XVII. European Stroke Conference
Nice, France

Oral Session:

Venous diseases 
Date: Wednesday 14 May 2008  
Time: 17:30 - 17:40 -  Room: Calliope
Chair: J.L. Marti-Vilalta, Spain and K. Muir, United Kingdom

07
Decompressive hemicraniectomy for severe cerebral sinus thrombosis
J.M.Coutinho    V.I.Kwa    B.A.Coert    J. Stam                                          
 

Academic Medical Center, University of Amsterdam, Amsterdam

THE NETHERLANDS

Background: Despite treatment with heparin, about 10% of patients with cerebral sinus thrombosis (CST) have a poor outcome. We recently analysed our experience with endovascular thrombolysis in 20 severe cases of CST (Stroke; in press). 9 patients had excellent outcomes, but 6 patients with large haemorrhagic infarcts and impending herniation died. Methods: Halfway 2006 we decided to apply decompressive hemicraniectomy (DHC) for such patients instead of thrombolysis. Here we report the results of this policy in the first two patients. Results: Patient A, a 39 year old man, was admitted with thrombosis of the left transverse and sigmoid sinuses. Despite high dose heparin he deteriorated and became comatose (E1, M4, Vtube) within 2 days. A new CT-scan showed a large, left sided hemorrhagic infarct with 1.2 cm midline shift. After emergency DHC he regained consciousness within hours. After 6 months a right upper quadrant hemianopia and a mild expressive aphasia were his only residual symptoms, and after one year he was back to work. Patient B, a 36 year old woman, was admitted with thrombosis of the superior sagittal sinus. Despite high dose heparin she deteriorated, with depressed consciousness and an enlarging right pupil, due to a large right sided hemorrhagic infarct with 1 cm midline shift. After emergency DHC she recovered rapidly and at 3 month follow up she was back to work, with only a left lower quadrant hemianopia. Discussion: Our results suggest that decompressive hemicraniectomy is not only life saving in patients with severe CST and impending herniation, but can also result in excellent functional recovery. Before we changed our policy, similar patients in our centre had a fatal outcome with maximal conservative treatment, including endovascular thrombolysis.

Venous diseases 
Date: Wednesday 14 May 2008  
Time: 17:40 - 17:50 -  Room: Calliope
Chair: J.L. Marti-Vilalta, Spain and K. Muir, United Kingdom

08
Delay in the diagnosis of cerebral vein and dural sinus thrombosis (CVT). Influence on outcome
J.M.Ferro    P. Canhão    M.G.Bousser    J. Stam    F. Barinagarrementeria    A.  Massaro    X. Ducrocq    S.E.Kasner              
ISCVT Investigators

Hospital de Santa Maria

PORTUGAL

Diagnostic delay of CVT is a relevant clinical and medico legal issue, and may have an impact on outcome. Methods. In the ISCVT cohort (624 CVT patients) we analysed 1) which demographic, clinical and imaging variables influenced diagnostic delay 2) the impact of diagnostic delay on outcome. Diagnostic delay was defined as the interval from onset of symptoms to confirmation of CVT diagnosis by MR and/or angiography. Primary outcome was mRS>2 at the end of follow up. Secondary outcomes were mRS 0-1 at the end of follow up, death, visual loss, and % treated with IV heparin or LMWH in the acute phase. Subgroup analysis were performed for low and high risk (CVT risk score>3) patients and for patients presenting as isolated intracranial hypertension syndrome (IIHS). Non parametric statistics (median, interquartile range (IQR), Mann-Whitney and Kruskal-Wallis tests) were used for comparisons. Results. Information on diagnostic delay was available for 623 patients. Median delay was 7 days (IQR 3, 16). Delay (IQR) was 11 days (6, 19) in South-American, 8 days (4, 16) in North-American and 7 days (3, 14) in European centres (p=0.006). Patients with more severe clinical features (disturbance of consciousness (p=0.000) or of mental status (p=0.04), seizure(0.000) and with parenchymal lesions on admission CT/MR (p=0.000) were diagnosed earlier, while men (p=0.01) and those with IIHS (p=0.04) were diagnosed later. Fewer patients diagnosed later were anticoagulated. No statistical significant differences were found in the primary outcome (p=0.68) and in secondary outcomes mRS 0-1 (p=0.81) or deaths (p=0.77), both for the whole sample and for low and high risk patients. Visual loss was more frequent in patients diagnosed later (p=0.02), in particular among patients with IIHS. Conclusion and interpretation. CVT patients with more severe clinical presentation tend to be diagnosed earlier. Diagnostic delay had no influence on death or dependency, but was associated with an increased risk of potentially preventable visual los.

Venous diseases 
Date: Wednesday 14 May 2008  
Time: 17:50 - 18:00 -  Room: Calliope
Chair: J.L. Marti-Vilalta, Spain and K. Muir, United Kingdom

09
Long-term sequelae after cerebral venous thrombosis in functionally independent patients
K. Koopman    M. Uyttenboogaart    P.C.Vroomen    J. van der Meer    J. De Keyser    G.J.Luijckx                            
 

University Medical Center Groningen, University of Groningen

THE NETHERLANDS

Background: The majority of survivors of cerebral venous thrombosis (CVT) regain functional independence, but it is unclear whether these patients experience long-term sequelae. The aim of this study was to assess (1) the frequency of headache, fatigue, depression, and concentration impairment, and (2) the impact of these sequelae on daily life and employment in functionally independent CVT patients. Methods: We studied 56 CVT patients older than 15 years diagnosed between January 1997 and July 2006 who were functionally independent (modified Rankin scale score ≤ 2) at least 12 months after CVT. Headache was assessed by the Headache Impact Test, fatigue with the Fatigue Severity Scale, depression by the Center for Epidemiological Studies Depression Scale and concentration impairment with the cognition dimension of the 6-dimensional EuroQol. We studied the psychosocial impact (based on the Severity Impact Profile 68) and the impact on employment status. Results: The response rate was 79% (n=44). Median follow-up was 63 months (range 12-124). Thirty-three patients (75%) reported concentration impairment, 19 (43%) had clinically important headache, 13 (30%) were depressive and 13 (30%) complained of fatigue. These sequelae were correlated with each other, and with a higher psychosocial impact. Working was impossible for 8 (21%) and difficult for 13 (34%) of previously employed patients. Conclusion: CVT patients traditionally classified as having a good (independent) outcome often experience long-term complaints that have a negative impact on their psychosocial and employment status.