XVII

XVII. European Stroke Conference
Nice, France

Poster Session: Acute stroke: complications and early outcome

Session: Poster Session II
Date: Thursday 15 May 2008
Time: 12:30 - 14:00
Room: Agora 2


Tumor necrosis factor gene promoter polymorphism G-308A and poststroke mortality
A. Czlonkowska    G. Gromadzka    I. Sarzynska-Dlugosz     M. Baranska-Gieruszczak

Institute of Psychiatry and Neurology; Medical University

POLAND

Background and Purpose: The magnitude of brain and systemic inflammatory response is of prognostic significance in stroke. The inflammatory process in stroke is initiated and aggravated by pro-inflammatory cytokines (PICs). One of the most powerful PICs is tumor necrosis factor (TNF). The TNF G-308A genetic polymorphism is a basis for high inter-individual variation in TNF production; the -308A allele is associated with higher transcription of the TNF gene. The TNF production and bioactivity is regulated by sex hormones. We hypothesized that differences in TNF production, determined by the TNF -308 genotype, influence the course and outcome of stroke in a gender-dependent fashion. Methods: The study cohort consisted of 444 patients (217 men and 227 women) with first-ever stroke diagnosed according to the WHO definition. Clinical data were collected according to the Stroke Data Bank, NIH protocol. TNF G-308A genotyping was performed by the PCR-RFLP method. Results: A significant (p<0.00) interaction was found between the TNF -308 genotype and gender in predicting risk of death within one week, one month, and 3 months after stroke. In gender-stratified analyses, the TNF -308A allele carriership was a significant independent predictor of death within 1 week [OR 5.2 (95%CI, 2.0-13.3)], 1 month [OR 4.4 (95%CI, 1.9-10.2)], and 3 months [OR 3.15 (95%CI, 1.4-7.2)] after stroke in women patients only. Conclusions: The TNF G-308A polymorphism significantly influences mortality after stroke. Phenotypic effects of TNF -308G/A alleles in stroke are gender-dependent. The TNF G-308A polymorphism may be included into the list of SNPs which may be potentially useful for future prognosing stroke outcome, and for making personalized therapeutic decisions.

Session: Poster Session II
Date: Thursday 15 May 2008
Time: 12:30 - 14:00
Room: Agora 2


Age related mortality in acute stroke
P.K.Shibu    S.H.Guptha    P.O.Agyei

Peterborough District Hospital

UNITED KINGDOM

Background Inpatient stroke mortality has declined over the years but it is unclear whether this improvement is due to better management of stroke irrespective of the age of patient at admission. Methods Data on all patients aged 18 years and over admitted with acute stroke were collected for the years 1998, 2003 and 2005. We studied age related mortality beginning with patients <55 years of age and for each decade over 55years of age. We also assessed the performance of stroke management indicators such as rate of brain imaging, use of anti platelet agents and anticoagulants for each individual year. Results Total number of stroke patients admitted were 369(1998), 349(2003) and 331(2005). The rate of brain imaging was 66% in 1998 and 95% in 2005(p<0.05). The appropriate use of aspirin in ischemic stroke was 87%(156/179) in 1998 and 99%(260/262) in 2005(p<0.05). Inpatient stroke mortality declined from 40%(146/369) in 1998 to 29%(97/331) in 2005(p=0.005). Age related mortality declined from 46%(68/147) to 32%(41/129) in the 75-85 age group (p <0.01) and from 63%(43/68) to 49%(27/55) in the 85-95 age group.( p <0.05) Conclusion Our data show that rigorous implementation of stroke guidelines can result in a significant improvement on overall stroke care and reduce stroke mortality in all age groups.

Session: Poster Session II
Date: Thursday 15 May 2008
Time: 12:30 - 14:00
Room: Agora 2


Reliability of the ECASS radiological classification of post-thrombolysis brain hemorrhage
P. RENOU    I. SIBON    T. TOURDIAS     F. ROUANET     M. COUDERC    C. ROSSO     S. DELTOUR     S. CROZIER    Y. SAMSON

Urgences Cérébrovasculaires, Groupe Hospitalier Pitié-Salpêtrière

FRANCE

BACKGROUND Post-thrombolysis brain hemorrhages are often classified with the CT-based ECASS classification into four categories: hemorrhagic infarction (HI) types 1 and 2, and parenchymal hematoma (PH) types 1 and 2, the latter being associated with poor outcome. Yet, little is known about the reliability of this classification and about its extension to MRI. Therefore, we assessed the inter-observer reliability of this classification on CT and three MRI sequences. METHODS We selected forty-three patients with post-thrombolysis brain hemorrhages identified by one investigator on CT and/or at least one of the three following MRI sequences : FLAIR, DWI, and T2* gradient recalled echo (GRE) imaging. Twelve control patients were added, without any bleeding. Each series of image were independently classified with the ECASS method by three blinded observers. Inter-observer agreement was assessed with kappa statistics. RESULTS The overall concordance of the classification was moderate for T2*GRE and CT (kappa: 0.63 and 0.52 respectively) and low for DWI and FLAIR (kappa: 0.39 and 0.35 respectively). The concordance for PH (PH1 and PH2) classification was very high for T2* (kappa: 0.83), moderate for CT (kappa: 0.66), and lower for FLAIR and DWI (0.55 and 0.53 respectively). The concordance for PH2 was very high for DWI (0.85) and T2*(0.83), but lower for FLAIR (0.55) and CT (0.41). DISCUSSION The overall reproductibility of the ECASS classification of brain hemorrhage is moderate or low with all tested imaging methods. However, the reproducibility of the severe PH2 category is excellent and much higher with DWI or T2* than with the other tested imaging modalities

Session: Poster Session II
Date: Thursday 15 May 2008
Time: 12:30 - 14:00
Room: Agora 2


Stroke recurrence in acute phase of embolic stroke
S. Fujimoto    K. Toyoda    J. Jinnouchi     M. Yasaka     S. Sadoshima    Y. Okada

Natinal Hospital Organization Kyushu Medical Center Nippon Steel Yawata Memorial Hospital

JAPAN

Purpose: The purpose of the present study was to clarify the features of stroke recurrence in acute phase of embolic stroke. Methods: Among patients with acute brain infarction or transient ischemic attack, 270 consecutive patients who underwent transesophageal echocardiography and were diagnosed as having cortical or subcortical infarcts without significant occlusive lesions in the cerebral arteries were included in the present study. All patients were classified into 5 groups: patients only with cardiogenic embolic sources (C-Group), patients only with right-to-left shunt disease (P-Group), patients only with aortic arch atheroma of ≥4mm in thickness (A-Group), patients with two or all three embolic sources (M-Group), and patients without any embolic sources (U-Group). We observed the stroke recurrences during 14 days after onset. Results: Stroke recurrence was observed in 14 (5.2%) patients: 6.0% (3/50) of C-Group, 2.3% (1/42) of P-Group, 3.6% (2/55) of A-Group, 10.2% (8/78) of M-Group. Ten patients had cardiogenic embolic sources. Among them, 7 also had aortic arch atheroma of >/=4mm and were treated only with anticoagulant therapy in acute phase. Cardiogenic embolic sources (p<0.05) and diabetes mellitus (p<0.1) were more frequent in patients with than without stroke recurrence. Multiple embolic sources (p<0.05) were also more frequent in patients with than without stroke recurrence. The site, size, and multiplicity of the baseline ischemic lesions were not associated with stroke recurrence. Multivariate analysis was done with embolic sources (Model 1, multiple embolic sources; Model 2, cardiogenic embolic sources with aortic arch atheroma of >/=4mm) and diabetes mellitus. Cardiogenic embolic sources with aortic arch atheroma of >/=4mm (OR, 3.59; 95% CI, 1.20-10.75) was an independent predictive factor for stroke recurrence in the acute phase. Conclusions: Patients with multiple embolic sources, especially with cardiogenic embolic sources and aortic arch atheroma of >/=4mm, were at high risk state for stroke recurrence.

Session: Poster Session II
Date: Thursday 15 May 2008
Time: 12:30 - 14:00
Room: Agora 2


Pre-treatment with statins is associated with early stable curse in patients with initial mild atherotrombotic stroke or TIA
M. Sepulveda    A. Ois    A. Rodriguez-campello     J. Jimenez-Conde     E. Cuadrado-Godia    E. Giralt     J. Roquer

Hospital del Mar

SPAIN

Background and purpose: The roll and benefits of statins in cerebrovascular pathology has been demonstrated in the last years, although its mechanisms are not well known. Our objective was to evaluate the impact of pre-treatment over the early clinical curse in those patients with initial non-disabling stroke and severe symtomatic arterial disease. Methods: of a total of 1456 patients with first-ever acute ischemic stroke, prospectively assessed at emergency room of our centre in the last five years, we selected those patients with severe arterial symptomatic disease (>70% arterial stenosis or symptomatic extracraneal occlusion) and initial severity in the NIHSS of 7 or lower. We defined unstable curse when the patients had suffered a neurological event in the previous 7 days to admission or a NIHSS score increased 2 points or new event in the first 72 hours after admission. Age, initial stroke severity, vascular risk factors, pre-treatment with antiaggregants or statins, initial cholesterol and glucose levels were analyzed and related with unstable curse. Results: a total of 196 patients were included with a mean age of 72.6+/-10.7, range 39-96; initial severity median 3 (q1,q3: 2, 5). 26 patients (13.3%) with initial NIHSS=0. 23 patients (11.7%) with vertebro-basilar stroke. 41 patients (20.9) with only severe intracranial arterial stenosis. In univariate analysis initial severity (p=0.015) and pre-treatment with statins (p=0.05) as protector were associated with unstable curse. In multivariable model we found an independent association of unstable curse with: statin pre-treatment [p=0.008; adjusted OR=0.371, (95% IC 0.18-0.77) and initial severity p=0.023; adjusted OR=1.17 (95% IC 1.02-1.35)]. Conclusions: pre-treatment with statins is associated with a more early stable clinical curse in patients with severe arterial disease and acute non-disabling stroke.

Session: Poster Session II
Date: Thursday 15 May 2008
Time: 12:30 - 14:00
Room: Agora 2


Hemorrhagic transformation in acute ischemic stroke: structure and influence on the early clinical outcome.
E.I.Batishcheva

St. Ioasaf Regional Clinical Hospital

RUSSIAN FEDERATION

Hemorrhagic transformation (HT) of cerebral infarction is relatively often event. The incidence of symptomatic HT averages 0-6.8%, asymptomatic HT - 2.9-36.8%. There is an opinion that HT predicts unfavourable outcome of ischemic stroke. The aim: to estimate the structure of HT, to determine influence of HT on the stroke outcome. Material and Methods. 150 patients with ischemic stroke were examined: 75 patients with HT (basic grope), and 75 - without HT (control group). Patients in both groups were equal in age, gender, subtype of ischemic stroke, severity of stroke in onset, size of the infarction. CT and MRI, Glasgow scale, NIHSS and modified Rankin scale were applied on the 1st, 2nd, 21st hospitalization day. Results. Asymptomatic HT was diagnosed in 56 patients (74.7%), symptomatic HT - in 19 (25.3%). Hemorrhagic infarction of the 1st subtype (HI-1) presented in 32 patients (42.7%), HI-2 - in 19 (25.3%), parenchymatous haematoma of the 1st type (PH-l) - in 15 (20%), PH-2 - in 9 (12%). HI-1 and HI-2 were predominated in patients with asymptomatic HT (82.2%), PH-1 and PH-2 - in symptomatic HT (73.6%). The early outcome was better in patients with asymptomatic HT than in control group (p<0.05). There were no differences in outcomes between patients with symptomatic HT and patients of the control group (p>0.05). Conclusions: HT is not a predictor of unfavourable outcome of ischemic stroke. Asymptomatic HTs, consisting mainly of HI-1 and HI-2, can predict favourable clinical outcome. They can be considered as a marker of successful reperfusion.

Session: Poster Session II
Date: Thursday 15 May 2008
Time: 12:30 - 14:00
Room: Agora 2


Prevention of venous thromboembolism after acute ischemic stroke: results of a nationwide questionnaire
W.J.van der Eerden    V. Kwa    V. Gerdes     R. Sandkuyl

Nursing Home De Drie Hoven, Osiragroep

THE NETHERLANDS

Background Venous thromboembolism (VTE) is a common complication after acute ischemic stroke. Stroke patients may have multiple risk factors for deep-vein thrombosis (DVT) and pulmonary embolism (PE), the last representing a major cause of death after acute stroke. Recent guidelines recommend pharmacological thromboprophylaxis as the best strategy to prevent DVT and PE after stroke. Currently in the Netherlands most stroke patients are transferred from hospital to a rehabilitation unit within two weeks post-stroke. Since it was not known to which extent these guidelines are being applied to prevent VTE during this rehabilitation period, a national survey among Stroke Rehab-Units in the Netherlands was done to assemble an overview about the use of this pharmaco-thromboprophylaxis policy. Methods A survey of 11-questions was sent to over 1200 specialists active in the field of stroke rehabilitation in nursing homes in the Netherlands Results Total response was nearly 70% (847 out of total 1244). Only 15% had access to a local protocol on thromboprophylaxis; in 70% of the stroke cases prevention of VTE was by way of pharmacological thromboprophylaxis. Responses showed that information about the duration of thromboprophylaxis was indecisive in more than 50% of cases, while 22% of specialists applied oral anticoagulants as long as immobility lasted. On average 36 new stroke patients per unit were treated annually, with an incidence of 1.6 for DVT and 1.5 for LE, causing an estimated incidence of 1.6 annually for sudden death. Conclusion A nationwide survey in the Netherlands about the policy on prevention of VTE after ischemic stroke during the immediate rehabilitation period showed no consensus on the use of pharmacological thromboprophylaxis. Further research is needed to establish the best strategy to prevent DVT and LE for this high risk patient group.

Session: Poster Session II
Date: Thursday 15 May 2008
Time: 12:30 - 14:00
Room: Agora 2


Prevention of venous thromboembolism after acute ischemic stroke: results of a nationwide questionnaire
W.J.van der Eerden    V. Kwa    V.E.Gerdes     R. Sandkuyl

Nursing Home De Drie Hoven, Osiragroep

THE NETHERLANDS

Session: Poster Session II
Date: Thursday 15 May 2008
Time: 12:30 - 14:00
Room: Agora 2


Prospective Observational Study of Acute Cardioembolic Stroke in Korea: Design and Initial Report
S.W. Ha    D.E.Kim    J.KCha     H.G.Oh     J.H.Lee    A.H.Cho     J.H.Kwon     K.B.Lee    H.Y.Kim   K.U.Kwon

Acute Cardioembolic Stroke Registry steering committee

SOUTH KOREA

Background: Anticoagulation is the standard therapy for secondary prevention of cardioembolic stroke. However, there are great debates on when and how to initiate anticoagulation in acute cardioembolic stroke (ACS) due to hemorrhagic complications. To establish management guidelines, the investigators organized acute cardioembolic stroke registry (ACSR) Method: This prospective observational study is recruiting ischemic stroke patients with embolic heart disease who is admitted to 11 hospitals in Korea within one week after the onset since January 1st 2007. Immediate anticoagulation therapy is used to all patients except for those who had large sized infarction or significant hemorrhagic transformation (HT) on initial brain image. Follow up brain imaging studies are scheduled at one or two weeks after the onset. Primary outcome measure is modified Rankin Scale (mRS) score at 3months, and occurrence of cardiovascular events or hemorrhagic complications and mortality are monitored at 2 weeks and 3 months. Result: During the first year, 435 patients were recruited. The mean age was 69.3+/-11.9 and 239 patients (54.9%) were male. 14 patients (3.2%) had the history of stroke, and atrial fibrillation was found in 386 patients (88.7%). The mean National Institutes of Health Stroke Scale (NIHSS) score was 8 +/- 7. Immediate anticoagulation was performed in 291 patients (66.8 %). 61 patients (14%) showed HT on the initial brain imaging study. In 2 weeks, ischemic stroke developed in 8 patients (1.8%) and HT in 82 patients (18.8%) including 11 (2.5 %) with symptomatic HT. In 3 months, 38 patients (11.5%) died, but 164 patients (49.5%) had favorable outcome (2 point or less in mRS). Patients with favorable outcome had significantly lower initial NIHSS score and younger age. Development of HT was related with poor outcome. Discussion: This study is planned to recruit more than 1,800 patients with ACS for 4 years. We will evaluate the benefit and risk of early anticoagulation in selected population, and the predictable factors of their long-term outcome.

Session: Poster Session II
Date: Thursday 15 May 2008
Time: 12:30 - 14:00
Room: Agora 2


Significance of Microembolic Signals and New Cerebral Infarcts on the Progression of Neurological Deficit in Acute Stroke Patients with Large Artery Stenosis
Q. Hao    W.M.Lam    K.S.Wong

Department of medicine and therapeutics,Prince of Wales Hospital,the Chinese University of Hong Kong

HONG-KONG

Background:The artery-to-artery microembolism from large artery atherosclerotic lesions is an important mechanism of stroke, active emboli may also contribute to the early infarct recurrence and increasing and neurological worsening in acute phase. However, the time course of these changes remains uncertain. We try to elucidate the relationship among the infarct recurrence and increasing, the microembolic signal (MES) and neurological progression in acute phase. Methods:Stroke patients within 7 days of onset and with relevant middle cerebral artery or carotid artery stenosis were recruited. MES detection, Diffusion Weighted Imaging and neurological assessment by NIHSS were performed on day 1 and day 7 after the admission. Results:49 patients were recruited. On day 1 of the admission, in MES positive group, NIHSS was lower than that of MES negative group (mean, 3.4 vs 4.4), but not statistically significant (p=0.114). The number of the infarcts was significantly higher in MES positive patients (mean, 2.5 vs 1.2, p=0.026). On day 7, the NIHSS decreased less in MES positive group than negative group (0.71 vs 1.8, p=0.012), but the infarct recurrence and increasing happened more in MES negative group. Compare the MES on day 1 and outcome on day 7, the initial MES tended to associate with a higher NIHSS on day 7 and a less clinical improvement (p=0.702), the decreasing of MES also associated with more NIHSS reduction (p=0.05), both of them can’t predict the infarct recurrence and increasing on day 7. Furthermore, we found MES decreased in 58.3% of the patients receiving double antiplatelet, while only in 33.3% of patients who had aspirin alone. Discussion:The number MES on day 1 associated with the number of the infarct lesions, and tended to predict the severity of neurological deficits on day 7. Disappearance of the MES was a predictor of better improvement on day 7. Both of them didn’t associated with the infarct recurrence and increasing. Studies with large sample are required to reveal the progression of stroke or TIA in acute phase.

Session: Poster Session II
Date: Thursday 15 May 2008
Time: 12:30 - 14:00
Room: Agora 2


NEUROCARDIOGENIC INJURY IN PATIENTS WITH ACUTE STROKE
O. Dubenko    I. Rakova

Kharkov Medical Academy of the Postgraduate Education

UKRAINA

Background and purpose. Cardiac dysfunction is common complication of acute stroke. The aim of the present study is analyzed the association of ECG changes and serum levels troponin I in different type of acute stroke. Methods. The examination included 105 patients (55 men, 50 woman; mean age 58,3 years) who were hospitalized due to acute stroke. Ischemic stroke (IS) had 42 patients, primary intracranial hemorrhage (IH) – 40 and subarachnoid hemorrhage (SAH) – 23. We excluded from study patients with previous history of myocardial infarction, atrial fibrillation, cardiomyopathy, rheumatic heart diseases or congestive heart failure. Standard 12-lead ECG and heart rate variability and serum troponin I were performed at day admission and on 10 day after stroke. Result. S-T depression was found in 14,9% of patients with IS, in 10,0% of patients with IH and in 26,1% of patients with SAH, inverted T wave in 40,4% of IS, 32,5% of IH and 30,4% of SAH. Prolong Q-T interval was registered in 12,8% of patients with IS, in 27,5% - with IH and in 13,0% with SAH. Suppressed of all the spectral components of heart rate variability we observed in patients with brain infarction. However the ratio of LF to HF was significantly greater in patients with IH (2,8±1,3) and SAH (3,1±3,3) which reflect a change in sympathovagal balance in favor of increased sympathetic tone. Elevated troponin I (>0,3 ng/ml) was present at admission in 53,3% of patients with IS (range 0,4-0,8 ng/ml), in 72,2% of patients with IH (range 0,4-2,5 ng/ml) and in 72,2% of patients with SAH (range 0,5-4,3 ng/ml). A second measurement showed decreased troponin I levels in 20,0% patients with IS, in 16,7% - with IH and in 43,7% - with SAH. 16,7% of patients with IH and 40,0% with IS had later troponin I elevation. Discussion. The elevation of troponin I in acute stroke are prevalent in patients with IH and SAH. A rise troponin I is associated with increased of sympathetic activation and reflected myocardial damage in these patients. Patients with acute stroke should be treated with cardiac protection.

Session: Poster Session II
Date: Thursday 15 May 2008
Time: 12:30 - 14:00
Room: Agora 2


Late hemicraniectomy after neurological deterioration for massive hemispheric infarction.
H.L.Teoh    V.K.Sharma    C. Ning     B.P.L.Chan

National University Hospital, Singapore

SINGAPORE

Background: Extensive cerebral edema associated with massive hemispheric infarction carries a grave prognosis despite aggressive medical care. Decompressive hemicraniectomy is performed in many centers, usually in selected patients after clinical deterioration, or after significant cerebral edema or herniation seen on neuroimaging. Previous studies suggest a reduction in mortality rates. However, optimum timing of surgery and its impact on the functional outcome remains controversial. We report our experience and clinical outcomes when decompressive hemicraniectomy was performed in acute ischemic stroke patients with clinical and/or radiologolic evidence of cerebral herniation. Methods: In this retrospective study, we identified cases that underwent hemicraniectomy for hemispheric infarction after identification of progressive neurological deterioration, drop of 2 or more points on the Glasgow Coma Scale, evidence of cerebral herniation on clinical or neuroimaging grounds. Results: 14 patients satisfied our criteria for inclusion in this study. All cases had received intravenous mannitol preoperatively and managed in intensive care surgical unit. Mean age was 50years (range 36-72). Mean age of the survivors was considerably lesser than the fatalities (48 versus 55years). Mean NIHSS at presentation was 22 points (range 15-27). Mean time elapsed between stroke onset and surgery was 44 hours (range 29-76). We observed 30-day mortality of 22% while the mean Modified Rankin Scale (mRS) was 4.27 (range 3-5) in the 11 survivors (mRS grade 3,4 and 5 in 2,4 and 5 patients, respectively). Conclusions: We found favourable mortality rates in patients with massive hemispheric infarctions after decompressive hemicraniectomy (21.4% vs 78% after aggressive medical therapy in published literature). Despite a reduced mortality after surgical decompression the functional outcomes remained poor and, majority of the survivors remained moderate to severely disabled.

Session: Poster Session II
Date: Thursday 15 May 2008
Time: 12:30 - 14:00
Room: Agora 2


Serum uric acid is not associated with early outcome in patients with acute stroke.
C. Bairaktaris    G. Tsivgoulis    R. Psaras     K. Vadikolias     K. Sotiriou    K. Rallis     E. Ischaki     I. Papanastasiou

417 NIMTS, Veterans Affair Hospital, Athens

GREECE

Background: It is unclear whether high serum uric acid (SUA) promotes or protects against the development of cerebrovascular disease, or simply acts as a passive marker of increased risk.Recent studies have identified SUA as in independent predictor of stroke mortality and functional dependence in the acute stroke setting. Furthermore, it has been proposed that hyperuricemia may be considered as a modifiable risk factor for neurological worsening and treated aggressively in the acute stroke stage. In the present study we examined the association of SUA concentrations with the clinical outcome and the fatality rate of patients with acute stroke. Methods: Consecutive patients with acute (<24 hours), first-ever stroke were prospectively evaluated. Stroke risk factors and baseline stroke severity were recorded in all cases. SUA was measured on the first day of ictus. Functional outcome was assessed on hospital discharge and at 90 days following stroke onset using the modified Rankin Scale (mRS). Statistical analyses were performed using Spearman’s correlation coefficient (r) and multivariate logistic regression models. Results: Baseline stroke severity did not correlate with SUA levels (n=205, r=0.151, p=0.107). Similar SUA levels were documented in patients who were dead and alive at three months following stroke onset (6.3mg/dL vs. 5.9mg/dL; p=0.484). SUA levels did not differ between functionally dependent (mRS >1) and independent (mRS 0-1) patients at three months following stroke onset (6.2mg/dL vs. 5.4mg/dL; p=0.185). SUA levels were not associated with three-month mortality (OR: 1.08, 95%CI: 0.87-1.34; p=0.480) or functional dependence (OR: 1.21, 95%CI: 0.91-1.61; p=0.184) on univariate logistic regression models. Discussion: SUA levels do not correlate with stroke severity and are not associated with early outcome in patients with acute stroke. Further prospective studies are required to identify the precise role of hyperuricemia in cerebrovascular disease before routine treatment of this potential risk factor can be recommended.

Session: Poster Session II
Date: Thursday 15 May 2008
Time: 12:30 - 14:00
Room: Agora 2


EARLY SEIZURES IN PATIENTS WITH ACUTE STROKE: FREQUENCY, PREDICTIVE FACTORS AND EFFECT ON CLINICAL OUTCOME
A. Alberti    V. Caso    M. Paciaroni     M. Venti     F. Palmerini    S. Biagini     G. Agnelli

University of Perugia, Perugia

ITALY

Background: Early seizure (ES) may complicate the clinical course of patients with acute stroke. The aim of this study was to assess the rate of and the predictive factors for ES as well the effects of ES on the clinical outcome at hospital discharge in patients with first-ever stroke. Patients and Methods: A total of 638 consecutive patients with first-ever stroke (543 ischemic, 95 hemorrhagic), admitted to our Stroke Unit, were included in this prospective study. ES were defined as seizures occurring within 7 days from acute stroke. Patients with history of epilepsy were excluded. Results: Thirty-one patients (4.8%) had ES. Seizures were significantly more common in patients with cortical involvement, severe and large stroke, and in patient with cortical hemorrhagic transformation of ischemic stroke. ES was not associated with an increase in adverse outcome (mortality and disability). After multivariate analysis, hemorrhagic transformation resulted as an independent predictive factor for ES (OR= 6.5; 95% CI: 1.95-22.61; p= 0.003). Conclusion: ES occur in about 5% of patients with acute stroke. In these patients hemorrhagic transformation is a predictive factor for ES. ES does not seem to be associated with an adverse outcome at hospital discharge after acute stroke.

Session: Poster Session II
Date: Thursday 15 May 2008
Time: 12:30 - 14:00
Room: Agora 2


REMOTE INTRACEREBRAL HEMATOMA AFTER rtPA IN ACUTE STROKE
F. Falcão    P. Canhão    T. Melo

Santa Maria Hospital, Lisbon

PORTUGAL

Background and Purpose: Cerebral hemorrhage is the most feared complication of fibrinolytic therapy for acute stroke. Different patterns of hemorrhage are associated to distinctive pathophysiological mechanisms. Methods: Consecutive acute stroke patients admitted to a Stroke Unit and treated with IV rtPA according to EUSI recommendations are prospectively registered in a stroke database. From all patients treated from June 2003 to December 2007 we retrieved patients who had remote hematoma (distant from infarct zone) as rtPA complication. Results: Among 170 stroke rtPA treated patients, remote hematoma was diagnosed at follow-up CT scan in 3 cases. Clinical Case 1 – A 48 years old man with right middle cerebral artery (MCA) stroke and 9 at National Institute of Health Stroke Scale (NIHSS). Follow-up CT scan and MRI disclosed bilateral occipital hematoma. NIHSS 2 at discharge. The patient died at 2 months of carcinoma of the lung. Clinical Case 2 – A 66 years old woman with left MCA stroke (NIHSS 14) with NIHSS 4 at the end of rtPA perfusion. Follow-up CT scan disclosed right capsular-caudate hematoma. NIHSS 3 at discharge. Clinical Case 3 – A 76 years old woman with atrial fibrillation and right posterior cerebral artery stroke improved from NIHSS of 6 to 3 after rtPA. Follow-up CT scan showed leukoaraiosis, occipital-thalamic infarct with hemorrhagic transformation and left occipital hematoma. Diffusion-weighted MRI without silent ischaemia and revealed a left occipital cavernoma. NIHSS 2 at discharge. Discussion: Of all our rtPA treated patients, 1,8% had remote intracerebral hematoma, a similar value from other series (1,3% NINDS; 3,7% ECASS 1; 2,0% ECASS 2; 3% SITS-MOST). For each remote hematoma identified, different possible etiologies were considered: cerebral metastasis/blood dyscrasia associated with neoplasm, hypertensive angiopathy and cavernoma. Our cases emphasize the need to investigate patients with remote hematoma after rtPA to exclude underlying pathology. In this case series the occurrence of remote hematoma had no influence on prognosis.

Session: Poster Session II
Date: Thursday 15 May 2008
Time: 12:30 - 14:00
Room: Agora 2


BLOOD GLUCOSE LEVELS AFTER ISCHEMIC STROKE IN PATIENTS WITH AND WITHOUT SLEEP APNEA
M.M.Siccoli    P.O.Valko    C.L.Bassetti

University Hospital of Zurich

SWITZERLAND

Background/aims: The aim of our study is to investigate changes in blood glucose in patients with acute ischemic stroke and their relationship to sleep apnea (SA) severity and type. Methods: We included 33 consecutive patients with acute ischemic stroke, in which fasting blood glucose level was repeatedly assessed at day 1, 2, 3, 4, 7, and 15 after admission in the same period of time (between 6 and 10 a.m.). Stroke severity on admission and stroke outcome at discharge were recorded. Respirography was performed in the first night and scored according to standard criteria. Results: The mean age was 67+/-13 [25-82], 23 (70%) were male. Blood glucose on admission was 7.7+/-3.2 [4.1-17.9] and 6.5+/-2.0 [4.6-11.1] at day seven. We found a significant correlation between glucose at day seven and apnea-hypopnea-index (p=0.002, r=0.600), central apnea-index (p=0.010, r=0.538), and oxygen desaturation-index (p<0.0001, r=0.751) independent of cardiovascular risk factors, age, and body-mass index. Glucose at day seven also correlated with stroke severity on admission (p<0.0001, r=0.709) and with functional disability at discharge (p=0.014, r=0.528). Conclusions: Glucose level at day seven after ischemic stroke is a marker of stroke severity and short-term outcome, and is associated with severity of SA, central apneas, and oxygen desaturations. Further studies are needed to test the hypothesis that these findings may reflect an increased sympathetic activity possibly related to sleep apnea.

Session: Poster Session II
Date: Thursday 15 May 2008
Time: 12:30 - 14:00
Room: Agora 2


Acute Confusional State and Intracerebral Haemorrhages.
M.P.Rutgers    C. Cordonnier    R. Le Bouc     D. Leys     H. Henon

Lille University Hospital Stroke Unit

FRANCE

Background: Acute confusional state (ACS) has been mainly studied in cerebral infarction and in subarachnoid haemorrhages. No study has evaluated the incidence of ACS and their predictors in intracerebral haemorrhages (ICH). The objectives were to evaluate the incidence of ACS in non-malformative ICH and their predictors, including the pre-existing cognitive state. Methods: We diagnosed ACS with the DSM-IV criteria and the Delirium Rate Scale (cutoff : 10), in 373 consecutive non-malformative ICH patients. The cognitive status before ICH was assessed by the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). We evaluated the incidence of ACS, and its predictors with a multivariate survival analysis. Result: Of 373 ICH patients, 99 (27%) had an ACS. Independent factors associated with ACS were: excessive alcohol consumption, seizures pre-ICH, metabolic or infectious disorders and lobar ICH topography. In the subgroup of 265 ICH patients who had a reliable informant, preexisting cognitive decline was also a predictor on ACS. Discussion: approximately 1/4 of non-malformative ICH patients has an ACS. Patients with preexisting cognitive decline are at higher risk. They require a systematic identification.

Session: Poster Session II
Date: Thursday 15 May 2008
Time: 12:30 - 14:00
Room: Agora 2


THE DYNAMIC CHANGES OF D-DIMER FOLOWING ACUTE STROKE
L. Shapir    B. Gross

Western Galilee Hospital, Naharia, Faculty of Medicine Technion Haifa Israel

ISRAEL

Background: Various coagulation abnormalities according to stroke subtypes have been reported. The true relationship between plasma D-dimer and acute stroke remains uncertain. Purpose To investigate whether systemic D-dimer activated after intracerebral hemorrhage (ICH) and after acute ischemic stroke, and whether plasma D-dimer may predict the clinical outcome. Methods: 96 consecutive patients with acute stroke were recruited. Plasma D-dimer levels were determined on admission, 24 hours, one week and 3 months after the acute event. Stroke subtype was determined by clinical presentation according to TOAST criteria and by brain CT on admission. Stroke severity was evaluated by NIHSS. Results: There is elevated average level of plasma D-dimer after stroke with return to normal range after 3 months. D-dimer levels were higher in patients with intracerebral hemorrhage than in those with infarction, patients with infarction had higher D-dimer levels than those with normal brain CT on admission (P<0.021).The percent of patients with plasma D-dimer level above the normal range on admission with ICH was higher compared to the percent of patients with brain infarction and with TIA. Average level of D-dimer was higher upon admission and after 24 hours when the infarction was due to occlusion of large vessels, and decreased when territory became smaller. In lacunar stroke, D-dimer levels increased after 7 days. All D- dimer returned to normal level after 3 months.There is a correlation between the severity of the stroke and the percent of patients with plasma D-dimer level above the normal range (p=0.039), and between mortality and the percent of patients with plasma D-dimer level above the normal range (P=0.017). Conclusions: There is an association between plasma D-dimer levels and stroke etiologies, the size of the damaged area and stroke severity during the acute event, with return of plasma D-dimer levels to the normal range at 3 months. Increased plasma D-dimer levels following acute stroke is associated with early complication and high mortality.

Session: Poster Session II
Date: Thursday 15 May 2008
Time: 12:30 - 14:00
Room: Agora 2


Increased white blood cell count during the second day of ictus is an independent predictor of stroke mortality in patients with acute ischemic stroke.
C. Bairaktaris    G. Tsivgoulis    R. Psaras     I. Heliopoulos     K. Sotiriou    K. Rallis     E. Ischaki     I. Papanastasiou

417 NIMTS, Veterans Affair Hospital, Athens

GREECE

Background: Increased white blood cell count (WBC) on hospital admission is associated with poor outcome in acute stroke patients. Levels of WBC increase during the first days of ischemic stroke and may reflect stroke severity. We performed consecutive WBC measurements during the acute stroke stage and sought to evaluate their potential correlation with stroke severity and their association with early stroke mortality. Methods: Consecutive patients with acute (<24 hours), first-ever ischemic stroke were prospectively evaluated. Stroke risk factors and baseline stroke severity were recorded in all cases. WBC was measured on the 1st and 2nd day of stroke. Functional outcome was assessed on hospital discharge and at 90 days following stroke onset using the modified Rankin Scale. Statistical analyses were performed using Spearman’s correlation coefficient (r) and multivariate logistic regression models. Results: Baseline stroke severity correlated more strongly with WBC on the second day (n=117, r=0.445, p<0.001) than with WBC on hospital admission (n=117, r=0.224, p=0.014). Higher WBC both on the 1st and 2nd day were documented in patients who were dead compared to stroke survivors at three months following stroke onset (1st day: 10.997/µL vs. 8246/µL; p=0.009 , 2nd day: 12.324/µL vs. 8080/µL; p<0.001). Both WBC on the 1st and on the 2nd day were associated with higher case fatality rate at hospital discharge and at three months following stroke onset on univariate analyses. After adjusting for baseline stroke severity, stroke risk factors and body temperature on the 1st and 2nd day of stroke, only 2nd WBC emerged as an independent predictor of stroke mortality at hospital discharge (OR: 1.77, 95%CI: 1.07-2.94; p=0.026) and at 90 days following stroke onset (OR: 1.50, 95%CI: 1.07-2.10; p=0.018). Discussion: Although both WBC on the 1st and 2nd day of stroke both correlate with stroke severity and increased stroke mortality, only WBC during the second day was an independent predictor of increased three-month stroke mortality.

Session: Poster Session II
Date: Thursday 15 May 2008
Time: 12:30 - 14:00
Room: Agora 2


THE ROLE OF EARLY PHYSICAL THERAPY IN PREVENTION OF COMPLICATIONS IN PATIENTS WITH STROKE
D. Okiljevic    O. Perisic    R. Raicevic     Lj. Markovic     M. Cukic

Military Medical Academy, Belgrade, Serbia

YUGOSLAVIA

Introduction.Especially in the acute phase, ischemic brain disease (IBD) is related to significant degree of patients immovable handicapt that provides greatest opportunity for development of various secondary bacterial infections such as pulmonary and or urinary. The aim of our study was to assess the importance of the early started physical therapy in prevention of pulmonary bacterial complications in patients with IBD. Methods. Two groups of patients with cerebral infarction were followed in our study: first (n = 70), with the early started physical rehabilitation (passive kinesitherapy and deep breathing exercises) and second (n = 40) without early rehabilitation treatment. The effects of mentioned procedures were evaluated in relation to the basic neurological and general health condition of the treated patients. Patients of both groups had nearly similar degree of ischemic brain damage. Results.In the early started physical therapy group, high fever episodes with verified bronchopneumonia were observed only in 4 patients (5,7%), while in untreated group same complications were present in 8 patients (20%). Conclusion.The present study shows that early started physical therapy can be important factor for prevention of pulmonary bacterial complications in patients with IBD.