XVII. European Stroke Conference
Nice, France

Oral Session:

Acute stroke: clinical patterns and practise
Date: Thursday 15 May 2008  
Time: 10:30 - 10:40 -  Room: Clio/Thalie
Chair: R. Baumgartner, Switzerland and A.P. Sigurdsson, Iceland

01
Mobile versus Hospital Based Telestroke Service. A Controlled Analysis
J. Schenkel    S. Boy    R. Jankovitz    P. Pilz    G. Uyanik    J. Klucken    N. Fehm    H.J.Audebert              
 

Klinikum Munich-Harlaching

GERMANY

Background: Telemedicine is increasingly used to provide acute stroke expertise for hospitals without full-time neurological services. Teleconsulting via mobile laptop computers may offer more flexibility compared to hospital based services but concerns about quality and technical reliability remain. Methods: We conducted a controlled trial, allocating hospital based or mobile teleconsulting in a shift-by-shift sequence and evaluating technical parameters, perception of quality and impact on immediate clinical decisions. Both types of telemedicine workstations were equipped with DICOM (Digital Imaging and Communications in Medicine) viewer and videoconference software. The laptop connected via asymmetrical broadband UMTS (universal mobile telecommunication systems) technology with a one-way spoke-to-hub video transmission whereas the hospital based device used landline symmetrical telecommunication including a two-way videoconference. Results: 127 hospital and 96 mobile based teleconsultations were conducted between June 28 and August 26, 2007 without any technical breakdown. The rates per allocated time were similar with 3.8 and 4.0 per day. No significant differences were found for durations of videoconference (mean: 11±3 vs. 10±3 min, p=0.07), DICOM download (3±3 vs. 4±3 min, p=0.19) and total duration of teleconsultations (44±19 vs. 45±21 min, p=0.98). Perceived sound and video quality was rated worse but this did not affect the ability to make remote clinical decisions like initiating thrombolysis (18 vs. 13% of all consultations). Conclusions: Teleconsultation using a laptop workstation and broadband mobile telecommunication is technically stable and allows remote clinical decision making. There remain disadvantages regarding videoconference quality on the hub side and lack of video-transmission to the spoke side.

Acute stroke: clinical patterns and practise
Date: Thursday 15 May 2008  
Time: 10:40 - 10:50 -  Room: Clio/Thalie
Chair: R. Baumgartner, Switzerland and A.P. Sigurdsson, Iceland

02
Outcome of patients with negative CT angiography treated with intravenous thrombolysis
R. Mikulik    D. Goldemund    M. Reif    L. Bunt    P. Aulicky    P. Krupa                            
 

Masaryk University

CZECH REPUBLIC

Background: Stroke patients without evidence of artery occlusion may not be candidates for thrombolytic therapy (TL). In our study, we sought the outcome of patients with negative CT-angiography treated with TL. Given the increasing reliance on imaging technologies, such findings may impact physician’s decision to treat stroke. Methods: Patients treated with intravenous TL within 3 hours from symptom onset for meaningful neurological deficit at baseline, between August 2003 and June 2007, were included. All had documented negative CT-angiography on independent reviews. Outcome measures included modified Rankin score (mRS) at discharge, incidence of intracranial hemorrhage (ECASS classification) and infarction volume on control CT. Predictors of unfavorable outcome (mRS 2-6) were identified by logistic regression. Results: Altogether, 173 patients received intravenous TL and 138 had CT-angiography. In 39 (28%) patients CT-angiography was negative with mean age 71±10 year, 16 (41%) females, and median baseline NIHSS 11. At 3 month, the mRS 0 to 1 was achieved in 18 (46%) patient and 6 (15%) died. Three patients (8%) suffered from symptomatic parenchymal hemorrhage type 2. The median infarct volume was 1.5 (IQR 0-37). In multivariate logistic regression analysis, the independent predictors of unfavorable clinical outcome were higher age, (OR 1.15; 95%CI, 1.02-1.29), and baseline NIHSS>12, (OR 19.3; 95%CI, 1.9-196.6). One patient was diagnosed with encephalitis. Conclusions: Negative baseline CT-angiography is not infrequent. TL carries a similar risk of ICH as in unselected patient population. Given patients’ dim prognosis, indication of thrombolytic therapy seems justified, although etiologies other than stroke should be considered. More studies are needed.

Acute stroke: clinical patterns and practise
Date: Thursday 15 May 2008  
Time: 10:50 - 11:00 -  Room: Clio/Thalie
Chair: R. Baumgartner, Switzerland and A.P. Sigurdsson, Iceland

03
Frequency and outcome of patients wrongly treated with intravenous thrombolysis
S. Martínez-Ramírez    A. Vidal    L. Querol    M. Marquié    D. Alcolea    E. Martínez-Hernández    J.-L.Martí-Vilalta    J. Martí-Fàbregas              
 

Hospital de la Santa Creu i Sant Pau

SPAIN

BACKGROUND Patients with stroke-mimic or psychiatric disorder may be wrongly treated with thrombolytics. We review the frequency and outcome of misdiagnosed patients in a series of consecutive patients treated with rt-PA. METHODS We retrospectively reviewed all patients treated with intravenous rt-PA in the emergency department at our institution within the last 7 years. All patients were diagnosed and treated by a neurologist. We selected those patients with: 1) No evidence of acute infarction in neuroimaging (CT and/or MRI) before or after thrombolysis. 2) No evidence of vascular occlusion (transcranial Doppler or angio-CT) in the suspected symptomatic artery before thrombolysis. 3) An alternative diagnosis for the neurological symptoms and signs. Functional outcome was measured by the Rankin Scale at 3 months. A score of 0 to 1 was considered a favourable outcome. RESULTS We treated 199 patients from 2000 to 2007. Mean age was 65 years and 39% were men. 28 of them (14%) had no acute ischemic lesion in follow-up neuroimaging. From this subgroup, only 5 patients (2.5%) had no baseline vascular occlusion and an alternative explanation for their symptoms other than stroke, including epilepsy (n=1), encephalitis (n=1), conversion disorder (n=1) or malingering (n=2). None of these patients suffered hemorrhagic complications, and all of them had a favourable outcome at discharge and at the 3 months follow-up. DISCUSSION In our series, there was a small risk of misdiagnosis of stroke (2.5%) in the emergency room. Patients wrongly treated with rt-PA had an excellent short and long-term outcome.

Acute stroke: clinical patterns and practise
Date: Thursday 15 May 2008  
Time: 11:00 - 11:10 -  Room: Clio/Thalie
Chair: R. Baumgartner, Switzerland and A.P. Sigurdsson, Iceland

04
Episodic Long-Term Memory Deficits in Patients with Acute Hippocampal Stroke
A. Förster    T. Jäger    A. Gass    R.R.Kern    M.G.Hennerici    K. Szabo                            
 

Universitätsklinikum Mannheim, University of Heidelberg

GERMANY

Background: In hippocampal stroke (HS) clinically apparent mnestic syndromes may be missed even in cases with relatively large ischemic lesions. In this study we focused and evaluated systematically episodic verbal and nonverbal long-term memory in HS patients, both known to be mediated by the left and right medial temporal lobes. Methods: Twenty patients with acute HS (Left:11, Right:9) were tested - in addition to a standardized neurological examination and stroke MRI - with a detailed neuropsychological battery (test for aphasia and neglect, MMSE, Clock drawing test, short term memory, working memory, and episodic long-term memory). Results: Verbal long-term memory (Rivermead Behavioural Memory Test, RBMT, Auditory Verbal Learning Test, AVLT) test results were mildly (RBMT) or moderately (AVTL) impaired in HS with left hippocampal lesions compared to normative controls. Patients with left HS were significantly worse than patients with right HS who were only slightly below the mean of the normative sample. In the test for nonverbal long-term memory (Rey-Osterrieth Complex Figure Test, ROCF) patients with right HS showed moderate impairment compared to normative samples and performed significantly poorer than patients with left HS. All other neuropsychological tests in HS showed mild impairment or results within the normal range. Discussion: Detailed neuropsychological testing revealed episodic long-term memory deficits in patients with HS. Consistent with previous knowledge left HS showed deficits in verbal and right HS in non-verbal episodic long term memory, which both should be considered in the evaluation of these patients.

http://www.eurostroke.org/ni_graphics/g_aid923.htm
 

Acute stroke: clinical patterns and practise
Date: Thursday 15 May 2008  
Time: 11:10 - 11:20 -  Room: Clio/Thalie
Chair: R. Baumgartner, Switzerland and A.P. Sigurdsson, Iceland

05
Withdrawn !
T.G.PHAN    A.F.FONG    G.A.DONNAN    V. SRIKANTH    D.C.REUTENS                                   
 

MIND

AUSTRALIA

Withdrawn

Acute stroke: clinical patterns and practise
Date: Thursday 15 May 2008  
Time: 11:20 - 11:30 -  Room: Clio/Thalie
Chair: R. Baumgartner, Switzerland and A.P. Sigurdsson, Iceland

06
Is the ischemic tolerance in the posterior circulation higher than in carotid territory?
J. Pagola    M. Ribo    J. Alvarez-Sabin    M. Rubiera    E. Santamarina    O. Maisterra    R. Delgado-Mederos    C.A.Molina              
 

Unitat Neurovascular Vall d'hebron, Barclona

SPAIN

Previous studies have suggested that ischemic tolerance in the posterior circulation might be superior that in the anterior territory. We aimed to verify this theory by comparing neurological recovery according to time of ischemia in stroke patients treated with tPA METHODS Intravenous tPA-treated acute stroke patients with documented middle cerebral artery (MCA) or basilar (BAS) occlusion were studied. TCD assessed recanalization at different time points. According to elapsed time of arterial occlusion, patients were divided in 3 groups: total time of ischemia 0-6 hours, 6-24 hours or >24 hours. In order to compare clinical evolution in both groups, neurological improvement was defined as the percentage of recovery at discharge according to baseline NIHSS. RESULTS Two hundred and twenty-three patients were studied: 196 MCA, 27 BAO occlusions. Mean time to treatment was longer in BAS patients (231 Vs 172 minutes; p=0.031). Early recanalization, within 2 hours after tPA bolus, was more frequent among MCA occlusions (41% Vs 29%; p=0.039), and delayed recanalization, 6-24 hours after bolus, more frequent among BAS occlusions (25% Vs 13%); rate of no recanalization at 24 hours was similar in both groups. Clinical recovery according to total time of ischemia was similar in each group: <6 hours of ischemia: (n=8)BAS recovered 84% - (n=82)ACM 69%; 6-24 ischemia hours: (n=7)BAS 63% - (n=26)ACM 61%; >24 ischemia hours (n=12)BAS -44% - (n=88)ACM 11% (p=0.23). A linear regression model showed that for each additional hour of ischemia ACM patients recovered -1.78% and BAS patients -1.76% (p=0.39). CONCLUSION Our data do not support the theory of increased tolerance to ischemia in the posterior circulation territory.