XVII. European Stroke Conference
Nice, France
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Kind of presentation: Poster 
   
Poster Session I
Date: Wednesday 14 May 2008   Time: 12:30 - 14:00    Room: Agora 2
Chair:  
 

 
Is cerebral vasospasm the cause of “crack” cocaine-related ischemic strokes?
M.A.TAQI    E.A.GIRALDO                                                        
 

UNIVERSITY OF TENNESSEE

USA

Objective: To study the mechanism and prognosis of ”crack”cocaine-related ischemic strokes. Methods: Retrospective chart review of stroke patients admitted at the Regional Medical Center of Memphis. Results: Charts of 1219 consecutive stroke patient admitted between Jan 2001 and May 2006 were reviewed. 57 patients had ischemic stroke in the setting of recent cocaine abuse. 65% were male and the mean age was 48 years. Based on clinical and imaging findings, 75.4% had “other” stroke subtype, 8.8% had large-artery atherosclerosis, 7% had cardioembolic stroke, and 3.5% had small-artery occlusion. According to the OCSP classification of brain infarction, 72.2% had partial anterior circulation infarcts (PACI) and 20.4% had lacunar infarcts (LACI). In terms of arterial distribution, about 88% of patients had stroke in the middle cerebral artery (MCA) territory. The functional outcome scales used in the study indicate that these strokes were mild (mean admission NIHSS=5.5) except for 2 deaths and few patients with NIHSS > 18 in this group of patients. Conclusion: Strokes related to “crack” cocaine abuse are prevalent in our population. These results suggest that large or small artery diseases are not common in this cohort. CNS vasculitis although cannot be ruled out completely without brain biopsy but based on symptomatology and normal imaging findings, it is a very unlikely cause of stroke in “crack” cocaine abusers. Cardio-embolic source is another potential etiology but again none of these patients had bilateral or multifocal infarct and none of the patient had arrhythmias on telemetry, to suggest cardioembolic source as a potential cause. Based on these findings, we suggest that the most likely cause of stroke in these patients is cerebral vasospasm. This hypothesis is supported by the fact that most ischemic strokes were in the MCA distribution without evidence of arterial occlusion, and patients had mild strokes with low NIHSS, and therefore, good functional outcome without rt-PA use.

Kind of presentation: Poster 
   
Poster Session I
Date: Wednesday 14 May 2008   Time: 12:30 - 14:00    Room: Agora 2
Chair:  
 

 
Lack of association of knock-type Doppler signals (KTDS) with the presence of cerebral ischemia in the territory of the affected intracranial vessels.
G. Tsivgoulis    V.K.Sharma    B.L.Man    A.Y.Lao    HT Nguyen    K. Vadikolias    C. Piperidou    C. Bairaktaris    A.W.Alexandrov    A.V.Alexandrov
 

Comprehensive Stroke Center, University of Alabama at Birmingham Hospital, Birmingham, Alabama

USA

Background: Knock-type Doppler signals (KTDS) are detectable by TCD and it has been hypothesized that they are related to an occlusion of a small perforating artery and microvascular ischemia. However, the nature of KTDS has not been prospectively defined. We aimed at describing the spectral and power motion Doppler characteristics of KTDS and evaluating their potential association with cerebral infarction or microvascular ischemia in the territory of the affected intracranial vessels. Methods: Consecutive patients referred with symptoms of stroke or transient ischemic attacks to our cerebrovascular ultrasound laboratory were screened for the presence of KTDS. The presence of microvascular ischemia (hyperintense signal shown in the first and second echo images with sharp margins, <2.5 cm in diameter, located in the deeper structures and irrigated by penetrating branches) was assessed using brain MRI. Statistical analyses were performed by univariate and multivariate logistic regression models. Results: Among 327 patients with cerebrovascular symptoms, 46 (14%) had KTDS. KTDS was detected more frequently in posterior circulation vessels [VA, BA, PCA; 2.6% (42/1635)] than in the anterior circulation arteries [ACA, MCA, TICA; 0.5% (9/1962); p<0.001]. The frequency of KTDS was similar in patients with stroke (13%) and TIA (19%, p=0.312). The frequency of KTDS did not differ between patients with or without brain ischemia in the distribution of VA (p=0.607), BA (p=0.429), PCA (p=0.457) and MCA (p=1.000). There was no association between ultrasound identification of KTDS and the presence of brain ischemia in the distribution of any vessel (OR:0.37, 95%CI: 0.09-1.53, p=0.171) on univariate logistic regression analyses. KTDS was not related to the presence of microvascular ischemia on brain MRI (OR:1.12, 95%CI: 0.55-2.29, p=0.761). Discussion: Although KTDS can be distinguished from other spectral flow signals, they can be found in normal vessels, do not seem to be associated with the vessel affected by ischemia and should not be over-interpreted.

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

 
Human stroke promotes an anti-inflammatory phenotype on monocytes with expansion of CD14++CD16+ monocytes
X. Urra    A.  Cervera    N. Villamor    A.M.Planas    A. Chamorro                                   
 

Hospital Clínic Barcelona

SPAIN

Background. Stroke may increase the number of circulating monocytes but their phenotype and function is unknown. We sought to study monocyte subpopulations and their phenotype after human stroke. Methods. Flow cytometry was serially used in 12 healthy controls and in 42 stroke patients to assess monocyte subpopulations including classical CD14++CD16-, resident CD14dimCD16+ (strong producers of TNF-a) and mixed CD14++CD16+. Surface expression of HLA-DR, co-stimulatory CD86, scavenger receptor CD163, proangiogenic angiopoietin 2 receptor Tie-2, and intracellular production of TNF-a and IL-10 after lypopolisacharide stimulation (LPSE) were correlated with clinical course (NIHSS score), incidence of infections, and modified Rankin Scale (mRS) at 3 months. Results. Overall, stroke resulted in increased count of monocytes (p=0.03) characterized by a reduction of CD14dimCD16+ (p<0.001) and an increase of CD14++CD16+ (p<0.001) which expressed the highest levels of CD163 and Tie-2. Stroke was followed by a decrease of HLA-DR (P<0.001) and a reduced production of TNF-alpha (p=0.001) but not IL-10. These findings predominated in the 14 patients who developed infections, who also had lower levels of CD86 (p=0.04). Decreased production of IL-10 after LPSE was associated with poorer mRS (p=0.04). Discussion. Ischemic stroke drives a monocytic response characterized by an anti-inflammatory phenotype and promotion of tissue repair and angiogenesis. Whereas this response may favour the appearance of infection it is associated with increased neurological recovery.

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

19
Inflammatory Response after Occlusion-Reperfusion-Injury to the Brain
F. Leypoldt    M. Gelderblom    K. Steinbach    E. Tolosa    T. Arumugam    C. Gerloff    R. Martin    T. Magnus              
 

Experimental Research in Stroke and Inflammation (ERSI) Department of Neurology, University Hospital Hamburg-Eppendorf

GERMANY

schemic stroke is a devastating disease that represents the third leading cause of death in the western world. Early restoration of blood flow remains the treatment of choice for limiting brain injury following stroke but reperfusion of the ischemic brain can augment the inflammatory response that may cause additional injury to the cerebral microcirculation and adjacent brain tissue. Post-ischemic inflammation is a dynamic process involving a complicated spatially and temporally regulated interaction among various inflammatory cells and molecules. Objectives: The elucidation of the temporal distribution of inflammatory cell influx into the brain and their pattern of activation after ischemic stroke is not well characterized. Although T-cells have been shown to be an essential part of the post-ischemic tissue damage, not much is known about the dynamics of antigen presenting cells, e.g. dendritic cells, monocytes and resident microglia in this setting. Methods: The temporal distribution and activation patterns of different inflammatory cells after temporal middle cerebral artery occlusion (tMCAO) in mice was examined by whole brain FACS characterization of CD3, CD4, CD8, CD45, B220, CD11b, CD11c, NK1.1 and activation markers such as CD69, CD25, MHCII, B7-1 and B7-2. Results: Beginning 6 hours after tMCAO and peaking at 72 hours a strong ipislateral but not contralateral increase in activated dendritic cells was observed. In parallel, CD4 and CD8 positive lymphocytes appeared ipis- and contralateral after 12 hours and peaked at 72 hours. Conclusion: After experimental stroke, there is a significant increase in specialized antigen presenting cells ipislateral in the brain. These seem to communicate with other invading inflammatory cells such as lymphocytes. The further characterization of the molecular mechanisms and modulation of these could provide valuable insights into regulation of postischemic inflammation. These analyses might eventually allow the therapeutic shaping of the immune response towards a more restorative response rather than towards a detrimental immune response.

Kind of presentation: Poster 
   
Poster Session I
Date: Wednesday 14 May 2008   Time: 12:30 - 14:00    Room: Agora 2
Chair:  
 

 
Magnetic resonance-guided [18-F] fluorodeoxyglucose positron emission tomography in human carotid and vertebral arteries. Comparison of methods, reproducibility and partial volume correction
D. IZQUIERDO-GARCIA    J.R.DAVIES    M.J.GRAVES    J.H.F.RUDD    J.H.GILLARD    P.L.WEISSBERG    T.D.FRYER    E.A.WARBURTON              
 

WOLFSON BRAIN IMAGING CENTRE UNIVERSITY OF CAMBRIDGE

UNITED KINGDOM

Background Inflammation is a major risk factor for atherosclerotic plaque rupture and clinical events. Previous studies have shown that 18F-fluorodeoxyglucose (FDG) using positron emission tomography (PET) is able to identify inflamed plaques in stroke patients with carotid and vertebral disease. In this study we examined the reproducibility of three methods of quantifying plaque FDG uptake in the carotid and vertebral arteries using PET: vessel wall to blood ratio (VBR), standardized uptake value (SUV) and influx rate (Ki). The correlation between the two simplified uptake parameters (SUV and VBR) and the gold standard technique (Ki) was determined. We used magnetic resonance imaging (MR) to correct carotid plaque FDG uptake for partial volume error. Methods 7 patients with a recent carotid territory transient ischaemic attack were imaged twice within 8 days using MR and FDG-PET. Regions of interest were delineated on MR and PET was coregistered to MR to determine plaque FDG uptake and facilitate partial volume correction (PVC). Results SUV and VBR were the most reproducible measures for carotids (mean absolute inter-scan difference 5.7% and 6.4% respectively) and vertebrals (7.9%, 9.5% respectively). VBR correlated better to Ki than SUV for both the carotids (r=0.58 VBR, r=0.35 SUV) and vertebrals (r=0.96 VBR, r=0.68 SUV). PVC improved the correlation for carotid plaque to r=0.81 for VBRPVC and r=0.67 for SUVPVC. However, PVC also degraded reproducibility: SUVPVC was the most reliable measure after PVC (mean absolute % difference: 10.5%; SD: 11.6%, ICC: 0.84). Discussion MR-guided FDG PET is a highly reproducible technique for quantifying plaque inflammation in both the carotid and vertebral artery territories. SUV and VBR have similar reproducibility but VBR correlates better with influx rate. The excellent anatomical detail provided by MR facilitates PVC, which improved the correlation between the simplified methods and influx rate. A key area where this technique can be applied is proof of principle studies of plaque stabilising agents.

Kind of presentation: Poster 
   
Poster Session I
Date: Wednesday 14 May 2008   Time: 12:30 - 14:00    Room: Agora 2
Chair:  
 

 
Vascular assessement of acute posterior circulation cerebral ischemia with power motion Doppler.
G. Tsivgoulis    V.K.Sharma    HT Nguyen    A.Y.Lao    A. Robinson    I. Heliopoulos    C. Bairaktaris    C. Piperidou    A.A.Ardelt    A.V.Alexandrov
 

Comprehensive Stroke Center, University of Alabama at Birmingham Hospital, Birmingham, Alabama

USA

Background: Evaluation of posterior cerebral circulation (PoCC) with single-channel transcranial Doppler (TCD) is technically challenging and less accurate in comparison with anterior circulation. Power Motion-Mode TCD (PMD-TCD) simultaneously displays spectral information, real-time flow signal intensity, and direction over 6 cm of intracranial space. We evaluated the diagnostic accuracy of PMD-TCD compared to angiography in detecting acute PoCC steno-occlusive disease. Methods: Consecutive patients presenting to the emergency room with symptoms of acute (<24 hours) cerebral ischemia underwent emergent (<48 hours) neurovascular evaluation with PMD-TCD and angiography (CTA, MRA or DSA). Previously published diagnostic criteria were prospectively applied to PMD-TCD interpretation independent of angiographic findings. Results: A total of 213 patients (119 men; mean age 65±16years; ischemic stroke 71%, TIA 29%) underwent emergent neurovascular assessment. Compared to angiography, PMD-TCD showed 17 true-positive, 8 false-negative, 6 false-positive and 182 true-negative studies in the PoCC [sensitivity 73% (55%-91%), specificity 96% (93%-99%), PPV 68% (50%-86%), NPV 95% (92%-98%), accuracy 93% (90%-96%)]. In 82% of true positive cases, PMD display showed flow signatures complementary to the spectral display: reverberating or alternating flow, distal basilar artery flow reversal, high-resistance and bruit flow signatures. In 8% of the population, PMD showed findings complementary to CTA/MRA: flow reversal in the distal vertebral artery (VA) with proximal intracranial VA occlusions, real-time embolization distal to a steno-occlusive artery, blunted flow signals throughout the intracranial VA with severe extracranial steno-occlusive disease, and alternating PMD signals indicating subclavian steal phenomenon. Discussion: PMD-TCD has good agreement with angiography in evaluating acute PoCC ischemia. PMD display can depict flow signatures that are complementary to.

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

02
Symptoms associated with fatigue in patients with stroke and TIA
S.M.Walsh    M. Martin    N. Dooley    J.A.Harbison                                          
 

Department of Medical Gerontology, Trinity College Dublin

IRELAND

Introduction: Whilst a variety of symptoms are associated with fatigue in neurological diseases, those characteristic of post stroke fatigue have not been defined. Methods: A 25 item questionnaire of possible associations of post stroke fatigue was developed based on a literature review and patient interviews. A 5 point Likert scale of frequency of symptoms ranging from ‘never’ to ‘always’ was provided for each item. Correlations were determined between items and with the Fatigue Severity Score (FSS) for each subject. Subjects were recruited from a secondary prevention clinic. All were independent (modified Rankin Score <3) and had suffered a TIA or Stroke in the preceding 12 months. Results: 40 subjects were studied (35% Male, median 74years). Symptoms most frequently reported as occurring ‘often’ or ‘always’ in the population were early morning waking (55%), forgetting things (35%), mind working slowly (33%) problems falling asleep (33%), waking frequently at night (33%), lack of energy (30%) and muscle pain (26%). FSS correlated with muscle pain (r=0.425, p=0.09) and muscles feeling weak (r=0.470, p=0.003) reflecting the emphasis of the FSS on limitation of physical activity by fatigue. The frequency scale for ‘I feel physical fatigue’ correlated with 20 of the 24 other items, including anxiety (r=0.748, p<0.0001), shortness of breath (r=0.666, p<0.0001), lack of energy (r=0.644, p<0.0001), headache (r=0.505, p=0.001), problems falling asleep(r=0.547, p<0.0001), waking frequently at night (r=.540, p<0.0001), muscle pain (r = 0.477, p=002) and muscle weakness. (r=0.386, p=.014). Conclusion: Symptoms associated with fatigue are diverse, with myalgia and presence of sleep disorders being both highly prevalent and highly correlated with physical fatigue.

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

 
Outcome and characteristics of transient monocular blindness in SOS-TIA clinic.
L. Cabrejo    J. Labreuche    P.C.Lavallee    E. Meseguer    M. Mazighi    T. Slaoui    H. Abboud    I.F.Klein    P.J.Touboul    P. Amarenco
 

INSERM-U698 and Denis Diderot University-Paris VII

FRANCE

Background To describe characteristics of transient monocular blindness (TMB) in a TIA clinic and to evaluate the 90-day stroke risk. Methods 1,085 consecutive patients with a suspicion of TIA were admitted to the SOS-TIA clinic with round-the-clock access, immediate evaluation lasting <4 hours, and immediate multifactorial therapeutic interventions. In 643 patients with definite TIA, we compared clinical features, carotid duplex ultrasonography and 90-day stroke rate between patients with TMB and those with cerebral TIA. Results 110 patients (17%) had TMB. Compared to patients with cerebral TIA, TMB patients were younger (mean age 62 vs. 67, p<0.01), and had less cardiovascular risk factors, especially diabetes mellitus (5% vs. 71%, p<0.05), shorter duration of symptoms. (≤ 5 minutes, 69% vs. 32%, p<0.001), and more often had an unknwon underlying cause (67% vs. 51%, p<0.01). Internal carotid artery (ICA) atherosclerosis (plaques with and without lumen stenosis or occlusion) was less frequent in TMB group (49% vs 68%, p=0.01), except for severe ICA atherosclerosis (stenosis ≥70% or occlusion) detected in 11% (n=12) of TMB patients and in 7% (n=36) of patients with cerebral TIA (p=0.08). As part of multifactorial treament intervention, 8% (n=9) of TMB patients had a carotid endartectomy. Within 90-days from examination, there were no stroke in TMB patients and 12 (2.2%) in patients with cerebral TIA. The mean 90-day stroke rate expected from ABCD² score was 2.5% in TMB patients and 7.2% in patients with cerebral TIA. Discussion Among patients with definite TIA, 17% had TMB. One patient in 12 with TMB were elligible for carotid endarterectomy. Patients with TMB had better prognosis than patients with cerebral TIA.

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

08
An Analysis of Readmissions following Stroke
D. CHAN    O DSOUZA    M GARGET    L WHITEHEAD    SKMUNSHI                                   
 

Nottingham University Hospitals, Nottingham

UNITED KINGDOM

Background: Hospital readmissions following stokes are expensive in terms of costs and poor clinical outcome. Very little data are available on the burden of readmission after stroke. We analysed the reasons and rates of readmission in our stroke patients. Methodology: Readmission rates for patients discharged from five stroke wards between 1st Jan 2006 and 31st Dec 2006 were calculated at 28 days and at one year of discharge. Reasons for readmission were analysed, with special emphasis on whether these could have been prevented prior to the initial discharge. We used descriptive statistics to summarise the baseline characteristics of the cohort and proportions to describe the rates and causes of hospital readmission at 28 days and 1 year after the index stroke. Results: Out of 1449 patients discharged from the stroke units (mean age 78.1 years) 117 (8.1%) were readmitted within 1 year, with 30 (25.6%) of those getting readmitted in the first month after discharge. Chest infections accounted for a large proportion of readmissions, 24 % at 28 days and 18 % at one year. Urinary tract infections, C. difficile diarrhoea and cellulitis accounted for about 10 % of readmissions in the year after discharge, stroke related complications (seizures, dementia and pressure sores) accounted for 14 %, mobility problems, carer stress and breakdown of care package in 7 %, restroke in 9 % , myocardial infarction in 4.1 %, falls and fractures in 4% and drug related complications in 5%. Mortality rates among patients who were readmitted were 18.8 % at 6 months and 32 % at one year. Conclusion: The most common reasons for readmission could have been prevented by the establishment of good post-discharge care. Readmissions are expensive and associated with high mortality. Community based multidisciplinary input could prevent readmissions. Recurrent stroke prevention alone is not enough if we are to reduce our public health burden of stroke readmissions.

Kind of presentation: Poster 
   
Poster Session I
Date: Wednesday 14 May 2008   Time: 12:30 - 14:00    Room: Agora 2
Chair:  
 

 
Prevalence and possible risk factors for anosmia after aneurysmal subarachnoid hemorrhage treated with coiling: an observational cohort study
A.S.E. Bor    S.L.Niemansburg    M.H.M. Wermer    G.J.E. Rinkel                                          
 

Rudolf Magnus Institute of Neuroscience, University Medical Center Utrecht

THE NETHERLANDS

Background: Anosmia has an important impact on daily life, yet usually receives little attention from physicians. Anosmia has frequently been reported in patients after aneurysmal subarachnoid hemorrhage (SAH) treated with clipping. Recently it was found that patients with SAH treated with coiling may experience anosmia as well. The pathogenesis of anosmia after coiling is unknown. In an observational cohort study we analyzed prevalence and possible risk factors for anosmia after coiling for SAH. Methods: We interviewed all patients with SAH treated with coiling between 1997 and 2007 who had resumed independent living on loss of smell. Data on localization of the ruptured aneurysm, neurological condition on admission, hydrocephalus and treatment for hydrocephalus were retrieved from medical records. CT-scans on admission were analyzed for bicaudate index, amount of blood in the fissura interhemispherica and total amount of subarachnoidal blood. Risk factors were assessed by logistic regression analysis. Results: Overall, 197 patients were included, of whom 35 experienced anosmia (17.8%, 95%CI 12.4-23.1). Anosmia improved in 23 of the 35 (66%) patients; in 20 of them the recovery was complete. For 161 of the 197 patients the CT-scan on admission was available for assessment. None of the possible risk factors was statistically significant related to the occurrence of anosmia. Discussion: One in six SAH patients in whom the ruptured aneurysm is treated with coiling experiences anosmia. Anosmia after coiling has a good prognosis. The exact pathogenesis of anosmia after coiling remains unknown. There seems to be no relation with the amount or localization of subarachnoid blood or with the presence of hydrocephalus.

Kind of presentation: Oral 
Acute stroke: complications and early outcome  
 
Date: Thursday 15 May 2008   Time: 11:50 - 12:00    Room: Rhodes
Chair: G. Özdemir, Turkey and J. Norris, United Kingdom
 

09
STROKE PATIENTS WITH AND WITHOUT EARLY POSTSTROKE SEIZURES (EPS): DIFFERENCES IN NITRERGIC AND PROTEOLYTIC INDICES IN CEREBROSPINAL FLUID (CSF)
A. Guekht    N. Gulyaeva    I. Khaimovsky    A. Lebedeva    M. Onufriev    L. Brylev    E. Gusev                     
 

Russian State Medical University, Inst. of Higher Nervous Activity&Neurophysiol., RAS, Moscow

RUSSIAN FEDERATION

Background and purpose: EPS occur in 5-10% of all stroke patients and have deleterious impact on stroke outcome. EPS are associated with excessive neuronal excitability. The objective of the study was to compare neurochemical indices related to nitrergic system and major proteases executing neuronal cell death in CSF of patients with and without EPS. Methods: Twenty six patients with first-ever acute ischemic stroke were investigated: 14 - with and 12- without EPS. Groups were similar in age, gender, NIHSS values. NOx levels were measured using a fluorescent probe diaminonaphtalene. Proteolytic activities were assayed fluorometrically using specific substrates for caspase-3, calpain, and cathepsin B. Results: No increase in NO metabolites (NOx) level in CSF characteristic for acute stroke (5.5+/- 0.64 vs. 2.2+/- 0.43 µmol/l in controls, P=0.01) could be detected in EPS patients (2.6+/- 0,40 µmol/l). While no difference in cathepsin B-inhibiting CSF activity could be revealed between two stroke groups, the calpain-inhibiting activity was more expressed in EPS patients (45.6+/- 1.9% of residual activity vs. 56.4+/- 2.9%, P<0.05 ), while caspase-3-activating activity was more significant in CSF of patients without EPS (132.5+/- 4.7% vs. 115.5+/- 3.3, P<0.03) Discussion: The excessive generation of NO characteristic for ischemic brain is regarded as one of significant neuroprotective factors. We assume that EPS are related to the impaired ability of the brain to urgently increase NOS activity in response to an ischemic situation. The CSF of patients with EPS demonstrates higher ability to inhibit major cell death-related proteases (calpain and caspase-3) suggesting a higher risk for ischemia-induced neurodegeneration in these patients. Supported by RHSF grants

Kind of presentation: Poster 
   
Poster Session II
Date: Thursday 15 May 2008   Time: 12:30 - 14:00    Room: Agora 3
Chair:  
 

 
Gender Differences in Thrombolytic Treatment for Ischemic Stroke The SITS-MOST patients
A. Falcou    A. Niaz    S. Lorenzano    E. Puca    N. Wahlgren    M. Prencipe    D. Toni                     
 

Unità di Trattamento Neurovascolare Università La Sapienza Rome Italy

ITALY

Background The natural history of stroke shows that women have a worse outcome than men, whereas they could benefit from a better response to thrombolytic treatment with higher recanalization rate and better functional outcome. The hypotheses to explain this apparent influence of sex are multiple (size arteries, hormonal and coagulative factors). We analyzed the cohort of the Safe Implementation of Thrombolysis in Stroke Monitoring Study (SITS-MOST) in order to determine whether gender has an influence on response to intravenous rt-PA treatment for acute ischemic stroke. Methods We conducted comparisons between genders through univariate analyses of baseline characteristics (age, previous mRS, vascular risk factors, glycemia, NIHSS, blood pressure), time intervals to treatment, and outcome parameters (mRS, death, SICH, cause of death), obtained in the SITS-MOST patients. Results From December 2002 to April 2006, 3.902 men and 2.581 women have been included in the trial. The analysis of baseline characteristics shows statistically significant differences for median age (64,9 for men, 66,64 for women; p = 0,0000), diastolic blood pressure (83,4 in men, 81,1 in women; p = 0,0000), and NIHSS (12,5 in men, 13 in women; p = 0,001). As regard risk factors, there were significant differences in hypertension (p = 0,002) and AF (p = 0,0000), more frequent in women, and in smoke (p = 0,0000) and hyperlipidemia (p = 0,0000), more frequent in men. Outcome parameters revealed a significantly better functional prognosis in men (mRS 0-2: 56,2% vs. 52,8%; p = 0,008), not due to mortality nor hemorrhagic complications. Discussion These analyses confirm data learned in literature: stroke women are older, have a more severe deficit, and suffer more often from atrial fibrillation. Moreover, our study demonstrates that functional outcome after thrombolysis is better in men, following the natural history. The very large sample size can reasonably exclude the role of chance in these results. We conclude that there is no difference to thrombolysis response between genders.

Kind of presentation: Oral 
Experimental studies I  
 
Date: Thursday 15 May 2008   Time: 12:25 - 12:35    Room: Euterpe
Chair: M. Fisher, USA and O. Lindvall, Sweden
 

11
DIFFERENT INJURY MECHANISMS ARE ACTIVATED AFTER CEREBRAL ISCHEMIA DEPENDING ON THE OCCURRENCE OF REPERFUSION.
M. Gutiérrez    I. Ayuso    M. Salinas    E. Díez Tejedor    J. Masjuan    M. Alonso de Leciñana                            
 

Neurology and*Biochemistry-Investigat Ramón y Cajal Hosp. **Cerebrovasc Research, La Paz Hosp

SPAIN

Background and aims Different injury mechanisms might be responsible of ischemic cerebral damage depending on the occurrence of reperfusion. We study activation of calpain, implicated in necrosis, and caspase-3 in apoptosis, in a model of permanent or transient focal cerebral ischemia. Materials and methods Long- Evans rats were subjected to permanent middle cerebral artery occlusion for 5min (n=4), 30min (n=4), 1h (n=5), 3h (n=4), 72h (n=6), to transient occlusion for 1h followed by different reperfusion periods: 2h (n=3), 23h (n=3) and 72h (n=3), or to different duration of ischemia 1h (n=3), 3h (n=3), 24 h (n=3) followed by reperfusion up to 72 hours of survival. Samples were obtained from the cortex at the infarct core, the penumbra and from symmetrical areas in the contralateral hemisphere. Inmunoblots for espectrin degradation in its specific fragments of 120 KDa by caspase and of 145 KDa by calpain as well as cleavage of eIF4G were used to investigate activation of apoptosis and necrosis respectively. Results After 1 hour of permanent ischemia maximal calpain activation was observed at the infarct core while it was lower at the penumbra. There was no caspase activation. Reperfusion did not avoid calpain activation, but produced caspase activation that was greater in the core than in the penumbra. Conclusions Calpain activation causes necrotic death in permanent or transient focal cerebral ischemia, while caspase activation (i.e. apoptosis) is only present if reperfusion occurs. This indicates that reperfusion triggers additional injury mechanisms that should be specifically inhibited to ensure effective neuroprotection after reperfusion.

Kind of presentation: Oral 
Acute stroke: treatment concepts I  
 
Date: Wednesday 14 May 2008   Time: 8:50 - 9:00    Room: Clio/Thalie
Chair: W.D. Heiss, Germany and P. Trouillas, France
 

03
Thrombolysis in young patients: the SITS-MOST data.
A. Anzini    A. Niaz    L. Durastanti    N. Wahlgren    M. Prencipe    D. Toni                            
 

Unità di Trattamento Neurovascolare Università La Sapienza Rome Italy

ITALY

Background and purposes: data from the NINDS t-PA trial show that younger patients benefit more from thrombolytic treatment than older ones when adjusted for stroke severity. Aim of this study is to compare the response to i.v. thrombolysis of patients aged 18 to 45 years to that of older ones, who were treated in Safe Implementation of Trombolysis in Stroke Monitoring Study (SITS-MOST). Subjects and Methods: Clinical and radiological data of patients were collected before treatment and in acute and 3 month follow-up. In SITS-MOST, primary outcome measures were symptomatic intracerebral haemorrhage (SICH) and 3-month mortality rate. A secondary outcome was functional independence at 3 months (modified Rankin score 0-2). Additional outcome measures were SICH according to Cochrane/NINDS definition and ECASS criteria and a complete recovery (mRS 0-1) at 3 months. Results : Of 6483 patients, 412 (6,4%) were aged ≤ 45 and 6071 (93,6%) were over 45. Median baseline NIHSS score did not differ between the two age subgroups. At the univariate analysis, age ≤ 45 is significantly associated with a decreased rate of SICH, according to Cochrane/NINDS definition (4,1% vs 7,5%; p < 0.001) and a lower 3-month mortality rate (5,5% vs 11,7%; p < 0.001). Cerebral infarction was the most common cause of death (77,3%) in the younger patients. Functional independence was reported in 76 % and 53 % of patients in the two age subgroups (p < 0,001), while a complete recovery was observed respectively in 54 % and in 38 % of patients (p < 0,001). Conclusions: Our data confirm that outcomes are better in young ischemic stroke patients compared to older ones after treatment with intravenous t-PA. However, a more detailed critical analysis of indicators that might predict outcome and/or different response to intravenous thrombolysis between the two age subgroups is warranted.

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

 
The Significance of Blood Pressure Variation for the Development of Hemorrhagic Transformation in Acute Ischemic Stroke
Y. Ko    J.H.Park    M.H.Yang    S.B.Ko    M.K.Han    C.W.Oh    S.H.Park    J. Lee    H.J.Bae       
 

Seoul National University Bundang Hospital

SOUTH KOREA

Background: It is known that high blood pressure (BP) provokes hemorrhagic transformation (HT) of cerebral infarction and may contribute to its poor prognosis. However, BP is a very dynamic and complex phenomenon, especially in acute stage of stroke, and high BP itself may not be enough to explain the contribution of BP to HT. This study was aimed to elucidate the various aspects of BP, which were measured and defined in several ways, with respect to the risk of HT. Method: Based on the prospective stroke registry, the consecutive series of stroke patients who were hospitalized from 2004/1 to 2007/8 within 24 hour from onset and had relevant ischemic lesions on MRI were selected. Among them, those with no HT on initial MRI were recruited in this study and their BP measurements during the first 72 hours were gathered. Mean, standard deviation (SD), maximum, minimum, difference between maximum and minimum (DF1), maximum difference between successive BP measurements (DF2), and its variation (SV) were defined and calculated. With respect to HT on the follow-up images during 2 weeks after onset, the odd ratio (OR) of those parameters were calculated adjusting initial systolic BP (SBP) and other potential confounders. Results: Among 863 patients who met the eligibility criteria, 70 (8.1%) showed HT on follow-up images. The mean (adjusted OR, 1.25; 95% confidence interval, 1.02 to 1.53 per 10 mmHg), maximum (1.32; 1.13 to 1.54), DF1 (1.15; 1.04 to 1.28), and DF2 (1.10; 1.03 to 1.18 per 5 mmHg) of SBP were independent predictors of HT respectively. The statistical significance of the maximum, DF1, and DF2 did not change despite additional adjustment for the mean SBP. The analyses on diastolic BP also showed similar results. Conclusions: This study suggests that most parameters reflecting BP variation can contribute to HT of ischemic stroke independent of the initial and mean BP during the first 3 days. To prevent HT, we may pay attention not only to the absolute value of BP but also to its variation.

Kind of presentation: Oral 
Vascular - and Neurosurgery/Interventinal Neuroradiology  
 
Date: Friday 16 May 2008   Time: 9:40 - 9:50    Room: Erato/Uranie
Chair: R. Ackerman, USA and H. Sillesen, Denmark
 

11
The Effect Of Antiplatelets During Or After Endovascular Coiling For Aneurysmal Subarachnoid Haemorrhage
W.M.van den Bergh    R.S.Kerr    A. Algra    G.J.Rinkel    A.J.Molyneux                                   
International Subarachnoid Aneurysm Trial (ISAT) Collaborative Group

University Medical Centre Utrecht

THE NETHERLANDS

Background Antiplatelets (APTs) are often used during or after endovascular coiling of aneurysms in patients with subarachnoid haemorrhage (SAH). There is, however, no evidence that APTs improve outcome in these patients. Methods All 43 centres in the International Subarachnoid Aneurysm Trial (ISAT), comparing endovascular coiling with neurosurgical clipping in patients with ruptured intracranial aneurysms, were sent a questionnaire whether they never, sometimes or always used APTs during or after coiling. Risk ratios (RR) for coiling compared with clipping for poor outcome after 2 months and 1 year were calculated. These RRs were calculated separately for patients treated in hospitals that always used APTs during or after coiling and in patients treated in hospitals that used APTs never or sometimes. Results Nineteen centres responded, representing 1422 (66%) of the 2143 patients randomised in ISAT. Standard prescription of APTs during coiling was done in two responding centres (8% of coiled patients), whereas it was done after coiling in 6 centres (24%). The overall RR for poor outcome of coiling versus clipping was 0.67 (95% CI 0.57-0.79) after two months and 0.74 (0.62-0.89) after one year. For two months’ outcome RR was 0.82 (0.45-1.49) in hospitals that always used APTs during coiling versus 0.66 (0.55-0.78) in those that never or sometimes used APTs (ratio of RR’s 1.24, p=0.56). Similar observations were made for APT use after coiling. The ratio of RRs for one-year outcome was 1.01 (p=0.89) for APT use during coiling and 1.00 (p=0.77) for use after coiling. Conclusion The results of this study do not support the assumption that APTs during or after endovascular coiling improve outcome in patients with aneurysmal SAH.

Kind of presentation: Oral 
Brain Imaging: new developments    
 
Date: Thursday 15 May 2008   Time: 12:10 - 12:20    Room: Calliope
Chair: J.-C. Baron, United Kingdom and N. Nighoghossian, France
 

11
Performance of MRI based cerebral blood flow maps in early stroke compared to 15O-water positron emission tomography: threshold analysis and influencing factors
J. Sobesky    O. Zaro Weber    W. Moeller Hartmann    W.D.Heiss                                          
 

Unversity of Cologne

GERMANY

Background: The accuracy of perfusion weighted magnet resonance imaging (PW-MRI) based maps of cerebral blood flow (mriCBF) remains a matter of debate. We validated mriCBF on quantitative CBF measurement by 15O-water positron emission tomography (petCBF) with respect to penumbral flow (<20 ml/100g/min). Methods: In acute and subacute stroke patients, mriCBF and petCBF maps were compared. In a volumetric analysis, the performance of predefined mriCBF thresholds (<40,<30,<20,<10 ml/100g/min; quantitative analysis with arterial input function) was assessed using the volume of penumbral flow on PET as the target volume. The degree of congruence was expressed as the ratio C (C= Volume mriCBF / Volume petCBF). The influence of vessel pathology, hypoperfusion size and time point of imaging was described. Results: In 24 stroke patients (median time MRI to PET: 68 minutes; 16 patients imaged within 24 hours after stroke) the median volume of penumbral flow (petCBF) was 78.5 ccm. On visual inspection, an excellent qualitative congruence was found.for mriCBF. In the pooled analysis, mriCBF <20ml/100g/min best identified penumbral flow (median C-ratio: 1.0) but showed a wide interindividual range (C-ratio 0.3 to 3.5). Ipsilateral vessel pathology, time point of imaging and size of penumbral hypoperfusion did not significantly influence the C-ratio. Discussion: CBF maps using a threshold of <20 ml/100g/min well identified penumbral flow. However, a considerable interindividual variance was found and could not be explained by routine clinical data. Our results strongly support the validity of MRI based CBF measurement in clinical routine but they also underline the need of a further specification of the MRI based mismatch concept.

Kind of presentation: Poster 
   
Poster Session II
Date: Thursday 15 May 2008   Time: 12:30 - 14:00    Room: Agora 3
Chair:  
 

 
Evaluation of an intravenous (IV) insulin infusion associated with 0.9% NaCl perfusion in acute ischemic stroke
M. Bruandet    S. Deltour    S. Crozier    M. Lejeune    M. Zuber    Y. Samson                            
 

Urgences cérébro-vasculaires, groupe hospitalier Pitié-Salpétrière

FRANCE

Background and purpose: Early hyperglycemia is associated with poor outcome of stroke. We report the safety and biological efficacy of a predefined IV insulin protocol for acute ischemic stroke patients. Methods: Fifty-four consecutive patients with middle cerebral artery infarct admitted in stroke critical care unit within 6 hours of stroke onset were treated between April 2003 and May 2004 by insulin IV infusion. Infusion started as soon as possible after NIHSS, blood sampling, MRI, and the beginning of tPA infusion, if ever done. Insulin was infused in 0.9 % saline with an electric pump during 24 hours with hourly adjustment to capillary glucose level (CBG), according to a normogram starting at 1 UI/h above 100 mg/dl, up to 4 UI/h above 310 mg/dl. Results: The 54 patients had a median age of 59 years (IQR: 48-70) and the median baseline NIHSS was 16 (IQR: 12-20). Six patients (11%) were previously identified as diabetics. Thirty five patients (65%) were thrombolysed. Insulin protocol was started with a median delay of 195 minutes (IQR: 150-255) after stroke onset. The median initial CBG was 117 mg/dl (IQR: 104-138), and decreased to 111 mg/dl (IQR: 98-123) at 3 hours. Only one asymptomatic hypoglycemia below 67 mg/dl was observed. Three variables were independent predictors of mRs at 3 months: initial NIHSS (p<0.0001), recanalization status (p=0.0111) and mean CBG level between the fourth and sixth hours (CBG 4-6) (p<0.0001). A discriminant analysis showed that good outcome (mRs 0-2) was significantly more frequent when GBC 4-6 was ≤ 111 mg/dl (72 vs 19% of patients, p<0.0001). The 111 mg/dl threshold was achieved for the 4-6 hour slot in 67% of patients, but in only 2% of those with known diabetes. Conclusion: These preliminary data suggest an acceptable safety profile of this IV insulin protocol, when used in a dedicated critical care stroke unit. The toxicity threshold of glucose levels may be close to normoglycemia (111 mg/dl), and this goal was achieved at the 4-6 hour slot with the current protocol in 67% of consecutive acute MCA infarct patients.

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

 
PATTERNS OF BRAIN ARTERIOVENOUS MALFORMATION TREATMENT: PROSPECTIVE, POPULATION-BASED STUDY
J. van Beijnum    J.J.Bhattacharya     C.E.Counsell     V. Papanastassiou     V. Ritchie    R.C.Roberts    R.J.Sellar     C. Warlow     R. Al-Shahi Salman       
 

Division of Clinical Neurosciences, University of Edinburgh, Western General Hospital, Edinburgh

THE NETHERLANDS

Background – Only North American guidelines concerning the interventional treatment of brain arteriovenous malformations (AVMs) have been published. For comparison, we explored patterns of treatment at four neuroscience centres in one European country. Methods – We included every participant with an AVM in a prospective, population-based cohort study of Scottish residents, aged ≥16 years, at the time of their AVM diagnosis in 1999-2003 inclusive. Results – Patients who were managed at one of the four neuroscience centres in the population were significantly younger (median 47 versus 70 years, p = 0.002) and more likely to have symptomatic AVMs (odds ratio [OR] 3.8, 95%CI 1.1 to 13.2) than those who were not referred. The only difference between all the patients seen at the four centres was in AVM Spetzler-Martin grade (p=0.04). Patients who received interventional treatment were younger (median 43 versus 54 years, p = 0.0000005), more likely to have presented with haemorrhage (OR 2.8, 95%CI 1.6 to 4.9), and had smaller AVMs (median 2cm versus 3cm, p = 0.003) than those who were not treated. The four centres differed significantly in the Spetzler-Martin grade of the AVMs they treated (p = 0.002), and the interventional treatments used (p = 0.004). Discussion – Patient characteristics and patterns of interventional treatment for AVMs differ between neuroscience centres in the same population, necessitating careful consideration of these factors when comparing one hospital’s outcome with another.

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

 
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.

Kind of presentation: Oral 
Longterm outcome of stroke  
 
Date: Thursday 15 May 2008   Time: 17:40 - 17:50    Room: Rhodes
Chair: T. Karapanayiotides, Greece and J. Röther, Germany
 

08
Long-Term Follow-Up after Suboccipital Decompressive Craniectomy for Malignant Cerebellar Infarction
T. Pfefferkorn    U. Eppinger    J. Linn    A. Straube    T. Birnbaum    M. Dichgans    S. Grau                     
 

Klinkum Grosshadern, University of Munich

GERMANY

Background and Purpose: Suboccipital decompressive craniectomy is a life-saving intervention for patients with malignant cerebellar infarction. However, long-term outcome has not been systematically analyzed. Patients and Methods: In this monocentric retrospective study we reviewed the charts of all consecutive patients that were treated by suboccipital decompressive craniectomy for malignant cerebellar infarction in our institution between 1996 and 2006. Prior to surgery, all patients presented with space-occupying cerebellar infarction and a declining level of consciousness. Outcome data in survivors were obtained by telephone (modified Rankin Scale) and SF-36 questionnaires (quality of life). Results: A total of 57 patients were identified. The mean age was 59.2 years (27-81 years). Five patients were lost for follow-up. In the remaining 52 patients, the mean follow-up interval was 4.3 years (1-11 years). Twenty-one patients (40.4%) had died, 15 (29%) within the first six months after surgery. Among the 31 long-term survivors, functional outcome was good in 26 (mRS of 0-3: 84%) and poor in five patients (mRS of 4-5: 16%). All but two patients (94%) expressed retrospective contentment with the surgical intervention. The data on quality of life are pending and will be presented at the conference. Conclusions: The majority of survivors after suboccipital decompressive craniectomy for malignant cerebellar infarction have a good long-term functional outcome. Retrospectively, almost all of them are content with having received this treatment.

Kind of presentation: Oral 
Intracerebral and subarachnoid bleedings/ Cerebral haemorrhage and SAH  
 
Date: Friday 16 May 2008   Time: 9:10 - 9:20    Room: Clio/Thalie
Chair: A. Demchuk, Canada and C. Stapf, France
 

08
Comparison of primary and arteriovenous malformation-related intracerebral haemorrhages in population-based studies
J. van Beijnum    C.E.Lovelock    C. Cordonnier    P.M. Rothwell    C.J.M.Klijn    R. Al-Shahi Salman                            
 

Division of Clinical Neurosciences, University of Edinburgh

THE NETHERLANDS

Background – Non-traumatic intracerebral haemorrhage (ICH) has a high case fatality and leaves many survivors disabled. Clinical characteristics and outcome seem to vary according to the cause of ICH, but rigorous population-based comparisons are scarce. Methods – We studied two prospective, population-based cohorts to determine differences in presenting features and outcome (case-fatality and modified Rankin Score [mRS]) after incident ICH due to brain arteriovenous malformations (AVM) (Scottish Intravascular Vascular Malformation Study [SIVMS], n=90) and primary ICH (Oxford Vascular Study [OXVASC], n=60). Results – Patients with AVM-ICH were younger, had lower pre-stroke and admission blood pressures (BP), higher Glasgow Coma Scores (GCS), and were more likely to have an ICH in a lobar location than patients with PICH. Case fatality throughout two-year follow-up was greater following PICH than AVM-ICH (34/48 [71%] versus 13/90 [13%] at 2 years, odds ratio [OR] 14 [95% Confidence Interval (CI) 6 to 34]), as was death or dependence (mRS  3) (38/42 [90%] versus 31/81 [38%], OR 15 [95% CI 5 to 47]). Differences in 2-year outcomes persisted following stratification by age (<60 versus ≥60). In multivariable analyses, independent predictors of death at 12 months were PICH (OR 16, 95%CI 3.1 to 80) and ICH volume (OR 1.03, 95% CI 1.01 to 1.05), and independent predictors of death or dependence at 12 months were PICH (OR 10, 95%CI 1.9 to 51), ICH volume (OR 1.03, 95% CI 1.00 to 1.05), non-lobar location (OR 3.0, 95%CI 1.5 to 6.3), and low GCS on admission (OR 0.79, 95% CI 0.63 to 0.88). Discussion – Outcome after AVM-ICH is better than after PICH, independent of patient age, and other known predictors of ICH outcome. Although better outcome after AVM-ICH may partially be due to under-diagnosis of AVM in patients with fatal ICH, it is unlikely to account fully for the observed differences in outcome.

Kind of presentation: Poster 
   
Poster Session I
Date: Wednesday 14 May 2008   Time: 12:30 - 14:00    Room: Agora 2
Chair:  
 

 
Diastoilc flow reversal in cerebral arteries in severe aortic regurgitation
V.K.Sharma    H.L.Teoh    B.PLChan                                                 
 

National University Hospital

SINGAPORE

Background: Spectral flow pattern in the cervical segments of carotid arteries may be influenced by various cardiac valvular abnormalties. Depending on its severity, aortic regurgitation (AR) may cause diastolic flow reversal in aorta and its branches up to variable distance. The most severe case of flow spectral changes due to AR previously described in the literature showed diastolic flow reversal of varying degree in the extracranial arteries but the flow during the diastole remained antegrade in the intracranial arteries. Methods: We describe the findings of cerebrovascular ultrasound in a 72-years old woman, referrred to our tertiary care neurovascular laboratory following a transient left-sided weakness. Results: Doppler spectra obtained from the cervical ultrasound of both common and internal carotid arteries as well as vertebral arteries demonstrated an early-diastolic flow reversal with no discernible flow during rest of the diastole. Similar unusual spectral flow patterns with a holo-diastolic flow reversal were noted in middle anterior and posterior cerebral arteries, bilaterally. The Doppler spectra obtained from the basilar and the vertebral arteries showed only systolic spikes with no demonstrable diastolic flow signals. A transthoracic echocardiography performed later, confirmed severe AR. Conclusion: A holodiastolic flow reversal is an extremely abnormal finding in the intracranial arteries since the cerebrovascular system tends to ‘smooth-out’ the backflow effect of cardiac lesions by altering the peripheral resistance. To the best of our knowledge this is the first case of a severe AR with no diastolic flow in the vertebro-basilar arteries and holo-diastolic flow reversal in the remaining branches of the circle of Willis. Similar findings in multiple cerebral arteries are usually seen in patients with cerebro-circulatory arrest and may lead to an erroneous diagnosis and potentially serious prognostic and ethical considerations in critically ill patients with unknown intracranial pressure and previous history of valvular heart disease.

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

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.

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

21
Plasma homocysteine in ischemic stroke subtypes
K. Jood    L. Ögge Englund    C. Ladenvall    C. Blomstrand    C. Jern                                   
 

Institute of Neuroscience and Physiology, the Sahlgrenska Academy at Göteborg University

SWEDEN

Background: Elevated plasma levels of homocysteine (hcy) are associated with ischemic stroke. However, data on ischemic stroke subtypes are limited. Therefore, we investigated hcy in ischemic stroke subtypes. Methods: The material comprises the Sahlgrenska Academy Study on Ischemic Stroke (SAHLSIS), in which 600 consecutive patients with acute ischemic stroke (18-69 years) and 600 matched controls have been included. Ischemic stroke subtype was determined according to TOAST criteria. In this analysis, subjects on treatment with vitamin B12 and/or folate were excluded (n=107). Plasma hcy during the acute stage and at 3-month follow-up was determined using high performance liquid chromatography. Results: Among cases, there was a significant increase in plasma hcy at follow-up compared to the acute stage (p<0.001). At both time points, levels were significantly higher in cases compared to controls (p<0.001). Among subtypes, small vessel disease (SVD) displayed the highest, and cryptogenic stroke the lowest hcy level. However, plasma hcy did not differ significantly between subtypes (p>0.09). This is in contrast to other biomarkers in this sample, i.e. high-sensitivity CRP (hsCRP) and tissue-type plasminogen (t-PA) antigen, that differ significantly between subtypes with highest levels of both measures in large vessel disease (LVD). After adjustment for traditional vascular risk factors the association for hcy at 3-month follow-up remained significant only for SVD and cardioembolic stroke (OR per 1 µmol/L increase in plasma hcy 1.06 95% CI 1.01-1.11, p<0.05 and 1.08 95% CI 1.03-1.14, p<0.01, respectively). Analysis of two common variants in the gene encoding metyltetrahydrofolat reductase (MTHFR), i.e. MTHFR C677T and A1298C, confirmed an association to plasma hcy level for both polymorphisms. However, no significant association between genetic variants and ischemic stroke was detected. Conclusion: Plasma hcy levels are elevated in all ischemic stroke subtypes. In contrast to hsCRP and t-PA antigen, there is no significant subtype-specific difference in hcy.

Kind of presentation: Oral 
Recovery and rehabilitation  
 
Date: Thursday 15 May 2008   Time: 16:50 - 17:00    Room: Calliope
Chair: J. Bernhardt, Australia and V. Hömberg, Germany
 

03
5000 finger grip movements with a new robotic hand rehabilitation device – effects on grip abilities and functional MRI
C. Enzinger    P. Grieshofer    G. Reiter    R. Scherer    R. Linderl-Madrutter    C. Pargfrieder    S. Pegritz    W. Wurm    C. Neuper    F. Fazekas
 

Medical University Graz

AUSTRIA

Background: Successful rehabilitation of highly impaired finger and hand movements after stroke is challenging and often remains unsatisfactory with conventional therapies. We therefore developed a new mechatronic device for rehabilitation of hand function which allows delivering well characterised, high frequent, repetitive movement sequences in an individualised manner. The goal of the ongoing exploratory study is to assess the consequences of such training both directly regarding gains in performance and indirectly using functional MRI. Methods: To date, 11 stroke patients with a moderate to high-grade paresis of the upper limb (pinch grip force grades 2 or 3 according to MRC; spasticity according to the Ashworth Scale <3) have been included (mean age 62, range 47-78, interval to their stroke 41 to 434 days). Before and after three weeks of standardised training using a hand robot (developed at the clinic Judendorf-Strassengel) with an average of 5000 grip movements during 15 therapy sessions in addition to conventional physiotherapy, patients were both tested behaviourally and a subset underwent repeated fMRI using an identical paradigm at 3T. The fMRI experiment consisted of active and passive flexion and extension of the digits II-V of both hands. The Motricity Index (M.I.) before and after training and force measurements on the robot during each session served to assess gains in functional strength. Results: Following the robot training, we observed significant improvements of the patients’ functional strength, both clinically and by measurements of force using the device (M.I. pinch grip pre 23.3+/-6.6 vs. post 26.3+/-4.6, p=0.03; finger flexion pre 7.75+/-4.5N vs. post 11.9+/-4.8N, p=0.04). At baseline, movement of the paretic hand vs. rest was associated with activation of a more bihemispheric network with additional recruitment of ipsilateral motor areas in the undamaged hemisphere compared to movement of the unaffected hand. Subsequent to robot therapy, significant increases in activation in the cerebellum and basal ganglia were noted with movement of the paretic, trained hand. fMRI activation patterns with movement of the healthy (not-trained) hand vs. rest did not change (robust activation of contralateral primary sensorimotor cortex, supplementary and cingulate motor areas, ipsilateral cerebellum in expected somatotopy). Conclusion: These preliminary results suggest distinct changes in sensorimotor networks associated with robotic-assisted rehabilitation of hand function after stroke. The causes and clinical significance of these changes will need further exploration.

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

 
A telephone interview to diagnose transient ischemic attack is feasible and sensitive.
D. Manawadu    L.M.Davies    A. Salam    A. Shuaib    T.J.Jeerakathil                                   
 

University of Alberta

CANADA

Background There exists a need for an accurate telephone instrument to diagnose transient ischemic attack. Telephone contact may reduce delay in recognizing those who may have suffered a TIA, allowing early referral to stroke services. The current gold standard for comparison is the diagnosis made by a stroke physician after patient encounter. We hypothesized that our questionnaire would be accurate in making a diagnosis of TIA when compared with the clinic diagnosis made by a stroke physician. Methods We initially presented standardized clinical scenarios to 7 experienced stroke physicians to establish the particular combinations of symptoms, onset speed, and duration that most likely determined a TIA. A diagnostic algorithm was created from these responses. Patients already diagnosed in Stroke Clinic were telephoned by someone blinded to their diagnosis. Responses to a symptom questionnaire were recorded and the algorithm used to characterize patients into two categories: 1) definite/probable or possible TIA; and 2) non-TIA. Results Telephone interviews were done in 158 patients, 46% males, mean age 66. Average interview length was 10 minutes, performed at a mean of 20 +/- 8 days after Stroke Clinic consultation. The stroke physician diagnosis was definite/probable or possible TIA in 126 patients, and non-TIA in 32. The number of true positives detected by the algorithm was 120 and true negatives 10. The number of false positives diagnosed was 22 with 6 false negatives. The sensitivity of the questionnaire and algorithm for definite/probable or possible TIA was 95% with a specificity of 45%. Positive predictive value was 85% and negative predictive value 63%. Discussion A telephone interview to diagnose TIA is feasible. We noted high sensitivity and good positive predictive value of the questionnaire we designed for this purpose. Our questionnaire and algorithm might find future use as a rapid screening instrument to identify those with a potential TIA, since a screening instrument does not generally require a high specificity.

Kind of presentation: Poster 
   
Poster Session I
Date: Wednesday 14 May 2008   Time: 12:30 - 14:00    Room: Agora 2
Chair:  
 

 
Unlock the locked in
K.S.Sunnerhagen    Å. Schjoelberg                                                        
 

Rehabilitation medicine/Göteborg University

SWEDEN

Sometimes a stroke can lock in a person, which is a catastrophe. This happens with a stroke in the medulla oblongata and/or pons, resulting in tetrapareseses and paralyses of the lower cranial nerves (motion, respiration, communication and feeding). Other parts of the brain remain intact; rendering normal cognitive function. The locked in syndrome has spared eye/eyelid movement, locked in state also finger or toe movement. Luckily, this syndrome seems to be uncommon but the frequency after stroke is not known. Sunnaas University hospital has the responsibility for these rare persons in Norway. The aim of this study is to present cases which show the complexibility and the need (that requires the work) of different professions to work together towards a common goal. Material and method From a cohort we present 4 cases (2 men and 2 women with brain stem infarcts) to highlight the needs of the person and what is required from the team. Results: Communication at arrival: l eye movement for 3, weak voice for 1. At present (1-6 years later): computer assisted communication for 2, letter board for 1 and “normal” for one. The need of the person which is locked in requires a skilled team where different professional together can assess the person and help to find ways for alternative communication. Probably only one site per country can gather enough experience to give professional help. There is a need for follow up to re-assess skills and needs partly due to new techniques but also to see if the person need more assistance for adaptation with the alternative communication or extra information about communication for carers of the person

Kind of presentation: Oral 
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.

Kind of presentation: Oral 
Acute stroke: treatment concepts III  
 
Date: Thursday 15 May 2008   Time: 17:10 - 17:20    Room: Clio/Thalie
Chair: N. Bornstein, Israel and H. Mattle, Switzerland
 

05
STATIN TREATMENT PRIOR TO CAROTID ENDARTERECTOMY (CEA) REDUCES INFLAMMATION AS SEEN ON CONSECUTIVE 18FDG-PET IMAGING
M.A.Font Padros    A. Fernandez    I. Rico    M.M.Turu    A. Luque    C. Gamez    M. Slevin    F. Rubio    L. Badimon    J. Krupinski
 

Hospital Universitari de Bellvitge

SPAIN

Background Vulnerable atherosclerotic plaques have been characterized by their expression of high numbers of inflammatory cells. Fluorine-18 fluorodeoxyglucose (18-FDG) accumulates in inflamed tissues and several groups have established that inflamed blood vessels and atherosclerotic lesions have increased uptake of 18-FDG. Our aim was to investigate the effect of statin treatment prior to CEA on 18-FDG carotid uptake on consecutive PET scans in the contralateral carotid artery with low to moderate stenosis. Methods We enrolled 14 patients with unilateral carotid artery stenosis scheduled for CEA. In group A (n=7) patients received statins for at least 4 weeks prior to the first PET and continued throughout the study. In a group B (n=7) patients did not receive treatment with statins. The follow-up 18-FDG-PET was performed 116 +/- 22 days after CEA. A semiquantitative analysis of FDG-uptake values based on maximum standardized uptake value. Slice-activity curves were calculated in order to visualize plaque and basal metabolism. Carotid plaque morphology was assessed by examination of haematoxylin and eosin stained sections and the peroxidase method was used for immunohistochemical staining with monoclonal anti-CD68 antibody. Computer–assisted planimetry was used to quantify areas of staining in order to validate the PET FDG uptake correspondence with macrophage infiltrates. Results Statin treatment prior to the CEA (group A vs. B) was associated with a more pronounced decrease in 18-FDG-uptake on second PET in the contralateral carotid artery (p<0.05). This effect was independent of levels of total-cholesterol, LDL-cholesterol, HDL-cholesterol or triglycerides between two studied groups. We found a statistically significant correlation between the degree of FDG accumulation and the presence of macrophages in the atherosclerotic plaques (R=0,8, p<0,005). Discussion This pilot study demonstrates that pleiotrophic effects of statins in reduction of inflammation can be visualized in vivo by 18-FDG-PET imaging.

Kind of presentation: Oral 
Acute stroke: complications and early outcome  
 
Date: Thursday 15 May 2008   Time: 12:20 - 12:30    Room: Rhodes
Chair: G. Özdemir, Turkey and J. Norris, United Kingdom
 

12
Effect of intravenous thrombolysis in acute ischaemic stroke on outcome in daily practice; data from the PRACTISE study.
M.-Dirks    L.W.Niessen     P.J.Koudstaal     J.D.van Wijngaarden     R.J.van Oostenbrugge    C.L.Franke     D.W.J.Dippel                     
on behalf of the practise investigators

ErasmusMC

THE NETHERLANDS

Background: Thrombolysis with intravenous thrombolysis has been proven effective for treatment of patients with acute ischaemic stroke randomised clinical trials. In daily practice, the effect of thrombolysis may be less because of co-morbidity, less strict contra-indications and treatment by less experienced doctors. The aim of the current study was to assess the effectiveness of thrombolysis in an unselected observational cohort of patients within the setting of the PRACTISE trial, a multi-centre cluster-randomised trial of high intensity versus regular intensity implementation of thrombolysis for acute ischaemic stroke. Methods: Data were collected of all consecutive patients admitted within 24 hours from onset of symptoms with acute stroke for 2 years in 12 representative hospitals in the Netherlands. Contra-indications for thrombolysis and protocol violations were assessed. Within the cohort of patients with an ischaemic stroke admitted within 4 hours outcomes were measured using the modified Rankin scale. Data were analysed with a logistic regression model, using the sliding dichotomy approach. Results: Of the 5517 stroke patients included in the study, 1658 were admitted with an ischaemic stroke within 4 hours from onset, of whom 698 (42%) were treated with thrombolysis; 10 patients were treated with thrombolysis in the presence of contra-indications (1.4%.) The odds-ratio for improved outcome after thrombolysis was 1.6 (95% CI 1.3 – 2.1) after adjustment for age, sex, stroke severity, co-morbidity, and solid contra-indications for thrombolysis. Discussion: This study confirms that intravenous thrombolysis for acute ischaemic stroke improves outcome also in standard practice, outside the setting of a randomised clinical trial.

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

04
Experimental cell therapy of stroke - preclinical evaluation of transplantation modalities
D.C.Wagner    U.R.Schmidt    A. Foerschler    M. Kamprad    A. Kranz    D. Egger    F. Emmrich    J. Boltze              
 

Fraunhofer Institute for Cell Therapy and Immunology

GERMANY

Objectives The relevance of cell therapies in neurological affections has been shown in several preclinical studies. These auspicious results should be confirmed in clinical trials, but there are a couple of open questions. In our experiment we transplanted human umbilical cord blood cells (HUCBC) within different time points to evaluate the appropriate therapeutic time window. Furthermore, we compared the efficacy of intravenous and intracerebral transplantation. Materials and Methods Permanent middle cerebral artery occlusion (MCAO) was conducted in 61 male spontaneously hypertensive rats. A cell suspension of 10E6 HUCBC was injected intravenously at different time points upon MCAO: 4h (n=8), 24h (n=8), 72h (n=7), 120h (n=8) and 14d (n=8). The control group (n=8) received vehicle solution 24h following MCAO. Intrastriatal transplantation of 3x10E5 HUCBC (n=8) took place 24h upon MCAO, the corresponding control group (n=6) received vehicle solution intrastriatally. Functional outcome was examined by three behavioural tests (RotaRod, BeamWalk and modified Neurological Severity Score) from Day 1 to 30 regularly. Infarct volumetry was performed via magnetic resonance investigations on Days 1, 8 and 29. Immunohistochemical methods were used to investigate localization and differentiation of transplanted cells and to analyze glial scarring. Results We observed a significant reduction of sensorimotor defects when cell transplantations took place within the first 72h following experimental brain ischemia. These results were supported by a degradation of glial scarring and a decreased tissue lost. Transplantation 120h upon stroke induced a significant improvement of sensorimotor deficits without a measurable effect on glial activation and tissue lost. Transplantation after a two week period failed to show any beneficial effects. Local transplantation of HUCBC 24h upon stroke showed a significant improvement within all examination routines. We found no evidence for significant differences between local and systemic administration of HUCBC 24h following stroke.

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

07
Predictive value of clinical and CT signs prior to decompressive surgery in malignant MCA infarction on death and functional outcome
S. Schwarzlose    T. Beni    C.W.Wallesch    R. Firsching    M. Goertler                                   
 

University of Magdeburg

GERMANY

Background: Decompressive surgery in malignant infarction of the middle cerebral artery within 48 hours of stroke onset reduces mortality and increases favourable functional outcome. However, timing of surgery and variables indicating its necessity, e.g. level of consciousness, clinical signs of herniation, and midline shift on brain CT scans, are controversially discussed. We aimed to assess the predictive value of these variables in patients who underwent surgery before and after 48 hours. Methods: 60 consecutive patients (pts) (38 male, mean age 58 (30-80) years) underwent decompressive surgery. Median time from infarction to surgery was 37.7 hours (range 11.8 to 165). Median NIH Stroke Scale score was 21 (range 3 to 36) at admission and 35 (range 16 to 38) at surgery. 6 Pts with secondary parenchymal haemorrhage had been excluded from analyses. Results: 30 patients were comatose before surgery and 17 showed clinical signs of herniation. Midline shift on the level of the 3rd ventricle was 8.3 mm, on the level of the septum pellucidum 11.4 mm. Clinical signs of herniation (non-reactive pupil) were associated with an increased mortality (59% vs. 30%) (p = 0.04) and an unfavourable outcome (modified Rankin Scale 5) or mortality (82% vs. 54%) (p = 0.04). No association was found for the level of consciousness and the midline shift as measured on CT scans. Conclusion: Clinical signs of cerebral herniation but not the level of consciousness and the midline shift as measured on CT scan prior to decompressive surgery for malignant MCA infarction may be predictive for an unfavourable outcome or death at 6 months after stroke onset.

Kind of presentation: Poster 
   
Poster Session I
Date: Wednesday 14 May 2008   Time: 12:30 - 14:00    Room: Agora 2
Chair:  
 

 
Lesion localisation predicts response to Bilateral Arm Training (BATRAC) in chronic stroke survivors
C. Globas    J.M.Lam    B. Hertler    C. Becker    J. Whitall    S. McCombe-Waller    D. Hanley    A.R.Luft              
 

Centre of Neurology and Hertie Institute of Brain Research University Tübingen

GERMANY

Background and Purpose: In recent years several therapeutic approaches have been developed to improve motor function in stroke survivors with chronic disability. Bilateral Arm Training with Rhythmic Auditory Cueing (BATRAC) is an effective therapy to improve the arm function. But, not all individuals respond to this intervention. Here, the xobjective was to investigate the influence of lesion location on therapy response. Data collected as part of a randomized controlled trial conducted between 2001 and 2006 comparing BATRAC against standardized Bobath exercises, were analyzed. Methods: 17 chronic stroke survivors (first ever stroke> 6 months prior to enrollment) were BATRAC trained in 18 hourlong sessions 3x/week for 6 weeks. Upon rhythmic auditory cues, participants pushed and pulled bilaterally, in synchrony or alternation, 2 T-bar handles sliding in the transverse plane. The control group (18 patients) received standardized stretching exercises over the same time period 3x/week. Before and after the training period arm function was assessed through Fugl-Meyer Motor Performance Test (FM), and Wolf Motor Function scores (WMFT). For each patient anatomical MRI-scans (T1-weighted, 3D-MPRAGE sequence; 1x1x1 mm3) were collected. Voxel Based Lesion-Symptom Mapping (VLSM) was used to analyze the relationship between lesion morphology, arm motor function and therapy response (change in functional scores) on a voxel-by-voxel basis. Results: VLSM showed that lesions in premotor and frontal cortical areas were associated with poor improvement in FM score (p<0.01). There was a trend for a negative correlation lesion size and FM and WMFT improvement. Additionally, premotor cortex lesions were also associated with greater arm function deficit at baseline (n=42 subjects, BATRAC, control and dropouts combined; p<0.05). Conclusion: Lesions in frontal, especially premotor, cortical areas predict worse clinical outcome of arm function after stroke as well as poorer therapy response to BATRAC. This finding corresponds to the observation that responders to BATRAC show increased recruitment premotor cortex after threapy (Luft et al. JAMA 2004).

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

 
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.

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

23
Stroke Patient knowledge of Hypertension after discharge from hospital
L. O'Connor    M.T.Lonergan    N. Cogan    D. O'Neill    D.R.Collins                                   
 

Adelaide & Meath Hospital, Dublin

IRELAND

Introduction: Hypertension is the most prevalent and modifiable of cardiovascular risk factors but patient awareness of its importance may be poor even after a stroke [1]. It is a principle target for patient education and intervention in our stroke service. We assessed knowledge among our community patient population after discharge from hospital. Methods: Stroke patients returning to our clinic 1-2 years after stroke were invited to complete a questionnaire anonymously. Results: 100 patients participated. Only 56% were aware that the term “hypertension” meant blood pressure. 14% were unaware that hypertension can be asymptomatic and 11% were unaware of any symptoms of hypertension. 90% were aware that lowering blood pressure could improve health. 65% patients realised blood pressure was a risk factor for heart attack and stroke. 8% stroke only, 9% heart attack only and 9% were unaware of the risks of high blood pressure. 27% were aware of current BP targets. 36 % were aware of targets but couldn't identify the correct range. 37% patients were unaware of BP targets. Only 30% of those surveyed knew their recent blood pressure reading. 85% patients were aware that blood pressure could be controlled but 38% patients were unaware of lifestyle measures to lower blood pressure. 37% patients aware that exercise/diet could be effective in reducing blood pressure. Only 5% aware smoking cessation could help control BP. 27% of those studied were still smoking. Discussion:Survey highlights that despite having suffered a stroke and being given secondary preventative advice while in hospital, that knowledge of blood pressure and lifestyle measures is poor after discharge and smoking levels are high. Continued patient education is required after hospital discharge. 1. A Croquelois, JBogousslavsky Risk awareness and knowledge of patients with stroke: results of a questionnaire survey 3 months after stroke., Journal of Neurology, Neurosurgery, and Psychiatry 2006;77:726-728)

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

 
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.

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

 
Angioplasty with stent for post-irradiation extra-cranial stenosis
T.W.Leung    S. Yu    A. Lau    Y. Chan    W. Lam    K.S.Wong                            
 

Prince of Wales Hospital, The Chinese University of Hong Kong

HONG-KONG

Background and Purpose: Many long-term survivors of primary pharyngeal and laryngeal malignancy suffer from refractory transient ischemic attacks (TIA) and strokes from extensive post-irradiation extracranial stenoses which are not amenable for endarectomy. Methods: Fifty patients who had refractory TIA and/or strokes attributed to high grade (≥70%) post-irradiation extra-cranial stenosis consecutively underwent angioplasty with stent from Jan 2006 to Dec 2007. Results: Angioplasty was performed for 60 culprit lesions, distributing at common carotid artery (n= 13); proximal internal carotid artery (n=46), and vertebral artery ostium (n=1). In patients with bilateral carotid