XVII. European Stroke Conference
Nice, France

Oral Session:

Epidemiology of stroke II
Date: Thursday 15 May 2008  
Time: 16:30 - 16:40 -  Room: Erato/Uranie
Chair: V. di Piero, Italy and L. Girou, France

01
rt-PA and heparin in the LYON rt-PA protocol: beneficial effect of intravenous heparin on outcome and intracerebral bleeding at specific times of initiation (200 patients)
P. TROUILLAS    L. DEREX    F. PHILIPPEAU    S. CAKMAK    N. NIGHOGHOSSIAN    L. ZENG    M. HERMIER    J.C.FROMENT    M. HANSS       
 

Cerebrovascular Unit, Hôpital Neurologique, LYON, France

FRANCE

The issue of the adjunctive role of intravenous unfractionated heparin (IVUFH) in cerebral rt-PA intravenous thrombolysis remains pending, although heparin is generally banned for the first 24 hours in the guidelines. The LYON rt-PA protocol may give indicative data on this issue Patients and methods. Two hundred consecutive patients were submitted to 4 successive heparin regimens, including consecutive patients: immediate IVUFH, IVUFH at 12h, IVUHF at 24h after a non-hemorrhagic CT Scan and low molecular weight nadroparin at any time. The aPTT objective for the 3 IVUFH subgroups was 45 seconds, with a duration objective of 1 week. Results The 4 groups had non significant differences for baseline severity score, age and interval. Immediate heparin (n=31) resulted in a parenchymal hematoma (PH) rate of 9.6%, while heparin at 12h (n=10) and at 24 h (n=66) resulted each in a PH rate of 0%. Nadroparin (n=78) resulted in a PH rate of 14% and in a high early PH rate (8.9%). Concerning prognosis, immediate heparin resulted in a mRS 0,1 rate of 41.9%, while heparin at 24h resulted in a mRS 0,1 rate of 51.5% and heparin at 12 hours of 70%. Conversely, nadroparin was associated with a poor prognosis (mRS 0,1 rate: 16.7%). Use of IVUHF vs nadroparin was an independent factor of good prognosis (OR 2.61 95% CI 51.08-6.30). Discussion These results indicate that immediate IVUHF enhances early post-thrombolytic pro-hemorrhagic processes without outcome benefit. Conversely, IVUHF at 24H, after non-hemorrhagic CT Scan, results in a good prognosis effect and is extremely safe for ICH, even showing an unexpected anti-hemorrhagic effect. Conclusion. Intravenous heparin at 24 hours with an aPTT objective of 45 s, after a non hemorrhagic CT Scan, is safe and probably efficient in amplifying the rt-PA thrombolytic effect and preventing late reocclusion due to rt-PA induced thrombin generation.

Epidemiology of stroke II
Date: Thursday 15 May 2008  
Time: 16:40 - 16:50 -  Room: Erato/Uranie
Chair: V. di Piero, Italy and L. Girou, France

02
Imaging of hypoxic-ischemic penumbra with 18F-fluoromisonidazole and related glumatate levels in aneurysmal subarachnoid hemorrhage: preliminary results
A. Sarrafzadeh    M. Plotkin    M. Czabanka    P. Vajkoczy                                          
 

Charité Campus Virchow Medical Center, Berlin

GERMANY

Background and Purpose: Infarction following vasospasm or a concomitant intracerebral hemorrhage is a severe complication mainly contributing to the high morbidity and mortality in patients with aneurysmal subarachnoid hemorrhage (SAH). The most extensively investigated and validated positron emission tomography radiotracer of hypoxia to date is (18)F-fluoromisonodazole ((18)F-FMISO). It allows early imaging of the target of therapy being the severely hypoxic but salvageable tissue. We investigated the excitotoxic mediator and marker of ischemia glutamate, monitored with microdialysis (MD), in relation to 18F-FMISO PET findings in patients with aneurysmal SAH. Methods: Seven SAH patients (WFNS grade I-III, age 48.9 yrs) were prospectively studied with microdialysis monitoring and 18F-FMISO PET. The MD-catheter was inserted into the brain parenchyma of interest. Extracellular levels of glutamate were analyzed hourly for eight days. 18F-FMISO PET was performed within the period of occurrence of possible vasospasm (day 3-8 after SAH). Results: In asymptomatic patients (n=3) no hypoxic region was found and glutamate levels were low (<10 mMM). Symptomatic patients presenting acute (n=3) or delayed (n=1) neurological deficits had higher glutamate concentrations (10-35 mM). 18F-FMISO-uptake was increased in two of these cases within the microdialysis region of interest. When infarction was visible on computerized tomography (n=2), no uptake was observed. Conclusion: 18F-FMISO-PET is a promising method to early diagnose metabolically compromised lesioned brain tissue and possibly allows to image the part of salvageable tissue for future targeted therapy.

Epidemiology of stroke II
Date: Thursday 15 May 2008  
Time: 16:50 - 17:00 -  Room: Erato/Uranie
Chair: V. di Piero, Italy and L. Girou, France

03
Long-term Mortality, Morbidity and Hospital Care following Stroke: A 10-year Cohort Study
A.R.Finlayson    J.L.Bishop                                                        
 

Information Services, National Health Service Scotland

UNITED KINGDOM

Background and Purpose – Stroke is one of the leading causes of death and reasons for admission to hospital in Scotland. This study assessed survival, morbidity and cost of hospital care over ten years following a first-ever stroke. Methods – Patients with a first ever admission to hospital for stroke in 1996 were identified from routinely collected hospital data in Scotland. Patient characteristics (age, sex, length of stay, hospital) were analysed and long-term survival, morbidity, and treatment provided in hospitals were evaluated. Follow up outcome analyses were made possible by the record linkage between hospital records and to death registration records, which is carried out routinely in Scotland. Results - A total of 8368 patients diagnosed with a first stroke in 1996 were identified. Mean age was 73.4 years (SD 12.3) at stroke onset. In-hospital mortality was 29.7%, 32.4% at 90 days, 41.8% at 1 year, while 80.1% were dead within ten years. Mean number of days spent in hospital on initial admission was 19 days, rising to 77 days in total over the 10 years. 14% of patients were readmitted for stroke at least once over the next 10 years with a mean number of 1.8. 56% of patients were readmitted to hospital for any reason and the mean number of readmissions over the 10 years was 6.4. Conclusion – Patients suffering first onset of stroke require significant hospital resources, both during their initial hospital admission and throughout subsequent admissions. Although many people do not survive their initial onset of a stroke, those that do go on to have many more stroke related admissions. Most of these patients are elderly and as the number of elderly people in the population and the survival rate from initial stroke increases we can reasonably expect the amount of resources required by hospitals to cope with stroke admissions to rise.

Epidemiology of stroke II
Date: Thursday 15 May 2008  
Time: 17:00 - 17:10 -  Room: Erato/Uranie
Chair: V. di Piero, Italy and L. Girou, France

04
10 year trends in Cerebrovascular Disease mortality – the effect of rurality and deprivation in Scotland
J.L.Bishop    A. Redpath                                                        
 

Information Services, National Health Service Scotland

UNITED KINGDOM

Objectives: Cerebrovascular Disease (CVD) is the third main cause of death in Scotland and a leading cause of premature mortality. Scotland does not compare favourably with Western Europe and CVD became a priority for the Scottish Government. This study looks at 10 year trends in CVD premature mortality and determines whether rates vary by rurality and deprivation. Methods: Death registration data was used to calculate age-adjusted mortality rates from cerebrovascular disease for ages under 74 from 1995 to 2006. Area based indices of deprivation (quintiles) and rurality (urban or rural) were assigned based on address. Of particular interest was the deprived rural population which has long been assumed to be the most disadvantaged in Scotland. 3 year rolling averages of the rates were examined. Rates were adjusted for age and sex. Results: CVD premature mortality across all deprivation and urban/rural categories decreased in Scotland by 38% between 1997 and 2006 years and is on track to meet the 15 year 50% target reduction by 2010. However, for the first time there was a small increase in the male mortality rate from 23.0 per 100,000 population in 2005 to 23.6 per 100,000 population in 2006. Rates amongst deprived populations remained consistently higher than rates amongst affluent populations. The inequality ratio between the most and least deprived populations actually increased over the 10 year period from 2.5 to 2.8. Rates in urban populations were slightly higher than those in rural populations but we did not find any evidence of significant differences in rates between urban and rural populations within deprivation quintiles. Conclusions : Deprivation is the leading factor in differences in CVD premature death rates and despite the work being done by the Scottish Government, vast inequalities still remain . Whether a person lives in an urban area or a rural area does not seem to have any major effect. Although small in 2006,the upturn in male premature mortality requires further vigilance.

Epidemiology of stroke II
Date: Thursday 15 May 2008  
Time: 17:10 - 17:20 -  Room: Erato/Uranie
Chair: V. di Piero, Italy and L. Girou, France

05
Incidence, Risk Factors, Severity and Early Outcome of TOAST-defined Ischaemic Stroke Subtypes – The North Dublin Population Stroke Study
M. Marnane    O. Sheehan    A. Merwick    L. Kyne    A. Moore    P.M.E.McCormack    D. Harris    N. Fitzsimon    L. Daly    P.J.Kelly
 

Neurovascular Clinical Science Unit, Mater University Hospital and University College Dublin

IRELAND

Background: Large prospective population studies are important to accurately determine the frequency and natural history of ischaemic stroke while avoiding potential selection bias that may occur in hospital-based studies. Although the mechanism-based TOAST classification of stroke subtype is frequently used in observational studies and clinical trials, relatively little population data exists. Methods: The North Dublin Population Stroke Study is a prospective cohort study of stroke and TIA in 294,592 individuals over one year. Multiple validated overlapping (‘hot’ and ‘cold’ pursuit) sources of case ascertainment were used. Ischaemic stroke was classified according to TOAST subtype by a trained Stroke Physician using a standard data abstraction and classification algorithm. NIH Stroke Scale (NIHSS) and modified Rankin score (RS) were performed within 72 hours, and RS repeated at 7 and 28days. Results: 455 new (first-ever and recurrent) ischaemic stroke cases were ascertained. Crude subtype-specific incidence rates (per 100,000) were: Large artery (LA) 15, Cardioembolic (CE) 55, Small artery (SA) 20, Other 3, Undetermined 62. Patients with CE were older (p=0.0005) and more likely female (p=0.008) than those with LA or SA stroke. LA stroke was more common in males (p=0.008). Hypertension and diabetes mellitus were equally common. CE and LA stroke had greater NIHSS and RS than SA stroke at all time-points (p<0.01 for all). No differences in stroke severity, recurrence, or mortality at 7 or 28days were present between CE and LA subtypes. Conclusions: TOAST-defined subtypes were associated with distinct frequency, risk factor and outcome profiles. Improved prevention of CE and LA stroke is likely to provide most benefit in reduction of stroke-related disability and mortality.

Epidemiology of stroke II
Date: Thursday 15 May 2008  
Time: 17:20 - 17:30 -  Room: Erato/Uranie
Chair: V. di Piero, Italy and L. Girou, France

06
DISABILITY-ADJUSTED LIFE YEARS LOST FROM STROKE AND PER CAPITA GROSS DOMESTIC PRODUCT IN SOUTH-EAST ASIA: AN ECOLOGICAL STUDY
N. Venketasubramanian    R.N.Gan                                                        
 

National Neuroscience Institute

SINGAPORE

Introduction: Stroke is a major cause of death and disability in many countries of the world. South East Asia(SEA), home to 535 million people, comprises 10 developing countries with widely differing wealth status. Objective: This paper studies the association between disease burden due to stroke and per capita wealth along countries in SEA. Methods: Disease burden was measured in disability-adjusted life years lost(DALYs)/100 000 population due to stroke, age and sex-standardised to the World Standard Population. Wealth was measured in per capita gross domestic product(GDP) in International dollars(Int $). Data on DALYs and per capita GDP for the 10 SEA countries was obtained from the World Health Organisation(WHO) website (http://www.who.int/en/). The data of each country was plotted as continuous variables. Pearson’s correlation r was determined. Data was analysed using SPSS for Windows ver 12.0 Results: Latest data available was for 2002. DALYs due to stroke ranged from 1 in Brunei to 1311 in Indonesia, reflecting in part the size of the population in these countries, as Brunei has the smallest and Indonesia the largest population in SEA. Age-sex standardised DALYs ranged from 251/100 000 in Singapore to 991/100 000 in Laos. Values were in the lower range for Thailand, Malaysia and Brunei, and in the higher range for Khmer, Myanmar and Indonesia, with intermediate values for Philippines and Vietnam. There was an inverse exponential relationship between DALYs and GDP. When both data were log transformed, a linear relationship was obtained, r2=0.89. Conclusion: There is a strong inverse relationship between stroke burden and wealth in SEA countries. This study suggests that countries should strive to raise their wealth so as to reduce their disease burden due to stroke.

Epidemiology of stroke II
Date: Thursday 15 May 2008  
Time: 17:30 - 17:40 -  Room: Erato/Uranie
Chair: V. di Piero, Italy and L. Girou, France

07
No evidence for a role of thyroid autoimmunity in the pathogenesis of cervical artery dissections
C. Lichy    C. Becker    M. Kloss    M. Arnold    T. Brandt    A. Pezzini    C. Grond-Ginsbach                     
 

University of Heidelberg

GERMANY

Background A recent study suggested a role of antithyroid autoimmunity in the process of local inflammation related to spontaneous cervical artery dissection (sCAD). Presence of thyroid antibodies was found in 9 of 29 sCAD patients, but only in 2 of 29 patients with stroke of other etiologies. We aimed to confirm this finding by investigating an independent larger group of patients. Methods In 72 consecutive patients with MRI-confirmed sCAD (29 women, mean age 43.1 years), serum tests for antibodies against thyreoglobulin (TgAb), thyroid peroxidase (TPOAb), and thyroid-stimulating hormone receptor (TRAb) were performed. Additionally, TSH levels were measured in all patients and a systematic evaluation for clinical signs of thyroid disease was done. We used data of a historical control group of 6.850 healthy Caucasian subjects to estimate the significance of potential findings. Results In 12 (16.7%) patients (8 women, mean age 44.8 years) had TgAb and / or TPOAb levels above the upper limit of normal (4 TgAb, 2 TPOAb, 6 both). However, this is much lower than reported by the initial study and is within the range of thyroid-antibody positivity found in the healthy population (12.9+/-0.6%TgAb, 14.3+/-0.4%TPO Ab). No patient showed clinical evidence for thyroid disease. TSH levels were normal in all patients. One patient had a history of Grave’s disease, but none had increased levels of TRAb. Discussion In our study on the prevalence of antithyroid-antibodies in sCAD, we could not confirm a previously suggested role of antithyroid autoimmunity in the pathogenesis of this vasculopathy.

Epidemiology of stroke II
Date: Thursday 15 May 2008  
Time: 17:40 - 17:50 -  Room: Erato/Uranie
Chair: V. di Piero, Italy and L. Girou, France

08
Gender differences in patients with acute ischemic stroke
V. Caso    F. Corea    W. Ageno    A. Lanari    L. Bertolani    G. Comi    P. Previdi    G. Silverstrelli    A.MRBilleci    M. Paciaroni
 

University of Perugia, Ospedale S. Maria della Misericordia, Perugia

ITALY

Background. Population-based studies have shown that women, at any age, have a lower risk of stroke than men; but the risk of stroke increases with advancing age and women on average today live 5 to 10 years longer than men, so their overall burden of stroke is greater. However, a reduced diagnostic work-up in women affected by stroke has been evidenced as well as an undertreatment of complications compared to men. Methods: Data of consecutive patients included in a multicenter-study were analyzed from 1st of January 2006-30thof April 2007). Vascular risk factors, clinical presentation, NIHSS at admission, pre-treatment and stroke treatment during hospitalization and disability/death (mRS>3) at three months were compared in men and women. Results: A total of 1125 strokes were observed (women:494, 44.9%). The mean age was 76.36±12.93 for women and 70.07±12.95 for men (p<0.001). The vascular risk factors such as smoking (26.4v11.1%, p<0.001), alcohol abuse (5.3v 0%, p<0.001) and PAD (3.6 v1.1%. p=0.02) were higher in men, while women tended to have more atrial fibrillation (22.2% v17.1%, p=0.01). The mean baseline NIHSS was 9.47 for women and 7.67 for men (p=0.001). Women tended to have more TACI (19.4v11.2%, p<0.001) and more cardioembolic stroke(30.4v23.2%, p=0.04). No differences in previous anticoagulation treatment and acute thrombolitic therapy had been observed. At three months more women were dead or disabled (46.6%v 36.1%, p=0.001). However, female gender was not an independent factor for bad outcome in regression analysis, while older age, higher NIHSS-score and diabetes were predictors for bad outcome. Conclusions: Female gender is not an independent factor for bad outcome. However, women tend to be older than men and to have more severe stroke.

Epidemiology of stroke II
Date: Thursday 15 May 2008  
Time: 17:50 - 18:00 -  Room: Erato/Uranie
Chair: V. di Piero, Italy and L. Girou, France

09
Case fatality and disability of 3123 consecutive patients in Chengdu Stroke Register
M. Liu    W.Li     Y.Fang     B.Wu                                           
 

West China Hospital, Sichuan University

CHINA

Background and purpose： Community based stroke studies in China were mainly conducted in 1980s and have methodological limitations. Few prospective, consecutive and long term follow up hospital based stroke register was conducted in mainland China. No disability data were reported from community based or hospital based registers in China. This study analyzed data from Chengdu Stroke Register to provide information on short and long term case fatality and disability in stroke. Methods: We conducted a pilot study in 1998 to explore the feasibility. Since Mar 1, 2002 we have been registering prospectively stroke patients consecutively admitted to our hospital. The World Health Organization definition for stroke was used. Patients with stroke occurred within one month were included. The baseline demographic, risk factors, treatment, and outcome data were recorded. We followed up patients at 7 days, 1, 3, 6 and 12 months for death, disability and recurrence. Disability is defined as Modified Rankin Scale scored >/=3. Results: A total of 3123 patients registered from Mar 1, 2002 to Aug 31, 2006 were included. Age ranged from 14 to 98 years and the mean age was 63+/-18 years. Male patients accounted for 60%. 97% of the patients had brain CT or MRI scanning. The length of hospital stay ranged from 1 day to 113 days and the average is 11 +/- 9days. Ischemic stroke accounted for 62%, intracranial hemorrhage 28%, subarachnoid hemorrhage 4%, TIA 6%. 10% of the ischemic stroke patients arrived in hospital within 3 hours of stroke onset and 22% within 6 hours. Only 0.9% of the patients with ischemic stroke were treated with intravenous thrombolysis. 3% of the ischemic and 11% of the hemorraghic stroke patients died within 7 days, 5% and 14% at one month. 12% and19% at 12 months. Death or disability were 37% and 40% at 3 months, 33% and 39% at 12 month in ischemic and hemorraghic stroke patients. Conclusions: Short and long term case fatality and disability rates are relatively low in this group of patients. The reason is unclear and need further study.