XVII. European Stroke Conference
Nice, France

Oral Session:

Acute stroke: early management and stroke units
Date: Thursday 15 May 2008  
Time: 11:30 - 11:40 -  Room: Clio/Thalie
Chair: R. Baumgartner, Switzerland and A.P. Sigurdsson, Iceland

01
Stroke unit referrals via another hospital reduce chances for thrombolysis treatment: Analysis from The Austrian Stroke Unit Registry.
C. Tatschl    M. Brainin    Y. Teuschl                                                 
for the Austrian Stroke Unit Registry Group

Center Clinical Neurosciences, Danube University Krems

AUSTRIA

Background: Successful intervention in acute stroke depends on early arrival at the stroke unit. Aim of our study was to identify time-dependent factors for early treatment on a national level. Methods: Analysis of the internet-based acute stroke registry concurrently collected by 26 acute stroke units in Austria between January 2003 and February 2007. Results: Out of 15746 patients with acute stroke, time onset was not known in 6259 (40%) and in further 8768 (56%) arrival was within 24 hours. From those with known onset time the median NIHSS on admission was 4, median age 72 years. 84% were admitted directly to the stroke unit and 16% were transferred indirectly after having been seen at other hospitals. Demographic parameters differed significantly between patients admitted directly to the stroke unit compared to those transferred from other hospitals (median 74 versus 70 years of age, mean pre-stroke Rankin Score 0.74 vs 0.59 (p< 0.001), women 49% vs 46% (p< 0.05) , hemorrhagic stroke 9% vs 14% and prior stroke 26% vs 20%; all p< 0.001). Among patients transferred directly, 39% were admitted within 2 hours and 55% within 3 hours, the respective percentages for indirectly admitted patients being 13% and 28%. While the rate of patients admitted within a 2 hours time window improved from 30 to 42% between 2003 and 2007, the rate of thrombolysis increased from 4.8% to 9.5%, p < 0.001). Cumulative analysis showed that with indirect admission one out of three to four patients misses the time constraints for thrombolysis treatment. Direct admission increases the odds ratio for thrombolysis treatment (OR 1.8; 95% CI 1.414-2.207; p< 0.001) when compared to indirect arrivals. Conclusion: Acute stroke patients should be admitted directly to a stroke unit, this almost doubles the chances for thrombolysis treatment.

Acute stroke: early management and stroke units
Date: Thursday 15 May 2008  
Time: 11:40 - 11:50 -  Room: Clio/Thalie
Chair: R. Baumgartner, Switzerland and A.P. Sigurdsson, Iceland

02
INFLUENCE OF THE WAY OF TRANSFER TO THE STROKE CENTER OF ACUTE STROKE PATIENTS ON THE RESPONSE TO TRHOMBOLYTIC TREATMENT
N. Pérez de la Ossa    M Millán    J.F.Arenillas    J. Sánchez-Ojanguren    E. Palomeras    L. Dorado    C. Guerrero    A. Dávalos              
 

Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona

SPAIN

Background: Acute stroke patients can be transferred directly to the Stroke Center (SC) or may be first attended by another medical professional at community hospitals before their transfer to the SC, where acute stroke expertise is provided 24h/7d and the thrombolytic treatment is administered. Our aim was to analyse the influence of the way of transfer to the SC on the response to thrombolytic treatment and outcome of patients with ischemic stroke. Patients and Methods: We prospectively registered ischemic stroke patients treated with thrombolytic treatment between Jan-05 and Dec-07. The primary outcome variable was good functional outcome at 90 days (Rankin Scale, mRS 2). Secondary outcomes were neurologic improvement (4 in NIHSS score or NIHSS 0-1 at 24h) and symptomatic hemorrhage. Results: 153 patients were studied; 45 patients (29.5%) received first medical attention at another medical center. Median time from onset to thrombolytic treatment was shorter in patients directly transferred to the SC (135 min vs. 165 min; p<0,001) and stroke severity was higher (12 vs 9; p=0.017). Patients directly transferred had higher frequency of neurologic improvement at 24 h (59,3% vs 37,2%; p=0.014) and lower symptomatic hemorrhage (4,7% vs 14%; p=0.04). With respect to patients first attended into another medical center, direct transfer to the SC was associated with an odds of 2.48 (95%CI, 1.04-5,8; p=0,039) of good outcome after adjustment for stroke severity at baseline, atrial fibrillation and baseline glycaemia. Conclusions: The direct transfer of ischemic stroke patients to the SC is associated with a lower onset to treatment time, better response to thrombolytic treatment and better outcome in comparison with a first level of care in community hospitals.

Acute stroke: early management and stroke units
Date: Thursday 15 May 2008  
Time: 11:50 - 12:00 -  Room: Clio/Thalie
Chair: R. Baumgartner, Switzerland and A.P. Sigurdsson, Iceland

03
Relationship between stroke service characteristics and onset-to-CT time in patients with acute ischaemic stroke
M. Dirks    H.F.Lingsma     J.D.van Wijngaarden     L.W.Niessen     P.J.Koudstaal     R.J.van Oostenbrugge     C.L.Franke     D.W.J.Dippel               
on behalf of the PRACTISE investigators

ErasmusMC

THE NETHERLANDS

Background: The number of patients who are eligible for treatment with intravenous thrombolysis is limited because of the narrow time window. Clinical characteristics are known to influence the onset-to-CT time (OCT), but little is known about the influence of stroke service characteristics (SSC): ‘time from onset stroke to hospital door’ (ODT) and ‘time from hospital door to CT’ (DCT). Methods: In a cohort of patients admitted with acute ischaemic stroke within 4 hours from onset of symptoms, data were obtained. SSC data of 12 hospitals were acquired through structured interviews with intra- and extramural representatives, in order to asses 1) protocols and agreements, 2) training and education, and 3) complexity of infrastructure. Data were analysed with multi-level linear regression to adjust for clinical characteristics and centre characteristics. Results: In total 716 patients were included, 308 (43%) were treated with thrombolysis. Average DCT of all acute stroke patients admitted within 4 hours from onset was 131 minutes (range 20 -360). If the general practitioner had visited the patient first, ODT increased by 25 minutes (95% CI 18 – 32). The difference between the most complex stroke service infrastructure and most simple one was 20 min in ODT (95% CI 0 – 40). Within the hospital, a protocol arranging priority for CT scanning saved 10 min (95% CI 2 – 19) of DCT. Having an experienced consultant on call most of the time instead of an inexperienced registrar resulted in a 12 min (95% CI 3 – 21) decrease in DCT. Discussion: Interventions aimed at simplifying stroke service set-ups and improving clinical pathways may help to shorten onset-to-treatment time in stroke patients and hence may increase the eligibility for thrombolysis.

Acute stroke: early management and stroke units
Date: Thursday 15 May 2008  
Time: 12:00 - 12:10 -  Room: Clio/Thalie
Chair: R. Baumgartner, Switzerland and A.P. Sigurdsson, Iceland

04
Blood pressure treatment in systemic thrombolysis
B. Dimitrijeski    H.C.Koennecke    A. Hartmann                                                 
 

Charite-Universitätsmedizin Berlin Campus Benjamin Franklin

GERMANY

Background: Blood pressure (BP) monitoring is essential in patients with ischemic stroke treated with systemic thrombolysis. The guidelines require that their systolic BP is kept below 185 mmHg. However, there is no data confirming that lowering BP in these patients is safe, especially as cerebral autoregulation may be impaired in these patients. Methods: A total of 260 patients were treated with systemic thrombolysis within 3 hours according to the NINDS-study criteria. Baseline characteristics and BP at stroke onset was noted. If the systolic BP exceeded 185 mgHg, urapidil i.v. was administered according to published guidelines. Functional outcome at 3-months using the modified Rankin scale was compared between patients who required BP lowering medication and those with systolic BP < 185 mmHg before thrombolysis. Result: N=52 patients (20 %) had a systolic BP > 185 mmHg at stroke onset (median 190 mmHg) and were treated with urapidil intravenously before administering systemic thrombolysis. Unfavourable outcome (Rankin >2 at 3 months) occurred in 59 % compared with 47 % in patients with BP < 185 mmHg (p= 0.117). Symptomatic intracranial hemorrhage occurred in 2 % and 3.3 % (p=0.9), and asymptomatic hemorrhage occurred in 23% and 25%, respectively (p=0.9). Conclusion: In patients with ischemic stroke, lowering the systolic BP below the threshold of 185 mmHg with urapidil before the admistration of systemic thrombolysis has no negative effect on functional outcome. There is no increased risk of intracranial hemorrhage in the patients requiring BP lowering before thrombolysis.

Acute stroke: early management and stroke units
Date: Thursday 15 May 2008  
Time: 12:10 - 12:20 -  Room: Clio/Thalie
Chair: R. Baumgartner, Switzerland and A.P. Sigurdsson, Iceland

05
Isolated anterior cerebral artery stroke: presentation, lesion, and outcome in 30 consecutive patients investigated by diffusion-weighted MRI (DWI)
D. Ulbricht                                                               
 

Centre Hospitalier Emile Mayrisch

LUXEMBURG

Introduction: the anterior cerebral artery (ACA) feeds the frontomedian wall, anteroventral parts of the basal ganglia, and anterior 4/5 of the corpus callosum. Ischemic infarctions are rare and account for 0.6-3% of all territorial strokes. Most knowledge on ACA-stroke stems from few case series and case reports before the advent of neuroimaging. Patients and Methods: we applied routine work-up for ischemic stroke in 26 consecutive patients: MRI including DWI, extracranial ultrasound, ECG, Holter-ECG, transthoracal and transoesophageal echocardiography and EEG. ACA-stroke was clinically suspected and defined by the lesion appearing in DWI. Strokes related to neurosurgical conditions were excluded as were patients carrying significant older lesions. Results: mean age was 68 years (range 23-85), 14 were women, 16 men. Acute presentation was akinetic mutism (persistant, n=3, brief n=9), crural hemiparesis (n=7), sudden apathy (n=1), falls with anosognosia for falls (n=1), sudden maladaptive behavior (n=5), amnesia and mutism (n=1), sudden apathy, diarrhea and profuse sweating (n=1), and status epilepticus (n=1). Lesions were left in 17 and right in 12 patients; one had bilateral lesions. Etiology was mainly proximal embolism. One main lesion focus was the anterior cingulate cortex in 18 patients in the territory of the callosomarginal artery, the corpus callosum was affected in 13 patients. Signs of callosal disconnection were observed in 3 patients, and 10/12 patients with callosal lesion remained dependent in everyday life regardless of lesion size. Former daily activities could be resumed in 17 patients. Discussion: ACA-stroke presented with behavioral trouble and disturbed complex motor integration. Left prefrontal lesions had akinetic mutism of variable duration, their counterpart had acute trouble integrating the representation of the self and the others. Prognosis seems to be worsened by callosal lesions, but otherwise about half of the patients were able to resume their former daily activities.

Acute stroke: early management and stroke units
Date: Thursday 15 May 2008  
Time: 12:20 - 12:30 -  Room: Clio/Thalie
Chair: R. Baumgartner, Switzerland and A.P. Sigurdsson, Iceland

06
Can the organisational components of stroke unit care be applied to stroke care post discharge? An observational study
A.M.Cox    C.D.Wolfe    C. McKevitt                                                 
 

King's College London

UNITED KINGDOM

Background Improving the organisation of acute stroke care has resulted in improved outcomes for patients. Stroke care post discharge can be haphazard and patients report unmet needs. We investigated how organisational components of stroke unit care are operationalised in routine practice and how these might be applied to the organisation of care post discharge. Methods We observed care in 3 UK teaching hospital stroke units, using an observational schedule to record organisational components of effective stroke care as identified in the literature, and unstructured fieldnotes. These qualitative data were analysed for emerging themes. Results We observed 10 team meetings, 5 meetings between staff members, 2 outpatient clinics, 3 ward rounds and the work of rehabilitation therapy staff (6 days). There were variations in the use of formal organisational procedures including information communication, key working and joint working. In settings with fewer formal structures decision-making was led by groups of key individuals. In all settings strong leadership and patterns of hierarchy within and between professions were apparent. All settings held multi-disciplinary meetings but the extent and definition of multi-disciplinary working varied. Professional roles and identities remained distinct. The defined geographical location of the stroke unit facilitated opportunistic discussion about patients, particularly between professions with less formal routes of communication. Conclusion Organisation of acute stroke care varied widely in routine practice but geographical collocation facilitated communication. Improving the delivery of community care will require attention to organisational structures and effective leadership, as well as processes through which care is organised.