotid plaque, who were prospectively enrolled (Transcranial Doppler And Symptomatic Carotid disease study -TASC) within 24 hrs of symptom onset, underwent bilateral middle cerebral artery 1hr TCD emboli monitoring within 48 hrs. Those with positive MES underwent a second monitoring after 48hrs of initial study. Treatment given during the interval period is carefully recorded. Results: Out of 73 patients enrolled from March 2005 to November 2007, 22 (17 males, mean age 67.4 yrs) were positive for ipsilateral MES in initial TCD (30.1%). Ten were on a single antiplatelet agent (aspirin or clopidogrel) and one was on dual (aspirin and clopidogrel) therapy prior to the TCD. Single antiplatelet agent was started after TCD in seven (addition making it dual therapy in four), dual agents in six and unfractionated heparin in seven patients. Second TCD showed complete suppression of MES in 14 patients. Only one out of three patients on single antiplatelet agent alone had abolition of MES while all ten patients on dual antiplatelet agents had a complete suppression (p=.027, Chi-square test). Although heparin suppressed MES in 5/7 patients, all five had additional dual agent therapy. MES was not abolished in one patient treated with heparin alone and another on a combination of heparin and single antiplatelet agent. Discussion: Dual antiplatelet therapy abolishes MES in recently symptomatic CS. Unfractionated heparin alone or in a combination with a single antiplatelet agent cannot effectively suppress MES. So dual antiplatelet therapy with aspirin and clopidogrel should be considered as the standard of care in recently symptomatic carotid stenosis.

Session: Poster Session II
Date: Thursday 15 May 2008
Time: 12:30 - 14:00
Room: Agora 3


PRIOR ALCOHOL CONSUMPTION AND RECANALIZATION IN PATIENTS WITH MIDDLE CEREBRAL ARTERY OCCLUSION TREATED WITH TISSUE PLASMINOGEN ACTIVATOR
P. Sandoval    J.F.Arenillas    M. Millan     N. Perez de la Ossa     L. Dorado    C. Guerrero     M. Castellanos     M. Blanco    A. Davalos

Hospital Clinico Pontificia Universidad Catolica de Chile

CHILE

Background. Light to moderate alcohol consumption has been related with better prognosis in myocardial infarction. Moreover, an enhanced endogenous fibrinolytic activity with decreased plasminogen activator inhibitor-1 has been described in usual drinkers. We aimed to investigate the effect of prior alcohol consumption in recanalization of MCA occlusion in patients treated with thrombolytic therapy. Methods. We prospectively studied 85 consecutive ischemic stroke patients (mean age 67.8 + 10.7, median NIHSS 14 [IQ 9-18]) treated with IV tPA within 3 hours from symptoms onset who showed MCA occlusion on prebolus transcranial Doppler (TCD) examination. TCD follow-up was performed at 2, 6, 12 and 24 hours after tPA treatment. Thrombolysis in Brain Ischemia (TIBI) grades were used to define complete, partial or absent MCA recanalization. Alcohol consumption was recorded using a validated retrospective questionnaire. Results. No consumption (<10 g/day) was recorded in 62 patients, light to moderate (10 to 40 g/day) in 19 and heavy (> 40 g/day) in 4. Complete, partial and absent recanalization at 6 hours were seen in 26, 10, and 26 of the first group and in 11, 7, and 5 among alcohol consumers (p=0.15). Serum glucose > 150 mg/dL, but no other baseline variables, was associated with a lack of recanalization at 2 hours (p=0.003) and 6 hours (OR, 0.32; 95%CI, 0.11-0.87; p=0.027). There was not an alcohol by glucose effect interaction on recanalization. However, after adjusting for glucose levels, alcohol consumption was associated with an increased odds of recanalization at 6 hours (OR, 3.6; 95%CI, 1.06-12.1; p=0.040). Conclusion. These findings suggest that alcohol consumption may be associated with a higher probability of recanalization of MCA after tPA treatment.

Session: Poster Session II
Date: Thursday 15 May 2008
Time: 12:30 - 14:00
Room: Agora 3


Strategies to Expedite Stroke Thrombolysis at Emergent Room
C.H.Chen    M.L.Lai    H.W.Huang
For the NCKU Acute Stroke Treament Team
College of Medicine, National Cheng Kung University

TAIWAN

Backgrounds: Intravenous recombinant tissue plasminogen activator (rt-PA) has been approved for acute ischemic stroke in Taiwan since 2003, but only a very limited number of patients are actually being treated. The benefit declines over time and expedited rt-PA administration at emergent room (ER) is crucial for neurological outcome. We aim to evaluate whether applying these strategies can efficiently and safely reduce door-to-needle time at our hospital. Methods: These strategies include: 1) multi-departmental meetings and educational programs; 2) stroke code activation; and 3) acute stroke pathway modifications (no chest X-ray, rt-PA administration before laboratory data available). The safety outcome is symptomatic intracerebral hemorrhage within 36 hours after rt-PA infusion. Results: Between September 2006 to December 2007, 29 consecutive subjects (20 before and 9 after these strategies, respectively) received IV rt-PA treatment at ER. The mean door-to-CT time was reduced from 37 to 26 minutes (before and after, respectively). The mean door-to-needle time decreased from 105 to 72 minutes (before and after, respectively). The durations were significantly shortened: door to ER order (mean reduction, 6 minutes); door-to-needle (33 minutes) and onset-to-treatment (39 minutes reduction; 164 and 125 minutes before and after, respectively). There was no symptomatic intracerebral hemorrhage after applying strategies. Conclusion: These strategies can expedite rt-PA administration and appear to be safe. Further studies are warranted to demonstrate the benefits for long term outcome.

Session: Poster Session II
Date: Thursday 15 May 2008
Time: 12:30 - 14:00
Room: Agora 3


Thrombolysis targeting MRI defined tissue at risk in minor stroke
A.C.Krützelmann    S. Siemonsen    C. Gerloff     M. Rosenkranz     J. Röther    J. Fiehler     G. Thomalla

Universitätsklinikum Hamburg-Eppendorf

GERMANY

Background: Treatment with intravenous tissue Plasminogen Activator (IV-tPA) is not recommended for patients with minor stroke. However, a relevant proportion of patients with mild stroke symptoms suffers from a poor outcome and might benefit from thrombolysis. We studied clinical and imaging outcome after IV-tPA treatment in patients with minor stroke and tissue at risk of infarction defined by stroke MRI. Methods: Patients with minor stroke (National Institutes of Health Stroke Scale [NIHSS] score <4) were studied by stroke MRI including perfusion and diffusion weighted imaging (PI and DWI) and treated with IV-tPA </=6 hours. Final infarct volume was delineated on follow-up MRI. Clinical outcome was assessed after 90 days using the modified Rankin Scale (mRS). Results: Six patients with minor stroke deficit were treated with IV-tPA based on MRI criteria. Median NIHSS on admission was 2 (range=0-3). In all patients, an occlusion of the middle cerebral artery (MCA) was detected by MRA (MCA-branch n=3, MCA-trifurcation n=3), and in all patients, the PI lesion (41, 25-60 ml) was exceeding the DWI lesion (4, 1-23 ml). Final infarct volume was 9 (2-29) ml. Favourable outcome (MRS 0-1) was seen in 5/6 patients, independent outcome (MRS 2) in one patient. No intracerebral haemorrhages occurred. Conclusion: In this small series of patients with minor stroke and MRI-defined tissue at risk of infarction, treatment with IV-tPA was safe and appeared to be effective. MRI might be a useful tool to identify patients with minor stroke symptoms who may benefit from intravenous thrombolysis.

Session: Poster Session II
Date: Thursday 15 May 2008
Time: 12:30 - 14:00
Room: Agora 3


LOBAR HEMATOMA ASSOCIATED WITH SNEDDON SYNDROME: HOW AND WHEN TO TREAT
T. Karapanayiotides    E. Papamichalis    A. Anastasiou     G. Deretzi

Hippokrateion Hospital

GREECE

Background: Sneddon syndrome (SD), the combination of livedo reticularis and stroke is often, but not always, associated with antiphospholipid antibodies. Although infarcts are common, spontaneous cerebral hematomas (SCH) are exceptionally rare and their association with SS is questionable. Methods: We describe a challenging case of SCH in a setting of antiphospholipid negative SS. We discuss the diagnostic algorithm and the therapeutic dilemmas concerning the timing and nature of potential antithrombotic treatment. Case Report: A 34 year-old woman presented acutely left hemiplegia. Ten years before she had presented a seizure associated with a left parietal “lesion”. She had had three miscarriages over the previous years, had been suffering from generalized livedo reticularis and Raynaud’s phenomenon that had led to amputation of two toes, and had been treated with neuroleptics for “behaviour disorders”. Excepting smoking she had no known risk factors. CT and MRI revealed a large frontal hematoma and, surprisingly, four old MCA cortical infarctions bilaterally. MRA of the head, neck and lower extremities, and TEE were normal. Skin biopsy was nonspecific. Excepting high titers of antithyroid antibodies, her immunologic profile (including antiphospholipids) was normal. Screening for prothrombotic state was negative. A diagnosis of SS was presumed and despite the hematoma, she was put 3 weeks after admission on warfarin, which continues without complications until now. Discussion: this is an exceptional case of antiphospholipid negative SS with both ischemic and hemorrhagic manifestations associated with a severe “reversible” small vessel disease of the extremities. The pathophysiology of strokes in our patient and the optimal treatment remain a challenging debate.

Session: Poster Session II
Date: Thursday 15 May 2008
Time: 12:30 - 14:00
Room: Agora 3


Change of Cerebral Blood Flow Velocity (CBFV) in the Middle Cerebral Artery (MCA) during External Counterpulsation (ECP) in Acute Ischemic Stroke Patients and Healthy Controls
J.H.Han    T.W.Leung    W.W.Lam     Y.O.Soo     V.C.Mok    K.S.Wong

Chinese University of Hong Kong

CHINA

Background: ECP increases blood flow in the coronary and carotid arteries. Our previous study shown its clinical benefit for stroke patient, however, its effect on cerebral circulation is uncertain. We aim to investigate CBFV changes in bilateral MCAs during ECP by transcranial Doppler (TCD) in stroke patients and healthy controls. Methods: Twenty-eight acute ischemic stroke patients and ten age-matched healthy controls were studied. CBFV, heart rate and radial artery blood pressure (BP) were recorded before, during and after ECP. We recorded the baseline for 3 min. Then ECP was started with a cuff inflation pressure of 75 mmHg, the pressure gradually increases to 150 mmHg, 225 mmHg and 300 mmHg. Each stage lasted for 3 min. Three min after completion of ECP, we monitored for another 3min. Results: Mean BP increased by 9.4% for stroke patients and 5.2% for controls during ECP. A second diastolic peak flow in the MCA was shown in all subjects. Healthy controls had a significant reduction in systolic CBFV from baseline; while an increase was noted in patients during most of the time except under a pressure of 300 mmHg. Therefore, mean CBFV increased in patients while a decrease was found in controls, the difference between 2 groups was significant under all levels of cuff inflation pressure (p<0.001). Further, a parallel increase in mean CBFV was shown in stroke patients as the cuff inflation pressure rose. A maximal increase of 13.3% for the relevant MCA and 4.8% for the irrelevant MCA, were noted under a pressure of 225 mmHg (p=0.025). Discussion: The responses of CBFV to ECP were totally different between stroke patients and controls, which may be explained by the different status of cerebral autoregulation. Further studies are needed to determine an optimal cuff inflation pressure for stroke patients.

Session: Poster Session II
Date: Thursday 15 May 2008
Time: 12:30 - 14:00
Room: Agora 3

01
Bleeding incidence before and after stroke, a study of 105 043 patients reported to the Swedish National Quality Register for Stroke Care (Riks-Stroke)
S. Åsberg K. Henriksson B. Farahmand K. Asplund B. Norrving B. Stegmayr P.O.Wester K. Hulter Åsberg A. Terént

The Stroke Unit at Uppsala Unisversity Hospital

SWEDEN

Background: The choice of secondary preventive therapy after ischaemic stroke can be difficult. Anticoagulant (AC) or antiplatelet drugs (AP) are not suitable for all patients due to risk of bleeding. This study estimated bleeding incidence before and after stroke. Methods: Data on stroke patients admitted to hospital are collected in the Swedish National Quality Register for Stroke Care (RS). The first registration in RS, during 2001 to 2005, was in this study used as index stroke (InS). Bleedings requiring hospitalisation were identified through linkage with the Swedish Hospital Discharge Register (SHDR). Any bleeding in conjunction with InS and all traumatic intracranial (IC) bleedings were excluded. Observations were made in the SHDR from 1987 to 2005, and the observation time was 1.7 million patient years (p-yrs) before InS and 183 000 p-yrs after InS. Results: On admission 45 % of all stroke patients received antithrombotic treatment with AC or AP, and 73 % at discharge. Incidence of IC bleeding was 1.7 per 1000 p-yrs before and 7.3 after InS. Gastrointestinal (GI) haemorrhage increased from 5.6 to 11.3 per 1000 p-yrs. The incidence of anaemia after haemorrhage also rose, from 0.8 to 3.0 per 1000 p-yrs, as did bleeding after medical procedures, from 2.1 to 5.5 per 1000 p-yrs after InS. Genitourinary and eye bleedings changed from 3.8 to 4.6 per 1000 p-yrs and 0.8 to 0.9 per 1000 p-yrs respectively. The incidence of bleeding from respiratory passages decreased from 4.6 to 1.6 per 1000 p-yrs. Discussion: After stroke we found a 4-fold increase in the incidence of IC bleedings and a doubling of GI bleedings. Even before stroke, severe bleedings were relatively frequent, and this should be considered when choosing secondary preventive therapy after stroke.

Session: Poster Session II
Date: Thursday 15 May 2008
Time: 12:30 - 14:00
Room: Agora 3

02
Cerebral autoregulation in acute patients with malignant middle cerebral artery infarction under therapeutic hypothermia
H. Hentschel T. Ziemssen G. Gahn

University Hospital of Dresden

GERMANY

Cerebral autoregulation (CA) plays a major role in neuroprotection after acute stroke besides hemodynamic and cytochemical factors. Hypothermia has become an important neuroprotective therapy in malignant stroke. Prior studies indicated that hypothermia may influence CA. On the results of our investigations, we discuss the question which target temperature could preserve or disturb CA. We examined 10 sedated, intubated patients with >/=2/3 MCA infarction. Cerebral blood flow velocity (CBFV) in MCA, arterial blood pressure and cerebral perfusion pressure (CPP) were recorded simultaneously. Hypothermia was applied to these patients for 3 to 10 days (minimum 33°C). Re-warming was carried out during a period of 4-7 days. 4 patients died before reaching normothermia. The remaining 6 patients were measured under hypothermia and when reaching normothermia. CA was evaluated by performing cross correlation analysis of CBFV and arterial blood pressure. Cross correlation coefficients (CCC) are presented in correlation to temperature and to CPP. For the non-infarction hemisphere CA values show linear correlation with temperature. At side of infarction, the curve has a roughly negatively hyperbolic course, CA values approximated a maximum at 35°C. When correlating CCC to CPP, non-infarcted side also showed linear patterns. For infarction side, the hyperbolic curve approximated a minimum at CPP of 85mmHg. Time did not have strong influence on the course of CA values in infarction hemisphere, while on non-effected side CCC increased with time. Temperature seems to influence CA. Our investigations revealed maximum CA values at 35°C. Whether this should be considered an optimal target temperature cannot be concluded from our results. Instead, it remains uncertain whether temperature-associated worsening of CA outweighs the neuro-protective effects of hypothermia. A higher number of patients is needed to obtain statistically convincing results.

Session: Poster Session II
Date: Thursday 15 May 2008
Time: 12:30 - 14:00
Room: Agora 3

03
The safety and efficacy of continual transcranial Doppler monitoring of middle cerebral artery occlusion in acute stroke patients.
D. Sanak R. Herzig A. Bártkova D. Skoloudik S. Burval M. Kocher I. Vlachova M. Kral M. Herman P. Kanovsky

Stroke Unit, Dept. of Neurology and Radiology, University Hospital Olomouc

CZECH REPUBLIC

Background and purpose: The aim of our study was to assess the safety and efficacy of continual transcranial Doppler (TCD) monitoring of middle cerebral artery (MCA) (M1-2) occlusion in acute ischemic stroke patients compared to intra-arterial thrombolysis (IAT) and to intravenous thrombolysis (IVT) Methods: Forty consecutive acute IS patients who fulfilled the criteria for thrombolysis and presented with MCA occlusion on MRI were included. Continual 60 minute TCD monitoring of occluded MCA using 2-MHz probe was performed in patients between 3 and 6 hours since stroke onset. IVT was performed within 3 hours, IAT was performed between 3 an 6 hours since stroke onset. Neurological deficit was evaluated using NIH Stroke Scale on admission, 24 hours and 7 days later, the 90-day clinical outcome using modified Rankin Scale (mRS). The incidence of symptomatic intracerebral hemorrhage (sICH), clinical outcomes and recanalization rates were compared between TCD, IVT and IAT. Chi-square, ANOVA and Kruskal-Wallis test were used for statistical evaluation. Results: Ten patients underwent TCD, 10 IAT and 20 IVT. Median baseline NIHSS was 11.5 in TCD group, 15.5 in IAT and 13.5 in IVT group. Recanalization after TCD was found in 60 % of patients, after IVT in 45 % and after IAT in 80 % of patients (p=0.185).The good 90-day clinical outcome (mRS 0-2) was presented in 70 % of TCD patients, in 60 % of IAT and in 45 % of IVT patients (p=0.570). Incidence of sICH was 0 % in TCD group, 5 % in IVT and 20 % Conclusion: Continual TCD monitoring seems to be a safe method of MCA occlusion treatment. Acknowledgement: Supported by grant of IGA Ministry of Health Czech Republic NR/8579-3/2005.

Session: Poster Session II
Date: Thursday 15 May 2008
Time: 12:30 - 14:00
Room: Agora 3

04
Antioxidants in the treatment of acute ischemic thrombotic and lacunar stroke: a clinical study
A. Jurcau A. Simion D.S.Tertan S.D.Covaciu-Marcov

Faculty of Medicine and Pharmacy, Clinical Hospital of Neurology and Psichiatry Oradea

ROMANIA

Background: Oxidative stress has been increasingly involved in extending cerebral ischemic lesions. Our study evaluates the benefits of antioxidant treatment in macroangiopathic (MA) and microangiopathic (LA) strokes. Method: MA and LA cases were selected from 2 series of ischemic strokes according to the TOAST criteria. The NIHSS score and the Barthel index (BI) were recorded at admittance and discharge in each case. Oxidative stress was assessed by measuring the serum malondialdehyde (MDA) levels with the tiobarbituric acid method at admittance and on days (D) 3 and 7. The control group received conventional treatment; the study group received in addition antioxidants: 600 mg of alpha-lipoic acid IV in diabetics and 10 mg beta-carotene, 40 mg DL-alpha-tocopherol, 100 mg ascorbic acid, 50 micrograms selenium orally for the remainder of patients. Results: We had 18 MA and 16 LA as controls and 17 LA and 43 MA in the study group. Patients in the 2 groups exhibited similar NIHSS scores, BI, and MDA levels on admittance. The MA antioxidant-treated patients showed a constant decline of MDA, with highly significant difference on D3 (p<0.001) and less on D7 (p=0.03). In the LA antioxidant-treated group there were significantly lower levels of MDA recorded on D 3 and 7 (p=0.006, and 0.002) (table). Clinically, MA patients receiving antioxidants had significantly lower scores at discharge (p=0.03), but the course of LA strokes was not consistently influenced. Discussion: The antioxidant treatment improved recovery in MA but did not influence the clinical course of LA in spite of diminishing the oxidative burden.

http://www.eurostroke.org/ni_graphics/t_aid3015.htm

Session: Poster Session II
Date: Thursday 15 May 2008
Time: 12:30 - 14:00
Room: Agora 3

05
STROKE IN BELGRADE (SERBIA): ARE WE QUICK ENOUGH?
S. Bogunovic M. Tosic M. Kosjerina B. Lazic S. Petrovic Lj. Beslac Bumbasirevic

Emergency Medical Services of the City of Belgrade, Belgrade

YUGOSLAVIA

The aim of this study was to analyze the time interval between the call placed to the Emergency Medical Service (EMS) dispatch center and admission to the hospital of patients with stroke. Methodology: 7295 calls to dispatch center The time interval between aduring November 2007 were analyzed. We studied: receipt reception of the call by dispatch center and EMS physicians at the scene The time interval between the reception of– dispatch center response time; the call by EMS physician at the scene and admission to the neurology department Total time between a reception of– EMS physician at the scene reaction time; the call by a dispatch center and admission to the neurology department. Results: Out of 7295 calls 282 (3.87%) were evaluated as suspected stroke. 195 or 70% patients with stroke were immediately transported to the hospital. The time interval between a reception of the call by dispatch center and EMS physicians at the scene was 13.5 minutes on average. The time interval between the reception of the call by EMS physician at the scene and admission to the neurology department was 43.5 minutes, on average, out of which approximately 12 minutes were used on a transition time between the EMS and a scene. Total time between a reception of the call by a dispatch center and admission to the neurology department was 57 minutes on average, with 127 (65%) cases below 1 hour and 68 (35%) cases between 1 and 2 hours. Conclusion: Majority of patients with stroke were admitted to the neurology department within 1 hour of an initial call. Further efforts are needed to reduce the time from stroke onset to treatment and maximize the number of patients who are eligible to receive t-PA.

Session: Poster Session II
Date: Thursday 15 May 2008
Time: 12:30 - 14:00
Room: Agora 3

06
Thrombolysis in Brain Ischemia (TIBI) flow grade predicts response to intravenous or combined intravenous and intra-arterial thrombolysis in patients with acute ischemic stroke.
C. Bonvin L. Sekoranja K.O.Lovblad H. Yilmaz J. Loulidi P.R.Burkhard R. Sztajzel

University Hospitals of Geneva

SWITZERLAND

BACKGROUND AND PURPOSE To assess variables associated with early recanalization and outcome in patients undergoing intravenous (IV) or combined intravenous and intra-arterial (IV-IA) thrombolysis guided by transcranial color-coded duplex sonography (TCCD). METHODS Patients with an MCA or distal ICA ischemic stroke <3 hours were monitored with TCCD. Thrombolysis in Brain Ischemia (TIBI) classification was used to assess flow at baseline and during therapy. In case of some recanalization after 30 minutes, IV thrombolysis was completed. In absence of reperfusion, IA thrombolysis was administered. Uni- and multivariate analysis were performed. Clinical outcome was assessed at 3 months using dichotomized mRS (0-2 favorable / 3-6 unfavorable). RESULTS 54 patients underwent IV (n=33) or IV-IA (n=21) thrombolysis. A TIBI 3 baseline flow was the best parameter associated with early recanalization (OR 24.7, 95%CI 3.01-202, p=0.003) whereas absent flow (TIBI 0) reduced significantly the likelihood to reperfuse (OR 0.14, 95%CI 0.03-07, p<0.02). After 30 minutes, IV thrombolysis achieved some recanalization in 17(61%) patients. At this point, TIBI≥3 predicted a favorable outcome in 70% of the patients. Only 3 patients (3/10) with a TIBI 0 had a favorable prognosis in the IV-IA group. However, for those with a TIBI>0, further IA thrombolysis allowed a favorable outcome in 72% of the cases (OR 0.16, 95%CI 0.02-1.06, p=0.05). CONCLUSIONS Recanalization rates increased in proportion with baseline TIBI values. A TIBI 3 baseline flow was the best predictor of early recanalization during IV thrombolysis, whereas chances to reperfuse (either IV or IV-IA thrombolysis) were the lowest with a TIBI 0. The 3-month outcome in this latter group is statistically worse (Submitted to Stroke).

Session: Poster Session II
Date: Thursday 15 May 2008
Time: 12:30 - 14:00
Room: Agora 3

07
Integrated care pathway for acute stroke in an Acute Stroke Unit
P. Martinez-Sanchez J. Medina B. Fuentes M. Grande C. Llorente P. Parrilla A. Fuster A. Gil J. Garcia-Caballero E. Diez-Tejedor

Hospital Universitario La Paz. Madrid

SPAIN

BACKGROUND: In-hospital stroke care pathways were implemented in departments of Neurology, General Medicine or Rehabilitation, however there are few studies evaluating the development and the effects of introducing and integrated care pathway (ICP) in hospitals with an Acute Stroke Unit (ASU). Our aim was to develop an evidence-based multidisciplinary ICP for acute ischemic and hemorrhagic stroke care in an ASU. METHODS: A schedule of 1-h fortnightly meetings between the Department of Neurology, Emergency Services, Preventive Medicine and Rehabilitation was established for the ICP design. The evidence base was established through a systematic literature review. Following development, performance was assessed against standards in a before-and-after study. The ‘after’ (intervention) group comprised 36 consecutive stroke patients and the ‘before (control) group comprised 36 stroke patients admitted to the same ACU paired for age, sex, stroke subtype and stroke severity. RESULTS: the documents that compose the ICP are: clinical flowsheet; treatment sheets; patient and family information document; rehabilitation information document; patient/family satisfaction questionnaire and a didactic unit for patient/family education in stroke management and prevention. The patients mean age was 73.10 years (SD 9.5), 47.2% were male. The antiplatelet and fibrinolytic treatment and the evaluation of the dysphagia followed the standard in both groups (100%); the patient/family satisfaction level was high (90%) but the intervention group showed a better quality of documentation. The intervention group tended to a higher adjustment to the standard in laboratory results, first cerebral-TC and peripheral venous line removal times than the control group (51.6 vs. 40%, 42.9 vs. 32.2% and 60 vs. 39.3% respectively, P NS), as well as in the neurosonology tests and second cerebral-TC absolute times (0.87 vs. 13.3 days and 1.37 vs. 2.06 days respectively, P NS). DISCUSSION: introducing and ICP for acute stroke tends to improve the quality of documentation and process of care.

Session: Poster Session II
Date: Thursday 15 May 2008
Time: 12:30 - 14:00
Room: Agora 3

08
Intravenous thrombolysis in patients with acute stroke due to spontaneous artery dissection
D.R.Jovanovic Lj. Beslac-Bumbasirevic O. Savic I.I.Berisavac M.D.Ercegovac

Institute of Neurology

YUGOSLAVIA

BACKGROUND: Recently published meta-analysis of cases with an acute stroke caused by artery dissection suggested that intravenous thrombolysis should not be withheld in these patients. We describe 12 patients with acute stroke due to cervical artery dissection who were treated with intravenous thrombolysis. METHODS: All patients with ischemic stroke due to spontaneous artery dissection treated with intravenous thrombolysis in our department were included in the study. Neurological deficit was assessed with NIHSS score and functional outcome with modified Rankin Scale (mRS). All possible therapy complications were recorded. RESULTS: 12 patients with spontaneous artery dissection and acute stroke were treated with intravenous thrombolysis. Average age of these patients was 39.3 years, ranging 18 to 57, with 46% of them younger than 55. Nine patients had carotid and 3 vertebral artery dissection. Median initial NIHSS score was 13 with its decline during first 24 hours to median NIHSS 3. There were no new or worsened signs of artery dissection and no rupture of dissected artery. There was no symptomatic intracerebral hemorrhage. One patient deteriorated due to massive MCA infarction, and another had stroke recurrence. After 90 days of follow-up, 70% of patients had favorable outcome (mRS < 1), two patients had mRS 2 and one mRS 3. No patients died in this period. CONCLUSION: Based on our initial experience, we confirm that intravenous thrombolysis is effective and safe for the patients with acute ischemic stroke due to spontaneous artery dissection.

Session: Poster Session II
Date: Thursday 15 May 2008
Time: 12:30 - 14:00
Room: Agora 3

09
Spontaneous Cervical Artery Dissection: Clinical and Neuroimaging Aspects
A. Pieri M. Spitz W.M.Avelar R.A.Valiente A.R.Massaro

Escola Paulista de Medicina - Unifesp

BRAZIL

Introduction: Spontaneous dissection of the cervical arteries is considered a rare and unknown cause of stroke, particularly in countries with multiethnic populations. Objective: The aim of our study was to evaluate the clinical and neuroimaging characteristics of patients with spontaneous dissection of the cervical arteries in a multiethnic population. Methods: We studied sixty-six patients diagnosed with spontaneous dissection of the cervical arteries at two tertiary hospitals in São Paulo, Brazil. A questionnaire was administered initially and the patients were followed prospectively. Results: Among the 66 patients studied, 82% were Caucasian, 53% were male and the average age was 41,7 (20-62) years old. The most frequent cardiovascular risk factors were hypertension and smoking, detected in 38% and 51% of the patients, respectively. History of previous migraine was identified in 34 (51%) patients. Headache was the most common symptom at onset, described by 91% of the patients. Magnetic resonance angiography was diagnostic in 94% of the patients with carotid dissection. The most prescribed initial treatment was anticoagulation, in 58% of the patients. A favorable prognosis was observed in 74% of the patients and there was only one fatal outcome in the 6 months’follow-up period. Arterial recanalization in 6 months was detected in 53% of the patients and only 3 patients had recurence. Conclusion: Although the population studied was multiethnic, there was a remarkable predominance of Caucasian patients. The analysis of the clinical and neuroimaging characteristics of the patients with spontaneous dissection of the cervical arteries provides a better understanding of the disease, leading to an earlier diagnosis and more adequate treatment.

Session: Poster Session II
Date: Thursday 15 May 2008
Time: 12:30 - 14:00
Room: Agora 3

10
Should anticoagulation be delayed in acute spontaneous cervical artery dissection?
F. Perren T. Landis R. Sztajzel

HUG, University Hospital and Medical School, Dept. of Neurology

SWITZERLAND

Background and Purpose: Acute spontaneous cervical artery dissection (sCAD) is a frequent cause of stroke in younger adults. The usual, but not uncontested treatment is anticoagulation. We assessed the potential dangers of anticoagulation in CAD by studying the dynamics of residual flow and clinical development. Methods: 4-years non-randomized retrospective analysis of 34 patients admitted for CAD treated with anticoagulation, who were examined clinically (NIHSS) and with color-coded duplex flow and power mode imaging (CDFI and PMI) at admission and follow-up and underwent CT-, MR–, or RX-angiography. Results: In 18 patients (group 1) there were no significant clinical or hemodynamical changes. In 16 patients (group 2) residual flow on CDFI/PMI in the dissected vessel worsened and there was clinical worsening in 7 patients. In 11 patients of group 1 anticoagulant therapy after symptoms onset was delayed (3-10 days). In group 2 all patients received anticoagulant therapy within the first 72 hours. The interaction between the frequency of hemodynamic worsening and onset of anticoagulation was significant (p<0.001), while the interaction between clinical worsening and onset of anticoagulation showed a trend (p=0.069). Discussion: This retrospective study shows that worsening, either hemodynamic or clinical is not rare and might be due to anticoagulation in the early phase after CAD, and suggests that delaying anticoagulation therapy by some 72 hours may reduce hemodynamic and clinical deterioration.

Session: Poster Session II
Date: Thursday 15 May 2008
Time: 12:30 - 14:00
Room: Agora 3

12
Recombinant tissue plasminogen activator (rt-PA) for acute ischaemic stroke
L. He H. Zheng M. Yang H. Zhou H. Wu L. Liu J. Yang D.Z.Zhou S. Zhang M. Liu

West China Hospital, Sichuan University

CHINA

Background: The one of effective therapy demonstrated to improve outcomes in acute stroke is the administration of recombinant tissue plasminogen activator (rt-PA) within 3 hours after onset. However, it has not been widely utilized to patients and few data about its application has been obtained in southwest of China. This article is to summarize its application, effectiveness and safety in our hospital in recent 3 years. Method: A series of 12 consecutive patients (mean age, 60 years; 7 men and 5 women) treated with rt-PA from Nov 2004 to Dec 2007 at our institution was retrospectively reviewed. Among them, 10 were treated with intravenous rt-PA, while the other two underwent intra-artery rt-PA. National Institute of Health Stroke Scales (NIHSS) at the admission and 24 hours after administration, following-up disposition, as well as intracerebral hemorrhage and mortality rates, were recorded. Result: The mean NIHSS score of the 10 patients receiving IV rt-PA therapy reduced to 9.8' versus 13.0' before. Symptomatic intracerebral hemorrhage (SICH) occurs in 2 patients (22.2%), one died of a recurrent ischaemic stroke one month later and the other transferred for neurosurgery. 1 patient (11.1%)died within 24 hours after administration, who was in extremely poor condition with 35' (NIHSS) before therapy. The other 7 patients showed improvement when they discharged. The data of 3-month follow-up was obtained in 5 patients, the Barthel score was 100' for 4 patients and another one got 74'.The two patients underwent IA rt-PA were both posterior circulation infarction (POCI). One died of failure of circulation and the other died of multiple organ failure, however, they were in very poor disposition before therapy. Conclusion: In this series, intravenous rt-PA within 3 hours was effective in improving outcomes. The validity of intra-artery rt-PA needs to be identified by more clinical practice.

Session: Poster Session II
Date: Thursday 15 May 2008
Time: 12:30 - 14:00
Room: Agora 3

13
Cerebral blood blow augmentation in tPA treated ischemic stroke patients.
K.S.Butcher D. Emery D. Manawadu R. Ashforth T. Yeo A. Shuaib

University of Alberta

CANADA

Background: Many stroke patients do not improve following tPA treatment, possibly due to insufficient restoration of cerebral blood flow (CBF). Augmentation of collateral flow via abdominal aortic occlusion may increase CBF in stroke. We hypothesize that patients with persistent oligemia, despite tPA treatment are ideal CBF augmentation candidates and aimed to demonstrate the safety of this strategy. Methods: Immediately following treatment with tPA, patients underwent diffusion- and perfusion-weighted MRI (DWI, PWI). Patients with hypoperfused cortical tissue visible on PWI were treated with aortic occlusion, using a Neuroflo catheter, for 1 h. DWI, PWI, Gradient-Recalled Echo (GRE) and Fluid Attenuated Inverse Recovery (FLAIR) imaging was repeated immediately post procedure. Results: Five patients were treated with tPA and aortic occlusion. Median (range) NIHSS was 17 (7-19). Median time to tPA bolus was 2.3 h (1.4-3.4), initial MRI 5.0 h (3.9-14.0) and aortic occlusion 5.8 h (5.0-15.5). Mean (+/-SD) post-tPA DWI and PWI (Tmax+2s) volumes were 20.5+/-11.3 ml and 96.8+/-60.2 ml respectively. Four patients had penumbral patterns, demonstrated by PWI-DWI mismatch ratios >1.2 (mean 5.8+/-5.2). Following aortic occlusion, hypoperfused tissue (Tmax+2s) volumes decreased in 4 patients (mean change -33.9+/-31.8 ml). Mean DWI lesion size increased slightly (1.7+/-3.7 ml), with DWI reversal observed in 2 patients. Reduction in hypoperfused tissue volume occurred despite persisting MCA occlusion in 1 patient, indicating collateral flow as the likely salvage mechanism. Post-treatment GRE revealed evidence of asymptomatic petechial hemorrhage in 1 patient only. The Hyperacute Reperfusion Marker (HARM) pattern was seen on FLAIR imaging in 1 patient. Median (range) NIHSS improved at 24 h (3, 1-18) and 30 days (3, 0-8). Discussion: Collateral flow augmentation may be a useful adjunctive therapy in patients with persisting hypoperfusion following tPA treatment. These pilot data support the safety and feasibility of a randomized controlled trial designed to test this approach.