XVII. European Stroke Conference
Nice, France
XVII. European Stroke Conference
Nice, France
Poster Session: Acute stroke: clinical patterns and practise
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 3
02
Headache in stroke. Clinical features, related factors and outcome.
E. Palomeras
P. Fossas
A.T.Cano
P. Sanz
M. Floriach
Unit of Neurology. Hospital de Mataró
SPAIN
Background: Headache is present in 18-38% of acute strokes. There are few data about their clinical features. Predisposing factors, mechanism and prognostic value remain incompletely defined. Our aim is to determine the incidence of headache in acute stroke, their clinical features, factors related with it and implications for prognosis. Methods: Prospective series of 529 consecutive stroke patients. On admission they were asked to explain their symptoms. Patients were divided in 3 groups: Those who reported headache spontaneously (SH), those who referred headache after specific anamnesis (AH) and those who didn’t suffer from headache (NH). We compare stroke subtype, etiology, topography, severity of stroke and functional outcome in each group. Results: Headache was present in 33.2% of patients (SH: 15.6%, AH: 17.6%). It was defined as intense by 34.2%, it was bilateral in 76.5% and it lasted more than 24 hours in 42.5%. There were no differences in gender and age. Headache was more frequent in intracranial haemorrhages (IH) (p<0.001). Infarcts with cortical involvement (p<0.001) and vertebrobasilar infarcts (p: 0.004) were associated with headache. There were no differences in etiology. Mortality was higher in patients with headache. SH was associated with IH (p: 0.005), vertebrobasilar infarct (p: 0.03), cortical involvement (p:0.011), higher NIHSS score on admission (p: 0.003) and at discharge (p:0.01) and dependence for activities of daily life (p:0.008). Discussion: Headache was present in one third of stroke patients but half of them did not report spontaneously. IH, vertebrobasilar infarcts and cortical involvement were related to headache. If it was reported spontaneously, headache was associated to a worse outcome.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 3
03
Clinical presentation and outcome in basilar artery occlusion: results from the Basilar Artery International Cooperation Study (BASICS) registry
W.J.Schonewille
P. Michel
C.A.C.Wijman
C. Rueckert
C. Weimar
H.P.Mattle
S. Engelter
P.J.Lindsberg
A. Algra
L.J.Kappelle
on behalf of the BASICS study group
University Medical Center Utrecht
THE NETHERLANDS
Background Our limited knowledge on clinical presentation and outcome in basilar artery occlusion comes from small retrospective studies. Methods BASICS is a prospective, observational, multi-center, international registry of consecutive patients presenting with an acute symptomatic and radiologically confirmed basilar artery occlusion. Results From September 2002 until September 2007, 624 patients (mean age 64 years; range, 2 to 95 years; 63% male) with basilar artery occlusion were included. Eighteen percent had a prior TIA, 17% a prior stroke and 40% prodromal symptoms. Patients presented with TIA only (2%), fluctuating stroke (13%), progressive stroke (45%) or a maximum deficit from onset (38%). Sixty percent were comatose, locked-in or tetraplegic. The occlusion was located in the proximal (44%), middle (24%) or distal basilar artery (33%). The presumed aetiology was embolic (37%), atherosclerotic (35%) or dissection (5%) or unknown (23%). Patients were treated with antithrombotics (30%), intravenous (IV) thrombolysis (13%), IV and intra-arterial (IA) therapy (7%) or IA therapy alone (47%). Thirty percent had a good outcome defined as a modified Rankin score of 0 – 3 at one month. Mortality was 38%. Age < 70 years, distal occlusion, minor stroke, and basilar artery patency on follow-up were significant predictors of good outcome on univariate analysis. Prior stroke, and acute ischemic changes on CT scan prior to treatment were significant predictors of poor outcome. Conclusion The clinical presentation of basilar artery occlusion is highly variable. Despite recent advances in acute stroke care basilar artery occlusion is still associated with a poor outcome in the majority of patients.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 3
04
Impact of screening methods on time-to-treatment and clinical outcome in thrombolysis within 3 hours after stroke onset
S.H.Yoo
A.H.Cho
K.H.Cho
E.K.Kim
S.U.Kwon
J.Y.Koh
J.S.Kim
D.W.Kang
nane
SOUTH KOREA
Background and Purpose :Although multimodal MRI may be an effective screening tool for patient selection in thrombolysis, there is still a concern that MRI screening may delay time-to-treatment and thereby lead to bad outcomes. In this study, we sought to investigate the impact of screening method on time-to-treatment and clinical outcome in patients receiving thrombolysis within 3-hour. Methods :We reviewed acute stroke patients who received intravenous tissue plasminogen activator (tPA) with or without intra-arterial urokinase within 3 hours between March 2004 and March 2007. MRI was a routine screening imaging from March 2004 to November 2005. Thereafter, CT plus MRI screening was performed.: tPA of 0.6mg/kg was infused intravenously after CT screening, and further thrombolysis decision (i.e., intravenous tPA of 0.3mg/kg, or intra-arterial urokinase) was made after MRI screening. We compared time-to-treatment, symptomatic hemorrhage, and 3-month clinical outcome between screening imaging modalities, and also identified factors associated with clinical good outcome by multiple logistic regression analysis. Results : Eighty-nine patients were included for analysis: 43 were MRI screening group, and 46 CT plus MRI screening group. General characteristics, risk factors, and stroke severity were not significantly different between two groups. In MRI screening group, although door-to-needle time (p<0.001) and onset-to-needle time (p=0.003) were significantly longer, 3-month good outcome (mRS ≤ 2) was more frequent (p=0.01). Multivariate analysis also showed that MRI screening (odds ratio 3.97, 95% confidence interval 1.30-12.17, p=0.02) was independently associated with 3-month good outcome, after adjustment of age, diabetes, and baseline NIHSS score. Conclusions :These results suggest that patient selection may be more important than reducing time-to-treatment to improve clinical outcome after thrombolysis. Future prospective randomized comparison studies between screening imaging modalities will be required to confirm this observation.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 3
05
Evaluation of biochemical markers as a diagnostic tool for cerebral ischemia.
K. Knauer
H.P.Müller
R. Huber
University of Ulm
GERMANY
Background:Although sensitivity of CT for detection of cerebral ischemia is poor in hyperacute phase, it`s still the primary imaging technique. In this context, biochemical markers gain in importance. Triage® Stroke Panel detects concentrations of brain natriuretic peptide (BNP), d-dimers, matrix-metalloproteinase-9 (MMP-9), S100B and an index of all values (MMX). The aim of our investigation was to prove, whether this panel could enhance diagnostic reliability and differentiate between ischemic stroke patients and patients with stroke imitating diseases (mimics). Methods:We investigated N=174 patients (N=100 strokes,N=49 mimics,N=25 TIA`s) admitted to stroke unit at university hospital of neurology in Ulm between 04/2005 and 04/2006. Blood collection and clinical diagnostics happened within a time-frame of 6 hours from symptom onset. Values of biochemical marker were obtained by Sandwich-Fluorescence-Immunoassays using Triage® Stroke Panels. N=95 stroke patients, N=44 mimics patients and N=25 TIA patients got magnet resonance imaging. Lesion sizes of strokes where measured by an own developed volumetric software. Results:BNP levels were higher in stroke patients compared to mimics (p=0,02). Patients with cardio-embolic strokes had higher levels for BNP and MMX (p=0,0001 and 0,02). MMP 9 levels were similar in all subgroups. No statistics were performed for S100B as only N=4 reached lower measuring range. Levels for BNP, D-Dimers and MMX increased age-related (p<0,0001). Correlation with the clinical status (NIHSS) was found for D-Dimers and MMX (p=0,001). Discussion:Although some of the tested markers may be useful in subgroups of stroke patients, neither one marker nor combination of all markers are of significant benefit for diagnostic purposes in acute ischemic stroke.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 3
06
Diffusion-Weighted Imaging(DWI) Patterns of Cerebral Infarction in Patients with Malignancy
M.S.Park
I.K.Kim
J.T.Kim
S.H.Lee
S.M.Choi
M.K.Kim
K.H.Cho
Chonnam National University Hospital
SOUTH KOREA
Background: The pathogenesis of cerebral infarction in malignancy is complex and not yet completely understood. A hypercoagulable state, non bacterial thrombotic endocarditis and thrombotic arterial microangiopathy may be important causes of cerebral infarction in malignancy. The purpose of this study is to describe the diffusion-weighted imaging (DWI) patterns of cerebral infarction in patients with malignancy. Methods: We analyzed 28 patients with cerebral infarction in malignancy. We reviewed medical records and retrospectively analyzed the DWI scans in all patients. The presence, size, number, and location of all hyperintense lesions in the DWI were analyzed. Results: We classified the DWI lesions into 4 patterns; (1) single middle to large sized lesion, 3 cases(10.7%), (2) single small sized lesion, 5 cases(17.9%), (3) multiple lesions in single arterial territory, 10 cases(35.7%), (4) multiple disseminated lesions, 10 cases(35.7%). Single lesions were present on 8 scans(28.6%) and multiple DWI lesions were present on 20 scans(71.4%). All patients with multiple lesions had at least 2 more small lesions. Conclusion: Cerebral infarction in malignancy usually have multiple and variable sized (especially small size) lesions. DWI patterns could provide some clues to detect malignancy when etiology of cerebral infarction is ambiguous.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 3
07
Towards a basic endoscopic assessment of swallowing in acute stroke – development and evaluation of a simple dysphagia score
T. Warnecke
S. Oelenberg
I. Teismann
J. Zimmermann
C. Krämer
M. Ritter
E.B.Ringelstein
W.R.Schäbitz
R. Dziewas
University Hospital of Münster
GERMANY
Background: Dysphagia is an important complication of acute stroke with a reported incidence of up to 78%. The purpose of this study was to develop and evaluate an endoscopic scoring system, which has the potential to guide dysphagia management in acute stroke patients. Methods: A fiberoptic endoscopic evaluation of swallowing (FEES) was carried out in 100 patients within 72 hours of stroke onset. During endoscopic examination, the secretion status was evaluated, and the patient was successively given standard volumes of puree consistency, liquids and soft solid food. Penetration and aspiration was assessed using a 5-point scale. Results: Nearly 80% of patients showed penetration or aspiration during FEES. These events occurred more frequently with liquids and soft solid food than with puree. Penetration or aspiration at any stage of examination predicted failure at the subsequent food consistency. Furthermore, key findings of endoscopic evaluation were predictive of the need for later orotracheal intubation. Based on these observations a 6 point score was developed that grades stroke-related dysphagia according to the risk of penetration or aspiration of the different food consistencies tested and helps to guide appropriate protective and rehabilitative measures. Assessment of inter-rater reliability by means of 25 additional endoscopic examinations resulted in excellent agreement between three investigators, reflected by a kappa-coefficient of 0.89. Discussion: Stroke-related dysphagia may effectively be graded using a simple endoscopic scoring system. The usefulness of this screening protocol with respect to patient outcome and intercurrent complications has to be studied in prospective clinical trials.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 3
08
Comparison of five stroke identification instruments in distinguishing stroke from non stroke
D. Tryambake
A. Mohd Nor
G.A.Ford
Newcastle University
UNITED KINGDOM
Introduction: Early diagnosis is crucial in order to initiate early and effective treatment for acute stroke patients. A number of clinical diagnostic instruments have been developed to assist in identification of stroke in the pre-hospital setting (CPSS, FAST, LAPSS, MASS) and in the ER (ROSIER). The diagnostic performance of these 5 instruments was compared in all patients with suspected stroke from a population of 300,000 admitted to a single stroke service. Methods: Data were prospectively collected over 21 months on 1596 patients referred to Newcastle Hospitals with suspected stroke. Clinical signs and symptoms were recorded by a research neurologist. All patients with suspected stroke after admitting medical assessment underwent brain imaging. Final diagnosis of stroke was made by a stroke specialist. We applied the five stroke scales to all patients to determine sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). Results: ROSIER had the highest sensitivity (94%) and NPV (91%) whereas LAPSS and MASS had the highest specificity (both 97%) and PPV (both 97%). Brain tumour, seizure, neuropathy and subdural haematoma were most common conditions misdiagnosed as stroke by ROSIER, FAST and CPSS whereas MASS and LAPSS excluded most of these. Migraine, somatisation and subarachnoid haemorrhage were misdiagnosed as stroke by all scales. Conclusion: If the main requirement of a stroke diagnostic scale is to identify most patients with stroke ROSIER performs best. If the main aim is to ensure high specificity for pre-hospital administered therapy MASS has the best performance. The differing complexity and ease of eliciting clinical symptoms and signs need to be taken into account in instrument selection.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 3
09
The clinical study of thrombolysis with rt-PA 50mg intravenous in acute ischemic stroke within 6 hours of onset
F. Feng Wang
Dan Xu
Hao Duan
Bin Zhang
Shanghai Jiaotong University
CHINA
Background:A randomized controlled trial of recombinant tissue plasminogen activator(rt-PA) in Chinese people demonstrated that intravenous rt-PA was beneficial for acute ischemic stroke patients within 6 hours of onset and a lower dosage of 0.7mg/kg was suitable for Chinese.In Japanese patients receiving 0.6mg/kg alteplase,the outcome and the incidence of sICH were comparable to published data for 0.9mg/kg. Based on previous studies,we performed a clinical trial with 50mg of rt-PA for each patient within 6 hours of onset,aming to assess the efficacy and safety of alteplase in acute ischemic stroke for the Chinese. Methods:84 patients within 6 hours after the onset of stroke were enrolled in our prospective,single-arm,open-label trial.The primary end points were the proportion of patients with a modified Rankin Scale(mRS) score of 0 to 1 at 3 months、the incidence of symptomatic intracranial hemorrhage(sICH) within 36 hours and the mortality in 3 months.The protocol was defined according to the National Institute of Neurological Disorders and Stroke(NINDS) rt-PA stroke study with slight modifications. Results: Twenty-nine (34.5%) patients treated were female.The mean age was 66+/-11 years,ranging from 38 to 81.The mean time from onset to treatment was 3.6+/-1.2 hours.The average body weight is 64.28+/-10.45 kg,and the range of the dosage that given to the patient is from 0.5882mg/kg to 0.9417mg/kg.Among the 84 patients enrolled,48 had an mRS of 0 to 1 at 3 months and 5 patients occurred sICH within 36 hours.10 patiens died in 3 months. Discusion:In patients receiving 50mg of alteplase within 6 hours of onset,the findings might offer a clinical efficacy and safety that are compatible with data reported in North America and the European Union for a 0.9mg/kg dose.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 3
10
Cortical Findings on NIHSS Predict Cortical Strokes and May Select Candidates for Neuroprotective Trials
S. Martin-Schild
M.M. Morales
A. D.Barreto
H. Hallevi
A. Abraham
M. R.Sline
J.C.Grotta
S.I. Savitz
UT- Houston Health Sciences Center
USA
Background: Neuroprotective agents reduce damage in the cortical penumbra. Penumbral imaging delays treatment and is impractical at community hospitals. We sought to determine the predictive value of cortical findings on the NIHSS for cortical strokes on MRI. Methods: 194 patients treated with IV t-PA within 3 hours of symptom onset over the last 3.5 years had DWI imaging revealing a stroke. We reviewed each MRI for the location of the DWI lesion. We challenged the total NIHSS score, presence of any abnormal cortical finding, cortical score (total points for abnormal cortical findings on NIHSS), and individual cortical findings on the NIHSS for their predictive value of a final cortical DWI lesion. Results: Cortical findings were present in 159/194 (82%) patients and 139/194 (71%) had a DWI lesion in the cortex. The median NIHSS was 12. The total NIHSS score did not reach a >80% PPV for a cortical DWI lesion until a score of ≥12 points. The presence of any abnormal cortical sign yielded a PPV of 81%, with increasing PPV for increasing severity. The presence of any two or more cortical signs increased the PPV to 88%. A total cortical score of ≥2 (range 0-10) yielded a PPV of 88% and would miss <20% of target subjects. Discussion: In our population, a total cortical score of >/=2 yielded the best combination of sensitivity, specificity, and PPV for identifying cortical strokes. If pre-enrollment penumbral imaging is not feasible or significantly delays treatment, the total cortical score might be used to identify target patients for neuroprotection with reasonable accuracy.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 3
11
Comparison of thrombolysis treatment in SITS and the English Royal College of Physicians Audit databases
G.A.Ford
A.G.Rudd
K.R.Lees
A. Hoffman
Newcastle University and Royal College of Physicians
UNITED KINGDOM
Background: The SITS-MOST study examined the safety of iv thrombolysis and outcomes of patients treated following provisional EMEA licensing. A condition of licensing was that details of treated patients, but not thrombolysis trial participants, were recorded in the SITS database. The extent to which patients were included from active centres in SITS is important in understanding any possible bias in the SITS results. Methods: We determined the extent of agreement in thrombolysis treatment rates in England and Wales between the SITS database and the Royal College of Physicians (RCP) Audit from April 06 to March 07. Active centres were identified from both databases. We compared the number of patients registered in SITS and the number recorded in the RCP Audit. Results: In the RCP Audit 28 sites, all in England, recorded 215 treated patients (range 1-22, mean 8). SITS had data on 151 patients from 23 sites (range 1-21, mean 7). All 23 sites recorded treatment in the RCP Audit; total 197 patients. Five sites not entering patients in SITS recorded treating 22 patients (range 1-10). Agreement between treatment numbers was good in 16 of the 23 SITS sites (identical n=8, +/-1 n=3, +/-2 n=5 sites). The remaining 7 sites recorded 66 treated patients compared to 30 SITS entries. Discussion with these sites indicated entry of trial and intra-arterial cases accounted for the difference in 3 of these sites. Discussion: In 2006/07 less than 0.2% of acute stroke patients in England were treated with thrombolysis. Most centres and all centres treating >10 patients/year fulfilled the regulatory requirement to record cases in the SITS database. In reporting centres agreement between reported treatments in the RCP audit and patient entries on SITS was good suggesting inclusion of patients on SITS was systematic and comprehensive.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 3
12
Early anti-platelet administration in ischaemic stroke saves lives
S. Ghosh
M. Hair
R. Cottrell
E. Barrie
S.K.Ghosh
The Ayr Hospital
UNITED KINGDOM
INTRODUCTION: Anti-platelet therapy in ischaemic stroke is known to be beneficial. METHODS: We wanted to find out if there was any survival benefit of early introduction of anti-platelet therapy following stroke. We used our stroke database to obtain details of all patients with ischaemic stroke who received anti-platelet therapy who were admitted between 1st January 2003 and 31st March 2007. We used the electronic prescribing database to document the time interval between admission and administration of anti-platelet agent. We used SPSS 15 to analyse the data obtained. RESULTS: 715 patients (50.9% males, 49.1% females), with mean age of 74.5 years were included. 104 patients died (14.6%). The mean time to medication was 79.7 hours. The mortality of patients became significantly different if they received antiplatelet after 96 hours following stroke as compared to those who received antiplatelet within 96 hours. Mortality within 96 hours was 10.6% (58/545), whereas it was 27.5% (46/167) in those who received antiplatelet beyond 96 hours. (Odds ratio was 3.19 & gamma=0.52). Logistic regression model using mortality as the dependent variable and time to medication, Barthel score and type of stroke as independent variables suggest that there was still a time to medication effect. CONCLUSIONS: Those who received anti-platelet treatment after 96 hours were 3.19 times more likely to die as compared to those who received treatment within 96 hours. Early antiplatelet therapy increases chance of survival regardless of the type of stroke and severity. Mortality increases with delay in introduction of anti-platelet agent and becomes significantly higher from 96 hours onwards.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 3
13
Effect of weekday, daytime or treatment year on thrombolytic treatment and outcome in acute stroke patients as indicator for quality of acute stroke treatment
M. Jauss
J. Allendoerfer
M. Sitzer
W. Oertel
H. Hamer
B. Misselweitz
University Hospital
Philips University of Marburg
GERMANY
Background and Purpose: Previous observational reports describe a more severe outcome for stroke patients admitted during weekends, doubts were raised, if a challenging medical procedure such as acute stroke treatment including thrombolysis with recombinant tissue plasminogen activator (rTPA) is available with the identical standard and outcome 24 hours and 7 days a week. Methods: We analyzed the subgroup of acute stroke admitted within 3 hours (n=8764), from a large state wide prospective stroke registry, 1406 actually received thrombolytic treatment with rTPA. Daytime, weekday and year (2003 vs. 2006) were compared. Results: Rate of thrombolysis was unaffected by time of day or day of the week. Patients showed the same rate of intracranial hemorrhage and clinical improvement regardless of time of day or day of the week or year. Comparison of 2003 with 2006 revealed secular trend for increase of patients with premorbid independent state at home, less motor deficits or disturbance of consciousness and a higher proportion of patients in good clinical state and a significant decrease of risk factors and concomitant diseases. Treatment success in terms of clinical improvement, good clinical state at discharge and lack of mortality and complications improved significantly from 2003 to 2006, with subsequent higher rate of discharge from hospital to home residence. From 2003 until 2006 proportion of patients treated with rTPA increased from 164 (8.9%) to 487 (21.8%). Logistic regression modeling the probability of clinical improvement during hospital stay revealed rtPA treatment as the only significant predictor for improvement, OR 1.19 [1.05-1.33]. Discussion: Supply of stroke treatment for potential candidates for thrombolytic therapy was on high level with no flaws on weekend or night. During 4 years it was possible to increase rate of rTPA treatment without increment of complications or death, confirming, that rTPA is save and can be implemented with full daily and weekly coverage.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 3
14
Pericallosal artery Stroke – Clinical spectrum and MRI Patterns of an SMA syndrome
A. Alonso
A. Gass
A. Förster
R. Kern
M. Griebe
J. Binder
M.G.Hennerici
K. Szabo
Department of Neurology, Universitätsklinikum Mannheim, University of Heidelberg
GERMANY
Background. Anterior cerebral artery (ACA) stroke accounts for about 3% of strokes. Subject to the affected ACA branches, different clinical patterns can be defined. We report clinical and MRI findings of isolated pericallosal (PC) artery stroke. Methods. From our stroke unit data bank 26 consecutive patients with isolated PC artery territory infarctions (12 left-sided, 13 right-sided, 1 bilateral) were analyzed. In all patients, a standardized stroke MRI protocol was performed. Results. Complete PC artery stroke extending from the olfactory tract to the corpus callosum (CC) and the superior frontal gyrus (SFG) was observed in 3/26 patients. Most patients (17/26) showed partial infarctions predominantly involving the SFG and CC. A different pattern with multiple small PC territory lesions was detected in 6/26. In 2/6 lesions were distributed randomly within the PC territory, while 4/26 showed a borderzone location of lesions, possibly indicating a hemodynamic mechanism. Core symptom of PC stroke was a contralateral hemiparesis with lower limb predominance (21/26). However, motor evoked potentials (13/21) in paretic patients were abnormal in only 2/13 (with lesions affecting the precentral gyrus). Visual or motor hemineglect was confined to 3/26 with right-sided stroke. Further characteristic symptoms were confusional state (n=4), psychomotor slowing (n=8), often associated with speech disturbances e.g. decreased verbal fluency. Conclusion. Patients with PC stroke mainly present with lower limb-dominant hemiparesis due to affection of the supplementary motor area (SMA) while the corticospinal tract usually remains intact. On MRI PC ischemia mostly results in partial territorial stroke; however multiple lesions suggest embolic/hemodynamic watershed patterns.
http://www.eurostroke.org/ni_graphics/g_aid523.htm
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 3
15
HEPARIN WITH rT-PA : TIME FOR A REAPPRAISAL IN SPECIFIC CONDITIONS (REVIEW)
P. TROUILLAS
Cerebrovascular Unit, Hôpital Neurologique, Claude Bernard University, Lyon, FRANCE
FRANCE
The main problems of intravascular thrombolysis - intravenous or intraarterial – consists in its limited clot dissolving efficiency, in a possible rethrombosis of the artery and in the occurrence of hemorrhagic lesions. The patency/hemorrhagic ratio is the great issue of thrombolysis in general, and of cerebral thrombolysis in particular. Thrombolytic agents – especially rt-PA- have collateral pro-thrombotic effects, mainly due to the activation and generation of thrombin. Thus, the rationale for an adjunctive heparin treatment exists. In cardiology, the question of the synergistic effect of heparin is no more discussed in ST elevation Myocardial infarction (MI). Thus, heparin appears as a kind of obliged companion of the thrombolytic drug. In cerebral infarct thrombolysis, the role of heparin is more subject to controversy. Heparin is forbidden during the 24 first hours in intravenous cerebral thrombolysis guidelines, while it is used in these 24 hours in many intra-arterial protocols, at various doses. We give here the main data of the literature that could lead to a rational reappraisal of the use of heparin in the neurological thrombolytic field, with a specific timing. In the cardiological literature, an aPTT of 60 seconds at 12 hours and 24 hours is a factor of good prognosis and of decreased hemorrhagic risk (GUSTO I and GUSTO IIb). These data are in keeping with the results of the LYON rt-PA protocol in cerebral intravenous thrombolysis, that suggested an improved outcome with intravenous heparin at 24 hours after anon hemorrhagic CT Scan, with an aPTT aim of 45 seconds. Thus, arguments exist to advise a delayed phase of decoagulation, especially at 24 hours, after intravenous cerebral thrombolysis. The dose should not be predetermined, but strictly based on an aim of aPTT, preferentially 45s, not beyond 60s. Ban of immediate bolus and strict aPTT surveyance should also be applied to intra-arterial thrombolysis. A clarification between the time of initiation of heparin (“heparin window”) and the duration of the heparin regimen is proposed.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 3
16
PRACTISE: Promoting Acute Thrombolysis for Ischaemic Stroke. A cluster-randomised trial of high intensity versus regular intensity implementation.
M. Dirks
L.W.Niessen
J.D. van Wijngaarden
H.F.Lingsma
P.J.Koudstaal
R.J.van Oostenbrugge
C.L.Franke
D.W.J.Dippel
on behalf of the PRACTISE investigators
Erasmus MC
THE NETHERLANDS
Background: Various barriers are hampering broad implementation of intravenous thrombolysis for acute ischaemic stroke. The aim of this study was to evaluate the effect of a high intensity compared with regular intensity implementation strategy to promote thrombolysis. The intervention consisted of training- and feed-back sessions according to the Breakthrough model. Methods: The PRACTISE study is a national cluster-randomised controlled trial, 12 hospitals participated. Data were collected of all patients over 18 admitted within 24 hours from onset of symptoms with acute stroke. The primary outcome was treatment with thrombolysis or not. Data were analysed with a multi-level logistic regression model. Results: Of the 5517 patients included in the study, 2284 (41.4%) were admitted within 4 hours and 712 (12.9%) were treated with thrombolysis. Data acquisition lasted for 2 years, 1 of the 6 intervention hospitals dropped out of the intervention halfway, but data-collection continued. The average proportion of patients receiving thrombolysis was 11.8% in the non-intervention and 15.3% in the intervention centres. The odds-ratio for receiving thrombolysis in the intervention group was 1.8 (95% CI 1.2 – 2.8) after adjustment for centre and patient characteristics. This increase in thrombolysis rate was accompanied by a statistically non-significant increase in symptomatic intracranial bleeding complications (4.6 % versus 5.6 %). Discussion: A high-intensity multi-dimensional implementation strategy aimed at resolving barriers for the delivery of thrombolysis in stroke increases the proportion of patients treated with thrombolysis. Further analyses are needed to investigate the effect on patient outcomes, and to identify particularly effective components of the intervention.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 3
17
The inaugural Australian national audit of acute hospital services: determining adherence to clinical recommendations with Level 1 evidence.
D.A.Cadilhac
G. Hankey
D . Harris
S. Hillier
M. Kilkenny
E. Lalor
National Stroke Foundation
AUSTRALIA
Background: Australian clinical guidelines for acute stroke were produced in 2003. How well these guidelines have been implemented has been unclear, particularly adherence to recommendations for care based on Level 1 evidence. The aim of this analysis was to assess adherence to Level 1 recommendations: eg access to stroke units (SU); and if ischaemic stroke, the use of intravenous thrombolysis (within 3 hours) and administration of aspirin (within 48 hours). Methods: Hospitals were invited to participate via letter. Sites were recruited between 1 November 2006 and 23 June 2007. Clinicians at participating sites completed a survey about the available services (Organizational Survey), and if able, conducted a retrospective audit of 40 patient case notes admitted between 1 October 2006 and 31 March 2007 (Clinical Audit). A National Advisory Committee developed both instruments. Results: 254 hospitals completed the Organizational Survey; 54 sites had a SU (21%). Subsequently, 89 hospitals (estimated as providing 68% of inpatient stroke care) participated in the Clinical Audit. Of these, 49 (54%) had a stroke unit. In total, 2,724 case notes were audited, 52% were male; median age 76 years. Adherence to Level 1 recommendations was variable. SU care was received by 50% of cases and in those with ischemic stroke, 92% received aspirin within 48 hours and 3% of eligible cases received intravenous thrombolysis. Conclusions: Analysis of the audit program data has provided insights into how Level 1 evidence is applied in Australia. Such audits permit comparisons across time and between countries. Although about 50% of patients received SU care, this is less than the United Kingdom (62%) and Scandinavian countries (~75%). The results will provide a basis for developing action plans to improve clinical practice and to demonstrate improvements over time. A key focus for action will be to improve rates for SU access to levels similar to other countries.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 3
19
Upgrading an ambulance service response policy to acute stroke in Ireland - impact on patient transport times.
L. Brewer
B. Whelan
R. Morton
P. Oman
P. Marsden
R. Lynch
C. Fallon
S. Murphy
Midland Regional Hospital
Mullingar, Co.Westmeath, Ireland
IRELAND
Background: Rapid ambulance response times are an essential element in the quest to improve clinical outcomes for patients with acute stroke. The HSE Dublin Mid-Leinster Ambulance Service in Ireland, one of 8 regional ambulance services, was the first to decree in November 2006, that all future calls for stroke should be given the highest response rating. The impact of this policy change on stroke patient transport times to hospital in a semi-rural setting is the subject of this report. Methods: Utilising Ambulance Service computerised records we ascertained the time interval from initial telephone request for hospital transport to arrival in the acute hospital (total response time) for all patients with possible acute stroke during January to May 2006 (pre policy change) compared with the same period in 2007 (post policy change). Response times for both 999 and non-999 calls were compared. Results: For 999 calls, as expected, there was no difference in total response time between 2006 and 2007 (62.8 vs 61.6 minutes; p>0.05). For non-999 calls, there was a statistically significant 18% reduction in total response time (70.6 vs 85.8 minutes; p<0.05) in 2007 compared with 2006. The differences in time to allocation of ambulance (6.9 vs 15.8 minutes) and time from ambulance being mobile to arrival at scene (18.6 vs 23.2 minutes) were both significantly shorter in 2007 compared with 2006 (both p<0.05). Discussion: The Ambulance Service policy change to give the highest priority rating to calls for acute stroke was initiated by the Stroke Service but was only made possible by the very positive involvement of colleagues in the Ambulance Service and Emergency Medicine Departments. The resulting faster transportation time of acute stroke patients to hospital was both clinically and statistically significant. This initiative should be rolled out across Ireland.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 3
20
Novel Approaches to Stroke Education: Internet-Supported Distance Learning for Acute Stroke Management with On-Site Clinical Skills Validation
A.W. Alexandrov
T. Baca
S. DiBiase
A.V.Alexandrov
For the NET SMART Clinical Education Consortium
University of Alabama - Birmingham
USA
Background: Despite increasing recognition of stroke as a major healthcare burden, only 2-3% receive iv tPA in US. Poor hospital organization and shortages of vascular neurologists, emergency physicians, and nurses contribute to inadequate treatment. Methods: We developed a novel, federally-funded, internet-based fellowship program called NETSMART (Neurovascular Education & Training in Stroke Management & Acute Reperfusion Therapies) to improve access to stroke education for heath-professionals. The program consists of 19 modules (approximately 150 hours) on various aspects of acute stroke diagnosis and management; each module is supported by clinical skills training requirements (approximately 800 hours) and post-tests (40 hours). Remote real-time internet and phone consultation is offered for fellows with limited local support. Once all modules are completed, fellows complete a 2-week, onsite clinical validation of their competencies in diagnosis and management at our center and other participating major teaching Stroke Centers. Ongoing assessment of fellows' stroke practice is conducted over the next two years. Results: The first cohort of 25 NETSMART Fellows were enrolled in December 2007 from 21 US states. Ongoing enrollment is open, enabling additional fellows to join. Of the first fellow cohort, 96% have never administered thrombolysis for acute stroke due to: 1) lack of expertise/training at local practice site; or, 2) no local neurologist to support or mentor. Metrics for knowledge and skills competency are being collected and will be presented. Conclusions: Acute stroke care, especially in areas with fewer specialized practicioners, will not advance unless novel training resources are provided to those seeking knowledge about stroke. NET SMART offers a realistic training option likely to develop more safe, evidence-based acute stroke clinicians. Partnership with international collaborating centers is underway to promote world-wide expansion of acute stroke training resources.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 3
21
Geographic Differences in Acute Stroke Care in Catalunya: Impact of a regional Inter-Hospital Network.
M. Ribo
C.A.Molina
M. Rubiera
M. Quintana
E. Santamarina
O. Maisterra
R. Delgado-Mederos
J. Alvarez-Sabin
Unitat Neurovascular Vall d'Hebron
SPAIN
Limited resources avoid availability of specialized care in community hospitals(ComH) challenging geographical equity. We studied the impact of a regional inter-hospital network based on urgent transfer from 4 ComH to a referral stroke center(RefSC). Methods During 2006 all stroke patients admitted to 5 networked hospitals (4 ComH, 1 RefSC) were studied: clinical pathways and stroke interventions recorded. Physicians at ComH decided emergent transfer under their clinical judgment. Quality therapeutic measures where defined: urgent stroke-neurologist evaluation, Stroke Unit admission and thrombolytic treatment. For patients receiving tPA, demographic and outcome data were recorded: Clinical improvement (decrease>=4 NIHSS points at discharge), total recovery(three months mRS<=1) Results 1925 acute stroke patients were admitted to RefSC (1396 primaily). Of 529 primarily admitted to ComH 191(36.1%) were emergently transferred. Patients primarily admitted to RefSC were more frequently evaluated by neurologist (100%Vs34%; p<0.001) and admitted to Stroke Unit(22.7%Vs11.7%; p<0.001). However the rate of thrombolytic treatment was similar (4.4%Vs5.1%;p=0.491). After initial assessment at RefSC 92(48.2%) transfers were considered unnecessary. Transferred patients accounted for 27/88 (30.7%) thrombolysis performed in RefSC. Baseline characteristics were similar, except longer time-to-treatment (164Vs211 min;p=0.004) and more frequent early ischemia CT-signs among transferred patients(23%Vs53%;p=0.037). Clinical improvement (62% Vs 50%;p=0.273 ) and symptomatic hemorrhagic transformation (6.8% Vs 3.8%;p=0.596) were similar. However among transferred patients the degree of total recovery was lower (44% Vs 22%; p=0.05) Conclusion An inter-hospital network based on transfers to RefSC does not warrant geographical equity: equal access to best therapeutic interventions is only partially achieved at the expense of high unnecessary transfers.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 3
22
Identification of Stroke Mimics In the Emergency Department Setting
W.O.Tobin
B.J.Bobrow
J. Hentz
B.M.Demaerschalk
Mayo Clinic, 13400 E Shea Blvd, Scottsdale, AZ 85259 , USA
IRELAND
Objective: Development of a clinical prediction model to identify stroke mimics. Background: Thrombolysis is an established therapy for acute ischaemic stroke, requiring identification of potential stroke, clinical assessment and all within a three hour treatment window. Previous studies have shown a stroke mimic rate of 9-19%. Identification of stroke mimics could allow more targeted therapy. Methods: Stroke alerts were identified from July 2005 to March 2006 in a primary stroke center. 31 clinical variables were identified by chart review. Final diagnosis was defined as the most probable diagnosis at discharge, or if necessary on further follow up. Multivariable regression analysis was used to define clinical predictors of stroke mimic. Results: 196 patients presented with stroke alert status during the study period. 22 percent were classified as stroke mimics (95% CI = 17% to 29%). The strongest predictor of a stroke mimic was the absence of initial lateralizing signs. 43% (32/74) of patients without initial lateralizing signs were stroke mimics; while only 10% (12/122) of those with initial lateralizing signs were stoke mimics. The absence of initial lateralizing signs, having a history of Stroke/TIA, and low diastolic blood pressure(<55mmhg), were independently related to being classified as a stroke mimic. These criteria resulted in <1% of stroke cases being misclassified as mimics, but also only identified 7% of the mimics. Patients with these criteria had a 75% chance of being a mimic while patients who did not had a 21% chance of being a mimic. Conclusions: The absence of lateralising signs, low diastolic blood pressure and a history of stroke/TIA were strong positive predictors of stroke mimic. The formula SCORE = 1.399 1.971 LAT + 0.928 stroke/TIA 0.025 DBP predicts stroke mimic with a sensitivity and specificity of 7% and 99% respectively (LAT=lateralizing signs 0=no 1=yes, stroke/TIA=history of stroke/TIA 0=no 1=yes, DBP=diastolic blood pressure in mmHg).
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 3
23
Evaluation of a 2-years activity of fibrinolysis for ischemic stroke in a French general hospital
A. Niclot
F. Yekhleff
S. Descombes
J. Richecoeur
A. Alnajjar
J. Servan
Unité Neurovasculaire, centre hospitalier René Dubos PONTOISE, FRANCE
FRANCE
Introduction : Fibrinolysis of cerebral infarct with intravenous t-PA is effective in our hospital since 11/2005. We present the results of the first two years of activity. Method : A primary stroke centre has been established in our hospital since 11/05. All patients treated by intravenous tPA for ischemic stroke have been included in a prospective registry. NIHSS score, delays of treatment, complications and evolution of Rankin score at three months have been collected. Comparison of means has been made with t-test. Results : During 24 months, 72 patients have been treated with IV t-PA (first year : 25 ; second year : 47). Mean delay of treatment is 152 min ; extra-hospital delay is 89 min and intra-hospital delay is 63 min. Nine patients (13%) have been treated before 120 min. During the first year, we have observed excessive delays to get the haemostatic results. After a meeting with haematologists and laboratory technicians, in 12/06, the procedure has changed : haemostatic samples are now identified by a distinctive mark and the results are directly communicated to the neurologist by the laboratory technician. Since 12/06, intra-hospital delay has been reduced from 67 min to 56 min (p<0,05) and total delay of treatment form de 155 to 145 min (p<0,05). Five complications has been observed : 1 cerebral hemorrhage (1,4%), 1 systemic hemorrhage (1,4%) and 3 allergic reaction (4%). 64 patients have been evaluated at three months : 41% had Rankin score 0-1 ; 9% were dead. Conclusion : The number of patients treated with tPA has enhanced during two years. The door-to-needle time has been reduced of 10 minutes and is now below 1 hour. The proportion of patients treated before 2 hours remains insufficient and could be by optimization of the extra-hospital delays.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 3
24
MEDIAL MEDULLARY INFARCTION: 12 CASES
F.I.ESEN
N. YEŞİLOT
N. BEBEK
O. ÇOBAN
S. ZARKO BAHAR
R. TUNCAY
Istanbul University, İstanbul Medical School, Edip Aktin
TURKEY
Background: Medial medullary infarction (MMI) is a rare type of posterior circulation stroke characterized by ipsilateral hypoglossal nerve palsy, contralateral hemiparesis sparing the face and disturbance of deep sensation. MMI is more frequent than previously thought and the classical clinical picture is rare. Methods: We studied 12 cases (8 male, 4 female, mean age 58 ± SD) with MMI diagnosed on MRI among 2333 consecutive patients with stroke registered in İstanbul Medical School Stroke Registry between 1994-2007. Routine laboratory examinations, electrocardiography and transthoracic echocardiography were performed in all, intracranial MR angiography in 8, Doppler Ultrasonography in 2 and cerebral angiography in 2 patients. Clinical findings, risk factors, etiology and prognosis were analyzed. Results: The infarcts were unilateral in 10 and bilateral in 2 patients. Three patients had concurrent lateral medullary infarction (LMI). Classical Dejerine’s syndrome was not detected in any patient. The major syndrome was contralateral sensorimotor hemiparesis. Vibration sense was decreased in 11, position sense was impaired in 5 patients. Hypoglossal palsy was rare, only seen in 2 patients with bilateral MMI and one patient with concurrent LMI. Only one patient with bilateral MMI suffered respiratory difficulties. The predominant etiological type was large artery atherosclerosis seen in 7 patiens, vertebral artery dissection in one and cardioembolism in one patient. Follow-up for six months showed that the outcome was generally poor, only 4 patients had no limitations of daily activities. Conclusions: The classical triad of MMI is rare, and makes it difficult to identify MMI based on clinical manifestations. MRI allows a clear identification of the ischemic infarction and should be done for correct diagnosis.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 3
25
CITOKINES, SELECTINS AND ADHESION MOLECULES PLASMA LEVELS IN ACUTE ISCHEMIC STROKE: RELATIONSHIP WITH STROKE SUBTYPE, ISCHEMIC LESION SITE AND CLINICAL OUTCOME
A. Pinto
A. Tuttolomondo
D. Di Raimondo
R. Di Sciacca
P. Fernandez
G. Licata
Biomedical Department of Internal and Specialist Medicine, University of Palermo
ITALY
Background Few study, to our knowledge, has evaluated immunoinflammatory activation of the acute phase in relation to each diagnostic subtype of ischemic stroke . On this basis the aim of our study is to evaluate in patients with acute ischemic stroke cytokines, selectins and adhesion molecules plasma levels in relation to diagnostic subtype and to evaluate the relationship between immunoinflammatory variables and clinical outcome . Materials and Methods : We enrolled all consecutive patients with a diagnosis of acute ischemic stroke and control patients without a diagnosis of acute ischemic stroke. The type of acute ischemic stroke was classified according to the TOAST classification .We evaluated plasma levels of IL-1β, TNF-α, IL-6 and IL-10, E-selectin, P-selectin, sICAM-1 and sVCAM-1, VWF TPA antigen and PAI-1 plasma levels .Neurological deficit score by Scandinavian Stroke Scale (SSS) on admission and disability degree at discharge by Rankin disability scale were obtained for stroke patients. Results : 120 subjects with acute ischemic stroke and 123 matched controls (without ischemic stroke). Patients classified as cardioembolic (CEI) showed, significatively higher median plasma levels of TNF-alfa IL-6 IL-1alfa whereas lacunars showed,significantly lower median plasma levels of TNF-alfa, IL-6, IL-1alfa. Multiple linear regression performed to investigate about association between some relevant variables and SSS as dependent variable showed a significative correlation between SSS score at admission and diagnostic subtype lacunar or cardioembolic and some inflammatory variable Discussion : Our finding concerning higher plasma levels of immunoinflammation markers in patients with cardioembolic stroke underline the role of inflammation in pathogenesis of cerebral cardioembolism. Interestingly in our patients most of lacunar stroke had a subcortical localization, whereas most of cardioembolic stroke had a cortical localization .
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 3
26
Electronic activation system reduce in-hospital delay in intravenous t-PA treatment for acute ischemic stroke
K.S.Hong
Y.J.Cho
S.H.Park
Ilsan Paik Hospital, Seoul National Bundang Hospital
SOUTH KOREA
Background: Organized program is strongly recommended to reduce in-hospital delay in intravenous (IV) tPA treatment for ischemic stroke. Electronic activation system (EAS) as well as organized protocol can improve the process in IV tPA treatment. Methods: To reduce in-hospital delay, we developed organized protocol and implemented EAS. Primary endpoint was mean time delay in door-to-needle. Secondary endpoints were the proportion of patients treated within 60 minutes, IV tPA treated patients among ischemic stroke patients administered via emergency department (ER), and mRS 0-1 at 3 months. Results: Door-to-needle time was reduced from 70.5±24.6 min to 59.4±24.7 min after organized protocol development (p=0.062), and to 48.3±20.2 min after EAS implementation (p=0.006). Proportion treated within 60 min increased from 37.5% to 54.8% after organized protocol development (p=0.278), and to 82.4% after EAS implementation (p=0.010). IV treated patients among the ischemic stroke patients administered via ER were increased from 6.7% to 12.5% after organized protocol development, and to 12.5% after EAS implementation. At 3 months, mRS 0-1 was 37.5% before protocol development, 35.5% after organzied protocol development (p=0.733), and 50% after EAS implementation (p=0.644). Conclusion: EAS implementation with organized protocol development improve the quality of IV tPA treatment process.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 3
27
Delays to hospitalisation following stroke: an analysis of patients screened for stroke studies
A.K.Mistri
T.G.Robinson
J.F.Potter
CHHIPS and COSSACS Trial Groups
University of Leicester/University of East Anglia
UNITED KINGDOM
Introduction The time profile from stroke symptom onset to specialist review is poorly understood. Delayed contact with a hospital is a common reason for ineligibility for thrombolysis, and research trial participation. Knowledge of reasons for exclusion may help optimise future trial design. Methods The timings of - stroke onset, hospital admission and screening by researcher, as well as reasons for trial exclusion, were recorded in patients screened for two UK-based multi-centre acute stroke-BP trials: COSSACS (Continue Or Stop post-Stroke Antihypertensives Collaborative Study) and CHHIPS (Controlling Hypertension and Hypotension Immediately Post-Stroke study). Results From January 2005-June 2006, 2267 patients were reviewed of whom 224 (9.9%) were recruited. 1448 patients (63.9%) had all 3 time points documented. Median onset-admission (OA) delay was 8.8 hours (IQ range:3.5-19.2), and median onset-screening (OS) delay was 24 hours (IQ range:13.7-43.7). On multivariate analysis, factors related to OA delay and OS delay were dysphagia-associated with a decreased OA (36%) and OS (24%) p<0.0001; stroke onset between 2000 and 0600 was associated with increased OA (118%) and OS (73%), p<0.0001. Every 10 mmHg rise in admission SBP was associated with a 3% and a 2% decrease in OA and OS delay respectively (p<0.05). Common reasons for exclusion were: baseline dependency (14.6%); admission beyond eligibility time window (14.4%); screened beyond eligibility window (11.6%); and contraindication to change in drug regime (9.4%). Conclusions We have identified factors significantly associated with delay to specialist review, and points to be stressed in public education. Further work is required to look at reducing delay to admission in high-risk patient groups, thus promoting early provision of hospital care as recommended in clinical guidelines. Identifying reasons for exclusion will help improve future trial design and to understand applicability of trial results in clinical management.
