XVII. European Stroke Conference
Nice, France

Poster Session: Heart & brain

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 3

 01
Emergent echocardiography is associated with a high rate of detection of cardioembolic source in acute ischemic stroke
E. SANTAMARINA    M.T.GONZÁLEZ - ALUJAS    A. PACCHIONI     O. MAISTERRA     R. DELGADO - MEDEROS    M. RIBÓ     M. RUBIERA     G. ORTEGA    J. ÁLVAREZ SABÍN   C.A.MOLINA
 
HOSPITAL VALL HEBRON

SPAIN

Fast-track emergent echocardiography within the first hours of stroke onset may increase the accuracy in the detection of fresh thrombi. We conducted a case-control study aimed to evaluate the yield of second harmonic transthoracic echocardiography(SHTTE) within the first hours of acute ischemic stroke. METHODS: We study consecutive non-lacunar ischemic stroke patients evaluated between November 2006 and April 2007. It included patients with a known cardioembolic source and patients with an undetermined origin. Emergent SHTTE was performed during the first hours(<24h) of admission (early SHTTE) These data were compared with age- and sex- matched historical controls (delayed SHTTE) who underwent SHTTE as part of the standard diagnostic work-up(>24h) RESULTS:350 patients underwent SHTTE. 165 were evaluated in the early group and 185 patients in the delayed SHTTE group. Mean time from stroke onset to SHTTE evaluation was 14±9 hours and 1076+/-168 hours in the early and delayed SHTTE, respectively. Among patients with stroke of undetermined origin, detection of a cardioembolic source of emboli was significantly higher in patients who underwent early(n=52;48%) compared to those who received delayed(n=16;23%) SHTTE (p=0.001). Main findings included severe aortic atheromatosis 24(22.2%)vs.3(3.5%), akynesia/hypokynesia 15(14%)vs.9(11%), PFO 8(7.4%)vs.8(9.5%), valvulpathy 6(5.6%)vs.2(2.4%) and dilated miocardiopathy 3(2.8%)vs.1(1.2%). The greater diagnostic accuracy of early compared to delayed SHTTE was mainly due to a higher detection of aortic arch atheroma with mobile thrombus. Early SHTTE evaluation increased in 7-fold the likelihood of detection of a mobile thrombus in the aortic arch as compared with delayed exam(22.2%vs.3.2%; p=0.001). CONCLUSION: The yield of SHTTE is markedly increased when performed during the first hours of acute stroke. Early SHTTE provides a higher detection of a cardioembolic source of emboli, mainly mobile thrombi engrafted in an aortic atheroma. These findings have an important impact on therapeutic decisions.

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 3

 02
Diagnosis of cerebral circulatory arrest by Doppler ultrasound in brain death: Do we need the cervical arteries?
G. Gahn    G. Hofmann    B. Widder                                                    
 
University of Technology Dresden

GERMANY

Background: Doppler sonography is widely used as a confirmatory test in the diagnosis of brain death for assessment of cerebral circulatory arrest (CCA). National guidelines vary widely in the significance and the requirements for Doppler procedure. International recommendations suggest documentation of Doppler signals typical for CCA intracranially (ic) in the middle cerebral artery (MCA), and in the distal internal carotid artery (icICA) and additionally extracranially (ec) in the cervical parts of the ICA and the vertebral arteries (VA). Evaluation of the icVA or the basilar artery (BA) is not mandatory but suggested in several countries. We hypothesized that transcranial Doppler (TCD) only of icICA, MCA and BA is sufficient to diagnose CCA. Methodik: We prospectively performed in 122 pat. with clincal signs of brain death Doppler sonography of icICA, MCA, BA, ecICA and ecVA. Doppler signals were allocated to three categories; clearly identifiable (1), disturbed, but identifiable (2), not detectable (3). Results: In 120/122 patients the diagnosis of brain death was made according to national guidelines. In 102 pat. the diagnosis of CCA was made by Doppler sonography. In 18 patients Doppler sonography could not be used as a confirmatory test because of undetectable transtemporal Doppler signals. In two patients TCD showed persistent cerebral flow signals incompatible with CCA. In 95/102 pat. (93,1%) clear or disturbed CCA-signals could be obtained in the icICA, the MCA and in the BA. The BA provided in 95.8% of patients sufficient signal quality, the ecVA in 91.9%. Middle signal quality was 2,49 +/-0,29 in the anterior and 2,34 +/- 0,37 in the posterior circualtion (p< 0,0001). Conclusion: In more than 90% of patients with suspected brain death, accessible by TCD, the diagnosis of CCA can exclusively be made by TCD-evaluation of the MCA, icICA and BA. Extracranial Doppler of the ecVA is only needed when BA signals can not be obtained.

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 3

 03
Transforaminal Doppler: An alternative to transtemporal approach for right-to-left cardiac shunt assessment in stroke patients
F. Perren    E. Savva    T. Landis                                                    
 
HUG, University Hospital and Medical School of Geneva

SWITZERLAND

Background:Even younger patients may have insufficient temporal bone windows (up to 10%). We thus studied prospectively if a transforaminal approach is an alternative to transtemporal Doppler in the detection and quantification of cardiac right-to-left shunt (RLS) due to patent foramen ovale. Methods: 64 patients subsequent to a recent stroke of unexplained origin underwent transtemporal (TTD)(middle cerebral artery) and transforaminal (TFD) (basilar artery) Doppler. Artificial high-intensity signals (HITS) produced by a 1ml/air-9ml/saline injection at rest and after efficient Valsalva's maneuver (VM) were measured by two sonographers. For more than 60 HITs or a "curtain effect" the number 60 was given. Results:TTD and TFD had a 100% agreement as to the absence of HITS (22 patients) and "curtain effect" (>60 HITS; 15 patients). Pearson correlation between the number of HITS of the two methods was highly significant at rest (r=0.875;t(df62)=14.202;p<0.000) and during VM (r=0.977;t(df62)=35.717;p<0.000). Even when discarding patients without HITS and those with a "curtain effect" (>60 HITS), the correlation remained highly significant at rest (r=0.776;t(df32)=6.956;p<0.000) and during VM (r=0.884; t(df23)=9.056;p<0.000) Discussion:The transforaminal Doppler approach could be a valid alternative in the detection and grading of cardiac right-to-left shunts in patients with poor temporal bone windows.

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 3

 04
Risk of coronary events in patients with stroke or TIA: Two-year follow-up data from the REduction of Atherothrombosis for Continued Health (REACH)RE
E. Touzé    J. Röther    M.J.Alberts     S. Goto     M.D.Hill    F. Aichner     P.G.Steg     D.L.Bhatt    J.-L.Mas      
on behalf of the REACH Registry Investigators
Service de Neurologie - EA 4055 - INSERM U894, Hôpital Sainte-Anne

FRANCE

Background: Cerebrovascular disease (CVD) patients are generally considered at risk for subsequent cardiac events, although the absolute risk in CVD patients without known coronary artery disease (CAD) is not well characterised. We assessed the risk of myocardial infarction (MI) in CVD patients with no history of CAD. Methods: The REACH Registry enrolled 68,236 outpatients with established or 3 risk factors for atherothrombotic disease from 44 countries globally. Among 18,189 CVD patients, 11,660 had no history of symptomatic CAD at inclusion. Incidence rates /100 persons-years (IR) and their 95% confidence intervals (CI) were calculated. Cox proportional hazards models were used to assess adjusted hazards of MI. Results: After a mean follow-up of 1.6 years, 164 patients (IR=0.88; 95% CI 0.75-1.03) had MI, including 107 non-fatal MI (IR=0.57; 95% CI 0.47-0.69) and 58 fatal MI (IR = 0.31; 95% CI 0.24-0.40). Risk of death from a non-stroke vascular cause was 1.02 (95% CI 0.88-1.17) and 700 patients had recurrent stroke (IR = 3.82; 95% CI 3.54-4.11). In multivariable Cox models, age (HR=1.45; 95% CI 1.26-1.66, /10 years), diabetes mellitus (HR=1.73; 95% CI 1.22-2.46), truncal obesity (HR=1.41; 95% CI 0.97-2.03), history of peripheral arterial disease (HR=1.77; 95% CI 1.07-2.94), and baseline blood pressure 140/90 mmHg (HR=1.46; 1.01-2.10) were associated with an increased risk of MI. Male gender increased the risk of fatal MI but not non-fatal MI. Past and current smoking increased the risk of non-fatal MI, but not fatal MI. Discussion: In CVD outpatients with no history of symptomatic CAD, the risk of MI is <1%/year during the first 2 years after enrolment, underlying the need to identify high-risk patients who could benefit from more intensive screening for CAD.

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 3

 05
T.A.C.E.T. - The Austrian Paradoxical Cerebral Embolism Trial
S. Horner                                                                  
for the Austrian PFO Study Group and the Austrian Society for Stroke Research
Medical University Graz, Department of Neurology, Graz

AUSTRIA

Background: T.A.C.E.T was designed as a prospective, national, multi-center, non randomized registry to document the baseline characteristics and results of diagnostic and treatment strategies in a cohort of stroke patients aged <= 55 years in whom contrast transesophageal echocardiography (cTEE) demonstrated cardiac (cRLS) or pulmonary (pRLS) Right-to-Left shunts. Primary endpoint of the study was to compare medical versus interventional therapy in respect of TIA/stroke recurrence and catheter-related complications. Methods and Results: During the 2-year inclusion period a total of 201 patients (105 males, 52.2%, 96 females, 47.8%, mean age: 42.1 +/- 10.1 yrs) with TIA (84, 41.8 %) or stroke (117, 58.2%) were registered by 15 Austrian neurological centers. cTEE led to the following diagnoses: cRLS (188, 93.5%), pRLS (11, 5.5%) or c+pRLS (2, 1%). 195 patients could be followed over an average of 26.4 months. Interventional therapy was performed in 111 (55.2%) patients, 109 successful transcatheter closures and 2 surgical closures. The catheter-related complication rate was 15/110 (13.6%), moderate/severe in one of the patients (unsuccessful closure attempt). During follow-up, 19/195 (9.7%) patients suffered from a recurrent cerebrovascular event. The overall recurrence rate was 10.2%, with 5 strokes (4 with cRLS and 1 with pRLS) and 15 TIA (12 with cRLS and 3 with pRLS) encountered. Pulmonary shunting as a possible cause of stroke was confirmed by angiography in one patient. Patients on conservative secondary prevention experienced 16 recurrent cerebral ischemic events (5 strokes, 11 TIA) compared to 4 recurrencies (4 TIA, no strokes) after intervention. Discussion: Results of T.A.C.E.T. suggest a non-significantly (p=0.144) lower frequency of recurrent cerebrovascular events after transcatheter closure when compared with conservative treatment. Nevertheless, long-term prospective studies are needed in order to weigh the benefits of interventional treatment against the efficacy and risks. www.meduni-graz.at/neurologie/TACET/Home.htm.

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 3

 06
Characteristics of children with underlying Cardiac defects who developed Arterial Ischaemic Stroke (IS)
V. Murugan    F.J.Kirkham                                                           
 
Neuosciences units, Institute of Child Health and Great Ormond Street Hospital, London,

UNITED KINGDOM

Background : Cardiac disease is a common underlying condition in children with arterial ischemic stroke (AIS). Embolism, dissection and moyamoya are recognised mechanisms and iron deficiency has been associated. However, few recent data exist relating the nature of the underlying cardiac defects, or associations with recent investigational or surgical procedures Objective: To investigate characteristics of children with underlying cardiac defects who developed AIS Method: Review of cardiac cases from Great Ormond Street first AIS cohort presenting 1978-2000 Results: Of 212 with AIS, 33 (16%) children had underlying cardiac disease, with more boys (23; 70%). Median age at presentation was 4.7 (range 0.6-16.3) years. 17 (52%) developed stroke following cardiac surgery, 1 following catheterisation and 15 (49%) spontaneously. 6 had another diagnosis (skin haemangioma, linear sebaceous naevus, Down syndrome, Williams syndrome, acute lympoblastic leukaemia and immunodeficiency). The majority had right sided cerebral infarction (49%) followed by left side (30%) and bilateral (21%). Anterior (n=30) was commoner than posterior circulation involvement (n=3). Cerebral infarction was purely subcortical in 8, purely cortical in 7, and involved both cortical and subcortical tissue in 18 children. 20 (60%) had arterial imaging which showed occlusion in 7, stenosis in 4, dissection in 2, moyamoya in 2 and normal vessels in 5. 6 (16%) died following stroke, 6 (16%) had recurrent stroke, and 4 (11%) had further transient ischaemic attacks. Seven (21%) had iron deficiency. Conclusion: Children with underlying cardiac defects comprised 1/6th of our AIS cohort; half had strokes spontaneously. Apparently primary cerebrovascular disease is as common as occlusion, presumably secondary to embolism. Iron deficiency was a risk factor in 1/5th but this and the other underlying diagnoses in addition to cardiac defects might increase the risk of developing AIS. This needs further investigation so that preventative strategies can be designed.

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 3

 07
RIGHT TO LEFT SHUNT AND RISK OF DECOMPRESSION SICKNESS
M. Sramek    A. Tomek    T.  Honek                                                    
 
Charles University, 2nd School of Medicine Prague

FRANCE

Background: The cause of decompression sickness (DCS) in scuba divers is bubble formation due to the sudden decrease in pressures in tissues and venous blood during underwater ascent. DCS may be divided into 3 categories: type 1 (joint pain or skin involvement), type 2 (neurological, inner ear or pulmonary disease), and arterial gas embolization (AGE). The presence of right to left shunt (RLS) is known risk factor for the most serious form of DCS (DCS 2, AGE) due to the possibility of paradoxical gas embolization from venous to arterial system overcoming lung filter. Aim of study: Determine prevalence and type of DCS in the relation to the presence of RLS in scuba divers population. Methods: We examined 109 divers, average age 40 years (16-62), who together made 31 520 dives (4-2000 per diver). Detailed history directed at DCS was taken. DCS episodes were evaluated as DCI type 1 (probably without bubbles arterialization) or DCI 2 (neurological symptoms, including arterial gas embolization). All divers were examined for the presence of RLS by contrast transcranial doppler sonography (TCD). RLS was assessed by TCD as low, medium or high grade. Results: There were 72 DCS episodes (55 DCS 1, 17 DCS 2) during 31520 dives. Total risk of DCS development was 22,84/10 000 dives, risk of DCS 2 was 5,39/10 000 dives. For divers with RLS the risk of DCS 2 increased to 9,68/10000 dives and for divers with high grade RLS even up to 12,39/10 000 dives. Divers without proved RLS had risk of DCS 2 0,67/10 000 dives. Conclusion: DCS with neurological symptoms is relatively rare complication during scuba diving. Its prevalence and seriousness is increased in the presence of RLS depending on its grade.

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 3

 08
Long term clinical and radiological follow-up of patients with patent foramen ovale and cryptogenic stroke treated with percutaneous closure
B. Guillon    P. Guérin    T. Manigold     J.M.Langlard     E. Auffray-Calvier    R. Fressonnet                             
 
Stroke Unit and Department of Cardiology, Laënnec Hôpital, Nantes

FRANCE

Background Several studies have shown a relationship between patent foramen ovale (PFO) and cryptogenic stroke in young patients. Percutaneous closure of PFO is one therapeutic approach to prevent further ischemic events. The aim of the study was to evaluate the risk of recurrent embolism based on clinical and MR imaging. Methods 50 consecutive patients with PFO and cryptogenic stroke (mean age 41±9; men 52%) were treated with percutaneous closure. During the 6-months post-procedure period, patients were treated with anticoagulant alone or in association with antiplatelet, and then, with antiplatelet alone. A long term work-up including neurological examination, T2/T1/DWI/FLAIR MRI sequences, transthoracic echocardiography and transcranial Doppler study (TCD) was performed after a mean period of 20.6±10 months (9 to 56 months). Results In 43 patients, PFO was associated with atrial septum aneurysm (ASA). Percutaneous closures were efficient in all patients without any major complications. No patients had symptoms of stroke or TIA during the follow-up period. MR study was performed in 44 patients and did not show any new lesion, except in one hypertensive patient with new bilateral lenticulostriate T2 hyperintensity. There was no device related adversity and no residual ASA on TTE. Based on TCD, a residual shunt was present at rest in 36% of patients and after Valsalva maneuvers in 76%. Discussion Transcatheter closure of PFO seems to be safe and efficient in order to prevent the risk of further embolism assessed with a sensitive tool such as MRI, despite a high rate of residual shunt.

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 3

 09
MANAGEMENT OF PATIENTS WITH CRYPTOGENETIC ISCHEMIC STROKE AND PATENT FORAMEN OVALE: A MODEL OF MULTIDISCIPLINARY DECISIONS.
F. Casoni    V. Agnoletto    M. Cavazzuti     A. Zini     D. Tosoni    P. Magnavacchi     P. Nichelli     R.G. Zennaro             
 
NEUROLOGICAL CLINIC. NUOVO OSPEDALE CIVILE SANT'AGOSTINO ESTENSE, UNIVERSITY OF MODENA AND REGGIO EMILIA

ITALY

Up to now studies of comparing medical and surgical therapies are ongoing and no guide lines for therapy has been published in patients with cryptogenetic stroke and patent formen ovale (PFO). We would present a flow-chart for management of patients with stroke positive for PFO. Our Group is composed of Neurologists and Cardiologists of the same Hospital.We performed: diagnostic flow-chart for stroke patients aged between 18-55 years; protocol for PFO detection in stroke patients by Transcranial Color Coded Doppler (TCCD) and Transesophageal Echocardiography (TEE); internal guide-line for therapeutic management of patients positive for PFO. Neuroradiological imaging and extracranial /intracranial arteries ultrasound, hypercoagulable status workup were performed in all stroke patients. TEE standardize protocol was: to have a complete opacification of the right atrium; to check suitable views al least 3 to best detect separation between septum primum and secundum; repeat injection in every views al rest and with Valsalva Maneuver (VM). TCCD was performed at rest and with VM; shunt quantification was defined followed published data. PFO closure was indicated in stroke patients with medium and large PFO, at rest and after VM, associated with atrial septal aneurysm and neuroimaging positive fro ischemic lesions. Transcutaneous closure of PFO has been performed by Cardiologists starting the procedure since January 2007. Results: 36 stroke patients, admitted to Neurological Department between April 2006 –December 2007 resulted positive for PFO at ETE and TCCD. A “small shunt” was found in 12 patients by TCCD and confirmed by TEE. The other 24 patients presented a large PFO associated with ASA, PFO closure has been indicated. Until now 18 patients underwent to surgical procedure without complications. Discussion:management of cryptogenetic stroke patients positive for PFO is still debated.We propose a model of a multidisciplinary flow-chart, to manage selected stroke patients positive for PFO, in which Neurologists and Cardiologists collaborate.

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 3

 10
Basilar artery disease is associated with structural changes in the left ventricle
K. Kang    S.-H.Lee    B.-W.Yoon                                                    
 
Department of Neurology and Clinical Research Center for Stroke, Seoul National University Hospital

SOUTH KOREA

Backgound: Structural changes in the extracranial carotid artery are associated with an increase in left ventricular (LV) mass and relative wall thickness. The aim of this study was to examine the correlation between structural changes in the intracranial large arteries and those in the left ventricle in ischemic stroke patients. Methods: We retrospectively analyzed the records of acute ischemic stroke patients who underwent echocardiography and intracranial and/or carotid magnetic resonance angiography (MRA). Patients with incomplete evaluations, potential sources of cardioembolism, or known causes of vascular stenosis including carotid dissection, vasculitis and moyamoya disease, were excluded from the study. LV mass indexes and relative wall thicknesses were estimated. MRA was used to evaluate atherosclerotic changes in the basilar arteries (BA), the horizontal portion of the middle cerebral arteries, and the extracranial portion of the internal carotid arteries. We also collected clinical information regarding the known vascular risk factors. Results: A total of 212 patients were included in this study. Logistic regression analysis revealed that BA disease was related to LV relative wall thickness (odds ratio 44.56, 95% CI 1.30 to 1526, p = 0.035), but not LV mass index. In addition, the presence of hypertension did not affect the association between increased LV relative wall thickness and BA disease. Atherosclerosis of the middle cerebral artery and carotid artery was not closely related to structural changes in the left ventricle. Discussion: BA disease was associated with increased LV relative wall thickness. Increased LV relative wall thickness may be an independent risk factor for BA disease or may share unknown pathogenic mechanisms with BA disease.