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Poster Session II Thursday 31 May 2007

Cerebrovasc Dis 2007;23(suppl 2):1–147

Risk factors of stroke the significant difference in BMI between the two examined groups suggests that
clopidogrel therapy should be weight-adjusted.

1 Risk factors of stroke


3 Risk factors of stroke
LUNG FUNCTION AND LONG-TERM FATAL STROKE
U. Goldbourt, D. Tanne ASSOCIATION OF METABOLIC SYNDROME WITH ISCHEMIC STROKE IN
Tel Aviv University Department of Epidemiolgy and Preventive Medicine, Tel PATIENTS WITH INTRACRANIAL ATHEROSCLEROSIS
Aviv, Israel J.H. Park
Myongji Hospital, Kwandong University, College of Medicine, Goyang-si,
Background: Research on lung function and incidence of stroke has yielded South Korea
conflicting results. Participants and methods: For 10,232 men of diverse countries
of origin, civil servants and municipal employees, who participated in the Israeli Background and purpose: Metabolic syndrome (MetS) is associated with intracra-
Ischemic Heart Disease (IHD) study in 1963, extensive demographic, biochemical, nial atherosclerosis. Patients with more severe MetS components were reported
socioeconomic and clinical information was collected in 1963, 1965 and 1968. Of to be more likely to have intracranial atherosclerosis. To elucidate the association
these men, 4330 underwent an assessment of forced vital capacity (VC) and 1.0 sec between MetS and ischemic stroke, we attempted to demonstrate the association of
forced expiratory volume (FEV). MetS and its individual components with frequency of ischemic stroke lesions and
Results: Over a 23-yr follow up, 1297 men died, among whom for 136 the investigated the independent associations between them in acute ischemic stroke
recorded underlying cause of death was stroke. For quartiles of VC, as % of age patients.
and height predicted level, there was a modest gradient of fatal stroke (18,16,14 Methods: We evaluated 370 acute ischemic stroke patients who underwent brain
and 13 per 10,000 person-years) which was erased upon age-adjustment. The magnetic resonance (MR) imaging and MR angiography. The stroke subgroups
corresponding rates declined from to 23 to 18, 10 and 8 per 10,000 person years were categorized as intracranial large artery atherosclerosis (IC-LAA, n=151),
for FEV, or 19,15,14 and 10 for FEV as percent of FVC, in the 1st,2nd,3rd, and extracranial large artery atherosclerosis (EC-LAA, n=29), and nonatherosclerosis
4th quartiles, respectively (P for trend=0.02 for the former and 0.55 for the latter (NA, n=190). MetS was defined using the criteria of the National Cholesterol
by Mantel-Cox trend test after age-adjustment and exclusion of baseline IHD and Education Program Adult Treatment Panel III.
cancer). Further adjustment for height which was markedly, inversely related to Results: Patients with IC-LAA group showed a higher rate of previous ischemic
stroke mortality eliminated both associations. There was no appreciable interaction lesions and MetS than those with EC-LAA and NA (all P<0.001). The number of
between smoking habits and lung function with respect to long-term fatal stoke. previous ischemic lesions showed a tendency to increase as the number of MetS
Conclusions: In this cohort, low FEV, whether in absolute terms or in relation to components increased in the IC-LAA group (P=0.002). In the IC-LAA group, MetS
FVC, did not appear to be an independent marker of risk for fatal stroke beyond was independently associated with previous ischemic lesions (OR, 3.80 P<0.001)
age and height. which was prominent with more severe MetS components after adjustment for risk
factors (P<0.001). Among the component conditions, high blood pressure, im-
paired fasting glucose, and abdominal obesity were predominantly associated with
2 Risk factors of stroke previous ischemic lesions (all P<0.001). Conclusions: MetS was associated with
ischemic stroke with IC-LAA. Controlling the MetS components is mandatory with
CLOPIDOGREL RESISTANCE: ROLE OF BODY MASS AND CONCOMITANT the aim of preventing from advanced intracranial atherosclerotic vascular damage
MEDICATIONS and ischemic stroke. Further studies of different ethnics need to be performed to
G. Feher, K. Koltai, B. Alkonyi, L. Szapary, G. Kesmarky, S. Komoly, K. Toth confirm whether MetS is more associated with those with IC-LAA.
University of Pecs, Medical School, Pecs, Hungary

Introduction: Platelets have a central role in the development of arterial thrombosis 4 Risk factors of stroke
and subsequent cardiovascular events. An appreciation of this has made antiplatelet
therapy the cornerstone of cardiovascular disease management. Recent studies have DEATH AND DEPENDENCE ONE YEAR AFTER THE FIRST TRANSIENT
described the phenomenon of clopidogrel resistance but the possible mechanisms ISCHAEMIC ATTACK: A POPULATION-BASED STUDY IN RURAL AND
are still unclear. URBAN NORTHERN PORTUGAL
Patients and methods: The aim of this study was to compare the characteristics M. Correia, M.R. Silva, E. Moreira, R. Magalhães, M.C. Silva
(risk profile, previous diseases, medications, hemorheological variables and plasma Institute for Molecular and Cell Biology, University of Porto, Porto, Portugal
von Willebrand factor and soluble P-selectin levels) of patients in whom clopi-
dogrel provided effective platelet inhibition with those in whom clopidogrel was Background and purpose: Information about prognosis of transient ischaemic at-
not effective in providing platelet inhibition. 157 patients with chronic cardio- and tacks (TIA) is scarce, particularly in population-based studies. Recent data showed
cerebrovascular diseases (83 males, mean age 61±11 yrs, 74 females, 63±13 yrs) a high early risk of stroke after a TIA, reaching 12.7% at seven days. In this study
taking 75 mg clopidogrel daily (not combined with aspirin) were included in the prognosis of a first TIA is evaluated in terms of risk of death and dependence,
study. taking into account the occurrence of stroke after the index event.
Results: Compared with clopidogrel-resistant patients (35 patients (22%), patients Methods: The 141 patients with a first–ever-in-a-lifetime TIA occurred between
who demonstrated effective clopidogrel inhibition had a significantly lower BMI October 1998 and September 2000 in a rural population of 18677 and an urban
(26.1 vs. 28.8 kg/m2 , p<0.05). Patients with ineffective platelet aggregation were population of 86023 were entered a registry. A neurologist observed these patients
significantly more likely to be taking benzodiazepines (25% vs. 10%) and selective soon after the episode and also at three and twelve months after the TIA. Previous
serotonin reuptake inhibitors (28% vs. 12%) (p<0.05). After an adjustment to dependence and dependence after the episode was determined by the modified
the risk factors and medications BMI (OR 2.62; 95% CI: 1.71 to 3.6; p<0.01), Rankin scale (score 3 or more).
benzodiazepines (OR 5.83; 95% CI: 2.53 to 7.1; p<0.05) and SSRIs (OR 5.22; 95% Results: One year after the TIA, 10 out of 105 patients (9.5%) in the urban area
CI: 2.46 to 6.83; p<0.05) remained independently associated with CLP resistance. were death, compared to 6 out of 36 (16.7%) in the rural area. Amongst the
There was no significant difference in the rheological parameters and in the plasma survivors 23.7% were dependent one year after the episode, 25.8% in the urban
levels of adhesive molecules between the two examined groups. area and 17.2% in rural area (excluding seven that were lost to follow-up). In the
Conclusion: The background of ineffective clopidogrel medication is complex. urban area this proportion reduces to 22.8% taking into account those previously
Drug interactions may play a role on clopidogrel bioavailability, on the other hand, dependent. Comparing the Rankin score before and one year after the episode, 77

Poster Session Cerebrovasc Dis 2007;23(suppl 2):1–147 81


Risk factors of stroke
(57.5%) become more dependent or died, 53 (39.6%) kept their score and only consistent and robust in a variety of sensitivity analyses. Notably, soluble RANKL
four patients improved their score (Wilcoxon test, z=7.5, p<0,001). As expected was not associated with carotid or femoral artery atherosclerosis assessed and
the occurrence of stroke during the follow-up period worsened the prognosis at one monitored by high-resolution ultrasound.
year (Mann-Whitney, z=2.7, p=0.007). Conclusions: Our study lends large-scale epidemiological support to a role of
Discussion: The occurrence of a first TIA carries out not only an early risk of RANKL in CVD. In the absence of a significant association between RANKL and
stroke, but most of the patients showed an increased degree of dependence one year atherosclerosis the view that RANKL promotes plaque destabilization and rupture
after the episode. The occurrence of stroke after a TIA is partially responsible for is a highly appealing concept.
this prognosis.
Study supported by: FCT/FEDER project POCI/SAU-ESP/59885/2004
7 Risk factors of stroke
5 Risk factors of stroke INCREASED PREVALENCE OF VASCULAR RISK FACTORS BUT EQUAL
ACCESS TO HOSPITAL SERVICES IN A DEPRIVED TRANSIENT
AGE PREDICTS DELAYED TRANSIENT ISCHAEMIC ATTACK ISCHAEMIC ATTACK POPULATION
INVESTIGATION AND MANAGEMENT T.J. Quinn, J. Dawson, K.R. Lees, M.R. Walters
T.J. Quinn, J. Dawson, K.R. Lees, M.R. Walters Gardiner Institute of Cardiovascular and Medical Sciences, University of
Gardiner Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
Glasgow, Glasgow, United Kingdom
Introduction: Cerebrovascular disease is over represented in socially deprived
Introduction: Cerebrovascular events increase in frequency and severity with age. communities but traditional vascular risk factors do not account for all the vari-
Recent studies suggest that elderly UK patients diagnosed with transient ischaemic ation. Unequal access to and uptake of specialist management could contribute.
attack (TIA) are inappropriately denied evidence based intervention. Similar ex- We analysed data on TIA clinic attendance, seeking effects of socioeconomic
amples of “ageism” have been reported in many other areas of hospital medicine. deprivation.
Due to the frequency of events immediately following TIA, urgent assessment and Methods: We serve an urban population including the most affluent and deprived
initiation of treatment is essential. We examined if age influenced referral to a areas of the city. We prospectively record structured details of patients seen at clinic.
“fast-track” TIA clinic. Socio-economic deprivation was measured from postcodes and the 2001 census,
Methods: Our TIA clinics assess all suspected cerebrovascular events referred. using the Depcat ordinal hierarchical scale, ranging from 1=least deprived to
Patient details are prospectively recorded in a comprehensive database. Data were 7=most deprived. We analysed the association between social deprivation, referral
collated for patients seen between August 1992 and January 2005. Patients were and vascular risk factors by ANOVA. We interpreted delay from symptom onset to
categorised according to age: 0-40; 41-65; 66-75; 76+. Associations between age clinic referral as a marker of access to specialist care.
and: mode of referral (letter; phone call; other); time to referral; time from referral Results: We assessed 3462 patients between August 1992 to January 2005. The
to appointment and initiation of treatment prior to clinic were analysed using the most deprived areas were over represented, with 1711 patients in Depcat 6 - 7.
Kruskal-Wallis test. There was no association between clinic referral or attendance and Depcat. There
Results: Full data were available for 3495 of 3596 patients assessed during the were significant associations between Depcat and “lifestyle” factors of smoking
study period, median age 67 (range 16-95). There was no significant association and alcohol excess (each p<0.005).
between increasing age and delay from symptom onset to referral time (P=0.014);
mode of referral (P=0.131) or time to appointment (P=0.652). The youngest patients
Depcat1 Depcat2 Depcat3 Depcat4 Depcat5 Depcat6 Depcat7
were less likely to be prescribed antiplatelet (P<0.001).
Delay to clinic (days) 16.5 35.2 28.9 33.9 37.5 89.6 55.3
Smoking % 6.1 13.9 24.7 34.6 24.8 40.1 46.3
Age (years) Median Referral Median Appointment Number of Number on Hypertension % 39 27.9 44.1 42.3 46.3 44.4 44.1
Time (days) Time (days) Phoned Referral Anti-platelet Diabetes % 5.1 3.7 7.8 18.6 7.5 9.3 7.7
Dyslipidemia % 16.9 8.9 16.3 18.7 14.2 19 17.9
0–40 (n=188) 6 8 28 (14.9%) 35 (18.6%)
Alcohol % 2.3 1.2 4.8 3.7 3.8 4.3 5.2
41–65 (n=1431) 8 9 191 (13.3%) 511 (35.7%)
66–75 (n=1035) 7 9 164 (15.8) 337 (32.6%)
Over 75 (n=805) 6 9 120 (14.9) 271 (33.7%)
Discussion: The effect of deprivation on cerebrovascular health inequality is partly
explained by certain vascular risk factors but not by access to hospital services.
Discussion: We have found no evidence of ageism in access to TIA services.
However, delays to clinic assessment remain substantial. Public education strategies
to promote early presentation with TIA symptoms are required. 8 Risk factors of stroke
DO CONVENTIONAL VASCULAR RISK FACTORS INFLUENCE BRAIN
6 Risk factors of stroke ARTERIOVENOUS MALFORMATIONS? PROSPECTIVE,
POPULATION-BASED COHORT AND CASE-CONTROL STUDIES
SOLUBLE RECEPTOR ACTIVATOR OF NUCLEAR FACTOR-KB LIGAND T.M. Brock, R. Al-Shahi Salman
(RANKL) AND RISK FOR CARDIOVASCULAR DISEASE Division of Clinical Neurosciences, University of Edinburgh, Edinburgh, United
S. Kiechl, G. Schett, J. Schwaiger, K. Seppi, P. Eder, G. Egger, P. Santer, Kingdom
A. Mayr, Q. Xu, J. Willeit
Innsbruck Medical University, Innsbruck, Innsbruck, Austria Background: Conventional risk factors for cerebral infarction and haemorrhage
are thought to play little – if any – role in either causing brain arteriovenous
Background: Overexpression of RANKL is a prominent feature of vulnerable malformations (AVMs), or influencing their behaviour.
atherosclerotic lesions prone to rupture and was suggested to contribute to the Methods: We extracted data on vascular risk factors from the medical records
transition from a stable to an unstable plaque phenotype in both human and of 229 adults newly-diagnosed with a brain AVM, who were enrolled between
murine atherosclerosis because of its ability to promote matrix degradation, 1999-2003 in a prospective, population-based cohort study in Scotland (SIVMS).
monocyte/macrophage chemotaxsis and vascular calcification. A sample of 36 adults with brain AVMs were sex-matched and age-matched (to
Methods and results: The Bruneck Study is a prospective population-based survey within 5 years) with 36 controls.
of men and women 40-79 years old at the 1990 baseline examination. Levels of Results: In the case-control study, adults with brain AVMs were more likely than
soluble RANKL and other variables were assessed in 909 subjects (1990) and controls to have smoked at some stage in their life (75% versus 50%, p=0.028;
up-dated every five years. All cases of cardiovascular disease (CVD) were carefully odds ratio [OR] 3.0, 95% confidence interval [CI] 1.1 to 8.1), but this relationship
recorded between 1990 and 2005. did not hold for current smokers, nor was it found for hypertension, ischaemic
During follow-up, CVD (defined as ischemic stroke and TIA, myocardial infarction heart disease, alcohol consumption, hyperlipidaemia, or diabetes mellitus. In the
and vascular death) manifested in 124 subjects. The level of soluble RANKL whole cohort, 116 (72%) had smoked sometime in their life, and 29 (14%) had
emerged as a highly significant predictor of vascular risk (adjusted hazard ratio hypertension prior to the first presentation of their brain AVM. There was no
[95%CI] 1.27 [1.16-1.40]; P<0.001). Predictive significance was independent of significant difference between adults who did (n=114) and did not (n=115) present
that afforded by classic vascular risk factors, C-reactive protein and osteoprotegerin with intracranial haemorrhage in pre-presentation hypertension, smoking, or any
concentration and severity of carotid atherosclerosis. Findings were internally other vascular risk factors.

82 Cerebrovasc Dis 2007;23(suppl 2):1–147 16th European Stroke Conference


Discussion: Smoking appears to be associated with the occurrence of brain AVMs, 11 Risk factors of stroke
but this finding needs confirmation in other cohorts, and larger studies. Vascular
risk factors do not appear to influence whether a brain AVM first presents with DEPRESSIVE SYMPTOMS AND RISK OF STROKE: THE ROTTERDAM
a haemorrhage or not, but their influence on the occurrence of haemorrhage after STUDY
AVM diagnosis requires further investigation. M.J. Bos, T. Lindén, P.J. Koudstaal, A. Hofman, I. Skoog, H.W. Tiemeier,
M.M. Breteler
Erasmus Medical Center, Rotterdam, Rotterdam, The Netherlands
9 Risk factors of stroke
Background: Results from previous studies that assessed whether self-reported
NO INCREASED RISK OF RECURRENT STROKE IN PFO CARRIERS depressive symptoms predispose to stroke in the general elderly population are
H. Poppert, A. Bockelbrink, M. Morschhaeuser, J. Schwarze, P. Heider, controversial and they did not distinguish between men and women, nor did they
L. Esposito, D. Sander perform psychiatric workups in those who reported depressive symptoms. We
Munich University of Technique, Munich, Germany examined the association between depressive symptoms, depressive disorder, and
risk of stroke in the general population.
Background: Contrast-enhanced transcranial Doppler ultrasonography (cTCD) is Methods: This prospective population-based cohort study was based on 4424
a sensitive noninvasive screening method for detection of a patent foramen ovale participants of the third Rotterdam Study survey (1997-1999), who at that time
(PFO). We aimed to investigate the relationship between a suchlike detected were ≥61 years of age, free from stroke, and underwent Center for Epidemiological
right-to-left shunt (RLS) and subtypes of cerebral ischemia as well as the risk of Studies Depression Scale (CESD) interview. Depressive symptoms were considered
stroke recurrence. present if CESD score was ≥16. Participants with depressive symptoms underwent
Methods: The records of 763 patients with definite diagnosis of cerebral ischemia diagnostic workup for depressive disorder. Follow-up for incident stroke was
at discharge were analyzed retrospectively. All patients had undergone TCD based complete until January 1, 2005. Data were analyzed with Cox proportional hazards
RLS detection. Stroke origin was subtyped using the TOAST classification criteria. models with adjustment for relevant confounders.
For follow-up all patients were contacted by mail. In case a patient did not answer, Results: Men with depressive symptoms were at increased risk of stroke (adjusted
we tried to contact the patient or the patients relatives and the family doctor by hazard ratio (HR) 2.15; 95% confidence interval (CI) 1.10-4.22) and ischemic
telephone. stroke (adjusted HR 3.25; 95% CI 1.62-6.50). In women there was no association
Results: A RLS was detected in 140 (28%) male and in 114 (42%) female patients. between presence of depressive symptoms and risk of stroke. The associations
These patients were younger (p<0.001) and in male patients presence of RLS that we found were at least partly attributable to persons who reported depressive
was associated with stroke of unknown origin (p=0.001). In female patients this symptoms but who did not fulfil DSM-IV diagnostic criteria for depressive disorder.
association was not significant (p=0.076). After adjustment for age no significant Discussion: Presence of depressive symptoms is a strong risk factor for stroke in
association was found in either group. men but not in women.
Complete follow-up data with a median follow-up period of 4 years could be
collected in 639 patients (83.7%). 10 shunt-carriers (4.7%) and 32 patients (7.6%)
without RLS (p=0.180) had suffered a recurrent stroke. Logistic regression adjust- 12 Risk factors of stroke
ing for age, gender and stroke subtype confirmed the lack of a positive correlation
(OR 0.7 (95%CI 0.33-1.48)). ASPIRIN RESISTANCE: POSSIBLE ROLES OF CARDIOVASCULAR RISK
Conclusion: We found age and gender to be important confounders in the often FACTORS, PREVIOUS DISEASE HISTORY, CONCOMITANT MEDICATIONS
cited association of PFO and cryptogenic stroke. This has not been taken into AND HAEMORRHEOLOGICAL VARIABLES
account in most previous studies. Furthermore, RLS did not correlate with stroke G. Feher, K. Koltai, B. Alkonyi, L. Szapary, G. Kesmarky, S. Komoly, K. Toth
recurrence, thus weakening the thesis of a PFO generally being an important risk University of Pecs, Medical School, Pecs, Pécs, Hungary
factor for stroke.
Introduction: The aim of this study was to compare the characteristics (risk
profile, previous diseases, medications and haemorrheological variables) of patients
10 Risk factors of stroke in whom aspirin provided effective platelet inhibition with those in whom aspirin
was not effective in providing platelet inhibition.
TYPE 3 PHOSPHODIESTERASE INHIBITORS MAY BE PROTECTIVE Patients and methods: 599 patients with chronic cardio- and cerebrovascular
AGAINST CEREBROVASCULAR EVENTS IN PATIENTS WITH diseases (355 men, mean age 64 ± 11 years; 244 women, mean age 63 ± 10
CLAUDICATION years) taking aspirin 100-325 mg/day were included in the study. Blood was
W.M. Stone, S.R. Money, R.J. Fowl collected between 8:00am and 9:00am from these patients after an overnight fast.
Mayo Clinic Arizona, Phoenix, AR, USA The cardiovascular risk profiles, history of previous diseases, medication history
and haemorrheological parameters of patients who responded to aspirin and those
Objective: The risk of cerebrovascular events in patients with mild to moderate who did not were compared. Platelet and red blood cell (RBC) aggregation were
peripheral vascular disease is significant. Cilostazol is a phosphodiesterase type 3 measured by aggregometry, haematocrit by a microhaematocrit centrifuge, and
(PDE3) inhibitor that is effective in the treatment of symptoms of peripheral arterial plasma fibrinogen by Clauss’ method. Plasma and whole blood viscosities were
occlusive disease. The method of action includes antithrombotic, vasodilatory, and measured using a capillary viscosimeter.
antiproliferative effects. Results: Compared with aspirin-resistant patients, aspirin sensitive patients had
Methods: The CASTLE trial was a prospective randomized double blinded trial a significantly lower plasma fibrinogen level (3.3 g/L vs 3.8 g/L; p < 0.05) and
to establish the safety of this PDE3 inhibitor use in 1435 patients with mild RBC aggregation values (24.3 vs 28.2; p < 0.01). In addition, significantly more
to moderate peripheral arterial occlusive disease. A post-hoc analysis of the patients with effective aspirin inhibition were hypertensive (80% vs 62%; p <
CASTLE trial was undertaken to evaluate Cilostazol usage on cerebrovascular 0.05). Patients who had effective platelet aggregation were significantly more likely
events. Blinded adjudication of all cerebrovascular events (stroke, TIA, and carotid to be taking beta-adrenoceptor antagonists (75% vs 55%; p < 0.05) and ACE
revascularization) in this trial was performed. Kaplan Meier analysis was used for inhibitors (70% vs 50%; p < 0.05), patients with ineffective platelet aggregation
statistical evaluation. were significantly more likely to be taking HMG-CoA reductase inhibitors (statins)
Results: The overall rate of cerebrovascular events was 4.6% (66 of 1435 patients) [52% vs 38%; p < 0.05]. Use of statins remained an independent predictor of
with a mean followup of 515 days. Ischemic vascular events were more common aspirin resistance even after adjustment for risk factors and medication use (odds
(2.5%) than hemorrhagic events (0.3%), (p<0.05). The placebo group demonstrated ratio 5.92; 95% CI 1.83, 16.9; p < 0.001).
a greater risk for events, 5.8% (42 of 718 patients) vs. the Cilostazol treated group, Conclusions: Impaired hemorheological parameters are associated with aspirin
2.9% (21 of 717 patients), (p<0.05). Cerebrovascular risk factors were similar in resistance. It is also possible that drug interactions with statins might reduce aspirin
both groups. bioavailability.
Conclusion: The risk of cerebrovascular events in patients with mild to moderate
peripheral arterial occlusive disease is 4.6% with a mean followup of 515 days.
Treatment with PDE3 inhibitors may reduce this risk. Further evaluation of the use
of PDE3 inhibitors for prevention of cerebrovascular events should be considered.

Poster Session Cerebrovasc Dis 2007;23(suppl 2):1–147 83


Risk factors of stroke
13 Risk factors of stroke All participants, who at baseline were free from previous stroke, were subsequently
followed for occurrence of stroke (average follow-up time 5.1 years). We calculated
PSYCHO-SOCIAL FACTORS INFLUENECE STROKE OUTCOME hazard ratios (HRs) with 95% confidence intervals (CIs) for the association between
G. Szabó, L. Molnár, C. Óváry, Z. Nagy hemodynamic parameters and risk of stroke using Cox proportional hazards models
National Stroke Centre/Budapest, Balassagyarmat, Hungary with adjustment for age, sex, systolic blood pressure, antihypertensive drug use,
diabetes mellitus, ever smoking, current smoking, carotid intima-media thickness,
Background: Factors influencing stroke outcome are subject of interest. The aim and carotid distensibility.
of present study was to compare the impact of “traditional” risks factors and Results: Risk of stroke (n=122) and ischemic stroke (n=89) increased with increas-
psychosocial factors on modified Rankin scale. ing middle cerebral artery flow velocity: when comparing the tertile with highest
Methods: In the stroke unite of a county hospital, 646 consecutive stroke patients velocity to the tertile with lowest velocity, the HR was 1.74 (95% CI 1.09-2.77) for
were include in this study. Determining disease outcome we used the modified the association between mean flow velocity and stroke, 1.63 (95% CI 1.03-2.58)
Rankin scale after 28 days of stroke onset. Stroke risk factors were recorded and for end diastolic flow velocity and stroke, and 1.33 (95% CI 0.86-2.08) for peak
psychosocial data (Beck depression scale, coping skills, educational attainment, systolic flow velocity and stroke. These estimates increased 10-26% when only
and isolation) were collected using the standardized questionnaires. For statistics ischemic strokes were included. We found no associations between vasomotor
we used a multiway contingency tables with log linear modelling. reactivity and risk of stroke.
Results: A log linear model fits well (p=0.786) to our data. Patients suffering form Discussion: Risk of stroke increased strongly with increasing middle cerebral
repeated stroke showed significantly worse outcome (p<0.001). Hypertension, artery flow velocity as measured with TCD in the general population.
diabetes mellitus, hyperlipidemia and smoking were not significant factors on
stroke outcome. On the other hand close relationship could be described in the
3-factors interaction among depression, isolation and stroke outcome, furthermore 16 Risk factors of stroke
among coping skills, depression, and stroke outcome, finally among coping skills,
educational attainment, and stroke outcome. The 2-factors interaction between A PROSPECTIVE STUDY OF PREVALENCE AND PROGNOSIS OF PVD IN
educational attainment and isolation, and between educational attainment and PATIENTS ADMITTED WITH ISCHAEMIC STROKE
depression could be also proved. V. Paranna, A. Gupta, R. Prakash, L. Bachegowda, G. Shankar, K.K. Manda,
Discussion: The significant effects of depression, insufficient coping skills, low ed- A. Watkins
ucational level, and isolation on stroke outcome were documented. Better managing West Wales Hospital, United Kingdom
of these factors may improve the quality of life after stroke.
Introduction: Atherosclerosis is a multisystemic,asymtomatic disease which is di-
vided into Cerebrovascular disease,Peripheral Vascular disease & Coronary Artery
14 Risk factors of stroke disease.Patients presenting with acute stroke are likely to have PVD which may be
unrecognised.Presence of PVD increases the risk of Myocardial Infarction & stroke
STROKE IN CHRONIC KIDNEY DISEASE: PATTERNS OF STROKE, by 2 fold.Early detection & management of PVD can avoid complications.Ankle
FACTORS AFFECTING DEVELOPMENT OF STROKE Brachial Pressure Index is simple bedside test useful in this process.
S. Jung, S.H. Hwang, S.B. Kwon, K.H. Kwon, I.S. Koh, K.H. Yu, B.C. Lee Objective: The aim of the study was to evaluate the prevalence of PVD in
Hallym University College of Medicine, South Korea stroke patients,to assess whether symptomatic or asymptomatic PVD,severity of
the disease & to evaluate whether PVD is an independent prognostic factor in the
Background: Patients with chronic kidney disease (CKD) have increased risk for outcome of stroke.
stroke. Although they share conventional stroke risk factors, not all CKD patients Method: Prospective comparative group study which was carried out in West
suffer stroke. We analyzed the pattern of stroke and tried to elucidate the factors Wales Hospital,Carmarthen,UK.A total of 100 patients have been included in this
affecting development of stroke in patients with CKD. ongoing study.This includes 55study group and 45 control group.Patients admitted
Method: We used data from Hallym Stroke Registry (HSR) for enrolling patients with ischaemic stroke were included in the study group & age and sex matched
with stroke and chronic renal failure (CRF) or end stage renal disease (ESRD) as non stroke general medical acute admission were included in control group.Etical
CKD. Forty patients were included from total 55 patients with acute stroke within committee approval obtained.
7 days of onset who were diagnosed as CKD from July 1996 through June 2005. Intervention:The data collected included demographics,barthel index,abbreviated
35 patients with CKD who did not develop stroke were selected as the control mental test,associated vascular risk factors,whether symptomatic PVD in the
group. We classified patients according to the modified TOAST classification past,ABPI during hospitalisation,discharge destination & follow up 3months after
and evaluated their neurologic manifestations. We also compared the properties discharge.Ankle BP was measured using handheld Doppler & ABPI was calculated
including stroke risk factors and laboratory findings between two groups. as systolic ankle BP/systolic arm BP.Pvalue was determined from by unpaired t test
Results: 29 patients had ischemic stroke and 11 patients had hemorrhagic stroke. for continuous variables & chi square test for discrete variables.
The percentage of hemorrhagic stroke was higher than general population in HSR Results: Average age of patients was 80yrs & 78yrs in the study & control group
(5.3%). The most common ischemic stroke subtype was small artery occlusion respectively.The average length of stay varied from 40 days (control group) to
(25.0%) and followed by large atherosclerosis (20.0%). The hypertensive nephropa- 59 days(trial group) with no statistical difference.Average Barthel Index though
thy was most common cause of CKD (47.5%) and duration of causative disease similar at admission(14),at discharge average BI was 14(trail gr) and 17(control
was 13.19±10.24 years. As compared to the control group, stroke patients with gr) with statistical significance(p=0.001).More number of pt had AMT<7 in study
CKD showed higher rate of hypertension, prolonged activated prothrombin time, gr with statistical significance(p=0.011).Study population had higher prevalence of
lower level of triglyceride and lower LDL cholesterol level. Hypertension(69%) & hypercholesterolaemia(18%) which was statistically signifi-
Conclusion: Strokes in CKD differ from general population in their pattern and cant(p=0.002 & p=0.011).67-80% of study population had mild to moderate degree
the risk factors. There is relatively larger incidence of hemorrhages compared to of PVD based on ABPI which is statistically significant(p=<0.001 & p=0.001)
non-kidney disease patients. Low lipid profile in CKD patients may suggest the which was previously undetected and asymptomatic.
protective effect of hyperlipidemia against the development of stoke as preventing Conclusions: The results of this study favoured PVD as a common asymtomatic
of malnutrition which is one of the most important cause of mortalities in CKD and unrecognised condition in patients with stroke.Early detection of PVD could
patients. prevent compilcations in high risk patients.There is also a need to educate,identify
& treat associated risk factors.The study is ongoing to include larger sample size
for multiple regressional analysis to evaluate the role of PVD as an independent
15 Risk factors of stroke prognostic factor following stroke.

TRANSCRANIAL DOPPLER HEMODYNAMIC PARAMETERS AND RISK OF


STROKE: THE ROTTERDAM STUDY
M.J. Bos, P.J. Koudstaal, A. Hofman, J.C. Witteman, M.M. Breteler
Erasmus Medical Center, Rotterdam, Rotterdam, The Netherlands

Background: We explored the association between transcranial Doppler (TCD)


hemodynamic indices and risk of stroke in the general population.
Methods: At baseline we assessed mean flow velocity, peak systolic flow velocity,
end diastolic flow velocity, and vasomotor reactivity (VMR) with TCD in 2022 Rot-
terdam Study participants of age 61 years and over in both middle cerebral arteries.

84 Cerebrovasc Dis 2007;23(suppl 2):1–147 16th European Stroke Conference


17 Risk factors of stroke assess the prevalence and incidence of risk factors for vascular disease. We also
assessed the control of known risk factors.
MIGRAINE MEDIATES THE INFLUENCE OF C677T MTHFR GENOTYPES Methods: All adult patients admitted with recurrent stroke in the year 2005
ON ISCHEMIC STROKE RISK WITH A STROKE-SUBTYPE EFFECT were included in the study. The Royal College of Physicians guidelines 2004 on
A. Pezzini, M. Grassi, E. Del Zotto, A. Giossi, R. Monastero, G. Dalla Volta, secondary prevention for stroke were used as the gold standard. We used our local
S. Archetti, C. Camarda, R. Camarda, A. Padovani diabetic guidelines to define the control of Diabetes Mellitus with a haemoglobin
Dipartimento di Scienze Medico-Chirurgiche, Neurologia Vascolare, Spedali A1C level of less than 8 as acceptable control.
Civili di Brescia, Brescia, Italy Results: 81(24%) of 331 stroke inpatients in 2005 had a recurrent ischemic stroke.
52(64%) patients had known hypertension of which 17(33%) were well controlled
Background: To investigate the role of C677T MTHFR polymorphism in migraine while 35(67%) patients had uncontrolled hypertension despite being on medication.
pathogenesis and in the migraine-ischemic stroke pathway. 12(15%) patients had newly diagnosed hypertension. 19(23%) patients were known
Methods: A first genotype-migraine association study was conducted on 100 to have diabetes mellitus of which 7(37%) had acceptable glycemic control and
patients with migraine with aura (MA), 106 with migraine without aura (MO), and 12(63%) patients had poor control. There were no new diabetics. 37(45%)patients
105 subjects without migraine, which provided evidence in favour of association had hypercholesterolemia despite being on statins. 10(12%) patients had untreated
of the TT677 MTHFR genotype with increased risk of MA compared to both hypercholesterolemia.12(14%) patients had new hypercholesterolemia. Significant
control subjects (odds ratio [OR], 2.48; 95% CI, 1.11 to 5.58) and patients with carotid artery stenosis was known in 3 patients and diagnosed in 2 new patients
MO (OR, 2.21; 95% CI, 1.01 to 4.82). Based on these findings, mediational models following admission. 47(58%)patients had not had carotid dopplers after their
of the genotype-migraine-stroke pathway were fitted on a group of 106 patients previous stroke. 13(16%) patients were current smokers and 39(48%) were ex
with spontaneous cervical artery dissection (sCAD), 227 young patients whose smokers. 12(15%) patients had known atrial fibrillation and 5 patients had newly
ischemic stroke was unrelated to a sCAD (non-CAD), and 187 control subjects, diagnosed AF.
and a genotype-migraine partial mediation model was selected. Conclusions: Most patients with recurrent ischemic stroke had multiple risk factors
Results: Both migraine and the TT-genotype were more strongly associated to identified at their first stroke but a majority of these risk factors were either under
the subgroup of patients with sCAD (OR, 4.06; 95% CI, 1.63 to 10.02 for MA; treated or untreated. There was evidence of substantial under-investigation with
OR, 5.45; 95% CI, 3.03 to 9.79 for MO; OR, 2.87; 95% CI, 1.45 to 5.68 for carotid dopplers. A smaller number of patients had newly identified vascular risk
TT genotype) than to the subgroup of patients with non-CAD ischemic stroke factors at their admission with recurrent stroke. Better identification of risk factors
(OR, 2.22; 95% CI, 1.00 to 4.96 for MA; OR, 1.81; 95% CI, 1.02 to 3.22 after a stroke and more aggressive control could reduce the burden of recurrent
for TT genotype) as compared to controls. The prevalence of migraine sufferers ischemic stroke.
carrying the TT677 MTHFR genotype turned out to be higher among patients
with multiple-vessel dissection (3/16; 18.8%) than among those with single-vessel
dissection (12/90; 13.3%) and control subjects (5/187; 2.7%) and the log-odds trend 20 Risk factors of stroke
statistically significant (χ2 (df) for log-odds trend = 11.2 (1); P = 00008).
Discussion: Migraine may act as mediator in the MTHFR-ischemic stroke pathway ANEMIA AND CHRONIC KIDNEY DISEASE ARE RISK FACTORS FOR
with a more prominent effect in the subgroup of patients with sCAD. MORTALITY IN STROKE PATIENTS
P. Del Fabbro, J.-C. Luthi, P. Michel, E. Carrera, M. Burnier, B. Burnand
CHUV Lausanne, Lausanne, Switzerland
18 Risk factors of stroke
Background: Chronic kidney disease (CKD) has been linked to higher stroke risk.
PATENT FORAMEN OVALE, THROMBOPHILIC DISORDERS AND Anemia is a common consequence of CKD, and recent evidence suggests that
MIGRAINE IN YOUNG PATIENTS WITH ISCHEMIC STROKE anemia is a risk factor for cerebrovascular disease. The purpose of this study was
P. Martínez-Sánchez, B. Fuentes, M.V. Cuesta, J. Domínguez, L. Idrovo, to examine among stroke patients, the association between CKD, anemia, hospital
L. Gabaldón, M.A. Ortega-Casarrubios, E. Díez-Tejedor mortality and one year mortality.
La Paz University Hospital, UAM, Madrid, Spain Methods: We performed a retrospective cohort study with consecutive stroke
patients over a 3 year period hospitalized in the stroke unit of a single university
Background: Patent foramen ovale (PFO) has been associated to inherited throm- hospital. We recorded demographic characteristics and risk factors for stroke. Re-
bophilic disorders, stroke and migraine separately. Our goal is to asses the duced kidney function was defined as a serum creatinine ≥80 μmol/L for women
relationship between PFO ± atrial septal aneurism (ASA), thrombophilic disorders and ≥106 μmol/L for men. Glomerular filtration rate (GFR) was also calculated.
and previous history of migraine in young patients with cryptogenic stroke. Anemia was defined when hemoglobine was below 12 g/dl on admission. The main
Methods: Observational study with inclusion of consecutive patients from the outcome measures were hospital mortality and one year survival.
Stroke Unit Data Bank (January 1995-October 2005). Patients under 55 years with Results: 963 patients aged between 16 and 97 years were included. Fifty-five-
an acute cryptogenic cerebral infarction were selected. We analyzed: demographic point-five percent had CKD according to our definition, and 12.1% had anemia.
data, vascular risk factors, stroke subtype, previous migraine and the presence Thirty-three (3.7%) patients died during their hospitalization; among those, 27
of thrombophilic disorders by a battery of hematological test. The presence of (81.8%) had CKD (p=0.002). 82 (9.6%) patients died during the first year after
PFO ± ASA was assessed by transcranial Doppler sonography monitoring and discharge from hospital, among them 54 (65.9%) had CKD (p=0.035). Anemia on
echocardiography. admission to the hospital was associated with an increased risk of death during
Results: 235 patients, mean age 42.97 ± 9.353 years. 16.6% had a PFO, 7.7% had hospitalization and at one year after discharge.
previous migraine and 7.2% were diagnosed of a thrombophilic disorder. Patients After adjustment for other factors, hemoglobine was independently associated with
with PFO had less traditional risk factors such as hypertension, current smoking an increased risk of death at the hospital and one year survival.
or coronary arterial disease (P<0.05). PFO+ASA was more common in women Conclusion: Both CKD and anemia are frequent among stroke patients and are
(9.3% vs 2.9%; P=0.044) and in patients with previous migraine (22.2% vs 4.1%; associated with an increased risk of hospital and one year survival.
P=0,011). Thrombophilic disorders were more frequent in PFO patients (15.4% vs
5.6%, P=0.043; OR 3.058: 95% CI 1.058-8.839) as well as in previous migraine
patients (22.2% vs 6%; P=0.031; OR 4.484: 95% CI 1.291-15.565). The frequency 21 Risk factors of stroke
of thrombophilic disorders was the highest in migraine + PFO patients (60% vs
6.1%, P= 0.003; OR 23.143: 95% CI 3.570-150.017). SUBCLINICAL HEMODYNAMIC ABNNORMALITIES IN SYMPTOM-FREE
Conclusions: In patients under 55 years, thrombophilic disorders are diagnosed HYPERTENSIVE PATIENTS DURING HEAD UP TILT TABLE TEST
more frequently in PFO-related cerebral infarcts, especially in migranous patients. L. Csiba, Z. Bajkó, K. Csapó, P. Soltész
Debrecen University, Debrecen, Hungary

19 Risk factors of stroke The dysregulation of the autonomic nervous system plays an important role in the
development of hypertension. The heart rate variability and baroreflex sensitivity
RISK FACTOR ANALYSIS IN PATIENTS ADMITTED WITH RECURRENT are established methodes for the evaluation of the cardiac autonomic activity and
ISCHEMIC STROKES provide the assessment of the sympathetic and vagal activity. Our purpose was
P.K. Shibu, S.H. Guptha, P. Owusu-Agyei to measure the cardiac parameters of the autonomic nervous system in essentiel,
Peterborough District Hospital, Peterborough, United Kingdom non-treated hypertensive patients and later the efficacy of the antihypertensive
treatment by non-invasive technique.
Background: We studied patients admitted with recurrent ischaemic stroke to Heart rate variability calculated with spectral analysis and baroreflex sensitivity

Poster Session Cerebrovasc Dis 2007;23(suppl 2):1–147 85


Risk factors of stroke
obtained by the sequence technique were measured in 28 healthy persons (age: of undetermined cause (IUC). Statistical analyses were performed using uni- and
48,29±8,14 yrs, m/f rate: 1) and 28 hypertensive patients (age: 46,11±6,54 év, m/f multi-variate logistic regression models
rate: 1,1) by Task Force Monitor during head-up tilt table test. Results: FHOS was identified in 17 (11.4%) out of the 149 first-ever IS patients
The number of the baroreflex sequences was significantly higher (66,9 vs 51,1; (mean age 38±7 years, male gender 58%). The distribution of FHOS among the
p=0,031), the baroreflex effectiveness index was significantly lower (67,3 v 58; TOAST subgroups was as follows: LAA 21% (4/19), CE 9% (2/22), LAC 17%
p=0,027) and also significantly lower heart rate variability was measured in the low (4/24), IOE 13% (5/38) and IUE 4% (2/46). FHOS was more prevalent (p=0.045)
frequency (LF-RRI) range(213 ms2 vs 468,2 ms2, p=0,018) in the hypertensive in the combined group of IS of vascular etiology (LAA/LA/IOE, 16%) than in the
group. group of patients with CE and IUE (6%). After adjusting for stroke risk factors and
The decreased baroreflex sensitivity and heart rate variability proved the autonomic demographic characteristics FHOS was independently (p=0.052) associated with
dysfunction, the lower sympathetitc activity indicated long-standing systemic IS due to LAA, LAC or IOE (OR:3.1; 95%CI:1.0-10.1).
hypertension in the hypertensive group. Discussion: Our findings indicate that young adults with IS of vascular etiology
The authors will also show the changes after 6 months antihypertensive therapy are more likely to have a positive FHOS than patients with CE or IUE.
(finished April, 2007).

24 Risk factors of stroke


22 Risk factors of stroke
METABOLIC SYNDROME IN SYMPTOMATIC AND ASYMPTOMATIC
PREVALENCE OF CONVENTIONAL VASCULAR RISK FACTORS IN PATIENTS WITH SEVERE CAROTID STENOSIS
STROKE PATIENTS UP TO 45 YEARS OLD. A COMPARISON WITH L. Tuskan-Mohar, I. Strenja-Linic, K. Blazina, I. Antoncic, S. Dunatov,
GENERAL STROKE POPULATION M. Bucuk, A. Jurjevic
J. Lopez-Fernandez, A. Gonzalez-Hernandez, O. Fabre-Pi, J.A. Suarez-Muñoz, University Hospital Center Rijeka, Croatia
M. Vazquez-Espinar, S. Diaz-Nicolas, V. Araña-Toledo, A. Cubero-Gonzalez
Hospital de GC Dr Negrin, Spain Background: Metabolic syndrome (MS) is a constellation of interrelated abnor-
malities that increase the risk for the development of cerebrovascular disease. The
Introduction: Ischemic stroke is considered a heterogeneous entity that presents aim of this study was to analyze a group of symtomatic and asymptomatic patients
differences in relation to aetiology, pathology and prognosis, which can vary with severe occlusive disease of extracranial internal carotid artery (ICA) and the
according to age groups. We have analysed the presence of conventional vascular presence of MS in these patients.
risk factors in a series of stroke in the young patient, which has been compared to Methods: One hundred and forty seven patients with severe carotid stenosis,
another series including the general population in our area. treated at Department of Neurology, Rijeka University Hospital Center, Croatia,
Material and methods: We performed a retrospective revision of the clinical his- were included into the study. Sixty two (42%) patients were asymptomatic and
tory of all patients admitted in our service in the interval 01/01/2001-31/12/2005. eighty five (58%) were symptomatic. We analized a combination of vascular risk
All ischemic strokes (ISs) or transient ischemic attacks (TIAs) in patients up to factors such as obesity, diabetes mellitus, dyslipidemia and hypertension, which are
45 years-old were included. We recorded parameters related to the presence of known elements of MS, in these patients.
conventional vascular risk factors — high blood pressure (HBP), diabetes mellitus Results: There were 147 patients with severe carotid stenosis, 101 (69%) men (age
(DM), dyslipemia (DLP), tobacco smoking, ischemic cardiopathy (IC), peripheral 65.5) and 46 (31%) women (age 68.3). MS with all its elements was documented
arteriopathy and atrial fibrillation (AF) — and compared them to the number of in 20% patients. The frequency of individual components of the MS: hypertension
total strokes in 2004 and 2005. 79%; diabetes mellitus 29%; abnormal lipid profil 67%; BMI>25 in 20% (BMI>30
Results: We included 536 patients (60,4% men and 39,6% women) in our period of in 12%). The combination of hypertension and abnormal lipid profil was the most
study; 70 of them (51,4% men and 48,6%) were up to 45 years-old. The prevalence common risk factor (43%). The all risk factors equally occurred in both sexses. MS
of HBP was 37,7% in the group <46 years-old and 62,9% in the total of strokes; was more common in symptomatic than in asymptomatic patients (p=0.001).
of DM, it was 7,24% vs. 34,9%; of DLP, it was 46,7% vs. 32,5%; of active tobacco Discussion: In our series one fifth of patients with severe carotid stenosis had MS
smoking, it was 59,4% vs. 42,4%; of IC, it was 8,6% vs. 14,1%; of FA, it was 1,5% which was prevailing in symptomatic patients. The combination of hypertension
vs. 20%; and of peripheral arteriopathy, it was 0 vs. 4,3%. and atherogenic dislipidemia was the most frequent risk factor. Focusing on the
Conclusions: In our series, the prevalence of some conventional vascular risk most prominent risk factors, which are modifiable, and treating them is the most
factors (HBP, DM, IC, peripheral arteriopathy and AF) is evidently minor in effective way to prevent stroke.
the up to 45 year-old stroke population, meaning that different etiopathogenic
mechanisms are involved. However, some conventional vascular risk factors (DLP
and tobacco smoking) show a higher prevalence in this group, which, associated 25 Risk factors of stroke
to other predisposing factors, could favour ischemic events. For this reason, both
primary and secondary prevention is highly necessary to avoid the conjunction of THE MOST FREQUENT RISK FACTORS FOR ISCHEMIC STROKE IN
prothrombotic disorders in the patient. YOUNG ADULTS
M. Jovicevic, I. Divjak, A. Jovanovic
Institute of Neurology, Clinical Centre Novi Sad, Univeristy of Novi Sad, Novi
23 Risk factors of stroke Sad, Yugoslavia

ASSOCIATION BETWEEN FAMILY HISTORY OF STROKE AND ISCHEMIC Background: The objective of the study was to investigate risk factors for ischemic
STROKE SUBTYPE IN YOUNG ADULTS stroke in young adults.
K. Spengos, S. Vassilopoulou, M. Papadopoulou, A. Konstantinopoulou, Methods: The study included 100 patients with ischemic stroke of both sexes
P.P. Zis, E. Koroboki, G. Tsivgoulis aged 15-45 years treated at the Institute of Neurology in Novi Sad. All patients
Eginition Hospital, University of Athens, Athens, Greece were divided into three age groups: 15-25, 26-35, 36-45 years. All study patients
met the clinical and radiological criteria for the ischemic stroke diagnosis. The
Background: Recent data have indicated that ischemic stroke (IS) subtype may following risk factors were studied: family history, diabetes, cardiac disease, patent
be associated with the family history of stroke (FHOS). Both population-based foramen ovale, hypertension, previous stroke(s), smoking, hyperlipidemia, obesity,
and hospital-based studies have shown that FHOS is more prevalent in IS pa- alcohol abuse, migraine, oral contraception, immunological diseases, pregnancy
tients. However, the potential relationship between the etiopathogenic mechanism and puerperium.
of cerebral infarction and FHOS has not been studied in the former stroke Results: Cardiac disease was found in 26% of all patients, of which none was in
subgroup. the youngest group, while it was most frequent in the group 26-35 years (p=0.011).
Methods: Consecutive first-ever stroke patients, aged between 15 and 45 years Patent foramen ovale was found in 6% of all patients and it was more frequent
and hospitalised in the stroke wards or referred to the stoke outpatient clinic in younger patients. Arterial hypertension was present in 51% of all patients
of our tertiary care University Hospital over a 5-year period, were prospectively and the percentage of patients with this risk factor was significantly higher in
included in a computerized observational data bank. Demographic characteristics, older age groups (8.3%:25%:63.9%) (p<0.001). Smoking was the most frequent
stroke risk factors and FHOS among any first-degree relative were documented risk factor, present in 55.6% and equally distributed in all age groups (p=0.918).
in all patients. According to the TOAST criteria, ischemic stroke was classi- Hyperlipidemia was the second most frequent risk factor (53.5%). Most patients
fied based on etiopathogenic mechanisms into the following groups: large artery with hyperlipidemia were in the oldest group, however there was no significant
atherosclerotic stroke (LAA), cardioembolic stroke (CE), small artery occlusion or difference (p=0.406). Oral contraception was used by 4% of patients. Five female
lacunar infarction (LI), infarction of other determined origin (IOE) and infarction patients were pregnant or in puerperium (2:1:2).

86 Cerebrovasc Dis 2007;23(suppl 2):1–147 16th European Stroke Conference


Discussion: Smoking was the most frequent risk factor, registered in 55.6% of 28 Risk factors of stroke
all study patients. Study of risk factors is essential for adequate prevention and
treatment of ischemic stroke. THE RATE OF STROKE ASSOCIATED WITH THE USE OF THORATEC
VENTRICULAR ASSIST DEVICE IN OLDER PATIENTS
M.B. Vijayappa, B. Clemson, M. Alsorogi, S. Al-Hawarey, D. Joseph,
26 Risk factors of stroke A. Talkad, M. Mathews, D. Wang
University of Illinois College of Medicine at Peoria, OSF, INI, Peoria, IL, USA
HEREDITARY TROMBOPHILIAS AND NEUROLOGICAL COMPLICATIONS
J. Szilasiova, B. Benova, D. Kozakova, E. Kahancova, E. Antolova, Background: Because of the shortage of heart donors, ventricular assist devices
Z. Gdovinova (VAD) are used to provide mechanical circulatory support in patients with heart
Faculty of Medicine P.J. Safarik University and Faculty Hospital Kosice, failure awaiting planned heart transplant or in patients who are not candidates for
Slovakia heart transplant. The use of VADs has been increasing due to the growth of the
aging population. However, it is unclear if there is an increased risk of developing
In patients with unknown etiology of stroke hereditary coagulation disorders can stroke relative to age. Our study was to determine the effect of age on the risk of
be the reason of stroke. There are also other neurological disorders which can be stroke after VAD implant.
caused by thrombophilias. Studies have shown that trombophilia testing influences Methods: This is a retrospective study exempted by the community IRB. From
less than 25% of physician’s treatment of stroke. 1996-2006, we reviewed records of all patients who received VADs as a bridge
The authors present small study consists from 10 patients (8 women, 2 men), to transplant. Demographic data, clinical and radiographic findings were collected.
mean age 28.5 years, with different types of hereditary coagulation disorders Descriptive statistics were applied. The patients were categorized according to age;
affecting cerebral circulation. In 5 patients (50%) isolated and in the next 5 Group I, less than 55 and Group II, 55 or older.
patients (50%) combined hereditary coagulation deffect were found. Deficit of Results: From 1996-2006, 45 patients received VADs. The number of patients in
antithrombin (AT) III, mutation of gene for methylenetetrahydrofolate reductase group I was 24 (53%) and group II was 21 (47%). Group I had 8 (33%) strokes; 6
(MTHFR), hyperhomocysteinemia, high factor VIII, factor V Leiden, protein S and (23%) were ischemic and 2 (8%) hemorrhagic. Group II also had 8 (30%) strokes,
C deficit, increased level of plasminogen activator inhibitor (PAI) webe detcted. 7 (32%) were ischemic and 1 (5%) hemorrhagic. In Group I; 4 (17%) had diabetes,
In four patients thrombosis of cerebral arteries and thrombembolic events were 13 (54%) hypertension and 7 (29%) left atrial cannulation. In Group II; 11 (52%)
preceded by delivery or using contraceptives. In four patients coagulopathy was had diabetes, 11 (52%) hypertension and 6 (29%) left atrial cannulation. The overall
found also in family members. In 9 cases neurological complications were the first mortality in group I was 11 (46%) and 10 (48%) in group II. One (4%) death in
manifestation of thrombophilia, in one stroke was preceded by phlebothrombosis each Group was associated with stroke.
of lower extremities. In five patients brain infarcts, in two cases thrombosis of Conclusion: Regardless of patient’s age, the occurrence of stroke associated with
brain venous sinuses were found and in the last three patients magnetic resonance the implantation of a VAD was similar. There was no significant increase in stroke
revealed demyelinating lesions. related mortality. Given the known benefit of VADs support to improve the rate
After therapy two patients have mild hemiparesis, next two vascular epilepsy and of successful transplantation and the absence of an increased risk of stroke in
last six patients are without any consequences. In patient with AT III deficit was older patients, the use of VAD support in appropriate patients should be carefully
in the same time present thrombembolia of pulmonal, radial, axillar and cerebral considered regardless of age.
arteries with numerous brain infarcts.
Hereditary thrombophilias are rare reasons of stroke, but with higher frequency in
younger patients. Their detection may provide prognostic information of the risk of 29 Risk factors of stroke
recurrent events as well as determine the most appropriate treatment.
ASSOCIATION OF CAROTID INTIMA MEDIA THICKNESS AND PLAQUE
WITH AORTIC ARCH CALCIFICATION
27 Risk factors of stroke B.-S. Shin, E.S. Lim
Chonbuk National University Hospital and Medical School, Jeonju, South
INFLUENCE OF VASCULAR RISK FACTORS ON OXIDATIVE STRESS, Korea
ASSESSED BY MEASUREMENT OF SERIC MDA LEVELS, IN ACUTE
ISCHEMIC STROKE SUBTYPES Introduction: Atherosclerosis is a generalized process and is the major cause of
A. Simion cerebrovasculardisease. The more advanced atherosclerotic lesions contain calcium
Faculty of Medicine and Pharmacy Oradea/Clinical Hospital of Neurology and deposits. Aortic arch calcification may represent a manifestation of generalized
Psychiatry, Oradea, Romania atherosclerosis. The carotid intima media thickness (IMT) is also recognized as
independent predictors of adverse cerebrovascular outcomes. The purpose of this
Background: Oxidative stress has been involved in the pathogenesis of several study is to examine the relationship between the degree of aortic arch calcification
diseases considered as risk factors for ischemic stroke. and carotid IMT and plaque.
Material and method: A consecutive series of ischemic stroke patients admitted Materials and methods: A total of 56 patients (31 men and 25 women) were
were evaluated clinically, with brain CT and/or MRI, Duplex sonography, electro- included. All patients had chest radiography in the posteroanterior view. Severity of
cardiography, transthoracic echocardiography, and biochemically (measurement of aortic arch calcification was graded as follows: grade 1 (small spots of calcification
lipid fractions and fasting glucose levels).Strokes were divided into large artery dis- or single thin calcification of the aortic knob), grade 2 (one or more areas of
ease (LAD), small vessel disease (SAD) and cardioembolism (CE) according to the thick calcification), grade 3 (circular calcification of the aortic knob). The degree
TOAST criteria.Risk factors were diagnosed according to the international criteria of carotid atherosclerosis was evaluated by measuring the maximum IMT of the
(JNC 7 for hypertension, ADA for diabetes, BMI>30 kg/m2 for obesity).Smoking common carotid artery, carotid bulb, and internal carotid artery by duplex carotid
and alcohol intake were recorded as admitted by the patient.We recorded the NIHSS ultrasonography.
score on admittance and Barthel index (BI) at discharge.Malondialdehyde (MDA) Results: The mean age of patients was 70.0 ± 9.1 years and the numbers of male
levels were measured on admittance(day 1, viewed as baseline levels)and on day 3 patients was 31. (55.4%). Severity of aortic arch calcification was grade 1 in 26
and 7. patients (46.4%), grade 2 in 18 patients (32.1%), grade 3 in 12 patients (21.4%).
Results: Patients with fewer risk factors had lower baseline-MDA levels.Smoking Aortic arch calcification was observed more commonly in elderly patients. There
raised the MDA levels in LAD significantly(p<0,001)and lowered BI(2,43 to 4,6; was no significant difference between aortic arch calcification and gender. There
4,18 to 5,9; 3,13 to 5,3).In SAD only baseline-MDA level was significantly higher was no significant relationship between severity of aortic arch calcification and
(1,83 to 4,5, p<0,001).Diabetes significantly increased oxidative stress at first carotid IMT. But there was significance between severity of aortic arch calcification
determination and worsened outcome in SAD(1,83 to 4,1, p<0,001).In CE the and plaque number (p=0.012).
MDA values were not as high as in microangiopathy, but outcome was even poorer.
Dislipidemia, obesity and hypertension raised the baseline-MDA levels nonsignifi-
cantly, except obesity in CE in which both MDA(2,17 to 3,5, p<0,001)and outcome
were significantly altered.Alcohol intake raises (p<0,001) MDA level in LAD (2,43
to 5,1; 4,18 to 5,9; 3,13 to 5,3).
Conlusions: Based on our results preventive antioxidant therapy would be most
beneficial in diabetes.

Poster Session Cerebrovasc Dis 2007;23(suppl 2):1–147 87


Risk factors of stroke
30 Risk factors of stroke 2 Stroke and diabetes
ISCHEMIC STROKE IN PATIENTS UNDERGOING DIALYSIS THE TEMPORAL PATTERN OF POST-STROKE HYPERGLYCAEMIA IS A
S. Jung, S.H. Hwang, S.B. Kwon, K.H. Yu, I.S. Koh, B.C. Lee PREDICTOR OF LONG-TERM SURVIVAL
Hallym University College of Medicine, National Medical Center, Seoul, South M. Koufali, R. Durairaj, R. Kumar, A.K. Sharma
Korea Aintree Stroke Team for Audit and Research, Aintree University Hospitals NHS
Foundation Trust, United Kingdom
Background: When we evaluated the patterns of stroke and risk factors in patients
with chronic kidney disease, it was difficult to analyze those results because the Background: Recent work has shown that persistent post-stroke hyperglycaemia
included patients were not homogenous. In that study, we included ischemic and (PHG) affects infarct size and clinical outcome. The purpose of this study
hemorrhagic stroke patients with either chronic renal disease or end stage renal was the detailed investigation of the association between blood glucose levels
disease (ESRD) undergoing dialysis. We performed this study in patient with (BGL)obtained over 24 hours and survival at 12 months following a stroke.
ischemic stroke with ESRD so as to elucidate the factors that affect developing Patients & Methods: 1496 patients, admitted during 2000-2005, with a confirmed
ischemic stroke in chronic kidney disease. diagnosis of ischemic stroke and not previously known to be diabetic were included
Methods: We enrolled patients with acute ischemic stroke in ESRD patients in this retrospective analysis. Only Caucasian patients with confirmed onset, ad-
undergoing dialysis using the data from Hallym Stroke Registry (HSR). Twenty mission, discharge and death dates were included in the study. BGL values were
patients were included from July 1996 through June 2006. Thirty patients with obtained upon admission and at 24 hours.
hemodialysis who did not develop stroke were selected as control group with age Results: Median admission BGL was 6.3 mmol/L, while median BGL at 24 hours
and sex matching. We compared the demographic features, stroke risk factors, post admission was 5.5 mmol/l. 987(66%) of patients survived at 12 weeks, 568
laboratory findings in ESRD patients with or without ischemic stroke. (38%) survived at 12 months, while 284(19%) patients died in hospital.
Results: The mean age of acute ischemic stroke patients was 60.75±10.19 and 807 patients (54% of total) were hyperglycaemic upon admission (glucose >6.1
male to female ratio was 0.82. The most common ischemic stroke subtype was mmol/L) with 256 of them (32%) remaining hyperglycaemic at 24hours post-
small vessel occlusion (SVO, 9 of 20 patients) and followed by large artery admission.
atherosclerosis (LAA, 7 of 20). Ischemic stroke patients showed longer duration Multiple regression analysis demonstrated that 24 hour PHG is independently
of causative disease of ESRD, higher rate of hypertension history, and low serum associated with: Death in hospital (p=0.017), survival at 12 months (p=0.009) and
LDL cholesterol level compared with the patients with control group. increased lengths of stay (p=0.005).
Discussion: Although low serum LDL level in stroke with CKD in our previous Conclusion: Evidence is presented that patients with persistent hyperglycaemia
study could be affected by relatively high frequency of hemorrhagic stroke, low over 24 hours have poorer outcomes. Further research is thus warranted which
serum LDL was also observed in ischemic stroke patients undergoing dialy- would allow us to target this group of patients for aggressive therapy for blood
sis. These finding shows that serum cholesterol level can reflects the status of sugar control following a stroke.
malnutrition rather than atherosclerosis at least in CKD patients.

3 Stroke and diabetes


Stroke and diabetes POST-STROKE HYPERGLYCAEMIA IS NOT AN EPIPHENOMENON OF
ISCHAEMIC STROKE SEVERITY
M.T. McCormick, T.A. Baird, K.W. Muir
1 Stroke and diabetes University of Glasgow, Glasgow, United Kingdom

THE EFFECT OF STATIN PRE-TREATMENT ON INFARCT VOLUME AND Introduction: Post stroke hyperglycaemia (PSH) is common and is associated with
DISCHARGE DISPOSITION IN ISCHEMIC STROKE PATIENTS WITH a worse outcome. It is postulated that hyperglycaemia reflects the stress response
DIABETES of a severe stroke. We sought to establish the prevalence of PSH within 48hours of
J.S. Nicholas, J.C. Thomas, Z. Rumboldt, P. Tumminello, S.J. Patel ictus and describe its association with stroke severity.
Medical University of South Carolina, Charleston, SC, USA Methods: Patients presenting within 24hours of a suspected stroke (April 2004-
January 2006) underwent 4 hourly capillary blood glucose (CBG) monitoring for
Background: Studies have indicated reduced rates of stroke among patients with 48hours. Baseline demographics, NIHSS, OCSP and time of stroke onset were
diabetes treated with statins. In contrast to stroke prevention, the purpose of this collected. Stroke severity was described as severe (NIHSS > 15); moderate (NIHSS
analysis was to examine post-stroke outcomes (infarct volume, discharge disposi- 7–15) or mild (NIHSS 0–6). Hyperglycaemia was defined as a CBG > 7mmol/l,
tion) among patients with diabetes who were taking a statin at onset of ischemic Results: 353 patients underwent CBG profiling. Median Age 72 (IQR 62,80);
stroke relative to those who were not. Median NIHSS 6 (3,13). 17% had diabetes. At presentation 29% of patients had
Methods: Study design was a retrospective cohort analysis of all verified ischemic PSH; Median time to CBG was 238 minutes (IQR 165,494). Over the 48hour moni-
stroke patients admitted to our university hospital 2002-2006 with magnetic res- toring period 75% developing Hyperglycaemia, with 25% euglycaemic throughout.
onance diffusion weighted imaging (DWI). Of these patients, 131 presented with Glycosylated Haemoglobin was statistically lower in patients with euglycaemia
diabetes or were newly diagnosed at admission. Infarct volume was calculated from compared to hyperglycaemia (p = 0.001). Stroke severity was not predictive
DWI, blinded to statin status. For patients with multiple infarcts, volume recorded of admission hyperglycaemia whereas glycosylated haemoglobin was (OR 2.97;
was the sum of all infarcts. Discharge disposition and clinical data were abstracted 95%CI 1.84-4.78; p < 0.001). There was no statistically significant difference
from hospital records. Statistical comparisons between statin and no-statin groups between mean blood glucose on initial monitoring between groups. However at 48
were made using 2-sided t-tests for continuous variables, chi-square for categor- hours, blood glucose was significantly lower in more severe strokes (NIHSS > 15),
ical, and Mann-Whitney for nonparametric. Variables pre-specified as potential CBG = 5.8mmol/l compared to milder strokes (NIHSS 0–6), CBG = 6.6mmol/l (p
confounders of infarct volume were time to imaging, location and type of stroke. = 0.015).
Results: Patients with diabetes who were taking a statin on admission had a statis- Discussion: Post stroke Hyperglycaemia is common. Overall prevalence for the
tically significant 55.1% decrease in median infarct volume relative to the no-statin 48hour period was 75%. Stroke severity was not predictive of post stroke hy-
group (1.02 cm3 statin versus 2.27 cm3 no-statin, Mann-Whitney p=.039, N=131, perglycaemia with more severe strokes having a statistically lower blood glucose
46.6% on statins). While differences in discharge disposition were not statistically compared to milder strokes at 48hours.
significant, those on statins were discharged sooner (mean 4.75 days versus 5.82)
and were more likely to be discharged home (37/61=60.7% versus 38/70=54.3%).
Time to imaging, location and type of stroke did not differ significantly between 4 Stroke and diabetes
groups in univariate analysis, nor did age, gender, or race (all p values >.05).
Discussion: In this study, statin-pretreated patients with diabetes experienced DIABETES MELLITUS AND THE EARLY RISK OF STROKE AFTER
significantly smaller median infarct volumes following ischemic stroke than those TRANSIENT ISCHEMIC ATTACK: A HOSPITAL-BASED CASE SERIES
not pretreated. Given the potential importance to treatment practices, this finding STUDY
and its implications for clinical outcome should be further investigated. G. Tsivgoulis, S. Vassilopoulou, E. Manios, P.P. Zis, K. Spengos
Eginition Hospital, University of Athens, Athens, Greece

Background: California- and ABCD-scores reliably predict short-term risk of


stroke after TIA. Both scores contain similar components. However, diabetes

88 Cerebrovasc Dis 2007;23(suppl 2):1–147 16th European Stroke Conference


mellitus (DM) is only included in the California Score. Aim of the present study groups. Detected differences were adjusted for age and sex by multivariable logistic
was to evaluate the potential relationship of DM with the early risk of stroke in a regression.
cohort of hospitalised TIA patients. Results: Between Jan 1995 and Dec 2004, diabetes was identified in 419 patients
Methods: All patients hospitalised in our Department with definite TIA during a (16.9%). The mean age of black diabetic patients was significantly lower than that
5-year period were identified and their medical charts as well as their Emergency of whit patients (68.9y versus 73.4y, respectively; p<0.001); no differences were
Room records were retrospectively reviewed by two investigators blinded to follow- found for sex. Among black diabetic patients, the prevalence of atrial fibrillation
up. Patients with previous history of stroke and those who missed their follow-up (OR 0.2; 95% CI 0.1-0.4) and of smoking (OR 0.5; 95% CI 0.3-0.7) was lower,
evaluations at the outpatient clinic of our Department at 1 month after admission and presence of hypertension higher (OR 2.7; 95% CI 1.5-4.8) compared to white;
were excluded. DM was specified as fasting serum glucose ≥7.0 mmol/L, nonfast- no other statistically significant differences for vascular risk factors were found.
ing serum glucose ≥11.1 mmol/L, or use of oral blood sugar-lowering drugs or Distribution of stroke pathology and of clinical subtypes showed no statistically
insulin. The outcome events of interest in all TIA patients were subsequent strokes significant variation between the two ethnic groups.
during the 1-month follow-up period. Statistical analyses were performed using Conclusions: Substantial ethnic differences were found in the prevalence of vascu-
the Kaplan-Meier product-limit method and stepwise Cox’s proportional hazards lar risk factors between black and white diabetic stroke patients. These differences
model. might reflect different risk factor profiles and possibly point to 2 clusters with
Results: The 30-day risk of stroke in the present case series (n=226) was 9.7% different interactions between risk factors
(95%CI:5.8-13.6%; 22 events). The 30-day risk of stroke was higher in patients with
DM (17.3%; 95%CI:7.6-27.0%) than in non-diabetic patients [(7.1%; 95%CI:3.2-
11.0%); log-rank test=5.20; df=1; p=0.0225]. After adjustment for demographic
characteristics, stroke risk factors, history and number of prior TIAs, duration and Etiology of stroke
symptoms of TIAs, as well as secondary prevention treatment strategies during
hospitalisation, DM was independently (p=0.015) associated with a three-fold
greater 30-day risk of stroke (HR:2.98; 95%CI:1.28-6.94). 1 Etiology of stroke
Discussion: DM is an independent predictor of subsequent stroke in patients
presenting with TIA. It should be taken into account by prognostic scores that CEREBRAL HEMODYNAMIC FEATURES OF ALCOHOLIC ABSTINENT
stratify the risk of early stroke in TIA patients. SYNDROME AND OPIATE ABSTINENT SYNDROME
I. Voznyuk, N. Artemyeva, S. Scherbak
Military Medical Academy, Russian Federation
5 Stroke and diabetes
Background: Chronic alcoholization and heroinism are characterized by various
PATIENTS WITH STROKE HAVE A HIGH PROBABILITY OF hemodynamic disorders, that promote the development of the cerebral pathology.
DYSGLYCAEMIA AS ASSESSED USING AN ORAL GLUCOSE TOLERANCE Methods and materials: The research involved 55 patients with the alcoholic
TEST abstinent syndrome (26-59 years old) and 40 patients with the opiate abstinent
S.H. Naqvi 1 , J.D. Lee 2 , V. Patel 3 , K.M. Sharobeem 1 syndrome (25-41 years old). The control group included 34 men and women
1
Sandwell General Hospital, Rowley Regis; 2 Department of Cardiology, George (18-47 years old). The clinical data and results of the Doppler sonography were
Eliot Hospital NHS Trust, Nuneaton; 3 Warwick Medical School, United investigated.
Kingdom Results: The similar decrease of the linear blood flow velocities in both middle
cerebral arteries was registered in 60% of the patients with the alcoholic abstinent
Background and aims: In the UK, the recently published Joint British Societies’ syndrome and in 54,5% of the patients with the opiate abstinent syndrome; in
Guidelines on the Prevention of Cardiovascular Disease recommend performing an both anterior cerebral arteries – in 56,4% and 43,8% correspondingly; in both
oral glucose tolerance test (OGTT) on subjects with an acute cardiovascular event. posterior cerebral arteries – in 47,3%, in both vertebral arteries – in 32,7% of the
In this study, we report our experience of performing an OGTT in those suffering a patients with the alcoholic abstinent syndrome. The decrease of the linear blood
recent acute stroke in a district general stroke unit. flow velocities in the basilar artery was detected in 58,2% of the patients with the
Methods: An OGTT was performed in clinically stable consecutive patients ad- alcoholic abstinent syndrome and in 20,7% of the patients with the opiate abstinent
mitted to the stroke unit with a diagnosis of acute stroke. The study was conducted syndrome; the diffuse increase of the vascular tone – in 54,5% and 48,5%; the
over a period of 3 months. Those with known diabetes mellitus were excluded. decrease of the integrated index of the cerebrovascular reactance – in 85,5% and
Results: Data on 71 patients were available. Mean age of subjects was 70 years 68,8% correspondingly. Restriction of the cerebrovascular reactivity was registered
(Range 24-96). 49% were male. 86% suffered a non-haemorrhagic stroke. The in 41,8% of the patients with the alcoholic abstinent syndrome (vasodilatation)
mean time of admission to OGTT was 8.5 days. Only 43% had a normal OGTT. The and in 28% of the patients with opiate abstinent syndrome (vasodilatation and
proportions of those with impaired fasting glycaemia, impaired glucose tolerance vasoconstriction).
and diabetes mellitus were 3%, 34%, and 20% respectively. Conclusion: The decrease of the linear blood flow velocities in the intracranial
Conclusions: Our data suggests that, based on the results of an OGTT, patients arteries, the diffuse increase of the vascular tone and the decrease of the integrated
suffering an acute stroke have a high probability of having dysglycaemia. The index of the cerebrovascular reactance occurs reliably more often in the patients
gold standard OGTT for diagnosing dysglycaemia should be employed as there is with the alcoholic abstinent syndrome and opiate abstinent syndrome, than in the
data supporting the prevention of diabetes mellitus in those with impaired glucose control group. The similar bilateral decrease of the linear blood flow velocities was
tolerance. Furthermore, early treatment of diabetes mellitus can potentially offset predominantly registered in the middle cerebral arteries and in the anterior cerebral
the appearance of classic diabetes complications. arteries.

6 Stroke and diabetes 2 Etiology of stroke


ETHNIC DIFFERENCES IN COMORBIDITIES AND STROKE SUBTYPES OF INTERPRETATION OF COMPUTED TOMOGRAPHY AND
DIABETIC STROKE PATIENTS: THE SOUTH LONDON STROKE REGISTER DIFFUSION-WEIGHTED IMAGING DURING ACUTE NEUROLOGICAL
(SLSR) EVENTS IN MITOCHONDRIAL RESPIRATORY CHAIN DISORDERS
A. Elmarimi, T. Rashid, J. Adie, O. Wood, P.U. Heuschmann, A.M. Toschke, S. Mittal, W. Watson, M. Aribandi, J.P. Hosey
A.G. Rudd, C.D.A. Wolfe Geisinger Medical Center, Danville, PA, USA
King’s College London, London, United Kingdom
Sudden neurological events are common and mimic acute stroke in mitochondrial
Background: Major differences in underlying risk factors of stroke have been respiratory chain disorders characterized by disruption of intracellular metabolic
identified between ethnic subgroups, which may have implications in directing pathways and energy failure. We had the opportunity to examine four separate
secondary preventive strategies. Data are lacking about differences in comorbidities sets of computerized tomography (CT), diffusion-weighted imaging (DWI) and
and stroke subtypes between black and white diabetic stroke patients. apparent diffusion coefficient (ADC) data collected during acute neurological
Methods: Data were collected from the South London Stroke Register (SLSR), events from two patients with defects in the mitochondrial respiratory chain
a population-based stroke register covering a multiethnic source population of function. Both had prior histories of mental retardation and seizures but no known
271.817 inhabitants (2001). Analysis was restricted to those with known diabetes mitochondria disorder. Clinically the events were characterized by acute onset
and to patients of black or white ethnic group. Demographics, major vascular hemispheric symptoms suggesting stroke. Initial evaluation with CT brain showed
risk factors and stroke subtype were compared between black and white ethnic hypodensity involving the temporoparietal region of the symptomatic hemisphere

Poster Session Cerebrovasc Dis 2007;23(suppl 2):1–147 89


Etiology of stroke
with effacement of sulci and surrounding edema indicative of subacute stroke. patient had an ICH into a germinative cell tumor metastases and the other three
DWI and ADC map were obtained within the first 48 hours; there was a delay had ischemic strokes- two had identified intracardiac emboli source (a fungi and a
of 168 hours in one event. All four DWI/ADC data were strikingly similar and nonbacterian thrombotic endocarditis).
showed restricted diffusion mixed with increased ADC in the temporoparietal Discussion: Patients with CVD and cancer in our hospital seem to receive a less
area indicating a combination of cytotoxic and vasogenic edema. One patient had thorough investigation of stroke etiology. Autopsy data seem to differ from clinical
A3243G mutation and the other a deficiency of cytochrome c oxidase activity and ones, maybe due to the severity of patients evaluated. A better investigation of these
partial deficiency of NADH dehydrogenase. Though presented acutely CT scans patients could help identify preventable causes of stroke recurrence.
in all four events suggested subacute stroke. With newer treatment modalities for
ischemic stroke widely available it is important to distinguish them from acute
events in mitochondrial encephalopathies. DWI helps distinguish between cytotoxic 5 Etiology of stroke
and vasogenic edema. Membrane ion pump failure and ingress of sodium into the
cell during acute ischemia cause restriction of movement possibilities of water EMBOLIC LESION PATTERN ON DIFFUSION WEIGHTED BRAIN IMAGING
molecules. Resultant uniformly reduced values of ADC are seen in infracted area AND AETIOLOGY OF STROKE
confined to a vascular territory. In our observation restricted diffusion was notably J.N.E. Redgrave, A. Chandratheva, D. Briley, P.M. Rothwell
confined to the cortical areas while the adjacent white matter showed increased Stroke Prevention Research Unit, Department of Clinical Neurology, Oxford
ADC which was felt to be unique to patients with mitochondrial encephalopathy University, Oxford, United Kingdom
presenting as acute neurological events.
Background: Diffusion-weighted MR-imaging (DWI) is highly sensitive to acute
cerebral ischaemia and may help to determine the likely underlying aetiology.
3 Etiology of stroke For example, several studies have reported an association between multiple acute
ischaemic lesions and ipsilateral 50% carotid stenosis, although none has quantified
STROKE PATTERNS IN PATIENTS WITH INTERNAL CAROTID ARTERY the predictive value.
DISSECTION – THE SIGNIFICANCE OF VESSEL PATENCY Methods: Consecutive patients referred to a specialist clinic with TIA or minor
L.H. Bonati, S.G. Wetzel, J. Gandjour, R.W. Baumgartner, P.A. Lyrer, stroke had DWI and carotid MR-angiography. Ipsilateral 50% carotid bifurcation
S.T. Engelter stenosis was related to the presence of solitary and multiple acute ischaemic lesions
University Hospital Basel, Basel, Switzerland on DWI.
Results: 500 patients (278 men) were studied. DWI showed acute ischaemic
Background: Spontaneous dissection of the internal carotid artery (ICAD) is an lesion(s) in 179/280 (63.9%) patients with minor stroke vs. 33/220 (15%) with
important cause of stroke in young and middle-aged patients. ICAD may lead to TIA (p<0.0001). 52 (10.4%) patients had symptomatic 50% carotid stenosis. A
a complete vessel occlusion or residual flow through a stenotic artery. Diffusion- solitary DWI lesion was not associated with symptomatic carotid stenosis (OR
weighted imaging (DWI) has the potential to highlight differences in the pattern of 1.00, 0.51-1.99, p=0.99) but multiple acute DWI lesions in the ipsilateral carotid
cerebral ischemia between occlusive and non-occlusive ICAD. territory was strongly associated (OR 5.87, 2.68-12.86, p<0.001) with carotid
Methods: DWI, Doppler and color duplex sonography, and angiographic studies stenosis, particularly the presence of >3 lesions (OR 8.87, 3.26-24.15, p<0.001).
were assessed in 40 consecutive patients (median age 47 years, interquartile range However, the corresponding sensitivities for prediction of the presence of 50%
[IQR] 39-56) with ischemic stroke caused by spontaneous ICAD, referred to two ipsilateral carotid stenosis were nevertheless low (25% and 15% respectively) and
university hospitals. Number, size and location of hyperintense lesions on DWI the imaging appearance was also associated with cardioembolic aetiology.
were correlated with vessel patency. Conclusion: Multiple acute ischaemic lesions on DWI are strongly associated
Results: Patients with non-occlusive ICAD (n=15) presented with more ischemic symptomatic 50% carotid bifurcation stenosis, but the appearance is likely to be of
lesions (median 5, IQR 1-10) than patients with complete ICA occlusion (n=25) limited use in aetiological classification.
(2, 1-3; p=0.014). In contrast, ischemic lesions were larger in occlusive ICAD (62,
50-99 mm) compared to non-occlusive ICAD (25, 10-50 mm; p=0.007). Stroke
patterns differed significantly between the two groups (p=0.002). Non-occlusive 6 Etiology of stroke
ICAD was associated with disseminated lesions involving borderzone territories,
whereas most patients with occlusive ICAD had large territorial infarcts. PREVALENCE OF FABRY’S DISEASE IN YOUNG MALE PATIENTS WITH
Conclusions: Our data suggest different stroke patterns in ICAD patients with STROKE OR TRANSIENT ISCHEMIC ATTACK
occluded ICA compared to those with stenotic ICA. These findings may be of A. Viguier, T. Levade, V. Larrue
relevance in the ongoing controversy about the acute treatment of stroke in ICAD. CHU de Toulouse, Toulouse, France

Background: Fabry’s disease is a rare inherited, X-linked storage disease that may
4 Etiology of stroke cause stroke or transient ischemic attack (TIA) in young subjects. We sought to
determine the prevalence of this disease in an unselected population of young male
STROKE IN PATIENTS WITH CANCER IN A GENERAL HOSPITAL: patients with stroke or TIA.
DIFFERENCES BETWEEN CLINICAL AND AUTOPSY SERIES Methods: Peripheral blood leukocyte alpha-galactosidase A activity was deter-
G.S. Silva, D.L. Gomes, M.M. Alves, J.A. Fiorot Jr, A.R. Massaro mined in male patients aged 18-55 years, consecutively admitted to a tertiary stroke
UNIFESP- Universidade Federal de São Paulo, São Paulo, Brazil unit for acute stroke or TIA. Causes of stroke or TIA were classified using the
TOAST classification.
Background: Cerebrovascular disorders (CVD) are frequent causes of neurological Results: 108 patients were recruited from January 2004 to June 2005. The mean
symptoms in cancer patients. Clinical and autopsy series differ in the importance age ± SD was 45 years ± 9. There were 71 ischemic strokes, 27 TIAs, 8 cerebral
of cancer specific conditions as causes of CVD in these patients. Our aim was to hemorrhages and 2 venous cerebral thrombosis. Causes of stroke or TIA were un-
describe the clinical features of patients with CVD and cancer admitted to a general determined in 51/98 (52%) patients. No patient had a deficient alpha-galactosidase
hospital, and to compare them to autopsied patients with the same diagnosis. A activity.
Methods: A retrospective analysis of patients with the diagnosis of CVD and Discussion: These findings confirm the rarity of Fabry’s disease among unselected
cancer in their discharge summaries from July 2005 to July 2006 was performed. young male patients with stroke and TIA.
The necropsies executed in our hospital from January 2004 to June 2005 were
reviewed. Data collected included: demographic, stroke and cancer features.
Results: Eleven patients (mean age 54 ± 13 years, 7 women) had a diagnosis 7 Etiology of stroke
of CVD and cancer. Intracerebral hemorrhages (ICH) (55%- 9% subdural and
46% intraparenchimal) were more frequent than ischemic strokes. Primary cancers WHITE MATTER LESION LOAD IDENTIFIED BY MAGNETIC RESONANCE
were: leukemia (36.4%), lung (18.2%), primary intracerebral cancer (18.2%), IMAGING IS NOT RELATED TO IPSILATERAL CAROTID ARTERY
colon, prostate and genitourinary tract (9.1% each). TOAST classification was STENOSIS
cardioembolic in 50% of the patients and undetermined in 50%. Oxfordshire F.N. Doubal, J.M. Wardlaw, M.S. Dennis
classification was partial anterior circulation in 66.7% and posterior circulation University of Edinburgh, Edinburgh, United Kingdom
in 33.3% of the patients. 66.3% of the patients died, and in 57.1% death was
stroke related. Echocardiogram was performed in 18.1% of the patients, magnetic Introduction: Cerebral white matter hyperintensities (WMH) on T2-weighted
resonance imaging in 9% and Doppler in 9%. From 350 necropsy studies, four magnetic resonance (MR) are common but their aetiology is unknown. They are
patients had a diagnosis of CVD and cancer (mean age 48 ± 63, 3 women). One associated with hypertension, diabetes and atherosclerosis, and may be caused by

90 Cerebrovasc Dis 2007;23(suppl 2):1–147 16th European Stroke Conference


small vessel disease or microemboli (e.g. from the heart, aortic arch or carotid artery Results: A total 404 lesions were present in 224 patients. Among these patients,
stenosis). Studies have linked the severity of any carotid stenosis to the severity single lesions were found in 64 (15.8%) and multiple lesions in 160 (84.2%).
of whole brain WMH load but have not specifically examined brain ipsilateral to Of the single lesions 24(37.5%) were intracranial stenosis and 50(62.5%) were
a stenosis. We hypothesised that if microemboli cause WMH, e.g. from carotid extracranial. Lesions were located in the anterior circulation in 42 patients (65.62%)
stenoses, more WMHs would be found in the cerebral hemisphere ipsilateral to a and in the posterior circulation in 22 (34.37%).
stenosis than in the hemisphere distal to a non-stenosed carotid. Among the 340 stenoses in the 160 patients with multiple lesions, 38 (23.75%)
Methods: We prospectively recruited patients with lacunar or mild cortical patients had 88 lesion in the intracranial, and 92 patients (57.5%) had 186 lesions
stroke from a tertiary hospital. Patients were imaged with a 1.5T MR scanner in the extracranial vessels solely and both intra and extracranial in 30(18.75%)
(T2/DWI/GRE/FLAIR) and carotid doppler ultrasound. We dichotomised carotid patients harboring 66 lesions.
stenosis as >or <50% NASCET. MRI scans were scored for deep and periventricu- Overall 142(35.1%) lesions were intracranial and 262(64.9%) were extracranial.
lar WMHs in each hemisphere using the Fazekas method, blind to carotid stenosis. Conclusion: Intracranial atherosclerosis is common in Indian patients with
We compared hemispheric Fazekas scores between patients with or without uni or atherosclerotic stenosis involving extracranial carotid artery disease.
bilateral carotid stenosis.
Results: Of 79 patients, 14 had asymmetrical carotid stenosis (one > and one
<50%), 1 had bilateral >50% stenoses and 64 had bilateral <50% stenoses. In the 10 Etiology of stroke
14 with asymmetrical stenoses there was no difference in deep or periventricular
WMHs between the ipsilateral (mean deep Fazekas 1.78; mean periventricular HOMOCYSTEINE IN STROKE SUBTYPES IN THE SOUTH LONDON BLACK
Fazekas 1.42) or contralateral hemisphere (1.78;1.36) to the stenosis. In the 64 with POPULATION
no stenosis bilaterally there was no difference in mean deep and periventricular U. Khan, C. Crossley, P. Collinson, H. Markus
Fazekas scores between the left (1.64;1.03) and right (1.62;1.08). The patient with St. George’s University of London, London, United Kingdom
bilateral stenoses had identical scores in each hemisphere.
Conclusions: We found no link between cerebral hemisphere WMH score and Introduction: Cerebral small vessel disease (SVD) is increased in black popula-
ipsilateral carotid artery stenosis, suggesting that microemboli, at least from carotid tions but the underlying mechanisms are poorly understood. In Caucasians elevated
stenoses, are unlikely to cause most WMHs. serum homocysteine (Hcy), and genetic variants causing increased Hcy levels,
have been associated with SVD particularly in cases which have accompanying
leukoaraiosis where pathological studies suggest an underlying small vessel arteri-
8 Etiology of stroke opathy and endothelial dysfunction is a proposed disease mechanism. We compared
Hcy levels from black strokes enrolled in the in the prospective South London
VASCULAR RISK FACTORS IN TRANSIENT ISCHAEMIC ATTACKS AND Ethnicity and Stroke Study with community controls.
LATE-ONSET EPILEPSY Methods: Hcy, B12, folate and creatinine were measured in black strokes (N=483)
M.O. McCarron, A. Hunter, M. Watt from three South London hospitals and controls recruited by random sampling of
Altnagelvin Hospital, Derry, United Kingdom family practices (N=276). All patients were subtyped by one rater using modified
TOAST criteria based on investigations. In SVD patients, leukoaraiosis was graded
Background: There is emerging evidence that late onset seizures may be the first according to severity (modified Fazekas scale) and patients divided into two groups:
manifestation of occult cerebrovascular disease. We sought to compare the vascular isolated lacunar infarction (ILI) and lacunar infarction in the presence of confluent
risk profiles in patients with transient ischaemic attacks and patients with late-onset leukoaraiosis (ischaemic leukoaraiosis (ILA)).
epilepsy for which no other cause was identified. Results: Hcy (μmol/L) was increased in black stroke patients (14.22 (8.80)) vs.
Methods: Consecutive patients attending a neurovascular clinic with a diagnosis controls (11.13 (5.34)) (OR: 4.63 (2.50-8.58), P<0.001) after adjusting for age,
of transient ischaemic attack (TIA) or epilepsy were eligible for study. Vascular gender, vascular risk factors, B12, folate and creatinine. Hcy levels were signif-
risk factors were prospectively recorded and compared in each group with the chi icantly raised in the following groups: SVD (OR: 7.16 (3.32-15.44), P<0.001),
square test. intracerebral haemorrhage (OR: 5.53 (2.07-14.72), P=0.001), cardioembolism
Results: One hundred patients were enrolled in each group. The distribution of (OR: 7.85 (2.87-21.42), P<0.001) and unknown aetiology (OR: 2.28 (1.15-4.52),
vascular risk factors was as follows: atrial fibrillation (2 in seizure group versus 0 P=0.018) with highest levels seen in SVD (16.19 (11.48)). Within the SVD group
in TIA group, NS), hypertension (59 versus 52, NS), diabetes (9 versus 10, NS), Hcy was higher in the ILA subgroup (19.63 (14.61)) vs. ILI (13.41 (7.06)) (OR:
cigarette smoking (52 versus 45, NS), heart failure (1 versus 0, NS), hyperlipi- 4.75 (1.53-14.69), P=0.007) and correlated with radiological leukoaraiosis severity
daemia (35 versus 33, NS), ischaemic heart disease (18 versus 23, NS), previous (R=0.265, P=0.001).
cerebrovascular disease (33 in seizure group versus 7 in TIA group, p<0.001), Conclusions: Hcy is a risk factor for cerebral SVD in blacks, especially in confluent
excess alcohol (19 versus 16, NS), and family history of stroke (52 versus 50, NS). leukoaraiosis. This is consistent with a role for endothelial dysfunction in SVD
Discussion: Vascular risk profiles are very similar among TIA and late-onset pathogenesis in this ethnic group.
epilepsy patients. This study also supports existing evidence that previous cere-
brovascular disease is a risk factor for late-onset epilepsy.
11 Etiology of stroke
9 Etiology of stroke DETECTION OF RIGHT-TO-LEFT SHUNTS IN PATIENTS WITH
HEPATOPULMONARY SYNDROME IS POSSIBLE USING TRANSCRANIAL
PATTERN OF INTRACRANIAL VERSUS EXTRACRANIAL DOPPLER
ATHEROSCLEROTIC CEREBROVASCULAR DISEASE IN INDIAN PATIENTS G.S. Silva, D.L. Gomes, M.G. Vasconcelos, J.A. Fiorot Jr, M.M. Alves,
WITH STROKE- AN ANGIOGRAPHY STUDY C.H. Fischer, A.R. Massaro
S. Husain, S. Sukumaran, A. Vajpayee, S.U. Khan, K.M. Rahman, UNIFESP - Universidade Federal de São Paulo, São Paulo, Brazil
S. Chaturvedi Gopal, S. Sharma
Sir Ganga Ram Hospital, New Delhi, New Delhi, India Background: Patients with liver failure can present with a large spectrum of neu-
rologic symptoms. Cerebrovascular disease has been described as one of the most
Objective: To evaluate the intracranial atherosclerosis among patients of atheroscle- frequent neuropathology findings after liver transplantation. Right-to-left shunts
rotic stenos-occlusive extracranial carotid artery disease undergoing cerebral DSA (RLS) were described in patients with hepatopulmonary syndrome, related to in-
for the evaluation of the cerebral haemodynamic. trapulmonary vascular dilatations. We assessed the hypothesis that intrapulmonary
Material & methods: Between May 1999 to March 2005, 224 cerebral DSA were RLS in patients with hepatopulmonary syndrome can be detected by transcranial
performed in symptomatic patients referred to us with evidence of extracranial large Doppler (TCD).
vessel disease, either on Doppler, CTA or MRA. The percentage diameter stenosis Methods: Patients with liver failure and hepatopulmonary syndrome, selected
for extracranial vessel was calculated by NASCET method and for intracranial ves- from the gastroenterology outpatient clinic of our hospital, and with a confirmed
sels as per WASID method. They were categorized as nonsignificant stenosis (0% intrapulmonary RLS on transesophagealechocardiography (TEE) were evaluated.
to 49%), significant stenosis (50% to 99%), and total occlusion. The intracranial A group of patients with intracardiac RLS on TEE was also studied. All patients
vessels were involved when a lesion was distal to the ophthalmic artery. For the were submitted to middle cerebral artery TCD monitoring by transtemporal ap-
vertebral artery, the distinction was made at the point where the artery pierced the proach after the injection of saline solution (9ml) and air agitated, in the right
dura at the level of foramen magnum. The intracranial extent of the stenosis was antecubital vein. Monitoring was performed during normal breathing and after
included in this study up to the M2 and A2 segments in the anterior circulation and Valsalva maneuver. The presence of microembolic signs (MES) was evaluated by
the P1-P2 segments of the posterior cerebral artery. three examiners, blinded to the patient‘s diagnosis.

Poster Session Cerebrovasc Dis 2007;23(suppl 2):1–147 91


Etiology of stroke
Results: Eight patients with hepatopulmonary syndrome (mean age 53,2 ± 12,3 renal FMD;III (n:12), isolated cervical FMD;IV (n:33) without FMD. Renal FMD,
years, 6 men) and 20 patients with intracardiac shunts (mean age 47 ± 16,8 years, bilateral in half of the cases,was significantly associated with an age over 40
8 men) were evaluated. MES were detected by TCD with a sensitivity of 87,5% years.Two out of patients with renal FMD had arterial hypertension.
in patients with intrapulmonary shunts and 90% in those with intracardiac shunts. Conclusion: The prevalence of combined cervical and renal artery FMD is 9% in
Time delay to first MES detection was higher in patients with intrapulmonary patients with CAD.More FMD cases(7%)are detected by cervical and renal DSA
shunts (15s X 10 s in patients with intracardiac shunts) (p=0,04). than by cervical DSA alone.The diagnosis of renal FMD could help in identify-
Discussion: TCD can detect intrapulmonary shunts in patients with hepatopul- ing patients at risk of renal artery dissection and renovascular hypertension.The
monary syndrome, with a sensitivity slightly lower than for the detection of presence of an arterial hypertension is not predictive for renal FMD.
intracardiac shunts. Time delay for intrapulmonary shunts detection is higher when
compared to intracardiac shunts. Paradoxical emboli should be investigated as a
potential cause of neurologic symptoms in patients with liver failure and TCD can 14 Etiology of stroke
be a useful screening method for this evaluation.
CAUSES HETEROGENEITY OF LACUNAR STROKE
O. Vinogradov, A. Kuznetsov
12 Etiology of stroke National Pirogov Centre of Therapy and Surgery, Moscow, Russian Federation

RELATIONSHIP OF CAROTID ATHEROSCLEROSIS WITH Background: Cerebral microangiopathy owing to hypertension or diabetes mellitus
LEUKOARAIOSIS IN ISCHEMIC STROKE PATIENTS is considered to be main cause of lacunar stroke (LS). But other causes of LS are
E. Ben-Assayag, M. Mijajlovic, S. Shenhar-Tsarfaty, I. Bova, L. Shopin, known too. The purpose of this study was to determine etiologies of LS other than
S. Berliner, I. Shapira, N.M. Bornstein small-artery disease.
Tel Aviv Sourasky Medical Center, Tel Aviv, Israel Material and methods: We have examined 105 patients with acute LS. We used:
diffusion-weighted MRI (Giroscan INTERA NOVA, Holland), transthoracic or
Background: Previous studies have shown that white matter lesions are associated transesophageal echocardiography, carotid duplex sonography (VIVID 7, USA),
with increasing age, hypertension, diabetes and history of stroke. Although several transcranial Doppler sonography with microemboli detection (Sonomed-300, Rus-
lines of evidence suggest a role of atherosclerotic processes in atherothrombotic sia); scale evaluation was performed according to NIHSS.
vascular events, their involvement in leukoaraiosis (LA) remains to be determine. Results: Patients with LS according to diffusion MRI were divided in 3 groups:
Our study examines the association between atherosclerosis, reflected as intima- group I – single small (less than 15 mm) lacunar focus – 59 patients (56,5%); group
media thickness (IMT) and carotid plaques and LA in a group of ischemic stroke II – large focus (more than 15 mm) or multiple small foci at the same vascular
patients. territory – 24 patients (22,9%), group III – multiple foci in different vascular
Methods: One hundred sixty four consecutive ischemic stroke patients were territory – 22 patients (20,9%). LS caused by small-artery disease was revealed
included (mean age 66.7± 3.4 years, 61% males). All patients underwent brain in 69 patients (65,7%). Stroke mechanism different from small-artery disease was
computed tomography (CT) and carotid dupplex with measurements of IMT in the revealed in 36 patients (34,3%). Significant differences in potential sources of
common carotid artery. The extent and number of white matter lesions (WML) cerebral embolism were revealed in group I in comparison with group II (p<0,05)
were recorded by 2 independent readers. and group III (p<0,001). Multiple lacunas or combination of lacunas and cortical
Results: Seventy two patients (44%) were found to have 1 or more WML on CT strokes is reliable cerebral embolism marker. Neurological deficiency was more
images located in frontal, parietal or occipital region. Of whom, 30% were recorded severe in LS patients with embolism (p<0,01).
to have advanced LA. Mean IMT was significantly higher in stroke patients with Conclusions: Causes of LS are heterogeneous. Choice of secondary prevention
LA (p=0.004) compared to those without it. Also, carotid plaque occurrence was regime demands of determination true cause of LS.
associated with LA (χ2 =6.154, p=0.013) and advanced LA (χ2 =7.673, p=0.006).
In logistic regression analysis, including age, gender, body mass index, and all
vascular risk factors, LA was found to be associated with age and IMT (O.R.
1.041, 95% CI 1.011-1.072, p=0.007; O.R. 2.365, 95% CI 1.129-4.954, p=0.022; Stroke and lipids
respectively). White matter lesion severity was also found to be associated with age
and IMT (O.R.1.064, 95% CI 1.028-1.1, p=0.001; O.R. 2.84, 95% CI 1.248-6.462,
p=0.013; respectively). 1 Stroke and lipids
Discussion: Stroke patients with LA present strong relationship with increased
carotid IMT and plaque occurrence. Association was independent of gender, body DEPLETION OF THE LIPID RAFT COMPONENTS CHOLESTEROL AND
mass index and all vascular risk factors. This suggests that advanced atherosclerotic SPHINGOMYELIN PREVENTS NMDA-INDUCED NEURONAL DEATH
process in LA. J. Ponce, N. Perez de la Ossa, O. Hurtado, M. Dolade, M. Millan, J. Arenillas,
A. Davalos, T. Gasull
Fundacio Institut d’Investigacio en Ciencies de la Salut Germans Trias i Pujol,
13 Etiology of stroke Badalona, Spain

FIBRO MUSCULAR DYSPLASIA AND CERVICAL ARTERY DISSECTIONS: Background and purpose: Excess brain extracellular glutamate in cerebral is-
VALUE OF RENAL ARTERY ANGIOGRAPHY chemia leads to neuronal death through overactivation of N-methyl-D-aspartate
J.M. de Bray, A. Pasco, F. Dubas, B. Vielle, J.F. Subra (NMDA) receptors. The cholesterol lowering-drugs statins have been reported to
University Hospital, France protect from NMDA-induced neuronal death but, so far, the mechanism underlying
this protection is unknown. Since NMDA receptors have been reported to be
Fibro muscular dysplasia (FMD) is a potential cause of cervical artery dis- associated with the cholesterol- and sphingomyelin-rich membrane domains known
section(CAD).Moderate forms of FMD are undiagnosed by magnetic resonance as lipid rafts, we have investigated the effect of treatments that deplete cholesterol
angiography.The use of renal intra-arterial digital subtraction angiography(DSA)in or sphingomyelin levels on NMDA-induced neurotoxicity. In addition, we have
identifying FMD in CAD has not yet been validated. An ancillary study from a investigated the effect of simvastatin on the percentage of NMDA receptors
prospective study was performed to determine the prevalence of the association associated to lipid rafts.
of cervical and renal artery FMD in CAD assessed by DSA and to define the Methods: Primary neuronal cultures were pre-treated with simvastatin, the inhibitor
diagnostic impact of renal DSA in these patients. of cholesterol synthesis AY9944, or the inhibitor of sphingomyelin synthesis fu-
Methods: A prospective study on symptomatic recurrence of CAD was performed monisin B1. Cell death was determined 24 h after the addition of NMDA. Lipid
from 1994 to 2004 and is in press in Cerebro.Vasc.Dis.103 patients were con- rafts from control and simvastatin-treated neurons were isolated, and Western blots
secutively included for a CAD diagnosed by cervical MRI or suggested by 2 were performed using an antibody specific for the subunit 1 of NMDA receptors
concordant cervical imaging methods.FMD(17 patients)was defined as a string of (NMDAR1).
beads image located in a non dissected vessel.The design of the ancillary study Results: Sustained treatment with either simvastatin, AY9944, or fumonisin B1,
consisted in including patients with CAD investigated by both cervical and renal protected neurons from NMDA-induced neuronal death by 70%, 56% and 30%,
artery DSA.Population:54 patients fulfilled our subgroup criteria were 31 women respectively. Simvastatin (250 nM) reduced by 40% the association of NMDAR1
and 23 men.The Chi square test and Fisher’s exact test were used for assessing the to lipid rafts and did not change total expression of NMDAR1.
association between renal FMD and vascular risk factors. Discussion: The inhibition of the synthesis of main components of lipid rafts
Results: According to the presence of FMD,4 sub-groups of patients were iden- protects from NMDA-induced neuronal damage. This protection might be mediated
tified.I (n:4),showed renal FMD but no cervical FMD;II(n:5), had cervical and by a reduced association of NMDA receptors to lipid rafts. Taken together these

92 Cerebrovasc Dis 2007;23(suppl 2):1–147 16th European Stroke Conference


findings suggest that lipid raft integrity is necessary for signalling to death through Methods: The cohort included all patients presenting to the Emergency Department
NMDA receptors. with an acute ischemic stroke over a 22-month period (March 04 to December
05). The lipid profile (cholesterol, triglyceride, LDL and HDL levels) measured
prior to or following admission was abstracted. Measurement of the panel ranged
2 Stroke and lipids between 15 days prior to the stroke to 17 days after the event (Mean 0.79 days ±
SD 2.53). Daily statin intake prior to the event and prescription on discharge was
STATIN USE, LIPID PROFILE AND SYMPTOMATIC INTRACEREBRAL also recorded. The primary outcome variable, functional disability, was determined
HAEMORRHAGE FOLLOWING IV THROMBOLYSIS using the modified Rankin scale (mRs, 0-2=good outcome, 3-6=bad outcome),
M.W. Koch, M. Uyttenboogaart, P.C. Vroomen, J. De Keyser, G.J. Luijckx which was calculated for each patient at the time of discharge. A Pearson’s
University Medical Centre Groningen, Groningen, The Netherlands chi-square test was performed analyzing the relationship between the functional
outcomes at discharge and statin intake at the time of the event.
Background: Intravenous thrombolysis with tissue plasminogen activator (tPA) Results: Of 508 patients, 207 (40% female) presented with an LDL of ≤100
improves outcome of acute ischaemic stroke, but increases the risk of symptomatic mg/dL. This group was divided into those who were on a statin on admission
intracerebral haemorrhage (sICH). It has been suggested that lower cholesterol (n=100) and those who were not (n=107). There was no significant difference in
levels may be associated with higher incidence of primary ICH as well as with the admission stroke severity measured by the NIHSS (p=0.18), age (p=0.31) and
sICH following tPA treatment. gender (p=0.06) between the 2 groups. The patients on a statin were significantly
Methods: From a prospective hospital based tPA registry comprising 309 patients, more likely to have a good functional outcome, (OR 0.5; 95% CI 0.29-0.95;
we selected all patients with known serum concentrations of total cholesterol (TC), p=0.033). Following adjustment for age and NIHSS, statin intake still predicted a
HDL, LDL and triglycerides (TG), modified Rankin Scale (mRS) scores at three better functional outcome (p<0.0001).
months and statin use (n=214). Lipid profiles were compared between patients with Conclusion: Daily statin intake appears to be associated with a better functional
and without sICH following tPA treatment and between patients with and without outcome following an acute ischemic stroke despite ideal LDL levels (≤100)
favourable outcome (mRS 0-2). and similar stroke severity on admission. Other mechanisms of action of statins
Results: Patients with sICH (n=10) had significantly higher TG (2.6 SD 1.9 vs 1.8 like plaque stabilization, improved endothelial cell function, anti-inflammatory,
SD 1.0 mmol/l, p=0.049) and lower HDL levels (1.0 SD 0.3 vs 1.2 SD 0.4 mmol/l, antiplatelet, anti-oxidant and antithrombotic effects may play a role in a better
p=0.049) Neither LDL (3.0 SD 0.8 vs 3.2 SD 1.0 mmol/l, p=0.59), TC (5.0 SD functional outcome.
1.0 vs 5.1 mmol/l SD 1.2, p=0.78) levels nor statin use (2 vs 30 patients, p=0.65)
were significantly different between patients with and without sICH. There were no
significant differences for any of these variables between patients with favourable 5 Stroke and lipids
and unfavourable outcome: TC (5.2 SD 1.3 vs 5.0 SD 1.1), HDL (1.2 SD 0.4 vs
1.2 SD 0.4), LDL (3.2 SD 1.1 vs 3.1 SD 0.9), TG (1.9 SD 1.2 vs 1.7 SD 1.0), statin SERUM CHOLESTEROL LEVELS AND SHORT TIME OUTCOME IN
use (15 vs 17 patients). STROKE PATIENTS
Conclusion: Although patients with sICH had marginally higher TG and lower P. Milia, M. Paciaroni, V. Caso, S. Biagini, M. Venti, A. Billeci, F. Palmerini,
HDL levels, statin treatment or overall lipid profile seem unrelated to functional A. Alberti, A. Baldi, G. Agnelli
outcome at 3 months. University of Perugia, Perugia, Italy

Background: Although cholesterol and stroke disorders has been extensively


3 Stroke and lipids studied, the relationship between serum cholesterol levels and short time outcome
after stroke has not been widely investigated.
HIGH TRIGLYCERIDE LEVELS IN SINGAPOREAN ACUTE ISCHEMIC Objective: To identify if serum cholesterol levels measured at admission after
STROKE PATIENTS REDUCES THE RISK OF POOR OUTCOME AT 1 YEAR stroke have any prognostic value on outcome at discharge.
AFTER STROKE Methods: Patients consecutively admitted to our stroke unit suffering of any type
J.L. Pascual, H.M. Chang, M.C. Wong, C.P. Chen of stroke were analysed. Fasting serum cholesterol was measured at 24 hours after
National Neuroscience Institute, Singapore General Hospital Campus, admission. Outcome was evaluated using mRS: we identified adverse outcome as
Singapore, Singapore mRS ≥3 at discharge. Data were analysed by univariate and logistic regression
analysis.
Background: Cholesterol reduction lowers risk for recurrent vascular events in Results: We collected 935 patients suffering of stroke (mean age 74.65±11; 789
stroke patients. However, low total cholesterol (TC) and low triglyceride (TG) levels ischemic, 146 hemorrhagic; mean NIHSS 8.67±6.5). Mean values of cholesterol
have been linked to increased risk for hemorrhagic stroke, and poorer outcomes at admission was 195.2±51 in the overall group with no differences between all
after stroke, respectively. We investigated the effect of lipid-lowering therapy on types of stroke (I 195.65±50; H 192.43±38). Functional outcome at discharge
the outcomes of Singaporean acute ischemic stroke patients. (mRS&≥3) was not influenced by levels of cholesterol in all the population after
Method: Consecutive acute ischemic stroke patients had fasting TC, high-density logistic regression analysis (OR 0.99 CI 0.99-1.0, p 0.4) and also in either ischemic
lipoprotein(HDL), low-density lipoprotein (LDL) and TG determinations. Elevated (OR 0.99 CI 0.99-1.0 p 0.7) and hemorrhagic strokes (OR 0.99 CI 0.98-1.0, p 0.2).
lipids were defined as follows: TC ≥ 5.2 mmol/L, LDL ≥ 2.6 mmol/L, and TG Conclusions: Serum levels of cholesterol are not associated with outcome in the
≥ 1.7 mmol/L. Prior lipid-lowering therapy was documented. At 1 year follow-up, early phase after ischemic and/or hemorrhagic stroke, suggesting that it doesn’t
functional outcome was assessed using the modified Rankin score (MRS). need to be treated in the acute phase as negative prognostic risk factor. Still remains
Results: 805 patients gave informed consent for fasting lipid profiles and 1 year uncertainty about its role at early and medium time on stroke patients.
follow-up. The mean TC was 5.66 mmol/L, mean LDL was 1.31 mmol/L, and
mean TG was 1.73 mmol/L. Patients with prior stroke, ischemic heart disease or
lipid therapy had lower TC and LDL levels (p < 0.05). At 1 year after stroke, 28%
of patients had mRS 3 or worse. Elevated TG independently predicted for good Acute stroke: clinical patterns and practise
functional outcome (HR = 0.41, 95% CI: 0.23 – 0.75).
Discussions: In agreement with previous studies, high TG is associated with better
outcomes after stroke. Whether elevated TG is itself protective or is associated with 1 Acute stroke: clinical patterns and practise
a higher probability of receiving lipid-lowering drugs remains to be elucidated.
EVALUATING THE USE OF HAND MITTENS IN POST STROKE PATIENTS
WHO DO NOT TOLERATE NASO-GASTRIC FEEDING
4 Stroke and lipids Y.-Y.K. Kee, W. Brooks, R. Dhami, A. Bhalla
Epsom and St. Helier University Hospitals NHS Trust, United Kingdom
ROLE OF STATINS IN FUNCTIONAL OUTCOME FOLLOWING AN ACUTE
ISCHEMIC STROKE Background: Early naso-gastric (NG) and consistent feeding in acute stroke
L. Vaidyanathan, G. Kumar, D. Nash, W.W. Decker, L.G. Stead patients has been shown to improve patient morbidity and mortality. However, after
Mayo Clinic, Rochester, USA an acute stroke, patients can be agitated and may frequently pull out NG tubes.
Recurrent NG tubes placements are associated with complications such as trauma
Hypothesis: Similar to the beneficial effect in acute coronary syndrome, daily and chest infections. The use of restraints such as hand mittens may improve
statin improves functional outcome following acute ischemic stroke by mechanisms nutrition and reduce complications of NG placements. This practice although
other than lowering LDL levels. uncommon in the UK, is used commonly in other countries. Few studies have been

Poster Session Cerebrovasc Dis 2007;23(suppl 2):1–147 93


Acute stroke: clinical patterns and practise
done to evaluate the use of such restraints in acute stroke patients. This study aims level of the midbrain. Only 1 arterial territory was involved in 7/14 cases and which
to evaluate the use of hand mittens in such patients. corresponded to the antero-medial territory in 6/7 cases. Antero-medial infarcts
Methods: We carried out a retrospective case control study with 18 patients over were always present in patients with diplopia and controlateral cerebellar ataxia.
a period of one year period (8 with, 10 without mittens). The following data was Among patients with III nerve palsy, infarct affected the nuclear (2/3) or fascicular
collected: number of NG tubes inserted during the patient’s admission, number of fibers (1/3). Motor deficit was associated with anterolateral infarct (5/6 patients).
aspiration pneumonias treated with antibiotics, number of chest x-rays the patient Discussion: The link between diploplia and controlateral cerebellar ataxia seemed
received, amount of feed received, weight loss/gain during admission, length of to relate specifically to a midbrain infarct located in the antero-medial territory and
stay. Results were analysed using GraphPad Prism 4 software with no predictive value for an antero-posterier extension of the infarct. A brachio-
Results: The median age in both groups was 81.5 years. 89% of patients had total facial motor deficit clearly implied the involvement of the anterolateral territory, as
anterior circulation stroke. Patients in the mitten group needed fewer ng tubes; 7 expected by the somatotopy of the corticospinal tract. The use of a practical tool
vs 10 p<0.05. There were less episodes of aspiration pneumonia, p<0.05. Patients to determine location of pure midbrain infarct enables the establishment of a good
with mittens experienced less weight loss; 0.7kg vs 5.2kg, p<0.05. There were correlation.
fewer deaths in the mitten group, 2 vs 7, p<0.05. There was a small reduction in
the length of stay 40 vs 48.5 days, p=0.15.
Discussion: The use of physical restraint is not universally accepted in the UK. The 4 Acute stroke: clinical patterns and practise
decision to use mittens in our patients was taken after discussions with the patient
or next of kin. The use of mittens resulted in better nutrition in our patients, as well PURE DYSARTHRIA AND DYSARTHRIA-FACIAL PARESIS SYNDROME
as a reduction in mortality and should be considered in patients who do not tolerate K. Yonemura, Y. Hashimoto, M. Uchino
their NG tubes. Kumamoto City Hospital, Kumamoto, Japan

Background: Pure dysarthria (PD) and dysarthria-facial paresis (DFP) are rarely
2 Acute stroke: clinical patterns and practise encountered clinical stroke syndromes, and seem to be regarded as an atypical
lacunar syndrome. We sought to clarify the clinical characteristics of PD and DFP
HEMOGLOBIN: A PREDICTOR OF FUNCTIONAL OUTCOME FOLLOWING in acute ischemic stroke patients.
AN ACUTE ISCHEMIC STROKE Methods: We selected patients with PD or DFP from 1,043 consecutive patients
L. Vaidyanathan, D. Nash, M.F. Bellolio, S. Enduri, S. Mishra, R. Kashyap, with first-ever acute ischemic stroke admitted over a 7-year period. Vascular risk
R.D. Brown, W.W. Decker, L.S. Stead factors, emboligenic heart disease, occlusive cerebral artery disease, infarct size
Mayo Clinic College of Medicine, Rochester, USA and location, stroke subtype according to the TOAST classification, and outcome
data were evaluated. Acute infarcts were all identified by diffusion-weighted MRI
Aim: To assess if the hemoglobin levels measured at the time of presentation to (DWI).
the Emergency Department in a patient with Acute Ischemic Stroke (AIS) would Results: A total of 34 patients were reviewed. They consisted of 16 patients with
predict the severity and functional outcome. PD and 18 patients with DFP. Hypertension was the most frequent in the vascular
Methods: The cohort included all patients presenting to the Emergency Department risk factors (13 patients with PD and 14 patients with DFP). Emboligenic heart
with an AIS over a 3.5 year period (from December 2001 through June 2005). disease and/or cerebral artery disease were detected in 13 (38%) patients (5 with PD
Hemoglobin levels measured at the time of admission was recorded. Stroke severity and 8 with DFP). DWI identified infarcts on the cortical motor area, centrum ovale,
on presentation was assessed retrospectively using the 42-point NIHSS scoring or corona radiata in 25 (74%) patients (12 with PD and 13 with DFP), whereas
system and the functional disability was scored at discharge from the stroke service brainstem infarct was demonstrated only in 1 patients with PD. 18 (53%) patients
using the modified Rankin scale (mRs). A statistical analysis of the data was (11 with PD and 7 with DFP) had infarcts <15mm in maximal diameter, and 15
conducted using the JMP statistical software. Analysis of variance (ANOVA) was (44%) patients (10 with PD and 5 with DFP) met the diagnostic criteria of lacunar
used to analyze the variables. stroke. Neurological deterioration occurred after hospitalization in 2 patients with
Results: Of the total cohort, (n=1018), 47.2% were female. The mean age was 72.3 DFP, but patients were discharged usually with mild or no disability.
years ±SD 14.7. Hemoglobin levels were documented in 96.2% (n=979) of the Discussions: Infarcts in the higher levels of cerebral hemisphere are responsible
patients. Lower levels of hemoglobin predicted a more severe stroke (p=0.0067) and for the majority of the PD and DFP syndromes. The predictive value of these
poorer functional outcome (p<0.0001). This significance was retained following syndromes for lacunar stroke is rather low, particularly in DFP.
adjustment for age in men (RANKIN p<0.0001 and NIHSS p=0.0004) and women
(RANKIN p<0.0001 and NIHSS p=0.0004).
Conclusion: Lower hemoglobin levels measured at the time of admission to the 5 Acute stroke: clinical patterns and practise
Emergency Department seem to predict more severe strokes with poorer functional
outcome at discharge regardless of the gender probably due to greater ischemia ACUTE VERTIGO OF UNDETERMINED ORIGIN: DIAGNOSTIC VALUE OF
resulting from the decreased oxygen carrying capacity of the blood. With early MAGNETIC RESONANCE IMAGING
recognition, active methods could be taken to raise the patient’s hemoglobin and, L. Huang, A. Villringer, A. Hartmann
thereby, possibly improve functional outcome. Charité Campus Benjamin Franklin, Berlin, Germany

Background: The origin of acute vertigo often remains undetermined after neuro-
3 Acute stroke: clinical patterns and practise logical, otological, and CT examination in the emergency room. We investigated
the diagnostic yield of magnetic resonance imaging (MRI) in these patients.
PURE MIDBRAIN INFARCTION: CLINICAL RADIO ANATOMY Methods: Patients were included in the study if they had presented with sudden
CORRELATIONS onset of vertigo to our Department between 01/2002 and 06/2005, and complete
R. Allibert, F. Vuillier, L. Tatu, T. Moulin neurological, otological and cranial CT investigation allowed no definite allocation
University Hospital Besançon, Besançon, France to peripheral or central origin of the vertigo. Results of cranial MRI including
diffusion-weighted imaging (DWI), clincal, and epidemiological information were
Background: Clinical anatomical correlation in pure midbrain infarct has not been taken to compare the patients with (group 1) and those without (group 2) acute
widely established in a standardised manner. The aim of the study was to analyse lesions on MRI using univariate statistics.
patients with pure midbrain infarcts using standardised protocols (clinical and Results: In the 108 patients with acute vertigo (mean age 61 years, 62% women),
imaging analyses). acute ischemic lesions were detected in 12% on DWI. Affected regions were
Method: Using a previously published arterial territories mapping, a correlation medulla oblongata, cerebellum, pons, thalamus, corpus callosum, temporo-occipital
between the clinical patterns, arterial territories and anatomical structures involved lobe, parietal lobe, both periventricular areas, and frontal lobe. Higher prevalence of
was established. Patients with pure midbrain infarct were selected from all patients vertigo-unrelated ischemic CT changes (p=0.01) and non-significant trends towards
admitted with first-ever stroke in our stroke unit. Clinical and imaging data were elevated serum cholesterol (p=0.06), older age (0.07) and higher blood glucose
standardised according to Besançon stroke registry criteria. All MRI images were levels (0.09) were observed in group 1 compared with group 2. All other clinical
retrospectively reviewed by 2 neurologists to confirm infarct location, vascular and epidemiolgical variables were similar in both groups.
arterial territories and brain stem structure. Conclusion: In patients with acute vertigo and inconclusive clinical and CT
Results: 14 pure midbrain infarcts were included. Clinical manifestations in- examinations, the diagnostic yield of cranial MRI is low. Patients with old ischemic
cluded gait ataxia in 2/14 patients, dysarthria in 4/14, limb ataxia in 10/14, sensory lesions on CT are more likely to have a central vertigo origin. Clinical and
symptoms in 1/14, third nerve palsy in 9/14, definitive limb weakness in 6/14 and in- epidemiological characteristics are not associated with higher detection rates of
ternuclear ophthalmoplegia. In most cases (9/14), the infarct was located in the high acute brain lesions.

94 Cerebrovasc Dis 2007;23(suppl 2):1–147 16th European Stroke Conference


6 Acute stroke: clinical patterns and practise 8 Acute stroke: clinical patterns and practise
COURSE OF CEREBROVASCULAR INCIDENTS IN PATIENTS WITH ISCHEMIC STROKE REVEALING SMALL INTRACRANIAL ANEURYSM.
PERMANENT AND PAROXYSMAL ATRIAL FIBRILLATION NATURAL HISTORY, MANAGEMENT AND RECOMMENDATION
J. Staszewski, J. Kotowicz, A. Stepien H. Desal, B. Daumas-Duport, F. Herisson, E. Auffray-Calvier, B. Guillon
Military Medical Institute, Warsaw, Poland Hopital Laennec, Centre Hospitalier Universitaire de Nantes, Nantes, France

Permanent atrial fibrillation (pAF) is an important risk factor for cerebrovascular Background: Ischemic stroke may be the first manifestation of small intracranial
incidents (CVI). The frequency and prognosis of CVI in patients with paroxysmal aneurysm, secondary to clot embolization from the aneurysmal sac. Pathophys-
AF (plAF) is not well known. The aim of this single center study was to assess the iology, clinical characteristics and outcome are not clearly identified leading to
course and risk factors of unfavorable outcome of CVI in ptAF and plAF. undetermined management.
Patients with established AF and acute, ischemic CVI were included to prospec- Methods: Patients admitted over a 6-year period in our stroke unit with ischemic
tive study with 6-months follow-up. The patients were classified on admission, stroke distal to small (< 25 mm) sacciform intracranial aneurysm, in the ab-
discharge and after 6-month as non-dependent (mRS ≤ 2) or dependent (mRS sence of other causes for the infarctions, were selected. Patients demographics,
≥ 3 ≤ 5). The course of CVI was categorized as favorable (non-dependence) or characteristics of aneurysms, outcome and management were analysed.
unfavorable (dependence or death). The risk of embolic complication in AF was Results: Eight patients fulfilled our selection criteria (5 women; mean age 50, range
assessed in CHADS2 scale. 38-58). Ischemic stroke and intracranial aneurysm involved the anterior circulation
Of 178 included patients 70 (39%) had plAF and 108 (61%) had ptAF. Groups in 3 patients and the vertebrobasilar system in 5. The mean size of the aneurysms
were similar in vascular risk profile. Cardioembolic strokes were more common in was 11 mm (range 3-18). Digital angiography showed partial or complete aneurysm
ptAF than in plAF group (56% vs 44%, p=0.03). The proportions of dependent thrombosis in 4 patients with occlusion of the parent artery in 2. An unexpected
patients at admission, discharge and at 6-month visit in ptAF were higher than subarachnoid haemorrhage was diagnosed in 3 patients. Two patients died during
in plAF (50% vs 19%, 81% vs 45%, 71% vs 40%; p<0.001). In-hospital and the 72-hours period following their admission because of severe subarachnoid
6-month mortality rates were higher in ptAF than in ptAF group (13% vs 3% and haemorrhage. In the other cases, prognosis was excellent after early endovascular
32% vs 13%, p<0.001). Unfavorable risk factors for short- and long-term outcome embolisation (3 patients) or spontaneous thrombosis (3 patients) of the aneurysm.
were: ptAF (OR 2.05, p=0.01), lack of chronic anticoagulation treatment (OR However, in these last 3 patients, 2 had a late partial recanalisation of the aneurysm
3.48, p=0.02), chronic heart failure (OR 2.54, p=0.05), diminished left ventricular that justified endovascular treatment.
ejection fraction (LVEF) (OR 2.15, p=0.01), non-lacunar cerebral infarction (OR Discussion: Our results suggest that ischemic strokes revealing intracranial
1.74, p=0.001) and increased (moderate to very high) risk of embolic complications aneurysm might be associated with an asymptomatic subarachnoid haemorrhage,
(OR 1.92, p=0.004). that should be ruled out by CSF analysis (with spectrophotometry). Antithrombotics
Results suggest significantly different course of CVI in patients with ptAF and should also be used cautiously in these high risk patients for haemorrhage. Early
plAF. Those with plAF had more favorable short- and long-term prognosis of CVI. endovascular or surgical treatment could prevent subsequent subarachnoid haem-
Risk factors for unfavorable stroke outcome were: ptAF, chronic heart failure, lack orrhage or stroke recurrence. Radiological follow up is required to detect further
of chronic anticoagulation, diminished LVEF, non-lacunar cerebral infarction and recanalisation, particularly in cases with early spontaneous aneurysm thrombosis.
presence of increased risk of embolic complications.

9 Acute stroke: clinical patterns and practise


7 Acute stroke: clinical patterns and practise
CEREBRAL MICROEMBOUS DETECTION IN PATIENTS WITH ACUTE
COMPARISON BETWEEN THE OCSP AND TOAST CLASSIFICATION ISCHEMIC STROKE
SYSTEMS IN THE DIAGNOSIS OF CEREBRAL SMALL VESSEL DISEASE IN J. Lee, S.J. Lee
THE SOUTH LONDON BLACK AND WHITE POPULATIONS Yeungnam University College of Medicine, South Korea
U. Khan, P. Jerrard-Dunne, L. Kalra, A. Rudd, C. Wolfe, H. Markus
St. George’s University of London, London, United Kingdom Background: Microembolic signals(MES) detected by transcranial Doppler(TCD)
have been considered as an independent predictor of recurrent ischemic stroke.
Background: Stroke classification systems based on clinical criteria, such as the However, the association between the presence of MES and the risk of stroke has
Oxfordshire Community Stroke Classification (OSCP), have been widely used in predominantly been studied on small and selected patients. To evaluate the clinical
epidemiological studies to diagnose lacunar stroke but may be inaccurate compared significance of MES in patients with acute ischemic stroke, we investigated the
with systems based on investigation results. We compared OSCP with a pathophys- prevalence of MES and analyzed the relationship between MES and stroke subtype.
iological classification (modified TOAST) in diagnosis of lacunar stroke in blacks Methods: We intended to perform TCD monitoring for 30 minutes to detect MES
and whites in the South London Ethnicity and Stroke Study. from the bilateral middle cerebral arteries in patients within 15 days of stroke onset.
Methods: African and African-Caribbean strokes presenting to three South London The strokes were subtyped using the TOAST classification criteria.
hospitals were prospectively recruited (N=600). 600 consecutive Caucasian strokes Results: Of a total of 884 consecutive ischemic stroke patients admitted to our
presenting to the same three centres were also recruited. All cases underwent stroke unit within 7 days of stroke onset, TCD study performed 590 patients, and
standardised clinical assessment, demographic and risk factor data collection and 65 were excluded because there was a long interval between onset of symptoms
investigations (brain imaging (CT 65.4%, MRI 8.3%, both CT and MRI 26.3%), and examination, an artificial heart valve, and inadequate temporal bone window.
imaging of the extracranial cerebral vessels (97%), echocardiography (56.7%)). MES were detected in 23(4.2%) despite the fact that all patients were receiving
All cases were subtyped using modified TOAST criteria (excluding the use of an antiplatelet or an anticoagulant treatment. Among patients with positive MES
hypertension as a criterion for diagnosis) by one observer with review of original detection, 7(31.8%) had recurrent MES during follow-up TCD monitoring within
imaging. Cases were also subtyped using the OCSP classification. 3 days after the first examination. MES were detected in 3.1% of patients with
Results: Using TOAST, lacunar stroke was more prevalent in blacks (OR 2.94(1.97- large-artery atherosclerosis stroke, 4.1% of cardioembolic stroke, 2.1% of lacunar
4.39)p<0.001) compared to whites. Similarly, OCSP-defined lacunar infarction was stroke, 9.1% of cryptogenic stroke, and 4.1% of undetermined stroke(p=0.241). In
increased in blacks but the association was weaker (OR 1.94(1.39-2.73)p<0.001). 6 of the 8 patients(75%) with the anterior circulation infarct, MES were observed
Taking TOAST classification as the gold standard the sensitivity of OCSP for ipsilateral to the affected territories.
detection of lacunar stroke was 84% (76% specificity). Positive predictive value Discussion: During antithrombotic treatment in patients with acute ischemic stroke,
(PPV) for lacunar stroke detection was 56.5% (negative predictive value (NPV): the prevalence of MES is low and MES detection dose not improve ischemic stroke
92.8%). Accuracy of OSCP for lacunar stroke diagnosis was worse in black subtype classification. The MES are frequent in the territories of symptomatic
patients: PPV 66.7% (NPV: 88.6%) compared to a PPV of 41.4% (NPV: 96.0%) in arteries in the anterior circulation stroke and recurrent MES are common during a
whites. short follow-up.
Conclusions: Lacunar stroke is increased in blacks compared to whites but use
of OCSP underestimates the difference. OCSP is less accurate at lacunar stroke
diagnosis in blacks, and this may introduce bias in studies comparing subtype
differences between ethnic groups if OSCP is used.

Poster Session Cerebrovasc Dis 2007;23(suppl 2):1–147 95


Acute stroke: clinical patterns and practise
10 Acute stroke: clinical patterns and practise 12 Acute stroke: clinical patterns and practise
FIRST-DAY BODY TEMPERATURE DYNAMICS – A CLINICIAN’S TOOL FOR ALBUMIN TO CREATININE RATIO (ACR) IS ASSOCIATED WITH THE
MONITORING PENUMBRAL TISSUE TRANSFORMATION AND UPDATING SEVERITY OF ACUTE STROKE AND PREDICTS THE OUTCOME OF ACUTE
PROGNOSIS AFTER ISCHEMIC STROKE? STROKE AND TRANSIENT ISCHEMIC ATTACK (TIA)
J. Mau, S.D. Jayavel K. Koniari, E. Gialouri, K. Makris, I. Drakopoulos, O. Glezakou
Heinrich Heine University Hospital, Duesseldorf, Germany General Hospital KAT, Athens, Greece

Background: Early normal but later rising body temperature (BT) was recently Background: Although microalbuminuria is associated with clinical risk factors
shown to robustly and independently reduce the likelihood of complete dependency for stroke, there is surprising little information regarding it as an independent risk
or death after hemispheric ischemic stroke. To substantiate this unexpected finding, factor for stroke or as a predictor of stroke outcome.
first-day BT dynamics were to be studied in data from the first European Cooper- Methods: In our study we investigated the prevalence of microalbuminuria in acute
ative Acute Stroke Study (ECASS) and explained within a model of progressive stroke patients and its association with the patients’ clinical status at admission
stroke. and outcome. We studied 60 patients (mean age 75 years) who were admitted
Methods: The ECASS had randomized and treated 615 patients to either 1.1mg/kg in our hospital’s ER within 6 hours of their first neurological symptom. A urine
rt-PA or placebo IV within 6 hours from symptom onset; 461 patients had sample was collected at the time of admission, along with morning collections
complete 0-2-24h profiles of 3 BT measurements. BT profiles were grouped at 24, 48, 72 hours and at the 7th day of hospitalization. ACR was measured on
into 37(10%) "ever constant", 34(7.4%)"early only rising", 123(26.7%) "late only a POCT instrument (Bayer DCA-2000). CT-scan was performed on all patients.
rising", 107(23.2%) "ever rising", 49(10.6%) "decreasing", 35(7.6%) "convex", Neurological deficit and clinical status was assessed by the Glasgow Coma Scale
and 76(16.5%) "concave", their association with baseline covariates tested with (GCS) on admission and on days 1, 2, 3 and by Glasgow Outcome Score (GOS) on
stratified chi-squares and dichotomized 90-day modified Rankin scores (mRS) discharge from the hospital.
logistically regressed on known predictors and trial medication. Results: The mean value of ACR, on the admission sample, in patients with severe
Results: Profile groups were equally distributed between rt-PA and placebo and all clinical status (GCS<8) was 354 mg/g, significantly higher than in patients with
baseline covariates but for initial BT (P<0.0001), initial stroke severity (P=0.0298), better clinical status (GCS 9-13 and GCS 14-15) 114 and 122 mg/g respectively
hypo-density extent in infarct territory (P=0.0164), and presence of infarct signs (p<0,01). The mean value of ACR on the last day of hospitalisation was highly
(P=0.0033) on baseline computed tomography. Specific interactions were signif- correlated with the outcome (reflected by GOS). It was 348 mg/g in patients
icant for the latter (P=0.041) and in BT > 37°C (P<0.0001) and BT<36°C with GOS=1, 209 mg/g in patients with GOS 2 -4 and 53 mg/g in patients with
(P=0.0025). "Ever rising" profiles increased 90-day fatality and "ever constant" GOS=5 (p<0,01). In addition concerning the question if ACR levels can predict
profiles reduced risk of long-term dependency (mRS 4-5) among survivors after the outcome, only in non-diabetic patients with poor outcome (GOS=1), the mean
24h, independently. Hence, associations of BT profiles were found for only the value of ACR of the 24 hours measurement was significantly higher than in those
lesion parameters and for specific long-term outcomes. with better outcome (GOS 2-4 and GOS=5) 262, 199 and 58 mg/g respectively
Discussion: A dynamic model of progressive stimulation of metabolic and apop- (p<0,01).
totic regulation after focal ischemia explains that BT dynamics appear closely Discussion: Our preliminary results from this ongoing study suggest that this
correlated with evolving transformations in the ischemic penumbra. marker, when determined on admission and within 24 hours might be useful in
Conclusion: Beyond clinically updating baseline prognosis after 24 hours, moni- determining the severity of the stroke independently of the type of stroke, and that
toring BT might also be used for timing neuro-protective interventions. these early measurements can be of value in predicting outcome in non-diabetic
patients.

11 Acute stroke: clinical patterns and practise


13 Acute stroke: clinical patterns and practise
DOES ACUTE STROKE UNIT CARE CHANGE DURING A REHABILITATION
CLINCIAL TRIAL (AVERT PHASE II)? RATE OF INTRACEREBRAL HAEMORRHAGE IN PATIENTS WITH MINOR
J. Collier, J. Bernhardt STROKE: A CLINICAL RULE TO REDUCE CT MISDIAGNOSIS
National Stroke Research Institute, University of Melbourne, Heidelberg West, C.E. Lovelock, J.N. Redgrave, D. Briley, P.M. Rothwell
VIC, Australia University of Oxford, Oxford, United Kingdom

Objectives: During A Very Early Rehabiliation Trial (AVERT) Phase II, we Background: Most studies of acute stroke management focus on the initial hours
randomised recruited stroke unit patients from two hospitals to receive either a following symptom-onset. However many patients with non-disabling strokes
very early mobilisation (VEM) protocol or standard (usual) care. Both patient present late. In a recent clinic-based Scottish study of patients presenting late (>4
groups were treated on the same ward. Given the potential for contamination effects days after the event) with minor stroke, around 4% had intracerebral haemorrhage
using this design, we aimed to investigate whether levels of physical activity for (ICH) on MRI, 75% of which appeared as infarcts on CT brain imaging. MRI was
non-recruited patients changed as a response to the trial embedded within each recommended when patients could not be CT scanned within one week of a minor
stroke unit. stroke. We aimed to determine the frequency of ICH in two cohorts of patients with
Methods: Prior to the trial, behavioural mapping procedures were used to evaluate minor stroke, and to identify clinical predictors for ICH, which might be used to
the proportion of the day patients were in bed, sat out of bed, and were standing or prioritise patients for MRI where resources were limited.
walking. Behavioural mapping requires structed observation and recording of pa- Method: We studied 343 consecutive patients with minor stroke (NIHSS≤3) in
tient activity over a single day. During AVERT, mapping procedures were repeated patients ascertained in the Oxford Vascular (OXVASC) Study (scanned using CT
to determine activity levels of patients receiving standard care. All patients <14 after a median delay of 4 days) and 245 consecutive patients presenting to a
days post stroke were eligible, with the exception of those requiring palliative care. hospital-based stroke clinic, all of whom had MRI.
We excluded clinical trial participants. Ten-minute observations were conducted Results: The rates of ICH were 4.1% (95%CI: 2.5-6.8%) on CT in OXVASC and
between 0800 to 1700 with patient activity documented, who was present and 4.5% (95% CI 2.5-7.9%) on MRI in the clinic cohort. In a pooled analysis (25 ICH
where patients were located. Stepwise binomial logistic regression was used to in 588 patients), severe hypertension (BP ≥ 180/110 mmHg) on assessment (OR
assess difference in activity between time periods (2001/2; 2004/5), controlling for 5.4, 95%CI 2.3-12.3, p<0.001), vomiting (OR 9.9, 3.7-26, p=0.001), confusion
differences in patient characteristics. at onset (OR 8.2, 3.1-21.4, p=0.001), and premorbid anticoagulation (OR 6.1,
Results: 51 patients (mean age 74.0 years, 51% male) were recruited at Austin 2.1-17.7, p=0.01) were predictive of ICH. The 178 (30%) patients who had at least
Health and St. Vincents Hospital, Melbourne. Patients spent 65% of the day resting one of these risk factors included 92% of patients with ICH.
in bed and 9% of the day in standing/walking activities. This was similar to Conclusion: The rate of ICH in minor strokes in our cohorts is consistent with that
the activity patterns of patients in the pre-trial sample (60% of day in bed, 13% in the only previous study. Several clinical variables were predictive of ICH, and if
standing/walking). No statistical differences between time periods was found (bed: independently validated could form the basis of a simple rule to select patients who
CI 95%-1.02.0, P=0.926; stand/walk: CI 95% -6.22.1, P=0.315). require MRI.
Conclusion: The level of physical activity of stroke patients receiving standard
stroke unit care did not change during conduct of an acute rehabilitation trial.
This finding supports the feasibility of conducting an individually randomised
rehabilitation clinical trial.

96 Cerebrovasc Dis 2007;23(suppl 2):1–147 16th European Stroke Conference


14 Acute stroke: clinical patterns and practise 16 Acute stroke: clinical patterns and practise
MRI PERFUSION-DIFFUSION MISMATCH IN PATIENTS WITH ACUTE TRANSIENT ISCHEMIC ATTACK IN ADULT ONSET MOYAMOYA DISEASE
ISCHEMIC STROKE J.-M. Kim, S.-H. Lee
S. Di Legge, M. Diomedi, F. Sallustio, S. Napolitano, G. Koch, B. Rizzato, Seoul National University Hospital, Seoul, South Korea
R. Floris, P. Stanzione
University of Tor Vergata, Rome, Italy Background and objective: There have been few reports about initial manifes-
tations in adult onset moyamoya disease. In this study, we described the initial
Background: The MRI perfusion-diffusion mismatch is viewed as a marker of manifestations of adult onset MMD including TIA symptom characteristics, and
still-salvageable tissue amenable to reperfusion therapies. Whether its presence is investigated the relationship between the initial manifestation and intracranial
an independent predictor of clinical outcome in non-thrombolytic series has not stenosis.
been extensively investigated. Method: Between 1999 and 2006, total of 65 patients who are older than 14 years
Objectives: To evaluate the occurrence, evolution, and clinical correlates of MRI were admitted and diagnosed as moyamoya disease at Seoul National University
perfusion-diffusion abnormalities in patients with acute ischemic strokes not treated Hospital. The patients were categorized into TIA, ischemic stroke, hemorrhagic
with thrombolytics. stroke, and nonspecific group due to the initial symptoms. The outcome after
Methods: Patients with acute ischemic stroke (AIS) admitted to our emergency surgical revascularization was evaluated in terms of two domains, which are the
room (ER) within 12 hours of symptom onset were screened for MRI eligibility. number of TIAs and stroke recurrence after surgery.
The MRI protocol included DW, PW MRI and intracranial MR angiogram (MRA). Result: Out of 65 subjects, the numbers of patients who had initial manifestation
All patients were admitted to a stroke unit and managed according to the current as TIA, ischemic stroke, hemorrhagic stroke and nonspecific symptom were 29
guidelines. Stroke severity was assessed by the NIH Stroke Scale (NIHSS) score at (44.6%), 11 (16.9%), 15 (23.1%), and 10 (15.4%), respectively. TIA manifestations
scheduled times. Patients with and without PW-DW mismatch were compared for were variable among subjects. Twenty subjects out of 29 experienced motor
demographic, clinical and imaging variables. dominant symptoms, whereas only two had sensory dominant symptoms. Isolated
Results: Over a 12-month period 189 patients with symptoms suggestive of AIS cognitive dysfunctions such as language dysfunction occurred in four subjects. The
were seen by the stroke team. Of them, 116 (61%) had an MRI study within 12 means of Suzuki grade in TIA group and ischemic stroke group were 2.90 ± 0.9
hours. Thirty (26%) patients did not complete the MRI study for lack of compliance and 3.64 ± 0.8 (p=0.022), showing significantly severe stenosis in ischemic stroke
or clinical instability. A perfusion-diffusion mismatch (M+) was detected in 29/86 group compared to TIA group. There was no statistically significant difference in
(34%) patients. The presence of PW-DW mismatch was associated with higher the surgical outcome in terms of TIA numbers and stroke recurrence between the
baseline NIHSS scores (p=0.02), intracranial stenosis (p=.001), lesion enlargement TIA and stroke groups.
on follow-up MRI (p=.001) and higher three-month mRS (0.04). At logistic Discussion: This study demonstrated that TIA is frequent as initial symptom
regression analysis the only independent predictor of poor outcome (mRS 3-6) at 3 among adult onset MMD, and TIA manifestations are variable among subjects.
months was onset NIHSS (OR 1.7, 95% CI 1.1-2.8; p=0.02). Patients whose initial manifestation is TIA have lower intracranial arterial stenosis
Conclusions: Up to one third of our AIS patients who completed the MRI protocol than stroke group, implying that TIA is earlier manifestation in the disease process
within 12 hours of stroke onset had a PW-DW mismatch. Its detection was than ischemic or hemorrhagic stroke.
associated with more severe strokes, intracranial artery occlusion, lesion growing,
and worse outcome. This information may help in establishing the efficacy of
thrombolitic therapy beyond the 3-hour window based on MRI parameters. 17 Acute stroke: clinical patterns and practise
INSULAR INVOLVEMENT IN ACUTE MIDDLE CEREBRAL ARTERY
15 Acute stroke: clinical patterns and practise TERRITORY INFARCTION
B.G. Yoo, J.K. Kim, J.H. Ko, E.G. Kim
SYSTEMIC THROMBOLYSIS WITH RT-PA IN POSTERIOR CIRCULATION Kosin University College of Medicine, Busan, South Korea
STROKE
B. Dimitrijeski, A. Villringer, H.C. Koennecke, A. Hartmann Background: The frequency and extent of insular involvement in middle cerebral
Charité Campus Benjamin Franklin, Berlin, Germany artery (MCA) territory infarction and its relationship with stroke severity and
clinical relevant disorders are not well established. The purpose of this study is to
Objectives: Ischemic stroke in the posterior circulation (PCS) accounts for 10-15% determine insular involvement in MCA territory infarction and its relationship with
of all strokes, representing a major cause for disability and death in stroke patients. clinical and laboratory parameters.
Treatment with rt-PA for acute ischemic stroke within a 3-hour time window has Methods: We analyzed a total of 73 consecutive patients with acute non-lacunar
been proven to be effective and reduces significantly disability. However, most data MCA territory stroke proved by an MRI scans.
on systemic thrombolysis refer to stroke in the anterior circulation (ACS). Results: Insular involvement were present in 52 patients (73%); 34 (65%) had
We compared the clinical outcome at 3 months in patients with PCS and ACS major insular lesions and 18 (35%) had minor lesions. The major insular in-
treated with rt-PA. volvement was associated with elevated serum CK-MB (p=0.044) and fibrinogen
Methods: 242 patients were treated between 1998 and 2006 within a 3-hour time (p=0.024), and size of MCA infarction (p=0.018) than minor insular lesion. The
window according to the NINDS-trial protocol, 216 (89%) with ACS, 26 (11%) anterior insular alone was involved in 14 (27%) patients, and the posterior insular
with PCS, 3 (1%) with basilar occlusion. alone was involved in 4 (7.7%) patients. Among patients with insular involvement,
Infarct localisation was n=11 brain stem, n=6 occipital lobe, n=2 thalamic, n=2 twenty-three patients (44%) had lenticulostriate territory infarction. Insular involve-
cerebellar and n=5 combined. ment was associated with larger MCA territory infarctions, more severe clinical
Neurological status was measured at admission and at 3-month follow-up using the deficits, and mortality. Isolated anterior insular infarcts were often accompanied by
NIH-Stroke-Scale (NIHSS) and the modified Rankin Scale. other infarcts in the superior territory, whereas posterior insular infarcts were often
Results: A total of 26 patients suffered from PCS (42% female, Mean NIHSS at accompanied by inferior division infarction.
admission 13, mean age 68y). Conclusions: The insular involvement is a common in patients with acute non-
Good functional outcome defined as Rankin ≤ 2 occurred in 16 patients (62%) lacunar MCA territory infarction. Major insular involvement is associated with
with PCS compared to 107 patients (50%) with ACS (p=0.25). large MCA territory infarction, proximal MCA occlusion, elevated serum CK-MB,
The mortality rate was n=4 (15%) in PCS and n=30 (13%) in ACS (p=0.51) and and greater neurologic severity than minor and no insular infarction.
symptomatic intracranial hemorrhage occurred in n=1 (4%) in PCS and in n=7
(3%) in ACS (p=0.60).
Conclusions: In our study population clinical outcome at 3-month follow up, 18 Acute stroke: clinical patterns and practise
mortality and intracranial hemorrhage rates are similar in patients with ACS and
PCS after treatment with systemic thrombolysis. COMPARATIVE ELIGIBILITY FOR ACUTE HEMORRHAGIC AND
It seems to be a safe and effective treatment in patients with posterior circulation ISCHEMIC STROKE TREATMENTS IN A DISTRICT GENERAL HOSPITAL
stroke. M.O. McCarron, M. Armstrong, P. McCarron
Altnagelvin Hospital, Derry, United Kingdom

Background: Thrombolysis treatment fot acute ischemic stroke (AIS) benefits


patients. Recombinant activated factor VII (rFVII) is emerging as a similar
time-dependent treatment for acute intracerebral hemorrhage (ICH). We sought to

Poster Session Cerebrovasc Dis 2007;23(suppl 2):1–147 97


Acute stroke: clinical patterns and practise
determine the relative proportions and absolute numbers of patients eligible for 3 month period was 66.9 [72.0] days. The mean wait for fast-track assessment of
acute stroke treatments in an Irish district general hospital. patients (n=62) from initial TIA to review was 4.5 [6.9] days. This decreased the
Methods: In a prospective observational study delays in admissions, demographic overall wait (n=168) in the 2nd 3 months to 29.6 [33.2] days, p<0.005.
details, and stroke severity were recorded in consecutive stroke patients admitted to Conclusion: The urgent daily assessment of TIAs provides significantly faster
a district general hospital over a 12 month period. The eligibility criteria for acute assessment, investigation and treatment compared with weekly one-stop clinics.
treatments were adapted from the NINDS study group for ischemic stroke and a This is essential to decrease the risk of recurrent stroke in patients with TIAs, in
phase two study of rFVII treatment, which excluded patients with any history of particular those with high grade carotid stenosis that may need subsequent Carotid
thrombotic or occluusive disease. Endarterectomy.
Results: 171 patients (96 men, 75 women, mean age 69.9±12.7 years) were
assessed. Multiple logistic regression showed that less severe strokes, living alone
and attending a general practitioner all independently delayed hospital admission. 21 Acute stroke: clinical patterns and practise
Patients with ICH arrived in hospital faster than AIS patients, p=0.03. ICH patients
had more severe strokes than AIS patients (median NIHSS 8 versus 4, p=0.006). ATRIAL FIBRILLATION IN ISCHEMIC STROKE PATIENTS: EVALUATION
Nineteen of 152 or 12.5% of AIS patients were in hospital within 2.5 hours of OF THE USAGE OF ORAL ANTITHROMBOTICS IN EUROPE
stroke onset with a NIHSS>4 and fulfilled the NINDS thrombolysis criteria. Seven B.M. Hamad, P. Nasuti, E. Yeung
of 19 or 37% of ICH patients were admitted within 3.5 hours and were eligible for IMS Health, London, United Kingdom
rFVII treatment.
Discussion: Although proportionately more ICH patients may potentially avail of Background: It is clinically known that atrial fibrillation (AF) is associated with
acute treatment than AIS patients, almost three times as many AIS patients were higher in-hospital mortality in ischemic stroke patients. The purpose of this study
eligible for acute treatment in this district general hospital. There may be less is to assess the use of oral antithrombotics among patients with AF and to illustrate
potential to decrease admission delays for ICH patients. the diffusion of recommended guidelines into clinical practice.
Methods: We conducted a patient-diary study in 296 hospitals in France, Germany,
Italy, Spain and UK. They treated total of 2,659 ischemic stroke patients, during
19 Acute stroke: clinical patterns and practise the period of July 2005 and December 2005, with a mean of 9 patients per hospital.
Hospitals were selected to be representative by geographic regions, size and stroke
A LINK BETWEEN LUNAR PHASE AND MEDICALLY UNEXPLAINED unit facilities in each country.
STROKE SYMPTOMS Results: Among the 2,659 patients, 478 (18%) pts were found to have chronic AF
F. Ahmad, T.J. Quinn, M. Walters, J. Dawson of whom 123 (26%) also developed AF acute event during the stroke hospitalisa-
Gardiner Institute of Medical and Cardiovascular Sciences, Glasgow, United tion. Also, 70 (3%) patients had experienced an acute event of AF for the first time.
Kingdom We report data from 548 ischemic stroke patients with AF, 75% were classified
as cardioembolic, 20% non-cardioembolic and 5% of uncertain cause. On-therapy
Background: Possible lunar effects on health have been postulated for centuries. analysis showed that 54% of pts received aspirin, 46% oral anticoagulants (OAC),
Association between phase of the moon and vascular; neurological and psychiatric 13% clopidogrel, 3% dipyridamole and 1% Aggrenox. We also analysed mono
disease have been reported. There are no published studies on the effect of lunar and dual therapies; 31% pts had aspirin only, 26% OAC only, 16% aspirin+OAC,
phase on cerebrovascular disease. A consistent proportion of stroke unit admis- 6% clopidogrel only, 6% aspirin and clopidogrel only, and interestingly 10%
sions remain medically unexplained despite extensive investigation. This cohort of didn’t receive any oral antithrombotic therapy. In-hospital mortality accounted for
Medically Unexplained Stroke Symptoms (MUSS) patients have been previously 12% of the patients, 27% discharged home independently, 15% discharged home
described and show a high rate of psychiatric comorbidity. We hypothesised that dependently and 43% transferred to rehab and long term care facilities.
admission to an acute stroke unit, with true stroke or MUSS, may be influenced by Conclusion: European guidelines recommend oral antithrmobotic therapy for
lunar cycle. ischemic stroke associated with AF for secondary prevention and this has been
Methods: All admissions to our Acute Stroke Unit are recorded in a comprehensive adopted widely in European hospitals treating ischemic stroke patients, however
database. Those admitted between 1st January 1993 and 30th September 2006 still 10% of patients are not receiving any form of oral antithrombotic therapy to
(MUS) were included in the study. The association between admission rate and prevent recurrent stroke, and only 45% are receiving OAC.
phase of the moon was calculated using a X2 test across the groups. We observed
admission rate for confirmed stroke and MUSS.
Results: There were 7219 admissions during the study period, which comprised 22 Acute stroke: clinical patterns and practise
167 complete lunar cycles. Stroke admissions were evenly spread throughout lunar
phases (p=0.72). Admission with medically unexplained stroke-like symptoms was TRANSIENT ISCHEMIC ATTACK IN ADULT MOYAMOYA DISEASE
significantly increased during full moon phases (p=0.023). J.-M. Kim, S.-H. Lee, J.-K. Roh
Discussion: There was a statistically significant association between full moon Seoul National University Hospital, Seoul, South Korea
lunar phase and diagnosis of medically unexplained stroke-like symptoms. There
was no association with other stroke diagnoses. This study adds to the growing Background: Transient ischemic attack (TIA) is a frequent initial manifestation in
literature regarding lunar effects on health. adult onset moyamoya disease (MMD). However, clinical characteristics of TIA
in adult MMD have not been fully understood, as compared with the numerous
reports on child MMD. In this study, we investigated the initial manifestations of
20 Acute stroke: clinical patterns and practise adult MMD including TIA symptom characteristics, and the relationship between
the initial manifestations and the extent of the disease progression.
IMPLEMENTATION OF FAST-TRACK ASSESSMENT OF PATIENTS WITH Method: We recruited 65 MMD patients of adult onset between 1999 and 2006,
TRANSIENT ISCHAEMIC ATTACKS IS MORE EFFECTIVE THAN WEEKLY who visited and diagnosed at the Seoul National University Hospital. We obtained
ONE-STOP CLINICS their basic demographic data, imaging files, and clinical information. The study
S. Goode, N. Altaf, J. Riley, J. Gladman, S. MacSweeney groups were categorized into TIA, ischemic stroke (IS), hemorrhagic stroke (HS),
Queens Medical Centre, United Kingdom and nonspecific (NS) according to the initial manifestations. Symptoms of TIA
were described via detailed interview. The outcomes after surgical revascularization
Introduction: The risk of stroke is highest immediately after an initial transient is- were evaluated in terms of stroke or TIA recurrence during the follow up.
chaemic attack (TIA). Current guidelines highlight the need for the rapid assessment Result: Out of 65 subjects, there were 29 (45%) TIA, 11 (17%) IS, 15 (23%) HS,
of patients with TIA. There is, however, a significant delay in the assessment of and 10 (15.4%) NS patients. TIA manifestations were variable among subjects.
patients with TIA in a weekly one-stop clinic. The aim of this study was to ascertain Twenty subjects out of 29 experienced motor dominant symptoms, whereas only
the impact of an urgent daily TIA clinic on waits for assessment and treatment. two had sensory dominant symptoms. Isolated cognitive dysfunctions such as
Methods: Retrospective analysis was performed on the delay between initial TIA, language dysfunction occurred in four subjects. Stages of MMD evaluated by
referral and clinic dates. This data was collected for a 3 month period during which Suzuki’s method were significantly higher in IS group (3.64 ± 0.8) than in TIA
the weekly one stop clinic was used to assess patients with suspected TIA. In group (2.90 ± 0.9; p=0.022). There was no significant difference in the surgical
addition, data was also collected during the 3 month period during which the pilot outcome in terms of TIA and stroke recurrence among the groups.
fast-track TIA assessment as well as the weekly one-stop clinic was functional. Conclusion: We showed that TIA is very frequent initial manifestation among
Results: 288 patients with suspected TIA were assessed over the study period. The adult MMD and that involvement of intracranial arteries are less extensive in TIA
mean age of the patients was 68 years (SD 10) and 51% were male. The mean group. Our results suggest that TIA as initial manifestation mainly occurs in the
interval between TIA (n= 120) and review in the weekly TIA clinic in the initial earlier stage of the MMD.

98 Cerebrovasc Dis 2007;23(suppl 2):1–147 16th European Stroke Conference


23 Acute stroke: clinical patterns and practise stroke patients to a general hospital. HIPE identified patients with acute stroke
presenting to our hospital from 01-01-05 to 30-06-05. Data was collected from
THE ULTRASOUND SIGNS OF ENDOTHELIAL DYSFUNCTION IN ACUTE the emergency service’s and hospital’s records. Time intervals from initial contact
ISCHEMIC STROKE with the emergency services to medical assessment in hospital were recorded. Data
M.A. Domashenko, A.O. Chechetkin, Z.A. Suslina on time of symptom onset was available for patients who arrived via personal
Institute of Neurology, RAMS, Moscow, Russian Federation transport.
Forty-six patients presented with an acute stroke (84.78% infarcts). Thirty-one
Background: The aim of the study was to evaluate the ultrasound signs of patients arrived by ambulance [12 by 999 call= (1), 19 non-999 call= (2)],15 via
endothelial dysfunction in patients with acute ischemic stroke [IS]. personal transport (3). Mean interval from the time of the ambulance call to arrival
Methods: The ultrasound evaluation of the endothelium-derived vasodilatation of at scene was 24 mins (1) vs 28 mins (2) [NS]. Mean interval from time of call to
the brachial artery [BA] was performed in 27 patients (age 67 [55; 79] years; 14 arrival in the emergency department was 66.3 mins (1) vs 74.4 mins (2) [NS]. Mean
males, 13 females) with IS in the first 48 hours of stroke onset. The maximal interval from time of emergency department arrival to medical assessment was 95
increase of BA diameter after “cuff test” [CT] with the transient occlusion of BA by mins(1), 105 mins(2) and 43 mins(3) [(1)/(2) vs (3) p=0.01/p=0.002].The average
the cuff of manometer was evaluated. 20 patients (age 64 [51; 72] years; 10 males, time from symptom onset to arrival in the emergency department was 861.6 mins
10 females) with the chronic ischemic cerebrovascular diseases were investigated for patients arriving by personal transport.
in the control group. The rapid ambulance response contrasts with the delayed medical response to acute
Results: The neurological deficit in IS patients was 79 [58,5; 90] on ESS and 4,5 stroke at our institution. Better public and medical awareness of the urgency of
[2,5; 9] on NIHSS. The initial linear speed of the blood flow [LSBF] on BA was 62 acute stroke management is necessary. This study has provided useful baseline data
cm/s [54; 65] and 58 cm/s [50; 65] and the initial diameter of BA was 4,6 mm [4,0; on our current performance regarding the transport and medical assessment of acute
5,1] and 5,1 mm [4,6; 5,4] in patients with IS and control group accordingly. After stroke patients. We plan to put in place an integrated response for acute stroke in
the CT the LSBF on BA increased on 121% [103; 219] and 184% [126; 223] in order to maximise patient outcomes.
patients with IS and control group (p=0,07). The increase of BA diameter after the
CT was 5,4% [4,3; 9;5] and 8,5% [6,8; 11,5] in patients with IS and control group
(p=0,035). The increase of BA diameter was directly correlated with ESS score (R
0,35; p=0,047) and indirectly correlated with NIHSS score (R -0,33; p=0,049). Acute stroke: complications and early outcome
Conclusion: The BA dilatation after CT in patients with IS was decreased com-
pared to patients with the chronic cerebrovascular diseases. The ultrasound signs
of endothelial dysfunction in patients with IS and their correlation with the stroke 1 Acute stroke: complications and early outcome
severity were demonstrated.
THE RELATIONSHIP BETWEEN THE LOCATIONS OF DEEP-VEIN
THROMBOSIS AND MOTOR IMPAIRMENT IN ACUTE ISCHEMIC STROKE
24 Acute stroke: clinical patterns and practise PATIENTS
D.G. Sherman, G.W. Albers, C. Bladin, C. Fieschi, A.A. Gabbai, C.S. Kase,
S100B AS A BIOMARKER: ITS OPTIMAL ROLE IN STROKE W. O’Riordan, G.F. Pineo, for the PREVAIL Investigators
P. Dassan, G. Keir, R. Jager, M.M. Brown University of Texas Health Science Center at San Antonio, San Antonio, TX,
UCL, Institute of Neurology, London, United Kingdom USA

Background: Blood biomarkers may be important in three areas of acute stroke: Introduction: Studies of major orthopaedic surgery have shown that deep-vein
diagnosis; as a surrogate marker for severity of brain damage; and predicting thromboses (DVT) do not always occur on the same side of the body as the surgical
prognosis. The S100B protein has been studied in each area individually in selected intervention suggesting that reduced mobility is not the only factor triggering
patients but there are no studies directly comparing its utility in these areas. We thrombus formation. We assessed the relationship between the side of the body
correlated all three measures with serial measurements of S100B in an unselected affected by motor impairment and the side with DVT in PREVAIL, a study of VTE
series to determine its optimal role. prophylaxis in acute ischemic stroke patients.
Method: Blood samples and National Institute of Health Stroke Scale (NIHSS) Methods: Patients with acute ischemic stroke, confirmed by CT scan or MRI, and
scores were taken on arrival to hospital and daily, where possible, for up to 6 days unable to walk unassisted due to motor impairment of the leg were randomized
after onset of symptoms in 40 consecutive patients with suspected ischaemic stroke within 48 h of stroke symptoms to enoxaparin 40 mg SC qd or UFH 5000 IU
(26 acute infarcts and 14 stroke mimics). Serum S100B was measured by enzyme- SC q12h for 10±4 days. DVT was confirmed by venography, or ultrasonography
linked immunosorbent assay. Infarct volumes were measured on diffusion-weighted when venography was not practical. PE was confirmed by VQ or CT scan, or
images. angiography.
Results: In patients venesected within 24 hours of symptom onset there was no Results: The PREVAIL study showed a 43% relative reduction in the risk of
significant difference in S100B levels between acute infarction and stroke mimics symptomatic or asymptomatic deep-vein thrombosis (DVT), symptomatic pul-
(mean 0.19 ng/ml vs 0.12 ng/ml). Peak S100B levels after 24 hours however, monary embolism (PE), or fatal PE with enoxaparin compared with UFH in acute
correlated well with both infarct volume and maximum NIHSS scores (r = 0.89, ischemic stroke patients (10.2% vs 18.1%; p=0.0001), with no increase in clinically
P<0.001 and r = 0.81, P<0.001 respectively). The highest level was seen in a important bleeding. A post-hoc analysis showed that 7.0% of patients developed a
patient with malignant middle cerebral artery infarction. Peak S100B level was DVT on the same side as the motor impairment, and 3.5% developed a DVT on the
a good predictor of dichotomised outcome after discharge (independent mean contralateral side.
0.14ng/ml vs dependent mean 0.36ng/ml, P<0.05). Conclusion: Although more DVT events occur on the same side as the motor
Conclusion: Serum S100B measurements are not helpful in distinguishing infarc- impairment, about one third occur in the contralateral leg. This suggests that while
tion from stroke mimics in the emergency room. Measurement of blood S100B flow-dependent thrombogenic factors (i.e. stasis) are triggers for thrombus forma-
levels after cerebral infarction is a useful measure of the severity of brain damage tion, some other factors may also be important. Rehabilitation and nursing care
and predicts prognosis. It may also be a useful predictor of malignant infarction. should focus on mobilization of the patient as well as providing VTE prophylaxis.

25 Acute stroke: clinical patterns and practise 2 Acute stroke: complications and early outcome
PREHOSPITAL TRANSPORT OF ACUTE STROKE PATIENTS AND TIME TO PREVALENCE AND RISK FACTORS OF FAECAL INCONTINENCE IN
INITIAL MEDICAL ASSESSMENT IN AN IRISH GENERAL HOSPITAL STROKE PATIENTS ADMITTED TO THE ACUTE STROKE UNIT AND TO
R. Purcell, G. Bergin, C. Cooney, E. Farrelly, R. Morton, H. Logan, R. Lynch, REHABILITATION WARDS (PILOT STUDY)
S. Murphy U. Khan
Midland Regional Hospital, Mullingar, Co. Westmeath, Dublin, Ireland Oxford Redcliff, Abingdon, United Kingdom

The aims of acute stroke management are to minimise neurological impairment Background and purpose: Faecal incontinence [FI] commonly affects patients
and maximise functional recovery. Rapid patient transfer to acute stroke units is after stroke. This is an observational study to assess the prevalence of and risk
essential to achieve these aims. In Ireland, there is no nationally agreed policy on factors for FI in stroke patients admitted to the acute stroke unit & to rehabilitation
acute stroke care. wards.
A retrospective study was performed to examine prehospital transport of acute Methods: 50 patients admitted in Oxford Radcliffe Hospital stroke unit from May

Poster Session Cerebrovasc Dis 2007;23(suppl 2):1–147 99


Acute stroke: complications and early
outcome
2006 for a period of 10 wks were enrolled and followed up in rehabilitation wards recommended (2000) in all groups, particularly those on modified diet (normal
and in the community. The prevalence of FI was assessed over a time period of diet mean 1311; SD 520, modified diet 765 SD 464, NG diet 1633 SD 780: all p
3 months and risk factors were assessed in the1st wk after admission. The main values<0.0001). Median daily protein intake was significantly lower in those on a
comparative statistical tool used was the Chi squared test or Fisher’s exact tests. modified diet (39.2g) compared with NG feeding (56.9g, p=0.012) a normal diet
Results: Pre-stroke FI was 2%.Post-stroke FI at wk1 was 34%, at wk 4 was 26% (50g, p=0.02) and recommended levels (50grams). Mean seven day total calorie
& at wk 12 was 21%. intakes were significantly lower than recommended levels (14000) in patients on
The characteristics of 17 FI patients were compared with 33 without FI.Total a normal diet (8854 p=0.023), and modified diet (5052 p=0.001) but not in those
anterior circulation stroke syndrome was strongly associated with FI (P<0.0001) being fed with NG (11436p=0.32). This interim analysis was not powered to
as was stroke severity, measured by NIHSS >14; GCS<15 (P<0.0001).There demonstrate reductions in weight, but patients on a modified and normal diet lost
was a significant association between poor cognition [MMSE score <25] and FI 3.5 kg in 7 days while those on NG lost 0.3kg. There was a strong negative
(P=0.009). Disability [Barthel Index<15] was also significantly associated with correlation between weight loss and both calorie and protein intake (Pearson -0.79,
FI (P=0.002). Concurrent urinary incontinence [UI] (P<0.0001) and diarrhoea and 0.-0.89 p= 0.001).
(P=0.027) were but constipation (P=0.70) and faecal impaction (P=0.327) were not Conclusions: Patients on modified diet are at risk of malnutrition. Consideration of
associated with FI. Enteral feeding was strongly associated with FI (P<0.0001). feeding supplementation should be given to patients with swallowing difficulties
Advanced age (>80) was not a significant factor when adjusted for gender
(P=0.061) but showed a positive trend.
Conclusion: FI is common in older stroke patients & resolves in <50% within 5 Acute stroke: complications and early outcome
3 months. Stroke severity, conscious state, level of disability, co-existing UI,
diarrhoea and enteral tube feeding are significant risk factors. This pilot provides THROMBOLYSIS WITH RT-PA DOES NOT PROMOTE EDEMA FORMATION
data to plan future larger studies of FI in stroke patients. IN ACUTE ISCHEMIC STROKE
V. Sachsenmaier, I. Dzialowski, C. Disque, G. Gahn
Technical University of Dresden, Dresden, Germany
3 Acute stroke: complications and early outcome
Background: There is ongoing controversy whether recombinant tissue plas-
COMPARISON OF 2 TYPES OF PROGRESSION AFTER ACUTE ISCHEMIC minogen activator (rt-PA) treatment is associated with excessive edema formation
STROKE: CONTINUOUS DETERIORATION VS. FLUCTUATION OF STROKE following acute ischemic stroke. Possible mechanism might be the toxic disruption
SEVERITY of the blood brain barrier and subsequent reperfusion injury. We studied the
Y.-J. Cho, K.-S. Hong, J.-.S. Koo, K.-H. Yu, H.-J. Bae, M.-K. Han, hypothesis that patients with large middle cerebral artery (MCA) infarctions treated
M.-K. Jeong, D.-W. Kang, J.-M. Park, B.-C. Lee with rt-PA develop larger cerebral edemae than controls.
Inje University Ilsan Paik Hospital, Goyang-si Gyeunggi-do, South Korea Methods: We retrospectively studied patients with large MCA infarctions from
07/2001-10/2006 defined by an Alberta Stroke Program Early CT Score (AS-
Background: To investigate the frequency, possible attributable factors and the PECTS) < 5 on day 1 – 7 follow-up imaging. Exclusion criteria were space-
prognosis of 2 types of progression after acute ischemic stroke. occupying secondary hemorrhage, hemicraniectomy, and thrombolysis with non-t-
Methods: All consecutive patients with first-ever ischemic stroke within 24 hours PA agents. We recorded baseline characteristics and rt-PA treatment status from the
from onset were recruited prospectively, who admitted 4 university hospitals in patient chart. We prospectively assessed the extent of cerebral edema applying a 5-
Seoul metropolitan region. Baseline demographics, stroke subtypes, past medical scale grading system (0, no edema, 1, compression of external subarachnoid spaces,
history, medical complications after stroke, and modified Rankin Scale at 3 months 2, compression of lateral ventricle, 3, midline deviation, 4, obstructive dilatation of
were assessed by predetermined protocol. Stroke severity was assessed by NIH opposite lateral ventricle, Borovich scale). We compared Borovich scores among
Stroke Scale (NIHSS) at admission, on hospitalization days 1, 2, 3, and week 1 and rt-PA treated patients and controls using non-parametric statistical testing.
2. Clinical deterioration was defined as decrease of 2 points in total NIHSS score Results: We identified 90 patients for our study with a mean age of 66 ±13 years,
or 1 point in motor scale score. 42% female, mean onset-to-imaging-time of 59 ±40 hours, median ASPECTS of 2
Results: Among 566 patients recruited, 142 (25.1%) worsened. One hundred thirty (iqr2-4). Of the 90 patients, 30 were thrombolysed and 60 were controls. Baseline
patients (91.6%) were deteriorated within 3 days after stroke onset. Continuous characteristics did not differ across the two groups. Distribution of Borovich scale
deterioration (CD) was found in 94 (66.2%), and returning to initial status after scores for the treatment (and control) group was 0 (0) % for grade 0, 0 (8) % for
fluctuation (F) was found in 48 (33.8%). CD patients are older (68.6±11.2 vs. grade 1, 43 (40) % for grade 2, 37 (33) % for grade 3, and 20 (18) % for grade 4.
62.0±12.4), and more likely to have higher initial NIHSS (median=7.5 vs. 6.0), Median Borovich scores among both groups did not differ significantly (median 3,
preceding systemic infection (24.5% vs. 12.5%), and worse functional outcome p=0.48).
(mRS 3-6=78.7% vs. 56.2%) at 3 months than F patients. After adjusting sex, hy- Conclusion: In our retrospective study, t-PA treatment did not exacerbate cerebral
pertension, diabetes, and stroke subtypes, age was the only significant independent edema in patients with large MCA infarctions. Further prospective evidence is
predictor of CD (OR=1.04, 95% CI=1.01-1.08) by logistic regression analysis. needed to confirm this result.
Discussion: Continuous deterioration of stroke severity after acute ischemic stroke 1723/1800 characters
results in poor functional outcome. Age, initial NIHSS, and preceding systemic
infection might predict further decline.
6 Acute stroke: complications and early outcome
4 Acute stroke: complications and early outcome ACUTE MORTALITY PREDICTION IN STROKE PATIENTS
M. Delobel, A. Viguier, M.C. Turnin, V. Larrue
COMPARISON OF NUTRITIONAL INTAKE IN POST STROKE PATIENTS ON CHU de Toulouse France, Toulouse, France
NORMAL, MODIFIED AND NG DIET
T. Nagarajan, A. Addison, M. Winder, A.G. Dyker We examined the use of the Simplified Acute Physiology Score II (SAPS II) for
Freeman Hospital, Newcastle upon Tyne, United Kingdom the prediction of in-hospital mortality in a large number of stroke patients managed
in a neurological intensive care unit.
Patients with swallowing problems after stroke are at risk of developing nutritional Data on SAPS II were prospectively collected in patients with ischemic stroke,
deficiencies. cerebral hemorrhage, transient ischemic attack, or subarachnoid hemorrhage, con-
Methods: Three groups of patients were studied: Normal diet (n=4), modified secutively admitted to a tertiary neurological intensive care unit. We constructed
thickened diet (n=5), and naso-gastric feeding(n=4). Patients were studied for seven receiver operating characteristic curves (ROC) to determine the ability of SAPS II
days. Full records were kept of patients’ nutritional intake. Patients were weighed to predict in-hospital mortality.
on day one and day 7. Results were tabulated using Excel (2003) and statistical 2214 patients were included in this analysis. 321 (14.5%) patients died in hospital.
analysis was carried out using MINITAB (14). Test for normality was carried out The area under ROC curve [95% confidence interval] was 0.83 [0.81-0.86]. With
on all analysed data and students T test was used to compare normally distributed a cut-off point of 30 the positive predictive value of SAPS II was 38.3%, and the
data while Mann–Whitney Tests and Wilcoxon Signed Rank test were used to negative predictive value 94.8%. Findings were similar in an analysis restricted to
compare non-normally distributed data. patients older than 40 years.
Results: Mean daily calorie intake was significantly lower in those being fed The findings indicate that SAPS II is a reliable tool to predict acute mortality in
a modified diet compared with NG (difference 546, p<0.0005) and normal diet patients managed for stroke in a neuroligical intensive care unit.
(difference 868, p<0.0005).There was no difference in daily calorie intake between
NG and normal diet. Average daily calorie intake was significantly less than

100 Cerebrovasc Dis 2007;23(suppl 2):1–147 16th European Stroke Conference


7 Acute stroke: complications and early outcome 9 Acute stroke: complications and early outcome
A NOVEL POLYMORPHISM IN THE PROMOTER REGION OF THE EARLY HEMORRHAGIC EVENTS AFTER INTRAVENOUS THROMBOLYSIS
SURVIVIN GENE IS RELATED TO HEMORRHAGIC TRANSFORMATION IN OF HEMISPHERIC AND BASILAR ISCHEMIA: RESULTS OF THE HELSINKI
PATIENTS WITH ACUTE ISCHEMIC STROKE STROKE THROMBOLYSIS STUDY
M. Castellanos, C. Gubern, J. Serena, J. Castillo, M.A. Moro, M. Millán, T. Bogoslovsky, O. Häppölä, L. Soinne, O. Salonen, P.J. Lindsberg, M. Kaste
R. Rodríguez, F. Nombela, O. Hurtado, J. Mallolas Helsinki University Central Hospital, Biomedicum, Neuroscience Program,
Hospital Universitari de Girona Doctor Josep Trueta, Girona, Spain Helsinki, Finland

Background: The expression of survivin, a member of the inhibitor antiapoptotic Early cerebral hemorrhages after ischemic stroke are the most feared adverse event
proteins family, has been shown to increase after cerebral ischemia in response following the theapeutic use of recombinant tissue plasminogen activator. The
to the release of angiogenic growth factors. This protein has been mainly located reason for bleeding is not known, but their incidence has been associated with
at the microvaculature within the infarcted and peri-infarterd area, and so we various premorbid factors, such as diabetes, the use of antithrombotics, the duration
aimed to investigate whether survivin gene polymorphisms were associated with and extent of cerebral ischemia as well as the perithrombolytic levels of blood
hemorrhagic transformation (HT) of cerebral infarction. glucose and blood pressure (BP). Onset-to-treatment times tend to be longer in
Methods: DNA was isolated from peripheral blood samples of 97 patients with basilar occlusions, but it is not known, if their bleeding tendency is different.
a hemispheric ischemic stroke and 38 controls. Polymorphism screening of the We aimed to asses the rate of hemorrhagic events within 24 hours after thrombolysis
survivin gene was performed by polymerase chain reaction, single-strand con- and the associated factors in consecutive anterior and posterior circulation stroke
formation polymorphism and sequencing analysis. DWI sequences were obtained patients treated in Helsinki University Central Hospital during years 2003 to 2005.
within 12 hours from symptoms onset and at 72±12 hours by using a 1.5-T MRI. Of 335 strokes 304 were hemispheric (HS) and 31 basilar occlusions (BAO). BAO
The presence of HT was determined on the second DWI sequence and classified patients had more severe strokes (median NIH Stroke Scale 20 vs. 10, p<.001) and
according to ECASS II criteria. longer onset-to-treatment times (873±1453 min vs. 127±43 min, p<.0001) and
Results: Forty-seven patients (48%) had HT: 27 patients had hemorrhagic infarc- less antiaggregatory treatment (22.6% vs 43.1%, p=.03), but similar age (64±17
tion and 20 had parenchymal hemorrhage (PH). Thirty-two patients (32%) received vs. 69±12 years, p=.14) and prevalence of diabetes [4(15%) vs. 33(12%),p=.72].
rt-PA. A novel polymorphism was identified in the promoter region of the survivin BAO patients had comparable prethrombolytic glucose (7.0 vs 7.1 mmol/l) and BP
gene which corresponded to an C-to-T transition at -241 bp from the transcription levels (systolic 152 vs 156 mmHg, diastolic 81 vs 82 mmHg). Overall incidence of
start site. The prevalence of the mutant allele (T) was similar in patients and postthrombolytic hemorrhages was 64 (21%) in HS and 5 (16%) in BAO (p=.52).
controls (14% vs. 16%, respectively; p=0.985). Seven patients (26.9%) with allele There was no difference in distribution into subgroups of hemorrhagic events
T had HT compared to 40 (56.3%) of wild-type (p=0.009). Logistic regression according to ECASS II classification or extraischemic or subarachnoidal bleeding.
analysis showed that the presence of the polymorphism was associated with a Despite 7-fold longer treatment delay and 2-fold stroke severity, thrombolysis of
lower risk of HT (OR 0.28; 95% CI, 0.08 to 0.97; p=0.045) independently of age, BAO is not associated with more major hemorrhages than that of HS.
baseline stroke severity, temperature, platelet count, glucose levels, systolic blood
pressure, DWI lesion volume and rt-PA administration.
Discussion: The -241 C/T polymorphism in the promoter region of the survivin 10 Acute stroke: complications and early outcome
gene is associated with a lower risk of HT in patients with acute ischemic stroke.
This polymorphism might be related with a decrease of survivin expression and ENDOTHELIAL DYSFUNCTION IN ACUTE ISCHEMIC STROKE IS
secondary down-regulation of the angiogenic process. CORRELATED WITH STROKE SEVERITY AND THE SIZE OF THE BRAIN
INFARCTION
M.A. Domashenko, S.V. Orlov, M.M. Tanashyan, V.G. Ionova, M.V. Kostyreva,
8 Acute stroke: complications and early outcome R.M. Umarova, A.S. Suslin, M.V. Krotenkova, Z.A. Suslina
Institute of Neurology, RAMS, Moscow, Russian Federation
STROKE PATIENT PROGRESSION IN DIJON FROM 1985 TO 2004
P. Decavel, Y. Bejot, G.V. Osseby, B. Parratte, T. Moulin, M. Giroud Background: The aim of the study was to evaluate the concentration of von
Besançon University Hospital, Besançon, France Willebrand factor [vWf] in acute ischemic stroke [IS] compared with the stroke
severity and the size of the brain infarction.
Background: Development of stroke management over a number of years has Methods: The concentration of serum vWf was investigated in 40 patients (age 65
changed the vital and functional prognosis of patients. [57; 74] years; 22 males, 18 females) with IS in the first 48 hours and on 21 day
Method: The main aim was to test the outcome of patients with first-ever stroke of IS onset. The size of the brain infarction was measured on diffusion-weighted
over a long period among a random population. A study was carried out into (DWI) MRI images (in the first 48 hours of IS) and on T2 MRI images (on 21
the progression of the number of deaths over 20 years, handicap development day of IS). Correlation analysis of vWf concentration, NIHSS score and the size of
according to the modified Rankin scale and the clinical state of patients coming brain infarction was performed.
into the department with a first-ever stroke identified in an ongoing registry of the Results: The vWf concentration was 158% [130; 181] and 170% [147; 200] in
population between 1985 and 2004. the first 48 hours and 21 day of IS accordingly (p=0,03). The neurological deficit
Results: The distribution of stroke type was as follows: 3142 infarctions, 341 on NIHSS was 4,5 [2,5; 9] and 1,5 [0; 4] in the first 48 hours and 21 day of
hematomas and 74 subarachnoid hemorrhages. Over 20 years, mortality has de- IS accordingly. The vWf concentration in the first 48 hours of IS was directly
clined by 0.94% per year (p<0.01), the number of patients able to walk 28 days correlated with NIHSS score (R 0,33; p=0,049). The size of the brain damage on
after stroke has increased by 0.78% (p=0.02) per year, with no increase in the DWI was 16,1 sm3 [4,7; 40,4] in the first 48 hours of IS and was directly correlated
number of patients severely handicapped (p=0.43). If the age at which the first-ever with vWf concentration (R 0,59; p=0,046). The size of brain infarction on T2 MRI
stroke took place has risen, the number of patients initially comatosed has not was 11,2 sm3 [6,8; 32,2] on the 21 day of IS and also was directly correlated with
changed (p=0.06). vWf concentration (R 0,71; p=0.009).
Discussion: The decline in mortality observed in Dijon confirms the tendency Conclusion: The serum vWf level is correlated with the stroke severity and the
observed in the majority of other registries. The Dijon registry is, however, the only size of the brain infarction in patients with IS.
one to be ongoing. The improvement in stroke patient progression is significant
despite the increase in the age at which the first event took place. Over a period of
20 years, a 50% decrease in stroke patient mortality with no rise in severe handicap 11 Acute stroke: complications and early outcome
has been observed in Dijon.
IS THE ASSOCIATION OF COAGULATION ACTIVATION MARKERS
WITHPROGRESSING STROKE DUE TO THE ACUTE-PHASE RESPONSE?
J.M. Barber, P. Welsh, P. Langhorne, A. Rumley, G.D. Lowe, D.J. Stott
Royal Infirmary, University of Glasgow, Glasgow, Airdrie, Scotland, United
Kingdom

Introduction: Early progression of ischaemic stroke is common, occurring in


around 25% of patients. This complication is associated with poor outcome. We
have demonstrated that progression is associated with elevation of markers of co-
agulation activation. We aimed to determine whether the association of progressing

Poster Session Cerebrovasc Dis 2007;23(suppl 2):1–147 101


Acute stroke: complications and early
outcome
stroke with haemostatic activation is due to an underlying enhanced acute phase 6 h and hemorrhagic transformation (HT) on MRI at 24-48 h. mRS score was used
inflammatory response. to assess 3-month outcome.
Methods: Consecutive ischaemic stroke patients were recruited. Progressing stroke Results: 66 (45.5%) patients had RHS. Baseline NIHSS was lower in RHS (median
was defined by deterioration in components of the Scandinavian Stroke Scale 17 vs 19, p=0.0001). Time to MRI was similar between both hemispheres. RHS
over the first 72 hours. Measures of Interleukin (IL)-6, IL-18 and tumour necrosis patients presented with larger DWI volume (73.9 vs 38.5 cc; p=0.004) and smaller
factor-alpha (TNF-A) were made in addition to highly sensitive C-reactive protein PWI/DWI mismatch (63% vs 79%, p=0.011). Only 13 (16.5%) patients with LHS
(hsCRP). did not meet MRI criteria for thrombolysis, compared to 21 (31.8%) of those
Results: We studied 150 patients of whom 35 (23%) had progressing stroke by with RHS (p=0.03). 85 (58.6%) patients were treated with tPA (34 RHS, 51 LHS;
European Progressing Stroke Study criteria. IL-6 levels [11.3 (6.0-16.6) v. 7.0 p=0.112). Among those treated with tPA, baseline NIHSS was lower in RHS (16 vs
(3.3-13.8), p=0.02] and hsCRP [8.66 (3.69-30.4) v. 5.26 (1.64-18.4), p=0.05] were 19; p=0.0004), whereas DWI and PWI/DWI mismatch volumes were comparable.
higher in the progressing group. IL-18 [median 295 (216-452) v. 280 (212-375), Recanalization rates (RHS 53.1% vs 52.2%, p=0.934) did not differ between both
p=0.42] and TNF-A levels [2.53 (1.86-3.67) v. 2.24 (1.58-3.10), p=0.18] were hemispheres. Only 1 patient had symptomatic HT. At 3 months, good clinical
similar in progressing and non-progressing cases. In binary logistic regression none outcome (mRS 0-2, RHS 33.3% vs 39.1%, p=0.609) and mortality (RHS 15.2% vs
of the acute phase markers were independent predictors of progressing ischaemic 23.9%, p=0.339) were similar between RHS and LHS.
stroke; thrombin-antithrombin complexes (odds ratio (OR) 7.74), admission mean Conclusion: Patients with a RHS present with larger infarct volumes and lesser
arterial blood pressure (OR 1.4 for each 10mmHg rise) and age (OR 1.05) were salvageable penumbral tissue, suggesting a possible less efficient pattern of collat-
independent predictors of progressing stroke. eral circulation in the right hemisphere. A MRI-based screening for thrombolysis,
Conclusions: Circulating levels of IL-6 and hsCRP are elevated in subjects with irrespective of the time window, may improve the selection of patients with RHS
progressing ischaemic stroke. However, these inflammatory markers are not inde- likely to benefit from tPA.
pendent predictors of stroke progression. The acute phase inflammatory response
is unlikely to be a major contributor to haemostatic activation in progressing
ischaemic stroke. 14 Acute stroke: complications and early outcome
IS RENAL FAILURE A PREDICTOR FACTOR OF POOR EVOLUTION IN
12 Acute stroke: complications and early outcome ACUTE STROKE?
L. Gabaldón, B. Fuentes, J. Fernández, L. Idovro, P. Martínez, E. Díez-Tejedor
THE EFFECT OF DYSPHAGIA ON COMPLIANCE AND OUTCOME IN THE University Hospital La Paz, UAM, Madrid, Spain
‘EFFICACY OF NITRIC OXIDE IN STROKE’ (ENOS) TRIAL
G.M. Sare, L. Gray, T.J. England, P.M.W. Bath, for the ENOS Investigators Background: Previous studies have pointed out that renal failure is an independent
Institute of Neuroscience, University of Nottingham, Nottingham, United factor of poor outcome in patients with cardiac failure, myocardial infarction and
Kingdom coronary surgery. However, no studies analysing its possible influence on stroke
outcome are available.
Introduction: About 50% of stroke patients have dysphagia at presentation and Methods: Observational study including consecutive first-ever acute stroke in-
this may result in the discontinuation of pre-stroke medical therapy and delay the patients with a two-years recruitment period. Renal failure was defined as
initiation of acute oral therapy. Enteral access is unreliable since naso-gastric tubes creatinine level 3 1.2 mg/dl on admission or previous diagnosis of it. In-hospital
can be difficult to insert and are often pulled out. Here we examine the relation mortality and outcome at discharge (modified Rankin Scale) were the main outcome
between the administration of oral and transdermal medication in patients with measures.
acute stroke. Results: 445 patients were included, mean age 69.7±13.2. In the univariate
Methods: ENOS is an international, randomised controlled trial in 5,000 patients analysis creatinine >1.2 mg/dl was associated to more in-hospital mortality (31.7
with acute ischaemic or haemorrhagic stroke which is investigating the safety vs 20.7%; p=0.04) but not to poor outcome at discharge. In multivariate logistic
and efficacy of lowering BP with transdermal glyceryl trinitrate (GTN, given for regression analysis the predictive factors independently associated to in-hospital
7 days). Patients taking pre-stroke antihypertensive therapy are also randomised mortality were: stroke severity on admission (OR 0.49; 95% IC 0.39-0.63) and the
in a partial-factorial design to continue or temporarily stop this. We compared development of systemic (OR 17.97; 95% IC 5.47-59) or neurologic complications
treatment compliance and outcome (Modified Rankin Scale (mRS) at 90 days post (OR 23.49; 95%IC 7.25-76.01) without any influence of renal failure.
randomisation) between those with and without dysphagia. Conclusions: Renal failure measured by creatinine serum level does not signif-
Results: As of 10 January 2007, 559 patients (28 centres, 9 countries) had been icantly influence in-hospital mortality or outcome at discharge in acute stroke
recruited into ENOS. 283 (51%) of these patients had dysphagia. In analyses patients. However, new studies analysing other parametres of renal function such
blinded to treatment assignment, 87% of dysphagic patients received all of their as creatinine clearance are need to get definite conclusions.
randomised treatment between days 1-4 in the GTN patch versus No GTN arm of
the trial compared to 76% in the stop versus continue arm (p=0.01). Those with
dysphagia had more severe strokes at baseline and significantly worse outcome at 15 Acute stroke: complications and early outcome
90 days compared to those without: median mRS 3 (inter quartile range, IQR 2-5,
n=283) compared to median 2 (IQR 1-3, n=276) (p<0.0001). SIGNIFICANCE OF COMMON COMPLICATIONS DURING THE FIRST
Discussion: Stroke patients with dysphagia were more likely to receive transdermal WEEK POST STROKE: IMPACT ON FUNCTIONAL OUTCOME AT 90 DAYS
treatment than oral antihypertensive medication. These data highlight the potential G. Rohweder, E. Naalsund, P. Oksnes, B. Indredavik
benefits of transdermal medications in this high risk population. St. Olavs University Hospital, Department of Neuroscience, NTNU,
Trondheim, Norway

13 Acute stroke: complications and early outcome Background: Little is known about the prognostic impact of acute post-stroke
complications. The aim of this study was to define the longterm functional outcome
SIDE DIFFERENCES ON THE EXTENT OF SALVAGEABLE ISCHEMIC in patients who experienced a common (>2.5%) complication during the first week
TISSUE IN HYPERACUTE STROKE after a stroke, while admitted to an acute comprehensive stroke unit and followed
R. Delgado-Mederos, M. Ribo, A. Rovira, J. Alvarez-Sabin, M. Rubiera, up by an early supported discharge service.
J. Munuera, E. Santamarina, P. Delgado, O. Maisterra, C.A. Molina Methods: 244 patients consecutively admitted to our stroke unit and with a mod-
Hospital Vall d’Hebron, Barcelona, Spain ified Rankin Scale (mRS) of < 2 were included on admission and followed with
assessment for 8 complications: fever, diffuse pain, progressing stroke, urinary tract
Background: Previous research has suggested that right hemisphere stroke (RHS) infection (UTI), isolated Troponin T elevation (Trop T), chest infection, non-serious
may achieve worse outcome after thrombolysis. We aimed to evaluate the influence falls, and acute myocardial infarction (AMI). After discharge, the patients were
of the side of affected hemisphere on the extent of baseline MRI abnormalities followed up for 90 days with weekly telephone assessments and a home-visit and
in acute stroke and to assess the value of MRI-based selection approach for tPA functional assessment after 3 months.
treatment in RHS. Results: The mean age of patients was 77 yrs., 56% were women. The frequency
Methods: We prospectively studied 145 acute stroke patients due to proximal MCA of complications were as follows: fever 26%, diffuse pain 25%, progressing stroke
occlusion imaged with MRI within the first 6 h from symptoms onset. Those with 18%, UTI 17%, Trop T 13%, chest infection 12%, non-serious falls 7%, AMI 6%.
unclear onset time were excluded. DWI and time-to peak (PWI) lesion volumes 48% of all patients had an improvement >1 on the mRS. Frequencies of mRS >
were measured. MRI inclusion criteria for tPA were PWI/DWI mismatch>20% 1 were as follows: In pts with a chest infection: 18%, without 52% (p=0.001). In
and DWI volume<50% of MCA territory. Recanalization was assessed by TCD at pts with Trop T: 34%, without 50% (p=0.089). In pts with AMI: 30%, without

102 Cerebrovasc Dis 2007;23(suppl 2):1–147 16th European Stroke Conference


49% (p=0.229). In pts with UTI 46%, without 48% (p=0.777). In pts with fever screening for aspirin resistance after a stroke might identify a sub-group of people
49%, without 48% (p=0.876). In pts with progressing stroke 60%, without 46% who may benefit from higher doses of aspirin and/or combination therapy.
(p=0.080). In pts with diffuse pain 62%, without 44% (p=0.012). In pts with
non-serious falls 81%, without 46% (p=0.006).
Discussion: This study suggests that the occurrence of chest infection during the 18 Acute stroke: complications and early outcome
first week after a stroke leads to a worsened outcome, while the occurrence of
Troponin T elevation and acute myocardial infarction may do so. Frequent falls WHAT FACTORS INFLUENCE EARLY RECANALISATION DURING
and diffuse pain are indicators of improved functional outcome at 90 days after a THROMBOLYSIS IN ACUTE ISCHEMIC STROKE?
stroke. Progressing stroke does not confer a worsened outcome under the current L. Sekoranja, H. Yilmaz, K. Lovblad, R. Grandjean, P. Temperli, R. Sztajzel
management. University Hospital of Geneva, Geneve, Switzerland

Purpose: We evaluated the factors determining récanalisation after thrombolysis.


16 Acute stroke: complications and early outcome Patients and methods: Patients with acute ischemic stroke (AIS) of < 3 h
underwent either IV or combined IV-IA lysis, if no recanalisation after 30’.
EARLY PULMONARY EMBOLISMS IN PATIENTS TREATED WITH FACTOR CT-angiography was done in all p and monitoring with TCCD during 60’ in case of
VIIA FOR INTRACEREBRAL HEMORRHAGE. CHANCE OR SAFETY IV and during 30’ in case of IV-IA lysis. TIBI was used to assess the residual MCA
CONCERN? flow before the lysis and to evaluate presence or absence of early recanalisation
W. Vadot, A. Jaillard, P. Bedouch, C. Chevallier, K. Garambois, O. Detante, (TIBI >1 at 30’).
B. Hommel, M. Hommel Results: 54 patients, 30 M, mean age 68.1 y. 33 p had IV and 21 IV-IA lysis. 43
University Hospital of Grenoble, Grenoble, France (80%) p had an MCA and 11 (20%) a T occlusion. Hypertension had 30 (55%),
DM 8 (15%), and AF 23 p (43%); 18 (33%) were on ASA and 11 (20%) on statins.
Introduction: Intracerebral hemorrhage (IH) was the least treatable type of stroke. Thrombolytic was given within 60 to 230’. NIHSS ranged from 5 to 21. Fifteen
Activated Factor VII (rFVIIa) IH Trial (FIHT) suggested that treatment of IH with (27%) p had a TIBI 0 before lysis, 9 a grade of 1(16%), 12 (22%) grade of 2 and
rFVIIa within 4 hours improves outcomes despite thromboembolic adverse events 18 (33%) grade of 3; 17 (31%) p received contrast because of insufficient temporal
(Mayer et al. 2005). Our aim was to evaluate feasibility and safety of rFVIIa in a window. After lysis 25 (46%) p improved > 4 points on NIHSS. Factors increasing
stroke Unit. the early recanalisation in univariate analysis: TIBI 1 to 3 respectively OR 8.1,
Methods: We consecutively included patients with IH admitted during years 2005 95% CI 1.1 to 59, p= 0.039; OR 8.7, CI 95% 1.3 to 59, p= 0.021 and OR 15.6;
and 2006, who met criteria for inclusion in FIHT. Patients admitted in 2006 were 95% CI 2.7 to 103, p= 0.002. The factors decreasing the early recanalisation: T
administered 80 μg of rFVIIa per kilogram of body weight and were compared with occlusion OR 0.02, 95% CI 0.003 to 0.20, p 0.001; M1 occlusion OR 0.11 95% CI
the historical controls admitted in 2005. Clinical outcome were NIHSS, Rankin 0.02 to 0.6, p 0.011. In a multivariate analysis factors increasing the likelihood of
score and mortality. Safety was assessed using serum troponin and D-dimer at early recanalisation: TIBI grades 1 to 3 respectively OR 11.9 95% CI 0.4 to 4.1, p=
baseline, 6 hours and on day 1, 2, 3 and later when necessary. Lower limb Doppler 0.025; OR 13.8, CI 95% 1.3 to 105, p= 0.014 and OR 24.7; 95% CI 0.07 to 1.1, p=
and thoracic CT scan were performed in patients with high D-dimer levels in order 0.075 and atrial fibrillation OR 0.28, 95% CI 0.07 to 1.1, p 0.075.
to assess deep venous thrombosis (DVT) and pulmonary embolism (PE). Conclusion: Presence of a residual flow of the MCA on TCCD (TIBI 1 to 3) was
Results: Among the 30 patients included (NIHSS=14), 15 received RFVIIa. In the best predictor of early recanalisation; presence of T or M1 segment occlusion on
this group, none had myocardial infarction, one died of cerebral edema, and two Angio-CT were associated with a lower one, however only on univariate analysis.
suffered PE. The first PE occurred at day one and the other at day 2 with re-bleeding
at day 3. Both patients with EP recovered. Because each received 7.2 mg of RFVIIa
in relation to high weight and had no other risk factor, we limited later on the 19 Acute stroke: complications and early outcome
highest dose at 4,8 mg. None of the next patients suffered PE but one had PVT. In
the control group, 2 patients died, 3 had DVT but none had PE. Clinical outcome THE IMPACT OF HYPERTHERMIA AND INFECTION ON THE ACUTE
was not different in the two groups. ISCHEMIC STROKE PATIENTS ADMITTED TO INTENSIVE CARE UNIT
Discussion: At our knowledge, early PE was not reported as thromboembolic W. Seo, S. Yu, J. Kim, S. Koh
complications in patients treated by RFVIIa for IH. A dose effect relation was Korea University College of Medicine, Seoul, South Korea
suggested by the high total dose received the two patients with PE.
Background: Despite well recognized deleterious effect of the hyperthermia on
critically ill neurological patients, few investigations were performed for the issue
17 Acute stroke: complications and early outcome about the fever after ischemic stroke in intensive care unit (ICU) setting. We tried
to prove the effect of hyperthermia on in-hospital outcome and the role of infection
ASPIRIN RESISTANCE IS ASSOCIATED WITH INFLAMMATION, ISCHEMIC on hyperthermia in the acute ischemic stroke patients admitted to ICU.
STROKE SEVERITY, AND POORER FUNCTIONAL OUTCOME AT 6 Methods: We reviewed medical records retrospectively for the acute ischemic
MONTHS stroke patients admitted to ICU within 24 hours from the onset between March
N.A. Englyst, G. Horsfield, C.D. Byrne 2004 and December 2006. The patients were assigned into normothermia, mild
University of Southampton, Southampton, United Kingdom hyperthermia (MH, ≥37.6°C and <38.0 ≥1;, at least one time during ICU stay)
and severe hyperthermia (SH, ≥38.0 ≥1;). Causes of hyperthermia were divided
Background: Stroke is the largest cause of disability in the UK but little is into infection and non-infectious cause. Outcomes were measured by in-hospital
known about which factors influence recovery. Aspirin is used in primary and mortality or long ICU stay (≥4 days). The logistic regression tests with factors
secondary prevention of stroke. Aspirin resistance is associated with a higher risk presumed to be related with hyperthermia were performed to predict the outcomes.
of developing stroke but its relationship with severity of stroke and functional Result: Among the 150 patients included (63.38 ± 12.13 years old, male 57.3%),
outcome after stroke is unclear. The aim of this study was to investigate the MH and SH were observed in 15 and 40 patients, respectively. SH was indepen-
relationship between aspirin resistance and inflammatory cytokines, stroke severity dently related to in-hospital mortality (OR 10.3, p < 0.01) and long ICU stay (OR
and functional outcome at 6 months. 7.8, p < 0.01). MH was related with long ICU stay (OR 4.2, p = 0.03). Among the
Methods: Aspirin resistance was assessed by thrombelastography in 100 people other factors, Glasgow coma scale was associated with in-hospital mortality (OR
with ischemic stroke and 100 community-based controls. Stroke outcome (degree 0.77, p = 0.02) and long ICU stay (OR 0.82, p < 0.01). The patients with infection
of disability) was assessed using the Rankin’s Stroke Scale within 72 hours of (39 patients) was more prevalent in SH than in MH (p < 0.01) and had longer ICU
stroke and at 6 months. Plasma interleukin IL-6 was measured by Enzyme Linked stay than non-infectious group (p = 0.01).
Immunosorbent Assay (ELISA). Discussion: Careful concern for the infection as well as effort for lowering body
Results: Aspirin resistance was associated with a higher Rankin’s scale at baseline temperature per se is needed to the acute ischemic stroke patients admitted to ICU.
(p=0.013), suggesting that aspirin resistance is associated with more severe strokes.
Aspirin resistance at baseline was also associated with higher Rankin’s scale
at 6 months (p=0.048). Aspirin resistance was associated with increased IL-6
(p=0.034) and higher levels of IL-6 were associated with poorer outcome from
stroke (p=0.017). IL-6 was independently associated with aspirin resistance in
multivariate analysis.
Discussion: Aspirin resistance in conjunction with increased plasma IL-6 may
indicate a high risk of poor functional outcome from stroke. These data suggest that

Poster Session Cerebrovasc Dis 2007;23(suppl 2):1–147 103


Acute stroke: complications and early
outcome
20 Acute stroke: complications and early outcome 22 Acute stroke: complications and early outcome
MAJOR NEUROLOGICAL IMPROVEMENT AFTER STROKE PREDICTORS OF INTRACEREBRAL HEMORRHAGE AFTER
THROMBOLYSIS IN A FRENCH COMMUNITY HOSPITAL INTRAVENOUS RTPA THERAPY FOR ACUTE ISCHEMIC STROKE IN
B. Barroso, C. Morisset, E. Bertandeau, H. Mangon, A. Dakar, J.M. Larrieu CLINICAL PRACTICE
F. Mitterrand Hospital, France D. Gasecki, G. Kozera, M. Swierkocka-Miastkowska, K. Chwojnicki,
B. Karaszewski, S. Szczyrba, M. Wisniewska, W.M. Nyka
Objective: A significant advancement in the treatment of acute ischemic stroke Medical University of Gdansk, Gdansk, Poland
management has been the use of recombinant tissue plasminogen activator (rtPA).
In practice, French community hospitals experience difficulty in treating their Background: Intravenous recombinant tissue plasminogen activator (rtPA) is an
patients because stroke units (SU) are missing in Neurology wards. To improve effective therapy for acute ischemic stroke, but it is associated with risk of
quality of care and to provide modern stroke therapy, we decided to assess whether intracerebral hemorrhage (ICH). Our aim was to identify baseline factors that are
thrombolysis was feasible in the Emergency department of our community hospital associated with thrombolysis-related ICH and to assess the clinical course of those
located in Pau (south-west of France). patients compared to patients without ICH.
Methods: Select patients were treated with rtPA and observed for 24 hours in the Methods: we analyzed 52 patients (18 women) with acute stroke treated with IV
Emergency department. They were then transferred to the neurological department rtPA within 3 hours of stroke symptom in Medical University of Gdansk, Poland,
for follow-up. By reference to French legislation this use of rtPA therapy was between 2000 and 2006.
defined as an "off-label use". NIHSS was obtained on admission, immediately Results: 2 (3,8%) patients developed symptomatic ICH, and 4 additional patients
after treatment and 24 hours post treatment. At that time we collected all major (7,7%) had asymptomatic ICH identified on a routine follow-up CT (within 22-36
neurological improvements defined as an NIHSS score equal to 0 or 1 or an hours of stroke symptoms). In analyses based on clinical and radiological variables,
improvement of more than 8 points compared to baseline. the attributes associated with ICH were advancing age (p<0,05), early ischemic CT
Results: Results from the first 40 patients are reported. They were treated between changes (p<0,05), a history of atrial fibrillation (p<0,05), and elevated pre-bolus
September 2004 and June 2006. A total of 1169 patients were admitted for stroke diastolic blood pressure (p=0,06). No association between diabetes mellitus, serum
during this period. We collected 349 transitory ischemic attacks, 192 hemorrhagic cholesterol, the initial stroke severity, neurological outcome at 7 or 90 day and ICH
strokes and 628 ischemic strokes. A total of 3.4% of strokes was treated by rtPA. A was found. Clinical relevant was only parenchymal type of ICH, in 2of 3 cases
major neurological improvement was present in 14 patients (35%). associated with early neurologic deterioration.
Conclusions: According to the infrastructural local criteria and preparatory pre- Conclusions: Advanced age, embolic stroke, elevated diastolic blood pressure and
requisites described in this study, thrombolysis is a viable and feasible treatment ischemic changes on CT could be predictive of ICH. Only PH-ICH seems to be of
option for stroke patients in Emergency departments of French community hospitals clinical significance.
even in lack of SU. It has been shown elsewhere that good outcome in the first 24
hours is an independent predictor of good functional outcome at 3 months. So, such
an emergency organisation could be used as a compromise as long as SU are not 23 Acute stroke: complications and early outcome
available enough.
THE "NO-REFLOW" PHENOMENON AFTER THROMBOLYSIS IN ACUTE
STROKE - A MARKER OF POOR STROKE OUTCOME?
21 Acute stroke: complications and early outcome A.Y. Jin, O. Islam, F.W. Saunders, A.M. Demchuk, D.G. Brunet
University of Calgary, Calgary, Canada
OUTCOME OF PATIENTS NOT TREATED WITH RT-PA DUE TO
SPONTANEOUS IMPROVEMENT Background: The “no-reflow” phenomenon after thrombolysis-induced recanal-
J. Martí-Fàbregas, E. Martínez, S. Martínez-Ramírez, D. Alcolea, D. Cocho, ization in acute stroke has not been well-described. We assessed the hypothesis
M. Martínez-Corral, M. Marquié, M. Suárez, L.A. Querol, J.-L. Martí-Vilalta that reperfusion failure despite thrombolysis-induced recanalization, i.e. no-reflow,
Hospital de la Santa Creu i Sant Pau, Spain is common and is associated with a poor early stroke outcome.
Methods: Patients treated with thrombolysis over a three year period (2001-2004)
Background: Rapid and significant spontaneous clinical improvement is an exclu- at Kingston General Hospital were considered in this retrospective study. Inclusion
sion criteria for intravenous thrombolysis. However, there is controversy about the criteria were: admission noncontrast CT (NCCT) scan with either transcranial
short- and long-term outcome of these patients. We report a prospective study of Doppler sonography (TCD), CT angiography (CTA), or CT perfusion (CTP) scan
consecutive patients. done before thrombolysis; follow-up NCCT and CTP scans done between Days 1 to
Methods: We studied patients with a focal neurological deficit admitted within 5 with either serial TCD examinations or CTA; and a modified Rankin Scale (mRS)
3 hours of onset of symptoms with the following characteristics: 1) Duration of score evaluated before hospital admission and at hospital discharge. Cerebral blood
symptoms >30 minutes, 2) NIHSS score of 5 or more points, obtained either by volume (CBV) and cerebral blood flow (CBF) maps were used to compare the
anamnesis (when it occurred outside the hospital) or by neurologic examination. affected and contralateral hemispheres before and after thrombolysis. Reperfusion
3) A spontaneous decrease in the NIHSS score to values <5 points that occurred failure was defined as any area with decreased CBV and CBF after thrombolytic
before the 3 hours-limit. Improvement was assessed either by anamnesis (when it therapy. Recanalization of the primary arterial occlusive lesion was evaluated by
occurred outside the hospital) or by direct examination. We used the SITS-MOST either serial TCD examinations or follow-up CTA. Reperfusion failure despite
criteria for intravenous thrombolysis. Favourable outcome at 24 hours was defined recanalization of the primary arterial occlusive lesion was classified as “no-reflow”.
as a NIHSS below 5 points. Favourable outcome 1 and 3 months after stroke was Results: 20 patients were included in this study. 19 patients showed recanalization
defined as a score < 2 on the Rankin scale. The diagnosis of an acute infarction of the primary arterial occlusive lesion at follow-up. Of these patients, 7 (37%)
demonstrated by neuroimaging within the study period was recorded. showed reperfusion failure on follow-up CTP scan. Among patients with recanal-
Results: We evaluated 15 patients, with a mean age of 69 ± 13.2 years, and ization, those with no-reflow had a median hospital discharge mRS of 4 (range 2 to
80% were men. Median NIHSS score at onset was 8, and median NIHSS score at 6), compared to a median mRS of 1 (range 0 to 4) in patients without no-reflow
inclusion was 3. Favourable outcome was observed in 13 (87%) patients at 24h, 11 (Mann Whitney U test: p (two-tailed) = 0.002).
(73%) at 1 month and 8/12 (67%) at 3 months. During the study period 11 (73%) Discussion: The no-reflow phenomenon is common despite thrombolysis-induced
patients developed a cerebral infarction. Mortality at 3 months was 13%. recanalization and is associated with a poor early stroke outcome. Possible causes
Discussion: The outcome of patients not given rt-PA due to spontaneous im- of no-reflow may include distal embolization, arterial reocclusion, and persistent
provement is not uniformly favourable. One third of patients had an unfavourable branch vessel occlusion.
outcome and 73% developed an acute infarct.

104 Cerebrovasc Dis 2007;23(suppl 2):1–147 16th European Stroke Conference


Acute stroke: treatment concepts of recanalisation rates after intravenous (IV) thrombolysis for stroke comparing
studies where contrast was administered to those where it was not.
Methods: Search results for MEDLINE and Embase from inception to October
1 Acute stroke: treatment concepts 2006 were screened and studies reporting recanalisation rates for IV thrombolysis
for anterior circulation stroke were selected. Additional data were sought from
OXIDATIVE STRESS, DOCUMENTED BY DETERMINATION OF MDA, IN two authors. We compared recanalisation rates for contrast (CS) and non-contrast
ACUTE ISCHEMIC STROKE SUBTYPES, ACCORDING TO TOAST (NCS) studies.
CRITERIA Results: We identified 31 studies (7 CS, 24 NCS). Non-ionic contrast was admin-
A. Simion istered for CT perfusion images (CTp) in 2 studies (40mls, n=1; 50mls, n=1), CTp
Faculty of Medicine and Pharmacy/Clinical Hospital of Neurology and +/- angiography (CTa) in 1 study (50mls +/- 50mls), and CTp and CTa in 1 study
Psychiatry, Oradea, Romania (weight adjusted; max 140mls). 3 studies involving catheter angiograms did not
specify type or volume of contrast. The mean time limit for thrombolysis was 6.1h
Background: In ischemic stroke, oxidative stress has been shown to worsen the (SD 2.1) in CS and 4.9h (SD 1.6) in NCS. Recanalisation rates were assessed by
extent of cerebral injury. Our study tries to correlate oxidative stress with the CTa, magnetic resonance angiogram and transcranial doppler ultrasound. Recanali-
subtype and outcome of ischemic stroke. sation was assessed late (>24h) in 6 CS, and 15 NCS. Precise occlusion site was
Material and method: We studied a consecutive series of 104 ischemic strokes, specifically indicated in 4/7 CS and 19/24 NCS.
evaluated with CT and/or MRI or MRA, Duplex sonography, transthoracic echocar- Recanalisation was non-significantly more frequent in CS (56/89, 63%) compared
diography, and electrocardiography. Strokes were divided into large-artery disease to NCS (841/1496, 56%) OR 1.32 (95% CI 0.85, 2.06). This remained true for late
(LAD), small-artery disease (SAD) and cardioembolism (CE), according to the recanalisation (OR 1.34, 95% CI 0.79, 2.29). and for MCA M1 or M2 occlusions
TOAST criteria. Cases with uncertain or unknown etiologies were excluded. Each (OR 1.17, 95% CI 0.47, 2.91).
patient was scored on the NIHS scale at admittance and had the Barthel index Discussion: This was an indirect comparison and not a randomised study, and there-
(BI) evaluated at discharge. Beside a complete laboratory evaluation, oxidative fore limited. However, we found no evidence that contrast impaired recanalisation
stress was assessed by measuring the seric malondialdehyde (MDA) levels with the rates with IV fibrinolytic therapy.
tiobarbituric acid method at admittance (day 1), and on days 3 and 7.
Results: We found different patterns for the course of oxidative stress in the stroke
subtypes. By day 3 we obtained significantly (p<0,001) higher level of MDA in all 3 Acute stroke: treatment concepts
ischemic subtypes (view Table 1), but by day 7 MDA levels were increased only in
CE (p<0,001) whilw in LAD they decreased (p<0,02) and showed non-significant PROGNOSTIC FACTORS OF THROMBOLYTIC THERAPY IN HYPERACUTE
variations (p>0,05) in SAD (view Figure 1). MDA values do not correlate with ISCHEMIC STROKE
NIHSS, or with BI. Complications, especially infectious ones, raise the MDA values J.H. Rha, B.N. Yoon, K.H. Ji, J. Lee
on the second and third determination, but only bronchopneumonia significantly Inha University Hospital, Seoul, South Korea
influenced the outcome.
Background: To investigate the prognostic factors of intravenous thrombolysis, we
Table 1. MDA values in stroke subtypes and overall evaluated 121 consecutive patients treated with IV tPA. Methods: Demographic and
LAD SAD CE Ischemic stroke clinical profiles, laboratory results, transcranial Doppler, and brain imaging were
evaluated. Clinical assessment was done by National Institutes of Health Stroke
MDA2 2,43±0,31 1,83±0,34 2,17±0,32 2,2±0,4 Scale (NIHSS) for one week, and by modified Rankin Scale (mRS) at baseline and
MDA3 4,18±0,43 3,86±0,46 3,07±0,43 3,7±0,6
three months. Early improvement was defined as the complete resolution of the
MDA3 3,13±0,43 4,06±0,64 4,61±0,52 3,9±0,5
neurological deficit or an improvement of 4 or more points by NIHSS within 24
hours of the stroke onset, and good outcome as mRS score of 2 or less at three
months. We assessed the possible relationship of the factors with early improvement
and good outcome, and also analyzed the correlation of TCD grade with NIHSS
score. Comparisons of variables were performed using Fisher’s exact test, t-test and
Mann-Whitney test. The predictors of early improvement and good outcome were
analyzed by logistic regression, and the correlation of TCD grade and NIHSS score
were analyzed by Spearman correlation.
Results: On univariate analysis, younger age, absence of abnormal CT findings
(hyperdense middle cerebral artery sign [HMCAS], focal hypodensity in the total
MCA territory > 33%) were significantly associated with early improvement.
Good outcome was associated with younger age, lower levels of baseline NIHSS
score, mean blood pressure, fasting glucose, lipoprotein (a) [Lp(a)], and absence
of abnormal CT findings. Multivariate analysis revealed age < 63 years and no
HMCAS as independent predictors of early improvement. Thrombolysis in brain
ischemia grade by TCD monitoring significantly correlated with NIHSS score for
24 hours.
Conclusions: These results suggest that younger age, normal CT findings are
important prognostic factors of acute thrombolytic therapy, whereas age, CT
findings, baseline NIHSS, blood pressure, blood sugar and Lp (a) level might be
associated factors of long term outcome. TCD can be a useful indicator of clinical
Fig. 1 improvement.

Conclusions: We presume that the high levels of MDA on day 7 in CE could be


tied to reperfusion. If so, antioxidant therapy would be most beneficial if given to 4 Acute stroke: treatment concepts
patients with embolic strokes or after thrombolysis.
STATES OF LEPTOMENINGEAL COLLATERALS AND RESPONSE TO
THROMBOLYSIS IN PATIENTS WITH ACUTE MCA INFARCTS
2 Acute stroke: treatment concepts K.H. Kang, H.C. Park, E.H. Kim, Y.S. Kim, C.K. Suh, Y.H. Hwang
Kyungpook National University Hospital, South Korea
SYSTEMATIC REVIEW OF THE EFFECT OF CONTRAST AGENTS ON
RECANALISATION RATE AFTER INTRAVENOUS THROMBOLYSIS FOR Background: MR-based thrombolysis using DWI/PWI mismatch is feasible
ACUTE STROKE method in selecting thrombolysis candidate. However, state of leptomeningeal col-
K.A. Dani, K.W. Muir laterals in conventional angiography (CA) may also affect response to thrombolysis
University of Glasgow, Glasgow, United Kingdom and clinical outcome. The purpose of this study is to correlate state of collaterals
with response to thrombolysis.
Background: Recent assertions that contrast agents impair fibrinolysis are based Methods: We retrospectively analyzed 16 patients from May to December 2006
on limited evidence from animal models. We undertook a systematic review who performed CA for Intra-arterial thrombolysis (IAT) in presumed MCA occlu-

Poster Session Cerebrovasc Dis 2007;23(suppl 2):1–147 105


Acute stroke: treatment concepts
sion with DWI/PWI mismatch. Angiographic states of leptomeningeal collaterals Results: Of the 100 subjects, 83 were felt to have suffered a cerebrovascular
were defined as minimal (retrograde flow to M4 segment), moderate (retrograde event. Twenty eight of the 83 subjects (34%) had symptoms lasting >24 hours. A
flow to M3 or M2 segment), and maximal (retrograde flow to distal to site of decision had been made that such patients should be admitted. Of the 55 remaining
occlusion). IAT was done using urokinase or tPA infusion and/or mechanical subjects, 15 (27%) had suffered other events in the preceding month (1-5 events,
thrombus crushing. median 1) necessitating admission. Of the 40 left, 19 (47%) had an ABCD score
Results: Mean values of onset to door and door to IAT were 231.9±53.3 min and of 5 or 6. Two patients had subsequent events in the following month. One had
143.4±11.5 min. Among them, 11 patients regained angiographic recanalization an ABCD score of 3 and the other a score of 5. The patient with the score of 3
(69%, TIMI Grade 2 or 3) and 6 patients had good clinical outcome (38%, mRS 0-1 was young, normotensive but suffered a prolonged event (>1 hour). None of the
at 1-3 months). There was no statistically significant results in recanalization rate patients underwent intervention other than the commencement of anti-platelet and
and clinical outcome among each collateral groups [response to thrombolysis - 3/3 antihypertensive therapy. None had suffered an intracerebral haemorrhage.
in maximal, 4/5 in moderate, and 4/8 in minimal, (P=0.23); good clinical outcome Conclusion: Use of the ABCD score 1-4 as a means of selecting suitable subjects
- 2/3 in maximal, 3/5 in moderate, and 1/8 in minimal, (P=0.12)]. However, the for outpatient management would have prevented the admission of 38% of the
rates of recanalization and good clinical outcome were much higher in maximal referrals (non-strokes and TIAs). It would have missed one subject who suffered a
collateral group. recurrent event, however admission of that subject did not alter his outcome. We
Discussion: Unfortunately, we did not show statistically significant results about decided to adopt the ABCD score but not use it in isolation and to admit subjects
effect of collateral circulation on response to thrombolysis and clinical outcome. with events >30 minutes duration.
However, we found trend that good collateral circulation is related to recanalization
success and better clinical outcome. In future, standardized method of collateral
grading system is needed for multi-center controlled study. 7 Acute stroke: treatment concepts
ANTICOAGULATION AND THE RISK OF ICH AFTER CARDIOEMBOLIC
5 Acute stroke: treatment concepts STROKE
H. Hallevi, K.C. Albright, A.D. Barreto, S. Martin-Schilde, A. Khaja,
PERSONAL EMAILS: A SIMPLE MEASURE TO IMPROVE THE QUALITY OF E.A. Noser, N.R. Gonzales, K. Illoh, J.C. Grotta
CARE IN THE STROKE PATIENTS University of Texas-Houston, Fannin, TX, USA
M.F. Bellolio, R. Kashyap, L. Vaidyanathan, S. Enduri, A.M. Hoff, A.S. Yassa,
S. Mishra, R.D. Brown, W.W. Decker, L.S. Stead Background: Heparin has not been shown to be effective in reducing mortality
Mayo Clinic College of Medicine, Rochester, USA and morbidity after acute cardioembolic stroke, however anticoagulation (AC)
eventually needs to be instituted for secondary stroke prevention. We aimed to
Background: Embolic or thrombotic arterial occlusion is a frequent cause of study the timing and mode of starting AC in cardioembolic stroke patients.
cerebral infarction, making antithrombotic therapy an important part of the care in Methods: We conducted a retrospective analysis of all cardioembolic strokes cared
stroke patients. Aspirin (ASA) reduces the risk of early recurrent ischemic stroke for by our Stroke Team over 3 years. Patients were monitored in our Stroke Unit.
when given within 48 hours of initial symptom onset. Neuroimaging was done on admission, at 24 hours and with any neurological
We hypothesized that sending a friendly remainder by email to the consultant who deterioration.
saw a patient with Stroke or TIA in the Emergency Department (ED) and for any Results: We included 204 patients with cardioembolic stroke in the analysis.
reason did not give ASA during the ED stay, could improve the rate of patients Full dose AC with IV Heparin or Low Molecular Weight Heparin (LMWH) was
receiving aspirin. given to 73 patients. Warfarin was started subsequently in 87% (63/73). Low dose
Methods: A consecutive cohort of patients presenting into the ED with a suspected AC (DVT prophylaxis dose) with or without aspirin was given to 131 patients.
diagnosis of TIA or Stroke were prospectively enrolled. We excluded patients with Warfarin was given subsequently to 26.7% (35/131). There were 22 (10.8%) cases
suspected diagnosis of intracerebral hemorrhage and those receiving thrombolytics. of asymptomatic hemorrhagic transformation (HT). All but one occurred during the
The intervention was to track ASA administration and send out timely follow up to first three days. Three patients experienced symptomatic HT 6 to 12 days from their
those who did not provide the drug. This was done via individual (rather than group) stroke. In all three, warfarin was started while patients were “bridged” with full
email, specifically stating the name and clinic number of the patient, and noting dose LMWH and aspirin (3/21, 14.3%, p=0.001). Two cases of serious systemic
lack of aspirin administration as well as lack of documentation for not doing so. hemorrhage occurred among patients treated with IV heparin (2/48, 4.2%, p=0.054).
Results: Our study group was 64 patients in the pre-intervention period (Aug-Sept) Overall acute anticoagulation was associated with 6.8% (5/73) serious bleeding
and 59 post-intervention (Oct-Nov). (p=0.05). Recurrent strokes occurred in two cases despite effective anticoagulation
During the pre-emails period 43.8% of the patients received ASA, and 66.1% after in one (0.1%, p=0.53). There were no cases of hemorrhage in patients treated with
sending the emails (p=0.013) low dose AC and warfarin.
After the intervention, the patients with stroke or TIA were 2.51 times more likely Discussion: Symptomatic HT after cardioembolic stroke occurred late and was
to receive aspirin in the ED (95%CI 1.21-5.21) associated with aggressive anticoagulation and simultaneous ASA use in our series.
Discussion: This simple method of personal emails has been improving not only Early asymptomatic hemorrhage seems unrelated to anticoagulation. Low dose
the rate of patients who receive aspirin, but also the quality of the documentation AC appears safe, even in the setting of asymptomatic HT. Our data suggest that
(reasons why the patient is not a candidate for ASA, such as suspected hemorrhage “bridging” patients with full dose LMWH until anticoagulated with warfarin may
or ASA given by the pre-hospital services personnel) and has been maintained over not prevent early stroke recurrence and is associated with an unacceptable risk of
the months. symptomatic HT.

6 Acute stroke: treatment concepts 8 Acute stroke: treatment concepts


CAN WE USE THE ABCD SCORE TO SCREEN PATIENTS FOR A WEEKLY EFFECTIVENESS OF THROMBOLYSIS IN PATIENTS OVER 80 YEARS OF
TIA CLINIC? RETROSPECTIVE APPLICATION OF THE SCORE TO ASSESS AGE
IT’S SUITABILITY C. Rueckert, T. Staudacher, D. Bengel
B. Brady, M. Sekiguchi, B. Silke, J. Harbison St. Elisabeth Hospital, Ravensburg, Ravensburg, Germany
Stroke Service, St James’s Hospital, Dublin, Ireland
Background: Despite the fact that the clinical trials leading to the approval of
Background: Prior to the establishment of a weekly TIA in St James’s Hospital thrombolysis excluded patients over 80 years, in many centers this therapy is
in 2006 suspected TIA patients were routinely admitted for investigation. In offered to patients above this age.
developing protocol for the clinic we considered the ABCD score (1) as a potential Methods: In our series of 324 patients treated with thrombolysis between 12/2000
means of screening patients for the clinic rather than admission. The original paper and 01/2007 we analyzed the outcome of all 77 patients over the age of 80 (max:
reports a score of 5 or 6 being associated with a recurrence rate of >25% implying 92 years).
need for immediate admission. To assess the scores utility we applied the score Results: Overall median age was 71 years; 45,2% were women, 54,8% were men;
retrospectively to a sample of patients admitted with suspected TIA. in the subgroup of over 80 years 59,7% were women, 40,3% were men. 29,4% of all
Method: 100 sets of notes on patients admitted with suspected TIA were reviewed patients but 40,8% of the patients 80+ were admitted to the hospital within 1 hour
by 2 doctors. Diagnosis was reviewed, ABCD score applied from available admis- of onset of symptoms. There was no difference in mean door-to-needle-time (55
sion data and prior and subsequent admissions with TIA/stroke identified. Changes minutes), mean time from onset of symptoms to therapy (131 minutes), and stroke
in management resulting from admission were noted. severity at onset (mean National Institute of Health Stroke Scale=NIHSS 16).

106 Cerebrovasc Dis 2007;23(suppl 2):1–147 16th European Stroke Conference


57,8% of all patients versus 77,5% of patients over 80 had a cardio-embolic origin, but it lacks the plasmin-sensitive cleavage site and the lysine-binding kringle 2
17,7% (8,4%) an arteriosclerotic origin. domain found in rt-PA. The lack of the kringle 2 domain may explain the fact that
At discharge mean NIHSS was 10 (overall) versus 11 (80+). While median rDSPAα1 has the highest fibrin selectivity among PAs, with a 100,000-fold increase
Modified Rankin Stroke Scale (mRS) at discharge was 4 in both groups, there was in catalytic activity compared to a 550-fold increase for rt-PA and an absence of
a difference at three months: 2,7 (overall) versus 3,4 (80+). Accordingly, 25,6% of neurotoxicity in animal models of ischemic and hemorrhagic stroke.
all (14,7% of 80+) have reached Rankin 0/1, 36,6% of all (35,3% of 80+) have Discussion: The unique structural features of rDSPAα1 suggest an advantageous
reached Rankin 2/3. risk:benefit ratio and may explain the observed favorable clinical results including
Overall in-hospital mortality was 18,5%, in the group of 80+ 29%, but the inci- the potential for use in later time windows.
dence of symptomatic intracerebral hemorrhage was only slightly different: 3,7%
vs. 5,3%.
Discussion: In good correlation with previous reports our data show a slightly 11 Acute stroke: treatment concepts
but not significantly higher incidence of symptomatic intracerebral hemorrhage in
elderly patients. In-hospital mortality is higher and the proportion of favourable BRIDGING WITH GPIIB/IIIA-RECEPTOR-ANTAGONISTS COMBINDED
outcome lower than in younger patients. Nevertheless more than 20% of treated pa- WITH INTRA-ARTERIAL PHARMACOMECHANICAL THROMBOLYSIS IN
tients over 80 years reached Rankin 0-2 and about 50% Rankin 0-3. In our opinion ISCHEMIC STROKE
these data show the practicability of thrombolysis and support the effectiveness of R. Dabitz, U. Leppmeier, L. Fuhry, V. Collado-Seidel, R. Michailow,
this therapy in selected patients over 80. K. Schoeneboom, S. Triebe, H. Gunselmann, G. Ochs, D. Vorwerk
Klinikum Ingolstadt, Ingolstadt, Germany

9 Acute stroke: treatment concepts Background: The prognosis of ischemic stroke due to occlusion of the internal
carotid artery, the middle cerebral artery in M1 and the basilar artery is even after
PREVIOUS TREATMENT WITH ANGIOTENSIN II RECEPTOR BLOCKERS intravenous rt-PA usually very poor.
COULD PLAY A POSSIBLE PROTECTOR EFFECT IN ACUTE STROKE Patients: We report in a retrospective analysis about 76 consecutive patients (39m,
M.A. Ortega-Casarrubios, B. Fuentes, B. San José, M.J. Aguilar-Amat, I. Ybot, 37f; age 64 ± 12.2 years), who were treated with GPIIb/IIIa-Rezeptor-Antagonists
P. Martínez, E. Díez-Tejedor combined with pharmacomechanical intra-arterial thrombolysis. 25 pat. with tan-
Stroke Unit, Department of Neurology, La Paz University Hospital, UAM, dem occlusion of the ICA and MCA, 26 pat. with occlusion of the MCA and 25
Madrid, Spain patients with basilar artery occlusion.
The mean NIH-Stroke-Scale was 16.4, analogical to a mean modified Rankin Scale
Background: Previous studies with angiotensin II receptor blockers (ARB) have (mRS) of 4.7.
demonstrated a protective effect in spontaneously hypertensive rats from cerebral Materials: After exclusion of ICH 39 patients were bridged with Abciximab (due
ischemia. It is not known if all the hypotensor drugs share this property. Our goal is to the Abestt trial) and in 37 cases with Tirofiban followed by an intra-arterial
to analyse the impact of pre-stroke use of hypotensor drugs in stroke severity and thrombolysis with rt-PA.
outcome. Results: At the time of discharge the mean mRS was 2.8.
Methods: Observational study from the Stroke Unit data bank of the Department 23 pat. mRS: 0-2 (=31%); 2 pat. mRS: 3 (=3%); 21 pat. mRS: 4 (=28%); 6 pat.
of Neurology, with inclusion of consecutive stroke patients (January 2000-October mRS: 5 (=8%).
2005). Parameters analysed: Risk factors, previous hypotensor drug treatment, At the time of re-evaluation after rehabilitation the mean mRS was 1,8.
severity on admission(Canadian Stroke Scale, CSS),in-hospital complications, 32 pat. mRS: 0-2 (=42%); 13 pat. mRS: 3 (=17%); 5 pat. mRS: 4 (=7%), 2 pat
mortality and functional state at discharge (Modified Rankin Scale, mRS) mRS: 5 (=3%).
Results: 1738 patients were included in the study, 55,9% were men. Average 24 of 76 (=32%) patients died nevertheless
age: 69,61 ±12 years. 63,3% had high blood pressure and 27,9% DM. 39,4% 23 pat. (=30%) showed ICH in the CT-scan, 10 (=13%) of them were symptomatic.
received hypotensor drugs (90,2% of them for hypertension). Patients with ARB 8 of these 10 patients showed already malignant infarction at the time of bleeding
presented lower stroke severity on admission (EC ≤ 16 vs 29,4%, p=0,011) and due to unsuccessful rekanalisation. One patient died due to perforation of the
better functional state at discharge (mRS ≤ 78 vs 63,6%, p=0,008) The multivariate basilar artery.
logistic analysis showed that ARB pre-treatment was a predictive factor of lower Conclusion: Bridging with GPIIb/IIIa-Rezeptor-Antagonists combined with intra-
stroke severity, independent of age, sex and stroke subtipe (OR 0,4; 95% IC 0,2-0,7) arterial pharmakomechanical thrombolysis is feasible and may help to reduce the
Patients treated with diuretic drugs had higher severity on admission (EC ≤ 34,5 lethality and morbidity of ischemic stroke due to occlusions of the ICA, MCA and
vs 27,3, p=0,023) and worse outcome (mRS ≤ 58,9 vs 65,8%, p= 0,044). Other BA. The rate of complications and intracranial haemorrhage is in the range of those
groups of hypotensor drugs did not show significant benefit on stroke severity. reported in other cohorts
Conclusions: Previous treatment with ARB was associated with a lower acute
stroke severity on admission and better evolution, being an independent predicitive
factor of lower stroke severity. More studies are needed to confirm this posible 12 Acute stroke: treatment concepts
protector role.
WHY ARE EARLY ADMITTED STROKE PATIENTS EXCLUDED FROM TPA
THERAPY?
10 Acute stroke: treatment concepts S. Debiais, I. Bonnaud, B. Giraudeau, D. Saudeau, D. Perrotin, B. de Toffol,
A. Autret
LACK OF KRINGLE 2 DOMAIN AND HIGH FIBRIN SPECIFICITY CHRU Tours, Tours, France
DIFFERENTIATE THE NOVEL PLASMINOGEN ACTIVATOR
DESMOTEPLASE FROM RT-PA Introduction: Our University hospital (300 000 inhabitants) receives patients who
D.B. Bharucha, M.K. Pugsley, K.-U. Petersen, M. Soehngen may benefit from IV thrombolysis from the whole region. Since June 2003, an
Forest Laboratories/PAION Deutschland GmbH, Jersey City, NJ, USA acute stroke network comprising 2 beds of admission and thrombolysis was created
in the intensive care unit.
Background: Thrombolytic therapy with recombinant tissue plasminogen activator Objective: To assess conditions of treatment with IV thrombolysis and to determine
(rt-PA) is effective in treating acute ischemic stroke (AIS) within the first 3 hours why stroke patients admitted within 3 hours of symptoms onset (SO) are not treated
after symptom onset. Desmoteplase, or rDSPAα1 (recombinant Desmodus Salivary with IV TPA.
Plasminogen Activator α1), is a novel plasminogen activator (PA) shown to treat Methods: During 18 months were prospectively recorded the following data for
AIS up to 9 hours post-stroke onset with a positive risk:benefit ratio (in a Phase each patient: demographic data, delays of arrival and imaging, treatment and
IIa study in patients with penumbra) not shown in previous trials with rt-PA when outcome. For the patient arrived in the first 3 hours, the reason why IV TPA was
treating patients beyond 3 hours. The observed clinical benefit of rDSPAα1 may not administered was noticed.
relate to its unique structural features. Results: During 18 months, 364 patients were admitted, with a median delay of
Methods: Pharmacological and structural characteristics of desmoteplase are re- admission after SO of 2 h 50. Two hundred patients were admitted within three
ported using in vitro studies. Fibrin specificity was determined for desmoteplase hours and among them, 17 (8,5%) patients received IV TPA. Among the patients
and rt-PA using an enzymatic assay for the kinetics of plasminogen activation. admitted in the first 150 minutes, the main reasons for exclusion were: mild stroke
Neurotoxicity was determined using ischemic murine models. or clinical improvement (NIHSS < 6) for 48 patients, a non vascular diagnosis in
Results: rDSPAα1 is a glycosylated serine protease structurally similar to rt-PA 41 patients, aged older than 80 yo for 22, intracerebral hematoma for 17, NIHSS >
(with finger, epidermal growth factor-like, kringle 1, and serine protease domains), 23 for 13. For 13 patients the only cause was network internal dysfunction.

Poster Session Cerebrovasc Dis 2007;23(suppl 2):1–147 107


Acute stroke: treatment concepts
Discussion: In our institution, 18% of ischemic stroke patients are treated with IV associated with HMCAS, even though IAT was started later. Our results indicate
TPA. For the early admitted patients, main reasons of therapy exclusion are non that a randomized trial comparing both thrombolytic treatments in patients with
vascular diagnosis, mild stroke with NIHSS< 6, and age > 80 yo, as found in middle cerebral artery occlusion is warranted.
previous studies (Barber 2001; Huang 2006). Improvement of the pre-admission
selection, decrease of the delays of arrival and correction of the network dys-
functions could increase dramatically the proportion of treated patients. Moreover, 15 Acute stroke: treatment concepts
some patients with mild or improving deficits could also benefit from thrombolytic
treatment. IS INTRAVENOUS TPA TREATMENT BENEFICIAL IN ACUTE ISCHEMIC
STROKE RELATED TO INTERNAL CAROTID DISSECTION?
B. Fuentes, M. Alonso de Leciñana, J. Masjuán, J. Egido, P. Simal,
13 Acute stroke: treatment concepts F. Díaz-Otero, A. Gil-Nuñez, E. Díez Tejedor
University Hospitals La Paz, Ramón y Cajal, Clínico San Carlos and Gregorio
NOVEL APPROACH IN ACUTE STROKE MANAGEMENT THROUGH Marañón, Madrid, Spain
L-LYSINE MONOHYDROCHLORIDE INDUCED ANGIOGENSIS AND
REVASCULARIZATION Background: Small series reported the safety of intravenous tPA treatment in
S.C. Mukhopadhyay, G. Guha, M. Alam, A. Mukherjee, M. Hashini acute ischemic stroke (IS) related to extracranial internal carotid artery dissec-
Green Cross Therapeutics Pvt. Ltd., India tion (eICAD). However, no studies analysing specifically the posible benefits on
outcome are available.
Background: The efficacy and safety of L-Lysine Monohydrochloride (LMH) as Methods: Multicentre, prospective study conducted in 4 university hospitals. Con-
angiogenic agent was studied in acute ischaemic stroke management. secutive IS patients were included. Stroke severity (NIHSS) and 3-months outcome
Material and methods: 120 patients (mean age 61.3 yrs) with CT/MRI evidence (mRS) were compared: (1) tPA-treated patients with IS related to eICAD vs
of ischaemic stroke was studied. 80 received LMH,1gm I.V. 6 hrly x 7 days, 40 tPA-treated patients with other causes of stroke; (2) tPA-treated vs non tPA-treated
did not receive LMH. Both LMH and non- LMH grs. did not receive thrombolytic eICAD patients.
therapy but had routine stroke management. Modified NIHSS,MRS and BI were Results: 265 IS patients received intravenous tPA (7 of them with eICAD). There
used to assess clinical outcome, at baseline, 1 wk, 6wk, 3 mths and 6 mths. Basic were no diferences in baseline NIHSS between patients with or without eICAD
haematological biochemical and urine analyses were done at baseline, 1 wk, 1 mth. (14.3 vs 14.3; ns). However, NIHSS scores at 24 h and day 7 were significantly
MRI was done on a 1.5T whole body imager for T1 and T2 weighted, FLAIR, worse in eICAD patients (17 vs 9.6 at 24h; 15.6 vs 7.3; p<0,05). No eICAD
DWI, Angiography imaging sequences at baseline, 7th day and 6 wks. Adverse patients developed a significant improvement at 24h (decrease in NIHSS ≥ 8
events noted. points) as compared to 67 (32%) of patients with other IS causes. When comparing
Result: Patient Inclusion time for therapy varied between 6-98 hrs. There was no tPA-treated eICAD (n=7) with non-treated eICAD patients (n=7), a trend to higher
mortality or significant change in biochemical, hematological and urine analyses at improvement in 24h and day 7 was found in the non tPA-treated eICAD group
any stage of therapy. Mean baseline Glasgow Coma Scale Score was 13.9. Imaging (NIHSS 7.6 vs 17 at 24h; 6.4 vs 15.6;p=0.205) with no differences in baseline
revealed acute infarct in anterior, middle and posterior cerebral artery territory, but NIHSS. At 3 months, 80% of tPA-treated eICAD and 20% of non-treated eICAD
most in MCA area (68.75%). Clinical outcome by NIHSS in LMH gr. revealed patients were dependent (mRS>2).
15.05 ±3.52 at baseline, 7.95 ± 2.31 at 1 wk, 4.14 ±1.16 at 6 wks., 1.81 ± 0.88 at Conclusions: Although intravenous tPA treatment in IS related to eICAD seems to
6 months, vs. to 15.17 ± 3.50 (baseline)12.17 ± 2.92 (1wk), 8.61 ±1.85 (6wks), be safe, the benefit on outcome is significantly minor than in other causes of IS,
4.33 ± 0.84 (6months) in non LMH gr. with P Value 0.08(1wk), 0.02 (6 wk), 0.01 and possibly worse than in non tPA-treated eICAD.
(6 months). Decrease in NIHSS become more pronounced as time progresses in
LMH gr. Parallel improvements were seen in B.I at 90 days (≥95) and MRS (≤1).
Infarct area in DWI/T2 imaging at 7th day showed remarkable improvement in 16 Acute stroke: treatment concepts
LMH gr. compared to non- LMH gr.
Discussion and conclusion: LMH significantly increases both short term and long AN EMERGENCY CLINICAL PATHWAY FOR THE MANAGEMENT OF
term clinical, functional and imaging recovery and was due to revascularization CRITICAL STROKE PATIENTS: RESULTS OF A RANDOMISED CLINICAL
through angiogensis.Both anterior and posterior circulation improved equally. LMH TRIAL IN THE LAZIO REGION (ITALY)
can be given with much wider therapeutic window (upto 96 hrs) and has no adverse A. De Luca, D. Toni, L. Lauria, M.L. Sacchetti, M. Barbolini, E. Puca, M. Ferri,
effect. M. Prencipe, G. Guasticchi
Public Health Agency, Lazio Region, Rome, Italy

14 Acute stroke: treatment concepts Background: Emergency Clinical Pathways (ECP) may play a crucial rule in the
management of critical stroke patients. Objects To evaluate the effectiveness of
COMPARISON OF INTRA-ARTERIAL AND INTRAVENOUS introducing an ECP for the management of critical stroke patients in the emergency
THROMBOLYSIS FOR ISCHEMIC STROKE WITH HYPERDENSE MIDDLE system of Lazio region (Italy).
CEREBRAL ARTERY SIGN Methods: A cluster-randomized controlled trial (ISRCTN41456865) was designed
H.P. Mattle, M. Arnold, D. Georgiadis, C. Baumann, K. Nedeltchev, to compare the practice of a test group of health professionals (HP) pertaining to
D. Benninger, L. Remonda, C. von Büdingen, G. Schroth, R.W. Baumgartner Emergency Medical Services (EMS) and to Emergency Rooms (ERs), trained to
University Hospitals Bern and Zurich, Bern, Switzerland use the ECP, with that of non trained EMS and ERs control groups. Groups were
compared by chi2 or Fisher’s exact tests.
Background: It is unclear whether intra-arterial (IAT) or intravenous (IVT) throm- Results: the two groups were similar at baseline as type and number of EMS
bolysis is more effective for ischemic stroke with hyperdense middle cerebral ambulances and ERs. Over six months in 2005, 3298 suspected stroke patients
artery sign (HMCAS). The aim of this study was to compare IAT and IVT in such were enrolled (1353 in the test groups: 573 by EMS and 780 by ERs; 1945 in
patients. the control groups: 485 by EMS and 1460 by ERs). Both the test groups referred
Methods: Comparison of data from two stroke units with similar management of to our hospital more suspected stroke patients than the control groups: EMS:219
stroke associated with HMCAS, except that one unit performed IAT with urokinase (38.2%) vs 8 (1.6%) (p<0.05); ERs: 147 (18.8%) vs 116 (7.9%) (p<0.05).
and the other IVT with plasminogen activator. Time to treatment was up to 6 hours Confirmed ischemic stroke were (test groups: EMS =70, Ers=26; control groups:
for IAT and up to 3 hours for IVT. Outcome was measured by mortality and the EMS=4, ERs=13). Among ischemic stroke patients eligible for i.v. thrombolysis
modified Rankin Scale (mRS), dichotomized at three months into favorable (mRS (test groups: EMS=19, ERs=17; control groups: EMS=2, Ers=10), those referred
0-2) and unfavorable (mRS 3-6). by the test groups were treated more frequently than those of the control groups
Results: 112 patients exhibited a HMCAS, 55 of 268 patients treated with IAT and (EMS: 8 (42%) vs 0 (p>0.05); ERs:7 (41%) vs 2 (20%) (p>0.05).
57 of 249 patients who underwent IVT. Stroke severity at baseline and patient age Discussion: Adherence to the ECP improved the appropriateness of stroke patient
were similar in both groups. Mean time to treatment was longer in the IAT group referral and treatment in the SU, particularly by the EMS. Hence, the educational
(244 ± 63 minutes) than in the IVT group (156 ± 21 minutes; p=0.0001). However, program on early detection and timely transportation of stroke patients to the
favorable outcome was more frequent after IAT (n=29, 53%) than after IVT (n=13, appropriate ward will be extended to all emergency health personnel.
23%; p=0.001) and mortality was lower after IAT (n=4, 7%) than after IVT (n=13,
23%; p=0.022). After multiple regression analysis IAT was associated with a more
favorable outcome than IVT (p=0.003) but similar mortality (p=0.192).
Conclusion: Intra-arterial thrombolysis was more beneficial than IVT in stroke

108 Cerebrovasc Dis 2007;23(suppl 2):1–147 16th European Stroke Conference


17 Acute stroke: treatment concepts rt-PA administered in distant hospitals using telemedicine tools imlemented in the
RUN, compared to that of patients treated directly in the Besançon SU.
REMOTE CEREBRAL HEMORRHAGE IN PATIENTS TREATED WITH Method: All patients admitted to the SU who were treated with rt-PA for ischemic
INTRAVENOUS RT-PA stroke since 2005 were included. Patients were either treated in the SU after
J. Martí-Fàbregas, E. Martínez, M. Marquié, D. Alcolea, D. Cocho, admission or were transferred to the SU after receiving rt-PA in a distant hospital.
M. Martínez-Corral, S. Martínez-Ramírez, M. De Juan, R. Marín, The decision to administer rt-PA in distant hospitals was made by the SU neurology
J.-L. Martí-Vilalta team using “tele rt-PA” with telemedicine tools (video/imaging transfers). The
Hospital de la Santa Creu i Sant Pau, Spain thrombolysis decision respected contra-indication and followed the usual criteria
for patients admitted within 3 hours or was guided by MRI findings (after 3
Background:The frequency, clinical presentation and prognosis of remote cerebral hours). NIHSS scores were measured on admission, modified Rankin scores (mRS)
hemorrhage (rPH) after thrombolysis is poorly known. We report our experience in were determined after treatment and at discharge as well as stroke causes and
patients with ischemic stroke treated with intravenous rt-PA. haemorrhagic transformations (HT).
Methods: A retrospective review of consecutive patients treated at our Hospital Results: Of 34 patients treated by rt-PA, 16 were in distant hospitals and 18 in
from 1999 to 2006, according to the ECASS II and the SITS-MOST (since 2004) the SU. Median treatment times were 3hrs in the SU (4hrs25 for those transferred
criteria. A control Computed Tomography scan was routinely obtained in all there) and 2hrs30 in distant hospitals. Following rt-PA, 7/34 (20%) of patients
patients within the first 36 hours of treatment. Cerebral hemorrhagic complications developed HT, which was symptomatic in only 3 (8.8%), 1/3 of whom were treated
were classified according to the ECASS study in hemorrhagic infarction (HI-1 in distant hospitals. mRS distribution was not statistically different between the
and HI-2) and parenchymal hematoma (PH-1 and PH-2). rPH was defined as 2 patient groups: mRS 0-1 in 6/34 (18%), of which 4/6 (66%) were in a distant
any extraischemic hemorrhagic lesion observed in the control CT. Neurologic hospital, mRS (2-3) in 9/34 (26%), of which 4/9 (44%) were in a distant hospital,
worsening was defined as an increase in more than 3 points on the NIHSS score. A mRS (4-5) in 16/34 (47%) of which 8/16 (50%) were in a distant hospital, and 3/34
favourable outcome was defined as a score <2 on the Rankin scale. (8%) of patients died, all of whom were treated in the SU.
Results: We studied 163 patients (mean age 67.6 ± 11.8 years, 57% of them were Discussion: No significant difference was found concerning outcome or haemor-
men). The frequency of hemorrhagic complications was: HI-1 (2.4%), HI-2 (4.9%), rhagic complications between patients treated in the SU and distant hospitals. The
PH-1 (3.6%), PH-2 (2.4%), rPH (2.4%), rPH+PH-2 (0.6%). Patients with rPH study shows that “tele rt-PA” is safe and can improve patient outcome.
(n=5) had a mean age of 70.4 ± 8.1 and 40% were men. The median NIHSS score
was 15 and mean time to treatment was 134 ± 47.6 minutes. rPH were multifocal
in 2, single in 2, and associated with a PH-2 in one patient. The location of rPH 20 Acute stroke: treatment concepts
was lobar in 4 patients and in brainstem in one patient. rPH were symptomatic in
4 patients and asymptomatic in one. The neurologic worsening occurred 8, 14, 17 DIURNAL FLUCTUATIONS IN THE EFFICACY OF RT-PA IN ACUTE
and 30 hours after rt-PA. The outcome was unfavourable in all patients, with 3 ISCHEMIC STROKE
deaths. J. Gracia, S. Martinez-Ramirez, A. Ayo, D. Cocho, J. Martí-Fabregas, T. Segura
Discussion: Remote parenchymal hemorrhage is an uncommon complication after Department of Neurology, University Hospital of Albacete, Albacete, Spain
rt-PA (3%). It is usually lobar and symptomatic and has an unfavourable outcome.
Background: several studies have demonstrated that a circadian pattern of efficacy
exists in myocardial acute infarction, with a greater efficacy in the evening. This
18 Acute stroke: treatment concepts fact has been explained for the presence of different levels of plasminogen-activator
inhibitors and probably other haemostatic factors. There are not published data
A RETROSPECTIVE CLINICAL CASE-NOTE STUDY OF THE NUTRITIONAL communicating this fact in intravenous thrombolytic therapy in stroke patients
MANAGEMENT PRACTICES OF STROKE PATIENTS IN A SCOTTISH Objetives: to investigate possible diurnal fluctuations in the efficacy of intravenous
POPULATION thrombolysis in ischemic stroke patients
S. Ray, B. Al Falasi, P. Rana, M.A. Haleem, M. Rajput, S. Atkinson Methods: one hundred forty-eight patients with acute stroke treated with intra-
University of Dundee, Dundee, United Kingdom venous rt-PA were prospective enrolled in this study, conducted in two different
hospitals between January 05 and May 06. Efficacy of thrombolysis was deter-
A Retrospective Clinical Case-note Study of the Nutritional Management Practices mined according to accepted clinical criteria: neurological response was assessed
of Stroke Patients in a Scottish Population by NIHSS scale performed at 2 and 24 h after therapy, and long term functional
Background: Stroke is a leading cause of death and adult disability. Feeding in outcome was evaluated by modified Rankin scale at three months. We compared
stroke remains important as a number of stroke patients are undernourished on the results dividing patients into 2 different groups, day (08-20 h.) and evening
admission and nutritional status declines during hospital stay, with increased mor- (20-08am) and again dividing into 4 intervals of 6 hours: 0-06am, 06-noon, noon-06
bidity and mortality. The “Scottish Intercollegiate Guidelines Network”, “Quality pm and 06-00.
Improvement Scotland” and “Council of Europe” provide guidance for nutritional Results: The study population consists of 85 males and 63 females, age range 24-82
management of patients with dysphagia. This study aimed to assess the impact of years (mean 68.47, SD 11.2). There were no demographic or clinical differences
guidelines on the nutritional management of stroke patients. between the two cohorts from the different hospitals (74 patients every one) or
Methods: Retrospective case note analysis was done for ischemic strokes admitted among the pre-specified groups of time of thrombolysis. In the whole group,
to Ninewells Hospital, Dundee. This audit-type study looked at a 3-month period median NIHSS before treatment was 16 and median NIHSS at 2 h and 24 h were
prior to the establishment of guidelines and compared with 3 months post guideline. 11 and 9 respectively. There was no significant relationship between the clinical or
Results: There were 126 and 204 suspected cases of stroke in Periods 1 and 2 functional result of thrombolysis and the time of the treatment.
respectively. The corresponding number of CT diagnosed strokes was 78 and 107 Conclusions: Our results do not support the hypothesis that exist circadian
respectively. Out of these, 33 records were retrieved for patients in Period 1 and 43 variations in the response to thrombolytic therapy in ischemic stroke.
in Period 2. The weight recording rates were 27% in Period 1 vs. 35% in Period 2.
One- fifth of those weighed were monitored in Period 1 compared to one-third in
Period 2. 21 Acute stroke: treatment concepts
Discussion: There appear to be specific barriers to the implementation of guidelines
in daily practice. A continuing clinical nutrition education programme as an adjunct NO PREVIOUS EXPERIENCE WITH INTRAVENOUS THROMBOLYSIS FOR
to guidelines for stroke carers may help to overcome these limitations. ACUTE ISCHAEMIC STROKE DOES NOT INFLUENCE THE PROPORTION
OF PATIENTS TREATED
A. Kobayashi, M. Skowronska, T. Litwin, A. Czlonkowska
19 Acute stroke: treatment concepts Institute of Psychiatry and Neurology, Medical University of Warsaw, Warsaw,
Poland
IS REMOTE TELE RT-PA TREATMENT SAFE? THE EXPERIENCE OF THE
EMERGENCY NEUROLOGY NETWORK IN FRANCHE-COMTE (RUN) To determine the eligibility of ischaemic stroke patients admitted to the 2nd De-
E. Vidry, E. Medeiros, E. Revenco, F. Vuillier, P. Decavel, T. Moulin partment of Neurology for intravenous thrombolysis, identify the major exclusions
University Hospital Besançon, Besançon, France and assess if changes of the in-hospital pathway and informative campaign in the
local community and medical services can increase the number treated. To establish
Background: The only validated treatment for acute ischemic stroke is thromboly- if lack of previous experience with thrombolytic treatment or trials is predictive of
sis with intravenous alteplase (rt-PA) performed in a stroke unit (SU). Its efficiency a low proportion of patients treated.
is strongly time-dependent. Our aim was to evaluate the efficiency and safety of A survey of the database of stroke patients admitted during the first 30 months

Poster Session Cerebrovasc Dis 2007;23(suppl 2):1–147 109


Acute stroke: treatment concepts
following introduction of intravenous thrombolysis for acute ischaemic stroke in Results: After 5 days of using aspirin plus cilostazol, the extent of PAC-1 (58.5
order to identify eligible patients. This included patients admitted within 2 hours ± 19.2%, P<0.005) on activated platelet was significantly reduced compared with
of symptom onset (assuming a 1-hour door-to-needle time), age < 80 years, the baseline (71.0 ± 12.1%). But there was no any difference (34.1 ± 13.3 vs 30.9
National Institute of Health Stroke Scale (NIHSS) score from 5 to 22, seizures ± 10.5%) in aspirin only. In case of P-selectin, both aspirin and cilostazol group
at onset, platelet count >100,000 per ml, glycaemia from 50 to 400 mg per dl showed any differences of their expressions after 5 days of initiating treatment.
and international normalized ratio (INR) <1.6. We have compared the number of Compared clinical progression between two groups, there were no any significant
patients eligible with the number treated. changes of NIHSS in the observation period.
745 patients with acute ischaemic stroke were admitted. 18.4% were admitted Conclusions: In this study, we showed that the combined regimen of aspirin and
within 2 hours of onset, 71.0% were aged under 80, 55.4% had an NIHSS score cilostazol had beneficial effect to reduced PAC-1 activity on activated platelets
between 5 and 22. 96.1% had INR < 1.6, 98.9% had a platelet count higher than in acute ischemic stroke. However, this regimen did not showed better clinical
100,000 per ml, 99.4 had blood glucose between 50 to 400 mg per dl and 97.4% outcome than aspirin only. Therefore, we need the more detailed future study about
had no seizures at onset. After adjusting for all inclusion criteria 7.1% of patients the clinical benefit of cilostazol in acute ischemic stroke.
were found potentially eligible and 8.7% were actually treated (p=0.250). Out of
the 65 treated patients 63.1% were independent after 3 months, 16.9% had died
and none had a symptomatic intracranial haemorrhage. 24 Acute stroke: treatment concepts
The proportion of ischaemic stroke patients treated with intravenous thrombolysis
in a previously inexperienced centre is not lower than in other centres and countries CARDIO-PROTECTION IN ACUTE STROKE: HYPOTHESIS FOR
were this treatment is provided for a longer period of time. The number of patients INTERVENTION FOR MORTALITY REDUCTION
treated is higher than estimated mainly due to organizational changes introduced in J.C. Sharma, I.N. Ross, M. Vassallo
our centre. Kings Mill Hospital, United Kingdom

Background: Measures of damage limitation for acute stroke have not produced
22 Acute stroke: treatment concepts substantial benefit to reduce stroke mortality. Search continues for measures to
reduce stroke mortality.
NEUROPROTECTIVE EFFECT OF XG-102 ALONE OR IN COMBINATION Methods: Literature review for influence of cardiovascular factors, specifically the
WITH TISSUE PLASMINOGEN ACTIVATOR value of NT proBNP (a sensitive index of cardiac impairment) for stroke mortality,
K. Wiegler, C. Bonny, D. Coquoz, L. Hirt Results: Cardiovascular factors, in particular cardiac failure, adversely influence
Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland acute stroke mortality. Recent studies reveal that Troponin and NT-proBNP are
elevated in acute stroke patients, in response to the activated Renin-Angiotensin-
Background: XG-102 (formerly D-JNKI1), a TAT-coupled dextrogyre peptide Aldosterone-System and other neurohumoral changes, as a protective mechanism
which inhibits the c-jun N-terminal kinase (JNK), is a powerful neuroprotective for sympatho-inhibitory activity. Elevated NT-proBNP has been reported to be
drug in rodent models of cerebral ischemia (Borsello et al., Nat Med, 2003; Hirt et associated with higher short and long term mortality. In one study all patients
al., Stroke, 2004) when administered by intra-cerebro-ventricular injection (i.c.v.). who died at 4 months had NT-proBNP levels above the median, no patient with
We studied the feasibility of systemic administration. We also evaluated in vitro NT-proBNP below the median value died. Two studies revealed that NT-proBNP is
the effect of combined administration of XG-102 and tissue plasminogen activator more significant than clinical stroke severity for stroke mortality. Raised Troponin
(TPA), known to exacerbate excitotoxicity. indicates myocardial injury, raised NT-proBNP indicates occult cardiac impairment
Methods: Young adult male ICR-CD1 mice were subjected to 30 min transient in acute stroke patients. Protection of myocardium in stroke patients may be
suture MCAo. XG-102 was administered intravenously (i.v.) 6 or 9 hours after possible by the use of drugs such as beta-blockers and the drugs acting on RAAS.
ischemia. Neurological outcome was evaluated by neurological scores and rotarod Reduction of mortality in studies of candesartan (ACCESS) and prior betablockers
tests. Rat organotypic hippocampal slice cultures subjected to oxygen (5%) and is one such example.
glucose deprivation (OGD) for 30 minutes. Conclusion: Some stroke patients die due to occult cardiac impairment in acute
Results: XG-102 administered i.v. 6 hours after ischemia onset significantly phase due to common risk factors. This relationship between brain and heart needs
reduced the infarct volume at 48 hours. The lowest dose with maximal neuroprotec- evaluation. Protection of heart with currently available or new drugs in acute strokes
tion, was 0.3 μg/kg, which reduced the infarct volume from 62±19mm3 (n=18) for is worth investigating since this intervention could be applied to a large proportion
the vehicle-treated group to 18±9mm3 (P<0.001, n=5). Administration of XG-102 of acute stroke patients over a wide time window.
(1mg/kg) 9 hours after MCAo did not significantly reduce the infarct volume. The
behavioural outcome after transient MCAo was also considerably improved. In
organotypic slices, TPA alone (0.9 μg/ml) administered immediately after OGD, 25 Acute stroke: treatment concepts
increased cell death. XG-102 (12 nM), 6 hours after OGD onset, induced a strong
reduction (P<0.001) of cell death compared in the presence of TPA (49±19%, A NEW DEVICE FOR THE TREATMENT OF THROMBO-EMBOLIC
n=20 vs 12±14%, n=24). STROKES
Conclusion: XG-102 is a powerful neuroprotectant in our mouse stroke model, G. Pearce, N.D. Perkinson, J.H. Patrick
and can be administered i.v. up to 6 hours after MCAo. In vitro XG-102 can induce ORLAU, RJAH Hospital Oswestry, United Kingdom
neuroprotection also in presence of TPA.
Funding: CTI #7057.2 Each year in the UK 130,000 strokes occur (Arnold 2006), and it remains a heavy
burden on hospital and social service provision. We have invented a clot extraction
device for use in the acute situation-to reduce the continuing neuronal cell death in
23 Acute stroke: treatment concepts the penumbral area, (the “GP” Clot Removal Device). This device was invented by
Pearce and Perkinson (2005) has recently been published as a international patent
EFFECTS OF ASPIRIN PLUS CILOSTAZOL TO REDUCE THE PLATELET (W0206120464). The unique interior surface of this device facilitates controlled
ACTIVATION IN ACUTE ISCHEMIC STROKE removal of blood clots in arteries that block during thrombo-embolic strokes. Our
J.-K. Cha, S.S. Kim, H.W. Jeon, Jk Cha device has an inner surface that generates a helical vortex which actually removes
College of Medicine, Dong-A University Hospital, Busan, South Korea the clot. It has advantages are (i) it has no moving parts and (ii) it does not make
intimate contact with the blood clot or arterial wall. Complications should be lower.
Background: Aspirin has been still considered to be the most evidenced therapeutic In-vitro experimental results (Pearce et al 2006a, 2006b, 2006c, 2006d, 2007) show
regimen to prevent the recurrence of ischemic events in acute ischemic stroke. differences between fluid flow patterns when fluid is sucked through the device
Recently, Cilostazol, a Phosphodiesterase III inhibitor, has been known as useful (mounted within the catheter) compared to fluid sucking through a simple catheter.
antiplatelet agents to curb the progression of atherosclerotic ischemic stroke. In this We have also established that the device removes clots quicker and with less
study, we investigated the usefulness of cilostazol on the top of aspirin to regulate volume of blood being removed, than with simple catheter being use. Methylene
the expression of P-selectin and PAC-1 on activated platelet in acute ischemic stroke. blue dye has been used to effectively demonstrate the mechanism of the device.
Methods: We analyzed seventy-seven patients with acute ischemic stroke (<72 Pearce and Perkinson, 2007 have also undertaken radial flow rates within the “GP”
hrs). Among them, 50 patients were prescribed aspirin 100 mg per day and another clot removal device.
27 aspirin 100 mg plus cilostazol 200 mg per day. All patients were serially We have used both artificial clots and actual blood clots (abattoir sourced) to
valuated the expression P-selectin and PAC-1 on activated platelets at admission show clot removal in plastic tubes and porcine abattoir arteries. At vacuum suction
day and 5 days later. We also serially measured clinical progression by using NIH pressures of 66 KPa, when using the “GP” clot removal device (of internal diameter
stroke scale at same time period. 2.5 mm) occlusive clots of about 1cm long are removed.

110 Cerebrovasc Dis 2007;23(suppl 2):1–147 16th European Stroke Conference


26 Acute stroke: treatment concepts Methods: We prospectively included 14 patients treated with IV rt-PA within
3 hours after stroke onset (mean age 62.9±12.2 years, 10 (71%) male, mean
RAPID ALTERNATE DAY DOSE TITRATION OF DIPYRIDAMOLE IS WELL NIHSS score at admission was 12±5.8). A blood sample were obtained before
TOLERATED IN PATIENTS WITH ISCHEMIC STROKE and immediately after thrombolysis, in 24 hours, in 3 and 7 days after IS onset
J.L. Pascual, H.M. Chang, M.C. Wong, C.P. Chen to measure markers of fibrinolysis [Plasminogen Activator Inhibitor-1 – PAI-1
National Neuroscience Institute, Singapore General Hospital Campus, (IU/ml), normal value 1-7] and endothelial function [Matrix Metalloproteinase-9 –
Singapore, Singapore MMP-9 (ng/ml), normal value 169-705].
Results: Before thrombolysis increased plasma level of PAI-1 (14.1±17.9) and
Background: The combination of aspirin (ASA) and dipyridamole (DIP) has been decreased level of MMP-9 (102.9±106.8) was observed. After thrombolysis we
shown to be efficacious in the secondary prevention of acute ischemic stroke revealed the tendency towards decreasing PAI-1 (6.8±11.2) and increasing MMP-9
of arterial origin. However, DIP-induced headache is common and may affect (136±166.1). In 24 hours, 3 and 7 days after IS onset level of PAI-1 insignificantly
compliance. We aimed to determine the feasibility and tolerability of rapid dose increased (7.2±5.1; 10.3±18.1 and 10.6±11.6 respectively) and MMP-9 level
titration of DIP in Singaporean acute ischemic stroke patients. decreased (67.9±98.7; 35.1±7.5 and 54.3±26.6 respectively).
Method: Observational study of non-aphasic ischemic stroke patients requiring Conclusion: IV rt-PA therapy in stroke patients may reduce the activity antifibri-
anti-thrombotic therapy and without hypersensitivity or contraindication to DIP. nolytic system and cause short-term increase MMP-9 level.
Patients were allocated to either open label DIP starting at 25mg tds followed
by75mg tds and finally 150mg tds in either every other day(EOD) or week (EOW)
titration regimes at the choice of the attending physician. Follow-up was at 1 month 29 Acute stroke: treatment concepts
and occurrence of headache or other adverse effects, as well as any reason for
stopping the drug were documented. ANCROD IN A SIX HOUR TIME WINDOW? EVIDENCE FOR AND AGAINST
Results: 188 acute ischemic stroke patients were started on ASA + DIP over EFFICACY
a 6-month period. There were 113 patients on EOD and 75 on EOW titration D.G. Sherman, D.E. Levy
schemes. No significant differences in baseline characteristics between treatment University of Texas Health Science Center at San Antonio, San Antonio, TX,
groups were seen. The EOW regimen was associated with more adverse events USA
(22% vs. 9%, p < 0.05), predominantly headaches (72%), leading to more drug
discontinuations(12% vs 5%, p < 0.05). The majority of headaches in the EOD The publication in Lancet (2006;368:1871-78) of the unsuccessful European ancrod
group (70%) occurred at 25 mg tds, while in the EOW group, patients had trial (ESTAT), where the treatment began up to 6 hours after stroke onset, concluded
headache at 75mg tds or higher (88%). Discontinuation rates were similar for both that compared with the positive results of STAT (JAMA 2000;283:2395-2403) with
groups(13% vs 9%, p = 0.19). its 3-hour window, ESTAT’s results suggested that ancrod was ineffective if started
Discussions: Rapid titration of DIP is well tolerated. These findings need further later 3 hours. Although not published, ancrod’s efficacy was marginally better than
confirmation with randomized trials but may form the basis of a treatment regime placebo’s at 3-6 hours (43.2% vs. 42.3%) but was substantially worse at 0-3 hours
to be considered in acute stroke trials. (33.3% vs. 43.3%), inconsistent with attributing ESTAT’s poor results to its later
time window.
Pooled analysis of the North American data from STAT and an earlier 6-hour study
27 Acute stroke: treatment concepts (Stroke 2004:25:291-97) shows that efficacy vs. placebo is virtually identical in 0-3
hour (43.0% ancrod vs. 36.1% placebo) and 3-6 hour patients (43.4% vs. 34.1%)
COMBINED IV ABCIXIMAB/IA TPA TREATMENT OF ACUTE BASILAR with no significant interaction of time-to-treat on ancrod response (p=0.69).
ARTERY OCCLUSION Therefore, explanations other than enrollment beyond 3 hours must underlie the
U. Becker, G. Urban, R. von Kummer, G. Gahn unfavorable ESTAT results. These include the fact that higher blood pressures
University Hospital Dresden, Dresden, Germany were permitted in ESTAT (up to 220/120) than STAT (185/105). Symptomatic
intracranial hemorrhages occurred in 10.1% of ESTAT patients with systolic BPs
Background: Acute basilar artery occlusion (ABAO) is a disease with high of 185-220 vs. 6.9% of those with lower pressures. The ESTAT publication states
mortality and morbidity. The optimal therapeutic approach remains still unclear. that deaths rarely occurred in patients with symptomatic ICH (4/44 ancrod vs. 2/9
We intended to analyze the rate of recanalization, complications and outcome in placebo), but the actual data for 90-day mortality are 26/44 ancrod and 4/9 placebo.
patients with combined IV Abciximab/IA tPA treatment. Other explanations for the unsuccessful ESTAT results include age imbalance (69.3
Methods: Following a prospective protocol, patients, with ABAO received an IV ancrod vs. 67.6 placebo, p<0.03) and a 23% higher mean patient ancrod dose in
bolus of Abciximab (0,25 mg/kg bodyweight), followed by a 12 hours infusion of ESTAT than STAT.
Abciximab (0,125 mg/kg bodyweight). Immediately after the bolus, we performed The final answer on ancrod’s efficacy beyond 3 hours awaits conclusion of the two
DSA and administered tPA locally (up to 40 mg or until recanalization was currently-enrolling trials with 6-hour windows.
achieved). We investigated the rate of recanalization, complications and the clinical
course by standardized telephone interview after 6 months. Good outcome was
defined as a mRS < 3. 30 Acute stroke: treatment concepts
Results: Since 2003, we included 16 patients with ABAO, mean age was 60.9
years, 5 female, 11 male. Mean GCS ad admission was 9.4 (4-15), mean time PERFUSION-CT GUIDED INTRAVENOUS THROMBOLYSIS AT 3 TO 6
window 8.2 hours (3-25). HOURS: FEASIBILITY AND SAFETY STUDY IN 15 PATIENTS
Recanalization was achieved in 13 patients (87%), symptomatic hemorrhage oc- P. Michel, M. Wintermark, M.D. Reichhart, F. Vingerhoets, P. Maeder,
curred in 2 patiens (12%). Survival after 6 months was achieved in 7 out of 16 R.M. Meuli, J. Bogousslavsky
patients (44%), 3 of them had a good outcome (19%). Centre Hospitalier Universitaire Vaudois, Switzerland
Discussion: Regarding survival and good outcome we observed similar results
compared to other treatment regimes, however, the rate of recanalization was higher. Objective: To show the feasibility, safety and possible effectiveness of applying
We are encouraged to treat more patients with the combination of Abciximab and perfusion-CT (PCT) for patient selection for intravenous thrombolysis with rtPA 3
tPa to find out whether morbidity can be reduced. to 6 hours after onset of acute ischemic stroke.
Methods: Between 9/2002 and 1/2006, patients aged 18-80 with a NIHSS of 6-22
arriving too late in our stroke center for treatment within 3 hours were eligible for
28 Acute stroke: treatment concepts treatment. They had to have a minimal penumbra size for a given infarct (core) size
in the MCA-territory on PCT, according to a linear progressive cut-off table. This
DYNAMICS OF MARKERS OF FIBRINOLYSIS AND ENDOTHELIAL model was designed for maximal potential benefit: the smaller the core size is, the
FUNCTION IN PATIENTS WITH ISCHEMIC STROKE TREATED WITH smaller the lower limit of the penumbra needs to be for inclusion. The maximal
INTRAVENOUS RT-PA upper size for inclusion is a core of 30% of the MCA territory. The primary
N.A. Shamalov, A.S. Kireev, N.A. Pryanikova, G.R. Ramazanov, outcomes were symptomatic intracranial haemorrhage (ICH) and mortality at 90
A.G. Kobylyansky, I.A. Grivennikov, V.I. Skvortsova days. Secondary outcomes were independence at 3 months (modified Rankin scale
Federal Stroke Institute, Moscow, Russian Federation 0-2) and recanalisation rates at 24 hours measured by CT-angiography. The patients
were compared to 75 consecutive patients thrombolyzed in our center within 3
Background: The aim of this study was to assess the dynamics of the markers of hours based on NINDS-criteria (independently of their PCT results).
fibrinolysis and endothelial function in patients with ischemic stroke (IS) treated Results (median ± standard deviation): 15 patients fulfilled the clinical and PCT-
with intravenous (IV) rt-PA. criteria. Age and NIHSS were similar in both groups. Median time to thrombolysis

Poster Session Cerebrovasc Dis 2007;23(suppl 2):1–147 111


Acute stroke: treatment concepts
was 255 (± 45) min. in the 3-6 hour group and 152 (±34) min. in the comparison Conclusion: Based on our initial experience, we confirm that intravenous throm-
group. Symptomatic intracranial hemorrage was similar (6.7% vs. 6.7%) and bolysis carry a substantial benefit for the patients with acute IS. However, we also
90-day mortality (6.7% vs. 10.7%) were similar. Good outcome was seen in 60% uphold that one should strictly follow the thrombolysis protocol in order to avoid
and 52% respectively (non-significant), and 24 hour recanalisation rates were 60% possible complications.
and 50% (non-significant).
Conclusion: The time window for intravenous rtPA can safely be extended from 3
to 6 hours if perfusion-CT shows salvageable tissue and no extensive core volume. 33 Acute stroke: treatment concepts
Clinical outcome and recanalisation rates are comparable to 0-3 hour thrombolysis
based on plain CT. INTRA-ARTERIAL THROMBOLYSIS IN ACUTE STROKE DUE TO MCA
OCCLUSION
I. Henriques, A. Calado, R. Roque, A. Bandeira, I. Fragta, C. Ribeiro,
31 Acute stroke: treatment concepts J. Candido, J. Reis
Centro Hospitalar de Lisboa - Zona Central, Lisboa, Portugal
SYSTEMIC THROMBOLYSIS WITH ABCIXIMAB IN ACUTE ISCHEMIC
STROKE DUE TO ANTERIOR CIRCULATION INFARCTION BEYOND THE Background: Standard treatment for acute ischemic stroke in eligible patients is
3-HOUR TIME WINDOW intravenous (ev) thrombolysis, but efficacy is limited by low rates of recanalization.
K. Barlinn, U. Becker, G. Gahn Intra-arterial (IA) thrombolysis, combined transcranial ultrasound, or clot retrieval
University of Dresden, Dresden, Germany devices are being evaluated to improve thrombolysis efficacy. We prospectively
studied consecutive patients with acute MCA occlusion submitted to IA rt-PA
Background: Intra-arterial treatment of ischemic stroke using pro-urokinase is thrombolysis in the first 6 hours after symptoms onset.
the only recommended therapy within 6 h of onset of symptoms in patients Methods: We included patients not eligible for ev thrombolysis according to
with occlusion of the middle cerebral artery (MCA). Results from other trials ECASS criteria. We excluded patients with vertebrobasilar stroke and with previous
suggested that the glycoprotein IIb/IIIa antagonist Abciximab might also be useful concomitant ev thrombolysis. Symptomatic cerebral hemorrhage was considered if
in treatment of ischemic stroke in patients without MCA occlusion beyond the 3 h associated with clinical deterioration. Major neurological improvement was defined
time window. We aim to evaluate the safety and efficacy of Abciximab at standard as a reduction of more than 7 points in NIHSS after procedure. Excellent or good
dose in patients with acute ischemic stroke without MCA occlusion beyond the 3 h outcome was considered if modified Rankin scale was 2 or less. We studied 15
time window. consecutive patients referred to our stroke unit (5 male) with median age of 72 (43–
Methods: From May 2002 to January 2005, we retrospectively studied 7 patients 78) years.
with acute ischemic stroke attributed to the anterior circulation without MCA Results: Median NIHSS at admission was 19 (15-25), and 12 at discharge (2-25).
occlusion who were treated with Abciximab (0.25mg/kg bolus, followed by 0.125 MCA recanalization was total in 33% (TIMI grade 3) and partial (TIMI grade2)
μg/kg/min x 12h) beyond 3 hours from onset of symptoms. All patients had in 67%. In five patients, recanalization was achieved together with a mechanical
whether a progression or a fluctuation of focal neurological symptoms. MCA thrombectomy device. Hemorrhagic transformation was present in 7 patients (46%),
occlusion was excluded by computed tomography angiography (CTA). Intracranial and symptomatic in 5 (33%). Three patients died (20%) in the first 72h and none
bleeding complications were evaluated by CCT at day 1. National Institutes of after. At discharge, excellent or good outcome was observed in 27% of the patients.
Health Stroke Scale (NIHSS) was assessed at baseline and at discharge, modified Discussion: In this group of large MCA infarcts not eligible for ev thrombolysis,
Rankin Scale (mRS) was obtained at discharge. total recanalization was achieved in 33% and partial in 67%. Mechanical thrombec-
Results: Mean onset to treatment time was 9 (range 4,5-48) hrs. No symptomatic tomy device was used together with IA rt-PA thrombolysis in 33% of our patients.
intracranial haemorrhage occurred. There were no cases of extracranial bleeding Independency was achieved in 27% at discharge. Since patients not eligible for
complications. One patient had myocardial ischemia diagnosed. All patients (100%) ev thrombolysis with large MCA infarcts have a very high rate of disability and
improved clinically from mean NIHSS 7 (range 2-15) to 2 (range 0-10). The rate mortality, IA thrombolysis alone or together with mechanical device can be an
of favorable outcome (mRS 0-2) at discharge was 57% (4 of 7 patients). alternative to current treatment. Randomized trials may confirm safety and efficacy
Discussion: Regarding clinical outcome, the absence of symptomatic ICH and in larger series.
other bleeding complications, Abciximab seems promising in late thrombolysis of
acute ischemic stroke in selected patients without MCA occlusion and progres-
sion or fluctuation of symptoms. Nevertheless further prospective clinical trials are 34 Acute stroke: treatment concepts
necessary to select patients who benefit from treatment beyond the 3 h time window.
ARE POLYAMINE LEVELS USEFUL IN PREDICTING OUTCOME
FOLLOWING ACUTE STROKE?
32 Acute stroke: treatment concepts M.J. Macleod, P. Mahendra, M. Bruce, H.M. Wallace
University of Aberdeen, Aberdeen, United Kingdom
SETIS - SERBIAN EXPERIENCE WITH THROMBOLYSIS IN ISCHEMIC
STROKE Background: It is difficult to predict stroke outcome on infarct size and stroke
D.R. Jovanovic, Lj. Beslac-Bumbaširevic, G. Toncev, M. Živkovic, for SETIS severity alone. There is therefore interest in markers which might predict outcome
Group following acute stroke. The endogenous polyamines, putrescine, spermidine, and
Institute of Neurology, Clinical Center of Serbia, Belgrade, Yugoslavia spermine, are found in high concentrations in the brain and have a regulatory
role in apoptosis. When neuronal cells are damaged polyamines are ’mopped up’
Background: First intravenous thrombolysis in IS in Serbia was carried out in by erythrocytes. One small clinical study in acute stroke has suggested red cell
February 2006. We present our preliminary one year experience with intravenous polyamine levels may correlate with infarct size and severity. The aim of this study
thrombolysis in treating IS patients. was to replicate and extend these findings in a group of patients admitted with
Methods: All patients with IS treated with intravenous thrombolysis in Serbia were an acute cortical infarct of less than 48 hours duration. Patients with significant
included in the study. The time of stroke onset, first neurological exam, CT exam comorbidity or unable to give consent were excluded.
and beginning of therapy were recorded. The early CT signs of ischemia were Methods: Bloods and clinical assessment including NIHSS were performed at
graded by the ASPECTS score. Neurological deficit was assessed with NIHSS admission, 12, 24 and 48 hours (depending on time of admission after onset of
score and functional outcome with modified Rankin Scale (mRS). symptoms), 72 hours, 7 days, 14 days and 28 days. Samples were also available
Results: During one-year period 24 patients with IS were treated with intravenous for 8 control subjects. Erythrocytes were separated and washed with isotonic
thrombolysis in three tertiary care centers. Average age of patients was 50.5 years, NaCl, haemolysed with distilled water and extracted with HClO4. The extract was
ranging 18 to 78, with 62% of them younger than 55. Median time from symptom neutralised with KOH and frozen at -40 oC. Analysis of polyamines was performed
onset to hospital door was 52.5 minutes, median time door-to-CT was 37.5 minutes, using reverse phase HPLC and quantification by fluorescence detection.
and time from symptom onset to treatment was 165 minutes. Early CT signs of Results: Data from 10 patients is presented (6M/4F). Average age was 71.6 years
ischemia were present in 62% of patients with median ASPECTS score 9. Median (±8.9). Polyamine levels vary considerably between patients, but in all but one
initial NIHSS score was 14 with its decline during first 24 hours for at least 4 patient (who had a normal CT scan) were higher than normal control subjects at 7
points in 50% of patients. Symptomatic intracerebral hemorrhage was present in days (p<0.008). Patients had a significant rise in polyamine levels between baseline
two patients. After 30 days of follow-up, 33% of patients had favorable outcome (mean 8.7±5.4) and 7 days (mean 22.3±8.3), p<0.032. There was a correlation
(mRS < 1), 29% of patients had poor outcome (mRS 4-5) and two patients died, between total polyamine levels and NIH SS at day 7 post stroke (r=0.654, p=0.04).
one with malignant MCA infarction with symptomatic parenchymal hemathoma, Discussion: These findings confirm that polyamine levels are elevated after an
and the other patient with signs of heart insufficiency. ischaemic cortical stroke, and peak at 7-14 days. If the correlation with NIHSS is

112 Cerebrovasc Dis 2007;23(suppl 2):1–147 16th European Stroke Conference


confirmed in larger studies, polyamines may be a useful prognostic indicator after and 0.831 (95%CI 0.812-0.850), and in the end of follow up at 10 years 0.464
an ischaemic stroke. (95%CI 0.410 to 0.518) and 0.290 (95%CI 0.259 to 0.321) respectively, (log rank
test=24.23, p=0.0001). No differences were seen in recurrence rates (log rank
test=0.17, p=0.68).
Conclusion: Obesity in patients with acute stroke is associated with better short and
Long-term outcome of stroke long-term survival. The mechanisms involved in obesity-related neuroprotection in
acute stroke demand further investigation.

1 Long-term outcome of stroke


3 Long-term outcome of stroke
TIME SPENT AT HOME POST STROKE: “HOME-TIME” – A MEANINGFUL
AND ROBUST OUTCOME MEASURE FOR STROKE TRIALS BIOCHEMISTRY VERSUS CLINICAL SEVERITY OF ACUTE STROKE:
J. Dawson, T.J. Quinn, J.S. Lees, T.-P. Chang, M.R. Walters, K.R. Lees SIGNIFICANCE OF NT PROBNP TO PREDICT ONE YEAR MORTALITY
Gardiner Institute of Cardiovascular and Medical Sciences, University of J.C. Sharma, I.N. Ross
Glasgow, Glasgow, United Kingdom Kings Mill Hospital, United Kingdom

Background: Assessment of stroke outcome requires a measure of functional re- Background: We have investigated the value of biochemical measurements to
covery eg. modified Rankin scale. Such instruments are prone to bias and variation predict stroke mortality.
in clinical application. Approaches to improve rigour often increase complexity Methods: Logistic regression was used to investigate significant variables of the
without similar increases in clinical utility. Length of stay in hospital and nursing biochemical and clinical parameters in 125 previously independent (mRS <4) acute
homes is strongly related to incremental increases in mRs score but is weakened stroke patients for mortality at one year.
as an outcome measure because fatal outcomes tend to shorten stay. We examined Results: Age range 40 to 95, mean 73±12, Female:Male 63:62. 20 patients had
duration of stay in the patient’s own home or chosen environment – “Home-time” died at one year. Results are given for means ± SD between dead and alive patients
- as an alternative outcome more likely to show a graded response with less using Student’s t test. There was no significant difference in mean creatinine
confounding by survival issues. 111±32 vs 101±41, p=0.32, eGFR 54 vs 62, p=0.08; oxygen saturation–97.0 vs
Methods: We examined prospectively collected resource use data from the GAIN 97.0, p=0.60; HbA1C 6.01±0.7 vs 6.3±1.3, p=0.38; glucose 6.6±1.4 vs 7.0±2.8,
International trial. We assumed Home-time if patients returned to their own or p=0.53; serum osmolality 306±11 vs 303±18, p=0.52; cholesterol 4.5±1.1 vs
relative’s home after stroke, restricting analysis to the first 90 days and using 4.9±1.2, p=0.16 and HDL 1.4±0.7 vs 1.5±0.7, p=0.42. There was a significant
ANOVA with Bonferroni contrasts of adjacent mRS categories. difference in urea 10.1±4.6 vs 7.5±4.4, p=0.01; ALT 133.3±459 vs 30±33,
Results: We had full outcome data from 1717 of 1788 intent to treat patients. Mean p=0.02; alk phosphatase 140±116 vs 91.6±45, p=0.002; NT proBNP 980±1249
age ±SD was 70 ±12 years; 737 were female. Mean initial NIHSS was 13±6 and vs 125±244, p<0.001; Barthel Index 2.2±2.5 vs 7.1±4.9, p<0.001; Scandinavian
321 had primary intracerebral haemorrhage. Increasing Home time was associated stroke scale (SSS) 22±14 vs 35±12, p<0.001 and NT proBNP log 6±1.7 vs
with significantly improved mRs scores (p<0.0001; table). 3.5±1.7, p<0.001.
Logistic regression analysis using the significant variables from univariate analysis
revealed that NT proBNP was the most significant variable to predict mortality
mRs 0 mRs 1 mRs 2 mRs 3 mRs 4 mRs 5 mRs 6 (death) – Wald 17.9, p<0.001 followed by SSS – wald 5.7, p=0.02. Other biochemical
N 197 268 205 214 366 143 324 variables and Barthel Index were not significant to predict mortality.
Home-time duration Conclusion: NT proBNP, a measure of cardiac impairment, is the only significant
(mean) 72.6 64.1 45.9 31.5 11.2 9.1 1.0 biochemical variable to predict one year mortality, more significant than the
– * * * * p=0.37 p=0.0003 measures of clinical stroke severity. This provides an opportunity for intervention
95% CI 69.9–75.5 61.3–67.0 41.8–49.9 27.5–35.6 8.9–13.4 5.5–12.8 0.3–1.6 to reduce stroke mortality.
Home time = days spent living electively in existing setting, within the first 90d. *p<0.0001 compared
to preceding column
4 Long-term outcome of stroke
Conclusion: Recording of Home time offers a robust, useful and easily validated
outcome measure for stroke, particularly across better recovery levels. INFLUENCE OF STROKE SECONDARY PREVENTION DRUGS ON
MOLECULAR MARKERS OF INFLAMMATION. THE MITICO STUDY
J. Vivancos, J. Alvarez-Sabín, A. López-Farré, E. Martínez-Vila, J. Montaner,
2 Long-term outcome of stroke T. Sobrino, J. Castillo, on behalf of The MITICO Study investigators
Hospital Universitario de La Princesa, Stroke Unit, Neurology Service, Madrid,
THE IMPACT OF OBESITY ON SHORT AND LONG-TERM OUTCOME Spain
AFTER FIRST EVER ACUTE STROKE. THE STROKE OBESITY PARADOX?
S. Scalidi, K. Xynos, T. Pappa, J. Zafeiriou, N. Mentis, N. Kokolakis, Background: The MITICO study primary objective is to determine the prognostic
K. Vemmos value of inflammation molecular markers (IMM) in vascular recurrence risk.
Acute Stroke Unit, Dept. of Therapeutics, Univ. of Athens Med. School, As a secondary objective, we studied the influence of antiplatelet, statins and
Alexandra Hosp., Halandri, Greece antihypertensive drugs on IMM profile.
Methods: Multicenter prospective observational study, including non-anticoagulated
Background: Obesity has long been implicated as a higher morbidity and mortality ischemic stroke patients (within 1 to 3 months of stroke onset), with no inflam-
risk factor for cardiovascular disease. However, its potential role and pathophysio- matory processes. Four visits were performed during the one-year of follow-up to
logical significance on the outcome of patients after an acute stroke has not been identify vascular death (VD) or vascular event (VE). Blood samples were obtained
yet established. Our aim was to assess short and long term survival as well as at baseline visit for further determination of fibrinogen, high-sensitive C-reactive
recurrence rate of obese patients suffering an acute stroke, compared to that of the protein, IL-6, IL-10, ICAM-1, VCAM-1, MMP-9 and cellular fibronectin.
non-obese population. Results: From 965 included patients (recruited in 59 hospitals), 780 subjects
Methods: We prospectively studied 1998 patients with first-ever acute stroke. Apart (67.5±11.2 years, 33.6% female) were valid for the main analysis. One-hundred
from the stroke risk factors and body mass index (BMI), we scored consciousness and three patients (13.2%) showed a new VE and 116 patients (14.9%) either a VE
level and neurological deficit on admission by means of the Glasgow Coma Scale or VD (66.4% stroke, 21.5% coronary and 12.1% peripheral).
(GCS) and the Scandinavian Stroke Scale (SSS). Cox regression and Kaplan-Meier Only 21 patients were not taken antiplatelet drugs. Statins treatment was associated
method was used in order to estimate the impact of obesity on survival and with reduction of VE and VD (47.4% vs 28.2%. p=0.001). None of them modified
recurrence. the one-year functional outcome. There were significant changes between baseline
Results: In our study population, 473 patients (23.7%) were classified as obese and final plasma levels of IL6, MMP-9 and cellular fibronectin in statins-treated
(BMI>30) and 1525 (76.3%) as non-obese (BMI<30). Obese patients had higher patients in comparison with non-treated patients (IL6: 0.9 [-1.5, 6.5] vs 0.3
proportion of hypertension, diabetes and cholesterol. No significant difference in [-1.9,1.4] p<0.0001; MMP-9: 23.5 [-27.6, 119.5] vs -2.3 [-48.1, 34.4] p<0.0001;
age, GCS and SSS was observed between groups. After adjustment for age, sex, cFn: 4.4 [-4.8, 14.7] vs -6.1 [-10.8, 3.6] p<0.0001).
risk factors and stroke severity, obesity was an independent prognostic factor for Discussion: Statins treatment is associated with a significant reduction of VE and
survival Hazard Ratio=0.637 (95%CI 0.527-0.770), p=0.0001. Cumulative survival VD. Statins treatment influences IMM by lowering IL6, MMP-9 and cFn plasma
for obese and non-obese patients was: after 1 month 0.895 (95%CI 0,864-0.921) levels along follow-up period.

Poster Session Cerebrovasc Dis 2007;23(suppl 2):1–147 113


Long-term outcome of stroke
5 Long-term outcome of stroke 7 Long-term outcome of stroke
MORTALITY AND VASCULAR MORBIDITY AFTER ISCHEMIC STROKE AT LONG-TERM PROGNOSIS OF STROKE IN YOUNG ADULTS: RESULTS
A YOUNG AGE. A CROSS-SECTIONAL STUDY IN WESTERN NORWAY FROM THE FIRST 227 CONSECUTIVE CASES ENROLLED DURING
U. Waje-Andreassen, H. Naess, L. Thomassen, G.E. Eide, C.A. Vedeler 5-YEARS IN THE “ATHENIAN REGISTRY OF STROKE IN YOUNG ADULTS-
Haukeland University Hospital, Bergen, Norway ARSYA”
K. Spengos, S. Vassilopoulou, M. Papadopoulou, A. Papapostolou,
Background: The aims of this population-based long-term follow-up study were to G. Papadimas, E. Manios, G. Tsivgoulis
obtain data on cardiovascular mortality and recurrent stroke, coronary disease (CD) Eginition Hospital, University of Athens, Athens, Greece
and peripheral artery disease (PAD) for long-term survivors of ischemic stroke and
controls. Background: California- and ABCD-scores reliably predict short-term risk of
Methods: After a median observation time of 11.1 years we evaluated all 232 stroke after TIA. Both scores contain similar components. However, diabetes
patients aged 15-49 years with first-ever cerebral infarction in 1988-1997 and 453 mellitus (DM) is only included in the California Score. Aim of the present study
birthday- and sex-matched controls for causes of death. We used information from was to evaluate the potential relationship of DM with the early risk of stroke in a
the Norwegian national death register, from hospital records and autopsy reports cohort of hospitalised TIA patients.
when available. Among long-term survivors we evaluated 144 patients and 167 Methods: All patients hospitalised in our Department with definite TIA during
controls for cardiovascular events by questionnaires, hospital records and clinical a 5-year period were identified and their medical charts as well as their Emer-
examination including an electrocardiogram (ECG) for patients. gency Room records were retrospectively reviewed by two investigators blinded
Results: 45/232 (19%) patients and 9/453 (2%) controls died during follow-up to follow-up. Patients with previous history of stroke and those who missed their
(p < 0.0005). Causes of death among patients were: stroke (9), acute myocardial follow-up evaluations at the outpatient clinic of our Department at 1 month after
infarction (9), other heart disease (4), sudden death (5), unknown (5), cancer (7) and admission were excluded. DM was specified as fasting serum glucose 7.0 mmol/L,
others (7). One patient had 2 causes of death by autopsy. Controls died from acute nonfasting serum glucose 11.1 mmol/L, or use of oral blood sugar-lowering drugs
myocardial infarction (1), cancer (6) and others (2). Among long-term survivors or insulin. The outcome events of interest in all TIA patients were subsequent
recurrent stroke was registered for 38 (26.4%) patients versus stroke in 5 (3%) strokes during the 1-month follow-up period. Statistical analyses were performed
controls (p < 0.0005), CD occurred in 19 (13.2%) patients versus 9 (5.4%) controls using the Kaplan-Meier product-limit method and stepwise Cox’s proportional
(p = 0.018) and PAD occurred in 17 (11.8%) patients versus 2 (1.2%) controls (p hazards model.
< 0.0005). Results: The 30-day risk of stroke in the present case series (n=226) was 9.7%
Discussion: Mortality is increased after ischemic stroke at a young age and (95%CI:5.8-13.6%; 22 events). The 30-day risk of stroke was higher in patients with
cardiovascular death is dominating among patients. Cardiovascular morbidity is DM (17.3%; 95%CI:7.6-27.0%) than in non-diabetic patients [(7.1%; 95%CI:3.2-
higher on cerebral, coronary and peripheral level in long-term surviving patients 11.0%); log-rank test=5.20; df=1; p=0.0225]. After adjustment for demographic
compared with controls. characteristics, stroke risk factors, history and number of prior TIAs, duration and
Key-words: stroke, mortality, cardiovascular morbidity. symptoms of TIAs, as well as secondary prevention treatment strategies during
hospitalisation, DM was independently (p=0.015) associated with a three-fold
greater 30-day risk of stroke (HR:2.98; 95%CI:1.28-6.94).
6 Long-term outcome of stroke Discussion: DM is an independent predictor of subsequent stroke in patients
presenting with TIA. It should be taken into account by prognostic scores that
EFFECTIVENESS OF THROMBOLYTIC THERAPY ON OUTCOME WITHIN stratify the risk of early stroke in TIA patients.
3 MONTHS AFTER ISCHEMIC STROKE: THE TELEMEDICAL PILOT
PROJECT FOR INTEGRATIVE STROKE CARE (TEMPIS)
A.M. Toschke, P.U. Heuschmann, J. Schenkel, H. Audebert 8 Long-term outcome of stroke
King’s College London, London, United Kingdom
LONG-TERM SURVIVAL AFTER FIRST-EVER STROKE IN THE BESANÇON
Background: Randomized trials showed a benefit of intravenous application of STROKE REGISTRY: IMPACT OF STROKE UNIT ORGANISATION
tissue-type plasminogen activator (tPA) for ischemic stroke patients after three P. Decavel, E. Medeiros, E. Vidry, F. Vuillier, E. Revenco, M. Pellicier,
months. Observational studies reported inconsistent results regarding effective- T. Moulin
ness of this treatment in terms of early mortality. Data on mortality after tPA University Hospital Besançon, Besançon, France
administration after 3m outcome from unselected community hospitals are scarce.
Methods: Data were collected from the Telemedical Pilot Project for Integrative Background: Development of stroke management over a number of years has
Stroke Care (TEMPiS) in Southern Germany including comprehensive stroke changed the vital and functional prognosis of patients. The aim was to test the
centres and community hospitals. Patients were followed three months after influence of stroke management on the long-term survival of patients admitted with
stroke onset. Propensity score analysis was used for adjusting differences in first-ever stroke in the Besançon stroke registry.
sociodemographics, clinical characteristic, stroke severity, and comorbidities by Method: To test long-term outcome of patients with first-ever stroke over 3
tPA treatment. different periods (period 1: 1987-1994; period 2: 1998-2002; period 3: 2003-2006)
Results: Between July 2003 and March 2005 1710 patients after ischemic stroke corresponding respectively to “basic stroke unit” period, stroke unit organisation
were observed with a mean age of 74y (SE 0.3y); 48% were male. 76 (4.4%) period and network organisation period in 3 cohorts of unselected stroke patients.
patients were treated with tPA. Patients receiving tPA were younger, more often Results were statistically adjusted according to age, gender and stroke character-
male, had less often recurrent strokes; prevalence of diabetes, atrial fibrillation, istics. During the different periods, all patients with a first-ever stroke (infarction,
dyslipidemia and hypertension did not differ compared to non-tPA patients. The haematoma and TIA) admitted to the Besançon university hospital were registered
proportion of tPA patients who died in-hospital or after 3 month was similar prospectively and assessed according to standardised diagnostic criteria. Patients
(7.9% or 14.5%) compared to patients not receiving tPA (6.4% or 15.4%; p=0.61 were followed up over several years and the outcome was analysed during the first
and p=0.83). After adjusting for baseline differences by propensity score, patients year.
receiving tPA tended to have a lower probability of death in hospital (odds ratio Results: There were 6103 patients (55% male) which included 4250 (70%) infarc-
(OR) 0.58, 95%CI 0.21-1.63) and at 3 months (OR 0.69; 95%CI 0.32 to 1.50). tions, 678 (11%) haematoma and 1175 (19%) TIA. The median age of the cohorts
Conclusions: The tPA treatment within the TEMPiS community hospitals had no was 71 years. The cohorts were different for each period in terms of recruitment
adverse effect on in-hospital and 3months mortality after stroke. (gender - p = 0.035 - and age - p < 0.000) and stroke subtypes (p < 0.000). In the
first year after stroke, the overall survival rate was 75% (period 1), 80% (period 2)
and 82% (period 3). Although there was no difference in survival rates for patients
with TIA in any period, there was continuous improvement in survival rates for
patients with haematoma (p = 0,041) or infarction (p = 0,022). Adjustments to age
and gender amplified these results.
Conclusion: This study shows the strong impact of stroke management organisation
on long-term patient outcome in the Besançon area.

114 Cerebrovasc Dis 2007;23(suppl 2):1–147 16th European Stroke Conference


9 Long-term outcome of stroke 11 Long-term outcome of stroke
DOES ADMISSION C-REACTIVE PROTEIN PREDICT OUTCOME IN CHANGES IN QUALITY OF LIFE FROM ONE TO SIX MONTHS
STROKE PATIENTS UNDERGOING THROMBOLYSIS? FOLLOWING ACUTE STROKE AND ITS DETERMINANTS
R. Topakian, A.M. Strasak, H.-P. Haring, K. Nussbaumer, F.T. Aichner O.M. Ronning, K. Stavem
Academic Teaching Hospital Wagner-Jauregg, Linz, Austria Stroke Unit, Akershus University Hospital., Lørenskog, Norway

Objective: After acute stroke, increased levels of C-reactive protein (CRP) mea- Background: There is little information available about change in health-related
sured at discharge are associated with unfavourable outcome. We tested the quality of life (HRQoL) during the first few months following acute stroke, and
hypothesis that admission CRP may predict outcome in stroke patients undergoing whether baseline variables can predict who will have the largest improvement
intravenous thrombolysis treatment (IVT). in HRQoL. This study assessed the change in HRQoL from one to six months
Methods: From January 2003 to June 2006, 129 patients underwent IVT for acute following acute stroke and the determinants of these changes.
ischemic stroke in our centre. 111 patients were valid for analyses after exclusion Methods: Patients > 60 years of age, who experienced an acute stroke and were
of those with stroke involving a territory other than the middle cerebral artery’s and admitted to hospital within 24 hours of onset, were followed prospectively. HRQoL
those probably infected (admission CRP >6 mg/dl). Patient data were collected was measured with the SF-36 health status questionnaire.
in a prospective local registry. CRP was measured by turbidimetry (Cobas Integra Results: Of the 550 eligible patients, 315 fulfilled the inclusion criteria and
700, Roche). were alive after 30 days. At one month 174 responded to the questionnaire of
Results: 52 (46.8%) patients were independent after 3 months, defined by a modi- whom 140 also completed the second questionnaire. The changes in HRQoL were
fied Rankin Scale (mRS) score <3. Admission CRP levels were non-significantly statistically significant on all the SF-36 scales (Physical functioning: p<0.001,
higher in 1) patients independent after 3 months compared to patients with mRS Role physical: p<0.001, Vitality: p<0.001, Social functioning: p<0.001, Role
>2 [median (range): 0.4 (0-5.7) mg/dl vs. 0.3 (0-5.9) mg/dl, p=0.131], 2) patients emotional: p<0.001, Bodily pain: p=0.016, General health: p=0.002, mental health
who survived (87.4%) vs. patients who died within 3 months [median (range): p=0.02). Mean scores for the two summary scales, physical component summary
0.4 (0-5.9) mg/dl vs. 0.2 (0.1-1.5) mg/dl, p=0.275], and 3) patients who did (PCS) and mental component summary (MCS), increased from one to six months
not deteriorate neurologically within 24 hours (91.9%) vs. those who developed from 36 to 42 (p < 0.001) and 43 to 53 (p < 0.001). Higher baseline scores at
deterioration defined by an increase of the National Institute of Health Stroke Scale one month were associated with lower changes in PCS and MCS in multivariate
(NIHSS) score of at least 4 points compared to baseline [median (range): 0.4 (0-5.9) analysis. Less severe stroke related to large improvement in PCS. Treatment in
mg/dl vs. 0.2 (0.1-0.7) mg/dl, p=0.091]. In multivariate logistic regression analyses, stroke unit was associated with a larger improvement in MCS.
baseline NIHSS was the only variable significantly associated with independency Discussion: In the present study we show a marked improvement in HRQoL from
after 3 months (OR 1.235, 95%CI 1.118-1.363, p<0.001). one to six months. There was a favourable change in all domains assessed.
Conclusion: Our findings suggest that admission C-reactive protein is not useful in
predicting outcome in stroke patients with thrombolysis treatment.
12 Long-term outcome of stroke
10 Long-term outcome of stroke LONG TERM SURVIVAL OF STROKE PATIENTS FOLLOWING AN
INPATIENT REHABILITATION ADMISSSION
INITIAL EXPERIENCE WITH VIDEO BASED MODIFIED RANKIN C.E. Connolly, J. Estell, F. Kohler, R. Renton
ASSESSMENT Braeside Hospital, Prairiewood, NSW, Australia
T.J. Quinn, J. Dawson, M.R. Walters, K.R. Lees
Gardiner Institute of Cardiovascular and Medical Sciences, Glasgow, United Objective: Patients admitted for stroke rehabilitation generally have numerous
Kingdom comorbidities and a significantly increased mortality rate compared to the rest
of the population. The pioneers of Rehabilitation medicine demonstrated that
Introduction: Modified Rankin Scale (mRs) is the preferred outcome measure in rehabilitation improved quality of life and minimised dependency. Limited research
stroke trials. Despite availability of training and structured interview interobserver has however been done to determine the survival period of patients after inpatient
variability remains apparent - kappa=0.75 among UK SAINT trial investigators. rehabilitation for stroke. The aim of this study is to determine the survival period
We hypothesised that “off-line” assessment of video recorded interviews would of stroke patients following an episode of rehabilitation in our unit.
offer the means to improve reliability. Method: All patients admitted to the Braeside Rehabilitation Unit (NSW Australia)
Methods: 102 consenting patients were graded independently by two assessors. for stroke rehabilitation in the two years from 1st January 1997 to 31st December
Patients were randomised to undergo of structured interview or standard assess- 1998 were identified. The hospital databases were checked to determine; the last
ment. One assessment from each pair was further randomised to video recording. date of patient contact with a health service, or any indication that the patient had
Videos were assessed by four experienced researchers, blind to interviewer’s and died, and if so, the date of death. If there was no recent contact or confirmed
other panellists’ gradings. date of death a search was performed on the National Death Register kept by the
Results: 100 videos were of technical quality to allow assessment. A range of ages Australian Institute of Health and Welfare to establish if death had occurred
(median:70 range:30-96) and stroke subtypes (Cortical 44; Lacunar 41; Posterior Results: 253 patients were admitted for stroke rehabilitation during the reference
9) representative of a trial population were included. Initial mRs scores agreed period. Of these 7 patients died within 28 days of discharge, 20 patients died within
in 66.7% of cases. Use of the structured interview did not significantly improve 1 year and 30 within 2 years of discharge. By the end of eight years 72 patients had
reliability. At video assessment there was consensus amongst scorers for 55% died.
of cases (kappa 0.70). Greatest variability was seen for mRs grades 2 and 4 Discussion: The study shows that 71.5% of patients who were discharged following
(kappa=0.60, 0.65). inpatient stroke rehabilitation remained alive 8 years later. Given the age of this
population and presence of multiple comorbidities this survival rate is high and
underlines the importance of maximising patient function and outcomes for this
Paired mRs Assessment Total Structured (n=49) Standard (n=53) patient group. Further investigation with regards the survival periods in different
Agreement 68 30 38 stroke subtypes is warranted.
Disagree = 1 mRs grade 29 14 15
Disagree > 1 mRs grade 5 5 0
13 Long-term outcome of stroke
Video Assessment (4 reviewers) Total Structured (n=48) Standard (n=51)
Consensus 54 24 30 ASSESSMENT OF QUALITY OF LIFE IN STROKE PATIENTS CAREGIVERS.
3/4 Agree 32 17 15 HOW TO PREDICT CAREGIVERS AT RISK
2/4 Agree 13 7 6 E. Marco, E. Duarte, M. Tejero, J.M. Muniesa, R. Belmonte, A. Aguirrezabal,
M. Pou, C.B. Samitier, F. Escalada
Discussion: We have shown that “off-line” assessment of mRs is possible in a mock Physical Medicine and Rehabilitation Department, Hospital de l’Esperança,
clinical trial setting. Video assessment did not alter interobserver variability but Barcelona, Spain
offers potential for central endpoint committee review with resultant improvements
in precision: pilot work to assess effect on reproducibility is now underway. Background: The increased proportion of stroke survivors has led to more impaired
and disabled subjects. The patient disability condition and the provision of care
have negative consequences for caregivers. Objectives: To detect the most affected

Poster Session Cerebrovasc Dis 2007;23(suppl 2):1–147 115


Long-term outcome of stroke
dimensions in quality of life of stroke patients caregivers, and predict caregivers at pneumonia during hospitalization. Data from a sample of 100 patients examined 2
risk of presenting a worse health-related quality of life. years before showed similar rates (dysphagia 27.0%, pneumonia 6.0%). Predictors
Methods: Cross-sectional study of 215 family caregivers of stroke patients. Main of increased risk of pneumonia were stroke severity, hemorrhagic (rather than
variables were assessed with: the Short Form 36 (SF-36), the Geriatric Depression ischemic) stroke, and the presence of a total anterior circulation syndrome.
Scale and the FIM-instrument. Statistical tests: Chi-squared and Fisher test, Student Discussion: The low incidence of aspiration pneumonia in our Institution supports
“t” test, ANOVA, Mann-Whitney “U” test and Spearman correlation. the effectiveness of a standardized swallowing assessment and feeding procedure,
Results: The SF-36 subscales of vitality, social function, emotional role and mental and continuous training of the nursing staff. The incidence of pneumonia remains
health are the most affected. There is a positive correlation between caregivers in fact persistently low over time. However, there is a small group of patients at
health perception and patients health perception in these subscales. Motor disability higher risk of developing pneumonia. These patients, who are likely to have an
and assistence time required are the patient characteristic with a major influence hemorrhagic stroke, severe symptoms and larger lesions, could benefit of more
in caregiver health perception. The presence of depression and osteoarthritis in selected strategies, to be eventually tested in this particular stroke subgroup.
caregivers have a significant effect on their perception of health. A model to be
used to detect the caregiver at risk of presenting a bad perception of health status
is constructed. This predictive model contemplates 8 different probability groups 16 Long-term outcome of stroke
ranging from 8.1 to 88.4%.
Discussion: Health-related quality of life of caregivers is affected in different QUALITY OF LIFE AND LONG-TERM FUNCTIONAL OUTCOME IN YOUNG
dimensions. To detect which caregivers are at most risk of presenting a bad PATIENTS AFTER AN ISCHEMIC STROKE
perception might be useful to provide resources and services to help caregivers in A.A. Gongora, C. Mader, J.P. Arroyo, R. Garcia, A. Leyva
charge of stroke patients. Institute National of Neurology and Neurosurgery, Mexico City, Mexico

Background and purpose: The purpose was to evaluate quality of life and long-
14 Long-term outcome of stroke term functional outcome in patients under 45 years, after ischemic stroke to identify
variables that will accurately predict quality of life and long-term functional
POSTSTROKE EPILEPSY IN PATIENTS TREATED WITH SYSTEMIC outcome.
THROMBOLYSIS Methods: This was a cross-sectional, descriptive correlational design. The modified
B. Dimitrijeski, A. Villringer, A. Hartmann Rankin scale, Barthel index and Short From -36 (SF 36) were administered to 192
Charité-Campus Benjamin Franklin, Berlin, Germany stroke patients under 45 years. Subjects were interviewed 1 to 5 years after the
stroke. Independent variables were age, sex, comorbidity, cause, and location of
Objectives: Poststroke Epilepsy (PSE) is an important complication after ischemic stroke. Multiple regression analysis was used to predict quality of life.
stroke. We aimed to asses the occurrence of poststroke epilepsy, and to identify Results: 192 patients with a previous history of ischemic stroke <45 years of age
possible predictors in patients with ischemic stroke treated systemically with were included. The cause of the stroke was cardioembolism 20%, major blood
thrombolysis. vessel atherosclerosis 9%, arterial dissection 28%, hypercoagulable state 15%, and
Methods: Patients with supratentorial stroke treated between 1998 and 2003 not determined 28%.
systemically with rt-PA according to the NINDS trial-protocol were followed The most important risk factors associated with the cause of the stroke were
prospectively. Neurological status was measured at admission, discharge, 3- hypertension and major blood vessel atherosclerosis with 82% (p < 0.0005),
months-follow-up and long-term follow-up. Occurrence of poststroke epilepsy was diabetes mellitus and major blood vessel atherosclerosis 47% (p < 0.0005). The
noted. Predictors for PSE were identified using univariate analysis. mean Barthel index was 95 with Barthel > 85 in 98% of cases. Rankin score was <
Results: A total of 134 Patients were treated. Long-term follow-up (mean follow- 2 in 48%. (Rankin 3 – 4 = 52%). There was no significant difference between the
up–time for the survivors was 39 months, range 14-66 months) was completed for cause of the stroke and the SF – 36 profile category results. The SF – 36 category
132 patients, 2 patients were lost to follow-up. Good clinical outcome (Rankin<2) which was affected the most, was emotional role with over 30% of patients with an
and mortality at 3 months was 50% and 13%, and at long-term follow-up 45% and average value of less than 33.
28% respectively. Conclusions: There seems to be no difference between the long term functional
Poststroke epilepsy occurred in 14 patients (11%). Factors univariately associated outcome and quality of life and the cause of the ischemic stroke. The identification
with poststroke epilepsy were NIH at discharge (p= 0.001), cardio-embolic stroke of alterations in the emotional role of patients furthers the need for support
(p=0.018) and increasing infarct size (p=0.003). programs.
Conclusions: The prevalence of poststroke epilepsy in patients treated with sys-
temic thrombolysis after a mean follow-up of 39 months was 11%. NIH-Score at
discharge, cardioembolic stroke and increasing infarct size are associated with a 17 Long-term outcome of stroke
higher risk for developing PSE.
PROGNOSIS IN FIRST-EVER ISCHEMIC STROKE/TRANSIENT ISCHEMIC
ATTACK PATIENTS WITH SIGNIFICANT EXTRACRANIAL CAROTID
15 Long-term outcome of stroke ARTERY DISEASE
H.J. Lin, P.S. Yeh
INCIDENCE OF ASPIRATION PNEUMONIA AFTER SYSTEMATIC Chi-Mei Medical Center, Yong Kang, Tainan, Taiwan
APPLICATION OF AN EXPERT BEDSIDE SWALLOWING EVALUATION AND
FEEDING PROCEDURE IN A STROKE UNIT Background: The impact of significant extracranial carotid artery disease on the
V. Palumbo, S. Centorrino, P. Nencini, G. Pracucci, D. Inzitari prognosis in patients with ischemic stroke or transient ischemic attack (TIA) is
University of Florence, Florence, Italy unclear in Taiwanese people, who have lower prevalence of such artery disease
than Western people.
Background: Aspiration pneumonia is one of the most common and severe Methods: From a prospective hospital-based registry of patients with first-ever
complications of stroke-related dysphagia. We aimed to evaluate the variation over ischemic stroke or TIA, we investigated the outcomes among those with newly
time of the incidence of pneumonia in acute stroke patients admitted to a Stroke found extracranial carotid artery disease > 50% stenosis. Data were collected
Unit, who underwent an expert swallowing assessment and standardized feeding according to predetermined evaluation systems and diagnostic criteria, and the
procedures. subjects received regular follow-up. The composite outcome endpoint was subse-
Methods: We evaluated after 2 years a second sample of 102 patients with quent stroke, myocardial infarction, or vascular death after the index event. The
acute stroke (83% ischemic, 17% hemorrhagic) admitted consecutively in a Stroke Kaplan-Meier product-limit method was used to estimate the cumulative risk of the
Unit over 6 months. All patients were systematically screened for dysphagia on endpoint, and the Cox regression model for evaluating prognostic factors.
admission using the Standardized Bedside Swallowing Assessment, which involves Results: We enrolled 109 patients with a mean age of 69 years and 72% of men. The
three stages: general evaluation (level of consciousness, postural control, voluntary mechanisms of the ischemic events included 64% of large artery atherosclerosis,
cough, voice quality and ability to swallow saliva), sipping water from a spoon, 13% of small vessel disease, 9% of cardioembolism, and 12% of undetermined
and, if safe, proceeding to drink water from a glass. If difficulty on swallowing was etiology. All patients received medical treatments only. After a median follow-up
present, non-oral nutrition was considered, and the patient was referred to a speech duration of 21.1 months, 33 events developed, including 14 strokes, 2 acute
therapist for expert assessment. myocardial infarcts, and 17 vascular deaths. The cumulative risks of the endpoint
Results: Median NIHSS of the cohort was 9, mean age 66.2 years, 63% of patients were 7% in 1 month, 24% in 1 year, and 31% in 2 years. The Cox model analyses
were male. revealed prior ischemic heart disease as a significant prognostic factor (hazard ratio,
Dysphagia was diagnosed in 18 (17.6%) patients; 6 (5.8%) patients developed 2.6; 95% confidence interval, 1.0-6.8)

116 Cerebrovasc Dis 2007;23(suppl 2):1–147 16th European Stroke Conference


Conclusions: Patients with first-ever ischemic stroke/TIA and newly found sig- Conclusions: More likely, [11C]-(R)-PK11195 uptake relates to macrophage (late
nificant extracranial artery disease are predisposed to grave vascular outcomes, in inflammatory response) rather than microglial activity. Because the uptake was
particular those with concomitant ischemic heart disease. higher in the normally perfused rather than chronically hyposperfused areas it may
be that reperfusion promotes the inflammatory response.

18 Long-term outcome of stroke


2 Brain imaging – new developments
PLASMA GLUTAMATE LEVELS PREDICT FATIGUE AFTER TIA AND
MINOR STROKE TC PERFUSION PREDICTS EARLY CLINICAL RESPONSE TO
A.B. Syed, L.M. Castell, A. Ng, C. Winward, P.M. Rothwell INTRAVENOUS THROMBOLYTIC THERAPY OF ISCHEMIC STROKE IN
Stroke Prevention Research Unit, Department of Clinical Neurology, University THE FIRST 3 HOURS
of Oxford, Oxford, United Kingdom M. Revilla, E. Palacio, F. González, C. Ramón, P. Sánchez-Juan,
A. González-Mandly, E. Marco de Lucas, A. Gutiérrez, M. Rebollo, J. Berciano
Background: Post-stroke fatigue (PSF) is common and can be severe, even after Hospital Universitario Marqués de Valdecilla, Santander, Spain
minor cerebral ischaemic events, but the mechanism(s) are poorly understood. High
levels of plasma glutamate are associated with fatigue in multiple sclerosis and in Background and purpose: CT perfusion (CTP) and CT angiography (CTA) imag-
chronic fatigue syndrome. We aimed to determine whether plasma glutamate and ing techniques identify tissue in penumbra and intravascular thrombus in acute
glutamine levels predicted PSF after transient ischaemic attack (TIA) and minor ischemic stroke, but their utility in the stroke therapy in the first three hours has
stroke. not been defined. We evaluated if CTP and CTA findings conditioned early clinical
Methods: We studied consecutive patients with TIA and minor stroke from the response to intravenous (iv) thrombolytic therapy in the first three hours.
Oxford Vascular Study (OXVASC). Participants were excluded if they had a Barthel Methods: Forty-seven consecutive patients were treated with iv tPA according to
Score less than 18/20, a Rivermead Mobility Index (RMI) of less than 10/15, or SITS criteria. Additionally, 33 of them were studied with CTP+/-CTA before tPA
Mini Mental State Examination (MMSE) less than 23/30. Blood samples were administration. We evaluated cerebral blood flow (CBF), mean transit time (MTT)
taken within one week of the presenting event and fatigue was assessed at home by and cerebral blood volume (CBV) images, CBF/CBV mismatch and arterial oc-
a research nurse (blind to all biochemical analyses) 6 months after the event with clusion. Early recanalization was detected with control CTA+/-transcranial doppler
the Chalder Fatigue Scale. Enzymatic spectrophotometric techniques were used to examination. Early clinical response was measured by NIHSS at 0, 1, 24 and 72
assay plasma glutamine and glutamate levels. hours post-treatment.
Results: Among 38 patients (28 stroke, 10 TIA, 15 male, mean age 74 yrs), 64% Results: Clinical evolution of patients by mean NIHSS was 13.5 (0 h), 10.8 (1 h),
of stroke patients and 25% of TIA patients reported PSF. PSF was independent 9.4 (24h) and 7.6 (72 h). Between 0 and 72 hours NIHSS differences, measured by
of age, sex, depression, smoking, medication and (among stroke patients) residual mean rank, were as follows: 16.4 vs 19.4 if there was CBF abnormality (n=26);
neurological deficit. However, there was a negative correlation between plasma 14.2 vs 19.3 if there was CBV abnormality (n=15); 15.2 vs 6.2 if there was
glutamine/glutamate ratio and PSF (r=-0.38. p=0.02). Plasma glutamate correlated CBF/CBV mismatching (n=21) (p=0.01, Mann-Whitney U); 12.9 vs 8.5 if there
positively with PSF (r=0.35, p=0.02). Discussion: Plasma glutamate and the glu- was arterial occlusion (n=15); and 13.2 vs 4.5 if there was early recanalization
tamine/glutamate ratio appear to predict PSF 6 months after TIA or minor stroke. (n=12) (p=0.001, Mann-Whitney U).
Further research is warranted to confirm the predictive value of these tests and to Conclusion: Findings of mismatch and early recanalization of arterial occlusion
determine whether the relationship is causal. in CTP/CTA images predict a better early clinical response and may help in the
selection of patients for iv thrombolysis of stroke in the first three hours.

Brain imaging -- new developments 3 Brain imaging – new developments


INTRAPLAQUE HAEMORRHAGE IS ASSOCIATED WITH MULTIPLE
1 Brain imaging – new developments DIFFUSION WEIGHTED IMAGING LESIONS IN SYMPTOMATIC PATIENTS
WITH HIGH GRADE CAROTID STENOSIS
THE USE OF [11C]-(R)-PK11195 LIGAND AND POSITRON EMISSION N. Altaf, S. Goode, P.S. Goode, J.R. Gladman, S.T. MacSweeney, D.P. Auer
TOMOGRAPHY IN ACUTE ISCHAEMIC STROKE: INSIGHTS INTO THE University of Nottingham, Nottingham, United Kingdom
INFLAMMATORY PROCESS
J.A. Zavala, M.N. Perera, H.H. Ma, G. O’Keefe, H. Tochon-Danguy, Introduction: Magnetic Resonance Imaging sensitively detects carotid intraplaque
U. Akermann, J. Ly, D. Reutens, C. Rowe, G.A. Donnan haemorrhage (IPH) that is increasingly accepted as surrogate marker of plaque
National Stroke Research Institute, Australia; Centre for PET Austin Health, instability. The aim of this study was to investigate an association between IPH and
Australia the presence, pattern and extent of cerebral acute and sub-acute ischaemic lesions
identified by diffusion weighted imaging (DWI).
Inflammation after an ischaemic insult to brain tissue may have a key role in Methods: 46 patients (18 females, mean age 71.5 years ± 10.7) with high grade
the survival of viable hypoperfused tissue. Microglial and other inflammatory carotid stenosis (>70% stenosis) presenting with stroke, TIA or amaurosis fugax
cells are rapidly activated (within hours) after pathological insults to the CNS. were prospectively recruited. All patients underwent MRI assessment of IPH in
Macrophages accumulate after a period of days. Peripheral benzodiazepine binding the carotid artery and DWI of the brain. The presence, extent and pattern of DWI
sites (PBBS) are mitochondrial membrane receptors in microglia and macrophages. hyperintense lesions were compared with the IPH status of the presenting carotid
(R)-PK11195 is a ligand that binds to PBBS. [11C] PET scan can be used as a artery.
non-invasive method of inflammatory response imaging. In this study we aimed Results: 32 (69.6%) patients had evidence of IPH in the presenting carotid artery
to understand the spatial and temporal changes of inflammatory response after and 26 (56.5%) had DWI lesions. The mean delay from the presenting symptom
ischaemic stroke. We hypothesized that [11C]-(R)-PK11195 uptake levels increase to MRI was 21.8 ± 18.5 days. Patients with carotid IPH were more likely to
not only within the core of the ischaemic lesion but also in hypoperfused regions. have ipsilateral DWI lesions than those without IPH (22/32 [69%] vs. 4/14 [29%],
Methods: We studied ischaemic stroke patients within 1 month of onset. Imaging P<0.05); had more lesions (mean 2.8 ± 3.3 vs. 0.7 ± 1.2, P<0.05); multiple lesions
was performed including CT, CT perfusion or MRI/A. [11C]-(R)-PK11195 was were strongly associated with IPH (17/32 vs. 1/14), whereas the DWI hyperintense
given intravenously followed by 3-dimendional dynamic acquisition (PET) over 60 lesion volume was similar (mean 2.1 ± 3.4 ml vs. 1.7 ± 4.0 ml, P=0.6).
minutes. Distribution volume ratio maps were created using ipsilateral cerebellum 18/32 (56.3%) of patients with IPH had multiple DWI lesions and 3/14 (21.4%)
as reference tissue. The PET images were then coregistered to DWI and perfusion patients without IPH had multiple lesions (P<0.05).
maps. The association between carotid IPH and the presence of DWI lesions was
Results: Fourteen patients were studied (median age 72 years, range 52 to 89 marginally significant (Odds ratio = 3.8; 95% C.I. 0.8 – 18.2, P=0.09) after
years). PET scans were performed from 48 hours to 20 days after stroke onset. Nine controlling for stroke and time between symptom and MRI.
patients had corresponding perfusion scans. There was no [11C]-(R)-PK11195 Conclusion: Intraplaque haemorrhage in the presenting carotid artery is moder-
uptake within the first 5 days (5 patients) but increased uptake in 7 of 9 scans ately associated with DWI ischaemic lesions and strongly with multiple lesions
performed from day 6 to day 20 after stroke onset. Increased uptake was found at supporting a thromboembolic pattern.
least as frequently beyond the infarct as within its core. For patients submitted to
perfusion scans, there was little uptake in chronically hypoperfused areas compared
to elsewhere outside the infarct core.

Poster Session Cerebrovasc Dis 2007;23(suppl 2):1–147 117


Brain imaging – new developments
4 Brain imaging – new developments 6 Brain imaging – new developments
TISSUE SWELLING WITHOUT HYPOATTENUATION ON NON-CONTRAST MRI ON DAY 1 IDENTIFIES PATIENTS AT RISK FOR DELAYED STROKE
CT IS RARE BUT POTENTIALLY REVERSIBLE IN ACUTE ISCHEMIC PROGRESSION AFTER I.V. THROMBOLYSIS
STROKE R. Kern, K. Szabo, S. Bukow, M. Griebe, A. Förster, M.G. Hennerici, A. Gass
I. Dzialowski, S. Subramaniam, V. Puetz, A. Krol, J.M. Boulanger, P.A. Barber, Universitätsklinikum Mannheim, University of Heidelberg, Mannheim,
M.D. Hill, S.B. Coutts, T. Watson, A.M. Demchuk, for the Calgary CTA Study Germany
Group
University of Dresden, Dresden, Germany Objective: Deterioration of clinical status after treatment with tPA for acute stroke
is a possible outcome but difficult to predict on an individual basis. Besides an
Background: Early ischemic changes (EIC) on non-contrast CT (NCCT) can early malignant course a delayed symptom progression can occur. In an approach to
represent tissue hypoattenuation or cortical swelling and are both scored tradi- characterize the stability in the post-tPA phase we performed systematic follow-up
tionally in the Alberta Stroke Program Early CT Score (ASPECTS). However, MRI in this patient group.
only hypoattenuated brain tissue seems to be specific for ischemic core whereas Methods: MRI (T2w, T1w, T2*w, DWI, TOF-MRA, PWI) was performed in 45
isolated cortical swelling (ICS) might be reversible. We sought to assess ASPECTS acute stroke patients on the first day after CT-based tPA therapy (3h time-window).
ignoring isolated cortical swelling (ASPECTS - ISC) and compare the incidence of 8/45 patients had an early malignant course and in 12/45 there was marked clinical
deviation from classic ASPECTS. improvement with MRI demonstrating successful therapy on day 1 and no further
Methods: We studied ischemic stroke patients from 04/2002-07/2005 presenting MRI was performed. In 25/45 patients MRI on the 1st and 7th day were compared.
within 24 hrs of onset in whom a NCCT was performed. We prospectively applied MRI findings on day 7 were either considered “improved” (= vessel recanalisation;
ASPECTS to all baseline NCCT scans by 3-reader consensus scoring any EIC. resolution of hypoperfusion), “stable” (= no progress of infarct size, of hemorrhagic
A normal scan scores 10, a complete middle cerebral artery infarction 0. In the transformation [HT], or of vessel pathology) or “progressive” (= progression of
same session, we interpreted ASPECTS - ISC. We independently assessed follow- infarcted or hypoperfused tissue size, HT or vessel pathology).
up ASPECTS at day 1-7. We determined the incidence of differences between Results: In 19/25 (76%) MRI was stable or improved on day 7, whereas 6/25
ASPECTS-ICS and ASPECTS and proportion of reversibility at follow-up. (24%) were progressive: 6 patients showed new DWI lesions - 4 in the same, 2 in a
Results: We identified 335 patients with a mean age of 67 years, mean onset-to- different vascular territory. One patient developed HT between day 1 and 7. 67% of
NCCT-time of 286 min, median baseline NIHSS score of 7 and median ASPECTS patients with persistent vascular obstruction and persistent hypoperfusion on day 1
of 10. We found ASPECTS - ICS > ASPECT scores in 7/335 (2.1%) of patients. had progressive MRI findings on day 7 and did not improve clinically.
In this group, mean onset–to-NCCT-time was 399 min and median ASPECTS-
difference was 2 (range 1-4). In 5/7 patients follow-up imaging was available
and 2/5 (40%) showed higher final ASPECTS (> 1-point increase) than baseline
classic ASPECTS consistent with reversibility. In the population without baseline
ASPECTS difference, 16/247 (6%) of available follow-up images showed higher
final ASPECTS than baseline classic ASPECTS.
Conclusion: In our study, isolated tissue swelling was rare but likely to reverse.
ASPECTS interpretation should ignore isolated cortical swelling to better represent
irreversible ischemic core.

5 Brain imaging – new developments


LACTATE DOES NOT PREDICT INFARCT GROWTH
V. Cvoro, J.M. Wardlaw, S. Muñoz Maniega, I. Marshall, P.A. Armitage,
C.S. Rivers, M.S. Dennis
Division of Clinical Neurosciences, University of Edinburgh, Edinburgh, United
Kingdom

Background: In patients with acute ischaemic stroke, the mismatch between mag- Fig. 1. MRI performed on day 1 and day 7 of a 68-year-old patient who underwent intravenous
netic resonance (MR) diffusion- and perfusion weighted imaging (DWI and PWI) thrombolysis 2.5 hours after symptom onset DWI on day 7 showed multiple new acute lesions in the
was initially thought to predict infarct growth, but recent studies have questioned the right PCA territory with a persistent perfusion deficit on TTP maps. On MRA, vascular obstruction of
strength of this association. Lactate is a marker of early ischaemia and is elevated the left PCA even became more prominent. MRI characteristics were considered progressive.
in acute stroke lesions. N acetyl aspartate (NAA) which represents neuronal loss
falls more gradually. We examined whether elevated lactate or decreased NAA in Discussion: MRI on day 1 can identify those patients with a persisting unstable
mismatch tissue predicted infarct expansion. situation at risk for stroke progression as indicated by hypoperfusion due to
Methods: Patients with acute ischaemic stroke underwent diffusion tensor imaging incomplete vessel recanalisation after thrombolysis. Identifying these patients is
(DTI), dynamic susceptibility contrast PWI, T2W and MR spectroscopic imaging important for clinical management with close monitoring and blood pressure
(SI) at admission, days 5 and 14, and 1 and 3 months. A 0.5 cm diam. voxel grid management.
was superimposed on the baseline DTI and metabolite data were extracted from the
normal, mismatch and DTI lesion tissue. Infarcts were categorized into those with
or without lesion growth. 7 Brain imaging – new developments
Results: 21 patients had DTI/PWI mismatch; 7 developed infarct expansion, 10 did
not (4 patients did not have follow up scans, and could not be included). Mean age TRANSCRANIAL SONOGRAPHIC DELINEATION OF INTRACEREBRAL
was 77 years (range 37-95), NIHSS 16 (range 7-29); 30% were first imaged <6 HEMORRHAGE –A PROSPECTIVE MULTICENTER STUDY
hrs, 40% from 6-12 hrs and 30% from 12-24 hrs. Lactate (34.4±21.2 vs 18.9±9.7 K. Meyer-Wiethe, R. Kern, S. Meairs, G. Seidel
p<0.01) but not NAA (122.1±23.9 vs 115±30.6 p=NS) was elevated in mismatch University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
tissue compared with normal brain. However, there was no difference in mismatch
tissue at baseline in lactate or NAA between infarcts that expanded versus those that Background: A prospective study was performed in patients suffering from acute
did not (lactate 39.3±20.5 vs. 23.9±27.3, p=NS; NAA 118.7±23.4 vs. 137±18, intracerebral hemorrhage (ICH) in two German stroke centers to determine sensi-
p=NS respectively). Furthermore there was no difference in mismatch tissue over tivity, extent of midline shift (MLS) and lesion volume determined by transcranial
the first five days in lactate or NAA between lesions that grew and not. ultrasound (US).
Summary: Lactate may be a marker of ischaemia, but its presence in mismatch Materials and methods: US was performed with two systems (Philips SONOS
tissue does not predict infarct growth. Infarct growth must be related to other 5500 and HDI 5000) via the temporal acoustic bone window. We used sector trans-
individual factors. ducers at 2 MHz obtaining axial and coronary imaging planes. The sonographers
were blinded to the results of computed tomography (CT) performed in each patient
as a reference.
Results: 33 consecutive patients suffering from acute ICH (mean age 65 years,
range 37 -84, median NIHSS 8/34) were investigated within 48h of symptom onset.

118 Cerebrovasc Dis 2007;23(suppl 2):1–147 16th European Stroke Conference


There was no difference in baseline characteristics between the patients from the Results: We analyzed 340 DWI and 177 MT scans and both modalities in 124
different centres. The localisations of the lesions were as follows: 23 basal ganglia, subjects. ADC and MTR values showed a significant inter-site variation which was
2 frontal, 5 parietal, 2 temporal, 1 occipital lobe. In 30 of 33 patients (91%), US stronger for the MTR. After z-score transformation multiple regression analysis
identified the lesion correctly. In three patients ICH could not be detected due to showed WMH severity and age as significant predictors for all ADC and MTR
inadequate insonation conditions. Both US and CT showed no case of significant histogram metrics of NABT. Only lesional ADC was increasing with WMH severity
midline shift of > 2 mm. CT depicted ventricular hemorrhage in 12 patients (US: 7 while such correlation was not seen with MTR.
patients – sensitivity 0.58, specificity 1.0). There was a close correlation between Conclusions: Despite some variation from a multi-centric collection of ADC and
blood clot volume measured in CT and US (r = 0.85, P < 0.001, n = 30). MTR data both modalities appear sensitive for changes in NABT which appear
Conclusions: In this prospective multicenter study US correctly diagnosed, lo- to occur with ageing and increase with the severity of WMH. However, the ADC
calized and measured intracerebral hemorrhage in patients with adequate bone was more sensitive for discerning tissue changes within WMH and their relation to
windows. In contrast, US depiction of ventricular hemorrhage showed high lesion size.
specificity, but low sensitivity.
This study is part of the UMEDS project (Ultrasonographic Monitoring and Early
Diagnosis of Stroke) funded by the European Commission (QLG1-CT-2002-01518). 10 Brain imaging – new developments
CHANGES IN BRAIN VOLUME 2 YEARS AFTER EC-IC BYPASS SURGERY:
8 Brain imaging – new developments A PRELIMINARY SUBANALYSIS OF THE JAPANESE EC-IC BYPASS TRIAL
J. Jinnouchi, K. Toyoda, T. Inoue, S. Fujimoto, S. Gotoh, K. Yasumori,
DIAGNOSTIC VALUE OF COMBINED ANALYSIS OF T2-WEIGHTED S. Ibayashi, M. Iida, Y. Okada
GRADIENT ECHO IMAGING AND POSTCONTRAST TIME-OF-FLIGHT MR National Hospital Organization Kyushu Medical Center, Nippon Steel Yawata
ANGIOGRAPHY IN HYPERACUTE ISCHEMIC STROKE Memorial Hospital, Kitakyushu, Japan
S.I. Sohn, C.H. Sohn, H.W. Chang, S.H. Choi, S.R. Kim, H.C. Park
Keimyung University, DongKang Hospital, Andong General Hospital, Daegu, Background: Changes in cerebral blood flow (CBF) may be associated with brain
South Korea atrophy, especially in patients with cerebral artery occlusive disease. However,
previous studies have failed to find a significant relationship between CBF and
Background: Identifying the composition and the length of clot may be important brain atrophy. Recently, Japanese extracranial-intracranial (EC-IC) bypass trial
in choosing the optimal treatment on acute thrombolysis. We assessed the diagnos- (JET) revealed that EC-IC bypass was effective for stroke prevention. JET is a
tic value of combined analysis of T2-weighted gradient echo imaging (GRE) and multicenter, randomized, prospective study of patients with hemodynamic brain
postcontrast MR angiography (PC-MRA) in patients with acute middle cerebral ischemia due to cerebral artery occlusive disease. Here, we compared the changes
artery (MCA) occlusion. in brain volume and cerebral hemodynamics in patients with and without EC-IC
Methods: From May 2004 and December 2006, consecutive 49 patients with bypass surgery.
occlusion of the MCA M1 segment within the first 6 hours from the onset of Methods: We registered 10 Japanese patients with mild ischemic stroke for the
symptoms admitted to our emergency department were enrolled. Then all patients JET. Six patients successfully underwent EC-IC bypass surgery and 4 were treated
were imaged using acute stroke MR protocol included GRE for susceptibility medically. We studied changes in brain volume on magnetic resonance imaging.
vessel sign (SVS) and pc-MRA for the length of occlusion and had conventional We also examined the association of cerebral hemodynamics on single photon
angiography. We classified into 4 groups as the visibility and length of GRE SVS emission computed tomography with the changes in brain volume. The differences
and the signal gap of PC-MRA: longer clot length of GRE SVS than the signal gap between patients with and without EC-IC bypass were investigated.
of PC-MRA (group A), longer signal gap of PC-MRA then the length of GRE SVS Results: The affected/unaffected ratio of the % brain volume declined in patients
(group B), the signal gap of PC-MRA without GRE SVS (group C), non-visible of without EC-IC bypass surgery (p<0.02, n=4), and the affected/unaffected % rCBF
the signal gap of PC-MRA and negative GRE SVS (group D). MR findings were ratio increased in patients with the surgery (p<0.03, n=6). Acetazolamide reactivity
compared with findings of conventional angiography. increased in the affected hemisphere of patients with surgery (p<0.01). Two-year
Results: Among 49 patients, 42 (85.7%) patients with good MR imaging were increase (decrease) in acetazolamide reactivity of the affected hemisphere showed
selected (23 men, mean age: 66.5). Group A was the most common type. The a significant positive correlation with 2-year changes in the affected/unaffected %
difference of the length and the gap in group A and B may be associated with the brain volume ratio (R2 = 0.737, p=0.0007).
shape of thrombus. Long difference assumed oval shape clot and short difference Conclusions: Change in acetazolamide reactivity might be a good predictor for
tended to be barrel shape clot. Group C showed focal occlusion of the MCA M1 brain atrophy in cerebral artery occlusive disease.
segment by atherosclerosis. Group D had poor collateral circulation on conventional
angiography.
Conclusions: Compared to independent analysis of GRE SVS or PC-MRA in 11 Brain imaging – new developments
patients with acute arterial occlusion, combined analysis was showed more accurate
information for the clot property and occlusion status. PERFUSION PATTERNS IN PATIENTS WITH SEVERE INTERNAL CAROTID
ARTERY DISEASE USING PERFUSION-CT
M.G. Delgado, V. Mateos, S. Calleja, R.L. Roger, P. Vega, C.H. Lahoz
9 Brain imaging – new developments Hospital Universitario Central de Asturias, Oviedo, Spain

GLOBAL CHANGES ON DIFFUSION WEIGHTED IMAGING (DWI) AND Introduction: Cerebral perfusion profile of patients with chronic internal carotid
MAGNETIZATION TRANSFER (MT) IN RELATION TO WHITE MATTER artery disease has not been well studied.
HYPERINTENSITIES: THE LADIS STUDY Material/Methods: Between January 2006 and January 2007, we studied consec-
S. Ropele, A. Seewann, W. van der Flier, L. Pantoni, E. Rostrup, T. Erkinjuntti, utive patients with severe internal carotid artery (ICA) disease by CT-Angiography
L.-O. Wahlund, R. Schmidt, F. Barkhof, F. Fazekas and Perfusion-CT. Hypoperfusion was defined as increased MTT, decreased CBF
Medical University Graz, Graz, Austria and CBV.
Five perfusion patterns are described: cerebral hemisphere hypoperfusion (type 1),
Objective: DWI and MT imaging should improve the detection and quantification middle and anterior cerebral arteries territory (MCA and ACA) hypoperfusion (type
of cerebral tissue changes associated with white matter hyperintensities (WMH). 2), MCA territory hypoperfusion (type 3), watershed territory hypoperfusion (type
Supportive data come mostly from single centres which studied only one modality 4) and normal pattern (type 5).
in small and selective groups of individuals. We therefore aimed to investigate Results: We identified 26 patients, 24 males and 2 females. 73% of patients had
and compare the sensitivity of these techniques for describing changes in normal critical ICA stenosis and 27% of patients had ICA occlusion. Perfusion patterns
appearing brain tissue (NABT) and WMH in a multi-centre setting. were: 38% type 1, 31% type 2, 15% type 3, 8% type 4, 11% type 5. In ICA
Subjects and methods: Within the LADIS study investigating the impact of WMH occlusion we only found 3 patterns: 43% type 1, 43% type 2 and 14% type 3.
on 65 to 85 year olds without prior disability we obtained DWI and MT in 9 In critical ICA stenosis we found: 37% type 1, 21% type 2, 16% type 3, 10%
centres with 1.5T whole body systems from different manufacturers. Lesions were type 4 and 3 patients (16%) had a normal perfusion study (type 5) with anterior
delineated on the FLAIR images; apparent diffusion coefficient (ADC) and MT collateral circulation preserved and ipsilateral posterior communicating cerebral
ratio (MTR) maps were calculated, co-registered and the respective values assessed artery absence. Six patients (26%) with abnormal perfusion study had a complete
globally for WMH and NABT by means of histogram analysis. The mean value, circle of Willis.
the peak position (PP), and the relative peak height (rPH) were related to subjects’ Conclusions: The majority of patients with critical ICA stenosis or occlusion had
age and WHM severity. cerebral perfusion deficit. There were more patients with critical ICA stenosis than

Poster Session Cerebrovasc Dis 2007;23(suppl 2):1–147 119


Brain imaging – new developments
occlusion with cerebral hemisphere perfusion deficit (type 1). A normal perfusion 14 Brain imaging – new developments
study can be found in symptomatic patients.
CT PERFUSION IN ASSESSMENT OF BRAIN CIRCULATION IN PATIENTS
WITH STENOSIS OR OCCLUSION OF INTERNAL CAROTID ARTERY
12 Brain imaging – new developments G. Witkowski, P. Richter, A. Rozenfeld, R. Poniatowska, A. Dowzenko,
H. Jarosz, D. Ryglewicz
INTER-OBSERVER AGREEMENT ABOUT THE PRESENCE AND Institute of Psychiatry and Neurology, Warsaw, Poland
DISTRIBUTION OF BRAIN MICROBLEEDS IN ADULTS WITH STROKE
C. Cordonnier, G. Potter, C. Jackson, C.L.M. Sudlow, J.M. Wardlaw, Background and purpose: The risk of stroke due to severe stenosis or occlusion
R. Al-Shahi Salman of internal carotid artery (ICA) is higher in patients with insufficient collateral
Division of Clinical Neurosciences, University of Edinburgh, Edinburgh, United brain circulation. Transcranial Doppler Ultrasonography (TCD) is routinely applied
Kingdom for assessment of collateral circulation. Computer tomography perfusion (CTP)
imaging is used in the clinical practice especially in the evaluation of brain blood
Background: The increasing use of haem-sensitive gradient echo (GRE, T2*) flow during acute stroke, transient ischemic attacks (TIA), in epileptogenic foci and
sequences in magnetic resonance (MR) imaging of stroke has lead to frequent differential diagnosis of brain tumors. CTP also can be applied in assessment of
detection of brain microbleeds (BMBs). If BMBs are found to be of diagnostic brain circulation in patients with unilateral stenosis of ICA.
or prognostic significance, and are used for these purposes in clinical practice, The aim of the present study was to correlate the signs of collateral circulation in
observer variation in their assessment must be known. TCD with the results of CTP in patient with symptomatic carotid arterial occlusion
Methods: Two doctors assessed the MR imaging of 264 adults with stroke. or stenosis.
BMBs were defined as small, homogeneous, round foci of low signal intensity on Methods: 17 patients hospitalized in First Department of Neurology, Institute of
T2*-weighted images of less than 10 mm in diameter. Reviewers were blinded, Psychiatry and Neurology with TIA due to stenosis or occlusion of ICA were
and quantified BMBs on each side of the brain in the following locations: lobar introduced to the study. 4 patients were previously treated with the intravas-
(cortex, grey-white junction, deep white matter), deep (basal ganglia grey matter, cular occlusion (Gold Baloon) because of carotid cavernous fistula and brain
internal capsule, external capsule, and thalamus), and posterior fossa (brainstem aneurysm. In Doppler examination blood flow through ophthalmic artery and
and cerebellum). anterior communicant artery was estimated. CTP was routinely applied in all cases.
Results: Thirty percent (95% confidence interval [CI] 26-34) of patients had 1 Results: Unilateral cerebral hypoperfusion was more pronounced in case of insuffi-
BMB or more. Agreement about the presence/absence of BMBs at any location was cient cerebral collateral circulation. In these patients Mean Transit Time parameter
moderate (75%, 95% CI 70 to 80; kappa 0.44, 95% CI 0.32 to 0.56). Agreement (MTT) was prolonged for about 30-40%.
was worse in lobar locations (81%, 95% CI 76 to 85; kappa 0.44, 95% CI 0.30 to Conclusion: CT perfusion can be considered as a complementary method to TCD.
0.58) than in deep locations (90%, 95% CI 86 to 93; kappa 0.62, 95% CI 0.48 to This examination helps to estimate the influence of arterial stenosis or occlusion
0.76) or the posterior fossa (95%, 95% CI 92 to 97; kappa 0.66, 95% CI 0.47 to on cerebral blood flow. It can also predict the increased risk of ischemic stroke in
0.84). patients with carotid stenosis.
Discussion: This study provides insight into one of the reasons why inter-observer
agreement about the presence of BMBs is only moderate. Agreement was moderate
in lobar locations, but substantial in deep areas and the posterior fossa. This may be
due to the existence of BMB mimics in lobar locations, especially vessel flow voids. Interesting cases
We will explore agreement about BMB size and number, and ways of increasing
agreement about lobar BMBs, in an effort to develop a BMB grading scale.
1 Interesting cases
13 Brain imaging – new developments MULTIPLE LOCALISED CERVICOCRANIAL ARTERY DISSECTIONS
DEVELOPING AFTER AORTIC ARCH DISSECTION
STUDIED ON BROCA’S APHASIA BY DIFFUSION TENSOR IMAGING A. Lovrencic-Huzjan, V. Vukovic, S. Antic, I. Galinovic, V. Demarin
Y. Zhang, S. Wang, C. Wang, X. Zhao, Y. Wang University Hospital, Zagreb, Croatia
Beijing Tiantan Hospital, affiliated with Capital University of Medical Sciences,
Beijing, China A 56-year old male without vascular risk factors, presented with syncope, shock
and encephalopathy afterwards. The diagnosis of aortic arch dissection was set.
Background and purposes: Diffusion tensor imaging (DTI) is sensitive to the rate Aortic arch was operated, aortic valve was replaced and warfarin was introduced.
and direction of water diffusion, The fibers distributing of language functional During the first year of follow up, he was symptom-free. However carotid color
areas exhibit that extensive and complicated relationship between language areas Doppler (CCD) showed a newly developed localized distal right common carotid
and other areas. We studied Broca’s aphasia cases by the technique in order to and proximal internal carotid artery dissection. During the second year of follow
comprehend clinic symptom of the aphasia type. up, he was ten months symptom-free. Afterwards, he had two attacks of vertigo
Methods: DTI in axial covering the entire brain volume were obtained in thirty and nausea, without vomiting. No other neurological symptoms or signs developed.
volunteers and thirty Broca’s aphasia patients who suffered from left hemisphere He started complaining on the pain in the right shoulder. CCD confirmed persistent
damaged after stroke. Used SIEMENS DTI software to post process and to measure right carotid dissection, and a new right subclavian artery dissection was displayed.
fractional anisotropy (FA) value and display the course of Broca’s area and the This is the first report of a previously healthy patient who developed consecutive
mirror side. localized carotid and subclavian dissections during two-year follow-up of aortic
Results: The results showed that the left Broca’s area FA of volunteers was 0.3081 arch dissection.
± 0.0325, the mirror side was 0.3069 ± 0.0630, and there were no significant
between them (p>0.05). On the other hand, the left Broca’s area FA of Broca’s
aphasia patients was 0.2578 ± 0.05260, right corresponding area was 0.3063 ± 2 Interesting cases
0.0562, there were significant between them (p<0.05).
Conclusions: The Broca’s area fibers of Broca’s aphsia were damaged. and using BILATERAL ISCHAEMIC STROKES IN A 33 YEAR OLD WOMAN WITHIN A
DTI can analyse the fibers distributing of language functional areas, offer anatomy FEW MONTHS OF PITUITARY IRRADIATION
information for clinic and explain the baffling of neurology of widen activating G. Beamond, K. Murray, P. Keston, C. Sudlow
signal language areas on cortex. Key words: DTI, Broca’s Aphasia, Broca’s area University of Edinburgh, Edinburgh, United Kingdom

Cranial irradiation is associated with increased stroke risk, usually years after
exposure. We describe a 33 year old female with recurrent ischaemic strokes,
starting only 4 months after cranial irradiation.
She presented initially with acromegaly and a pituitary macroadenoma on MR
brain scan. After transphenoidal hypophysectomy, she received octreotide and
45Gy of radiotherapy to the pituitary bed in 25 fractions over 5 weeks. Subsequent
hypopituitarism was treated with DDAVP, hydrocortisone, thyroxine and the oral
contraceptive.
4 months later she developed sudden onset apraxia, agnosia, acalculia and agraphia,

120 Cerebrovasc Dis 2007;23(suppl 2):1–147 16th European Stroke Conference


transient episodes of right arm jerking, right-sided weakness and dysphasia. MR cyclophosphamide. However his aphasia and weakness persisted. Retrospective
brain scan, MR angiography and CT angiography showed bilateral hemispheric analysis of his initial CT neck scan showed signs of inflammation within the left
watershed infarction, complete occlusion of the cavernous sinus portion of the right carotid sheath.
internal carotid artery (ICA) and severe stenosis of the intracavernous left ICA. She Wegener’s Granulomatosis is a rare cause of central nervous system infarction,
had no vascular risk factors, and investigations for causes other than radiotherapy usually due to small vessel vasculitis. We present a case of carotid artery thrombosis
were negative. She received aspirin and then warfarin. Her neurological deficit related to extravascular granulomatous involvement of a large vessel. There is no
almost completely resolved over the next few weeks, and subsequent CT perfusion reported association between ankylosing spondylitis and Wegener’s granulomatosis.
scan showed good perfusion bilaterally. 11 months after her initial strokes, warfarin
was discontinued and aspirin re-started. She re-presented 2 weeks later with further
left hemisphere ischaemic strokes and radiological evidence of complete occlusion 5 Interesting cases
of both intracavernous ICAs. Warfarin was re-started. Several months later she had
residual language difficulties and mild right upper limb dysfunction. CLINICAL PRESENTATION OF INTERNAL CAROTID ARTERY
We assume that her recurrent strokes are due to large artery radiation-induced arteri- DISSECTION: REPORT OF 10 CASES
tis with associated thromboembolism. Such early development of this complication I. Divjak, M. Jovicevic, A. Jovanovic
has not been described previously. Institute of Neurology, Clinical Centre Novi Sad, University of Novi Sad, Novi
Sad, Yugoslavia

3 Interesting cases Background: Internal carotid artery dissection (ICAD) is a recognized cause of
stroke, particularly in young adults. It may occur spontaneously or result from local
HEAD POSITION DEPENDENT VERTEBROBASILAR TIA’S trauma. Clinical diagnosis may be difficult and the classical triad of symptoms is
A.A. Weck, H. Hungerbühler, A. Mironov, G. Schwegler uncommon. Imaging plays a pivotal role in the diagnosis of ICAD. The aim was to
Cantonal Hospital of Aarau, Aarau, Switzerland analyze the spectrum of clinical presentation in 10 ICAD patients, with a special
emphasis put on a patient presenting with Horner’s syndrome and facial and neck
Based on studies using duplex ultrasonography mechanical compression of the pain as the only symptoms of ICAD.
extracranial vertebral artery (VA) during rotation of the head is not very rare, but Methods: Ten patients with ICAD aged 35-45 (mean age 42.1 years) were
hardly ever symptomatic with signs of vertebrobasilar ischemia. As a general rule, to evaluated in the period January 2001 – December 2006. The ICAD diagnosis was
become symptomatic prearranged anatomical conditions in the vertebrobasilar cir- established using MRI, MRA and duplex sonography in all cases. In one case CT
culation must be present: flow restriction in the contralateral VA (occlusion/severe angiography was additionally performed.
stenosis/hypoplasia) and lack of functioning posterior communicating arteries. Results: Four patients presented with facial pain, Horner’s syndrome and con-
We report a 62 years old man who suffered from blurred vision after head rotation tralateral sensorimotor deficit. One patient presented with facial and neck pain and
to the right side. Back in the neutral position his visual symptoms resolved rapidly. Horner’s syndrome only. Five patients presented with contralateral sensorimotor
Driving car was a major problem for him due to impaired sight by turning his head deficit, with or without speech impairment. Two patients had traumatic ICAD (one
to watch the traffic on the right side. while unloading sacks of corn and the other after sudden head turning) and other
Ultrasonography showed a normal right VA and a severe hypoplasia of the left VA eight patients had spontaneous ICAD. MRI revealed infarction in 9 patients, while
(1.2 mm diameter). Both posterior communicating arteries were absent. Transcra- in the patient presenting with facial and neck pain and Horner’s syndrome diffusion
nial colour coded sonography documented a massive decrease of flow velocities in MRI did not show evidence of infarction. Good outcome (defined as modified
the posterior cerebral artery during head turning to the right reproducing his typical Rankin score of 0-2) was seen in all patients. Complete recanalization of ICAD
symptoms (video demonstration) and a transient reactive hyperemia of BFV above was associated with favorable prognosis.
baseline values by return to the neutral position. Angiography of the right VA was Discussion: The spectrum of clinical presentation of ICAD is variable. ICAD is
normal in neutral position. By turning the head to the right, the VA became stenotic not necessarily accompanied by infarction on diffusion MRI.
at level C6-C7 (V2 entrance zone). After maximal head rotation the bloodflow
distal of the C6/7 segment stopped due to mechanical occlusion at that level. The
cervical spine CT revealed no relevant osteophyte formation at C5/6 and C6-C7. 6 Interesting cases
We suggest a rotational obstruction due to extraluminal cervical fascial bands of
the longus coli muscle. Surgical evaluation is planned. BILATERAL SPONTANEOUS CAROTID ARTERY DISSECTION
The TCCD monitoring of the posterior cerebral artery is a reliable and reproducible H. Weitenberg, M. Uyttenboogaart, J. De Keyser, G.J. Luijckx
method to detect cases of vertebrobasilar insufficiency dependent on head rotation University Medical Centre Groningen, Groningen, The Netherlands
and mechanical compression.
Background: Spontaneous carotid artery dissection is a cause of ischemic stroke
in the young. In this case we report a patient with spontaneous bilateral carotid
4 Interesting cases artery dissection.
Case: A previous healthy 40 year old man presented with an isolated Horner
INTERNAL CAROTID ARTERY OCCLUSION DUE TO WEGENER’S syndrome on the right side. Several weeks before patient had an upper airway
GRANULOMATOSIS infection. This was followed by a period of right sided headache. Besides the
T. Das, W. Sunman, R.H. Harwood, J. Beavan, S. Munshi Horner syndrome neurological examination was normal. MR angiography (MRA)
Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom revealed a dissection of the right carotid artery from bifurcation to skull base with
a fresh trombus and a dissection with a double lumen of the left carotid artery.
A 44 year-old male presented to the Emergency Department (ED) with profuse To prevent tromboembolic complications patient was treated with antiplatelet
epistaxis. Three months previously he was seen by otorhinolanrygologists for therapy for a year. Control MRA showed normalisation of the right and a slight
left sided otalgia, tinnitus and hearing loss. They noted left middle ear effusion pseudo-aneurysm of the left carotid artery.
and a polyp in the post-nasal space. Computed Tomography (CT) of the neck Discussion: The pathogenesis of spontaneous carotid dissection is at present
demonstrated an ulcerated pharyngeal mass. A nasopharyngeal biopsy showed uncertain. If multiple vessels are involved fibromuscular dysplasia, Ehlers-Danlos,
a granulomatous lesion with central necrosis. A diagnosis of tuberculosis was Marfan syndrome, osteogenesis imperfecta and alpha-1-antitrypsin deficiency
considered as he had severe ankylosing spondylitis and was being assessed for should be considered. These conditions were ruled out in this patient. Recently
anti-TNF therapy. He had no vascular risk factors. an association between spontaneous carotid artery dissection and upper airway
In the ED, he developed sudden-onset aphasia and right hemiplegia, with a left infection has been reported. Suggested pathophysiological mechanisms are local
Horner’s syndrome. CT head scan showed a hyperdense left middle cerebral artery infection of the arteries, or mechanical by sneezing. The higher incidence of carotid
and early signs of cerebral infarction. He had greatly raised inflammatory markers, artery dissections in autumn is an argument for the possible relationship with
a mild anaemia and normal renal function. Electrocardiography, urinalysis and upper airway infection. This case demonstrates that after excluding an underlying
chest X-ray were normal. His cANCA (PR3) level was high and indicative of connective-tissue disorder upper airway infection should be considered as a cause
Wegener’s granulomatosis. of spontaneous bilateral carotid artery dissection.
Magnetic Resonance Imaging showed a nasopharyngeal mass involving the hor-
izontal petrous carotid canal and occlusion of the left internal carotid artery
from its origin to the middle cerebral artery M1 segment. Catheter angiogram
showed no evidence of pseudoaneurysms in external carotid artery branches as the
cause of his epistaxis. He was treated with intravenous methylprednisolone and

Poster Session Cerebrovasc Dis 2007;23(suppl 2):1–147 121


Interesting cases
7 Interesting cases Wernicke’s aphasia is usually associated with a lesion of the posterior part of the
lateral temporal areas, namely Wernicke’s area, conduction aphasia is associated
TRANSIENT ISCHEMIC ATTACK AND LIVEDO RACEMOSA – with lesion of the left arcuate fasciculus or of the left supramarginal gyrus, and so
ANTIPHOSPHOLIPID SYNDROME on. However, we found that not all aphasia types met with the pattern.
L. Valdemar, A. Marinho, G. Lopes A fifty-six man suffered from aphasia after stroke, he understanded what words
Dept. Neurology, Hospital Geral de Santo António, Porto, Portugal mean, but had trouble performing the motor or output aspects of speech, and he
couldn’t communicate through writing. The results of Western Aphasia Battery
Background: The Antiphospholipid Syndrome (APS) is an autoimmune disor- showed he was Broca’s aphasia, but we found the damaged lesion was Wernicke’s
der characterized by persistently elevated titters of antiphospholipid antibodies, area instead of Broca’s area. On the other hand, we studied regional blood volume
associated to thrombotic events, without vasculitis, typically affecting females (rCBV) and regional cerebral blood flow (rCBF), mean transit time (MTT), and
(82%). Ischemic stroke is reported in 30% of the patients with APS, with transient time to peak (TTP) of Broca’s area of the patient by perfusion-weighted imag-
ischemic attacks (TIA) representing one third of them, but only 7% at disease ing, and compared with that of the contralateral hemisphere, we also measured
onset. Livedo Racemosa (LR) is a rare pathologic skin condition occurring in some the metabolic rate of N-acetylaspartate (NAA), choline (Cho), and creatine (Cr)
immunologic disorders. When associated to cerebrovascular disease it is called by magnetic resonance spectroscopy, and compared the results with that of the
Sneddon’s Syndrome (SS). contralateral hemisphere. We found the Broca’s area were in a hypoperfusion and
Case presentation: A fifty three years old male patient, with hypertension, hypometabolism state compared with the contralateral hemisphere, maybe this can
suddenly became nauseated, vomited, and had vertigo and disequilibrium. The explain why the type of this case was Broca’s aphasia while damaged lesion was
neurological examination showed dysarthria, right dysmetria and ataxic gait. He Wernicke’s area. The aphasia case challenged the anatomy of aphasia theory.
also had an exuberant LR. He completely recovered from all symptoms and
signs in less than 24 hours. The cerebral MRI showed bihemispheric ischemic
leukoencephalopathy and no signs of acute ischemia with diffusion technique. High 10 Interesting cases
and persistent titters of autoantibodies were found (anticardiolipin, antiB2GPI and
lupus anticoagulant). AngioMRI, transcranial Doppler, ultrasonography of cervical RECURRENT TRANSIENT ATAXIC HEMIPARESIS REVEALING A
and renal arteries, ECG, transesophagic echocardiogram and serologic studies were HYPOGLYCAEMIC PARANEOPLASIC SYNDROME
normal. Anticoagulation was started. P. Olivier, J. Zapf, P. Michel
Discussion: This patient, with a cerebellar TIA, presented as a SS and fulfils Centre Hospitalier Universitaire Vaudois, Switzerland
clinical, imagiological and laboratorial criteria for APS with LR. Ischemic cere-
brovascular disease can be a manifestation of APS, but its association with LR is Aim: We describe a patient presenting with recurrent ataxic hemiparesis as a
rare. This clinical presentation, in a male patient, is even less frequent. Relationship consequence of hypoglycaemia due to a benign pleural fibrous tumour.
between SS and APS with LR is not clear, as these two entities are clinically Case description: A 80 year old hypertensive women with a history of a pleural
indistinguishable and classified as a continuous spectrum of a disease. tumor resected 11 years earlier presented four episodes of mild transient right
hemiparesis and mild confusion upon awakening on four consecutive mornings.
On admission, mild right ataxic hemiparesis was present. At the end of her first
8 Interesting cases night in the stroke unit, worsening of the right ataxic hemiparesis and decreased
vigilance occurred.
AN UNRECOGNIZED CAUSE OF THUNDERCLAP HEADACHE: Investigations: Head CT and CT-angiography were performed. Blood sugar, in-
REVERSIBLE CEREBRAL VASOCONTRICTION SYNDROME suline, cortisol, C-peptide, insuline-like growth factor-I (IGF-I) and IGF-II were
K. Koopman, M. Uyttenboogaart, G.J. Luijckx, J. De Keyser, P.C. Vroomen measured. Thoraco-abdominal CT and PET were done.
University Medical Centre Groningen, Groningen, The Netherlands Results: Cerebral CT with angiographic sequences didn’t reveal any abnormality.
Hypoglycemia of 1.2 mmol/l was detected during worsening and neurological status
Background: An unrecognized cause of thunderclap headache (TCH) is Reversible normalized promptly with treatment. Recurrent hypoinsulinemic hypoglycaemia
Cerebral Vasoconstriction Syndrome (RCVS). We describe 3 patients with RCVS. (glycemia 1.0-2.2 mmol/L; insulin <2mUl/l (5.0-18.0); C-peptide < 0.30 ugL
Cases: Three women, aged between 40-55 yrs, presented with TCH. One patient (0.7-3.0)) was documented and required continuous glucose perfusion. Cortisol and
had a history of migraine with sumatriptan abuse and one had an exacerbation IGF-I were normal. IGF-II (740ng/ml) and "big IGF-II” fraction (212 ng/ml; 28.7%
of Crohn’s disease. SAH was ruled out by CT scan and CSF examination. MR of total IGF-II, N<15%) were elevated. An extrapulmonary tumor occupying most
venography was normal. Brain MRI in 2 patients showed infarction in the posterior of the right hemithorax was found, consistent with a benign pleural tumor on
regions. Cerebral angiography (DSA) showed diffuse beading in one patient. She PET. Thoracotomy revealed a benign pleural fibrous tumor of the fuso-cillary type,
was suspected of having primary angiitis of CNS (PACNS) but did not respond to identical to the one resected 11 years earlier. After complete resection, no more
treatment with immunosuppressants. All had increased velocities on TCD. RCVS symptoms occurred, and IGF-II and its fractions normalized.
was diagnosed and they were treated with calcium channel inhibitors. This led to Conclusion: This elderly lady presented with recurrent ataxic hemiparesis sug-
clinical improvement and normalisation of TCD within weeks. gestive of a lacunar warning syndrome. Demonstration of severe hypoglycaemia
Discussion: RCVS is characterised by a reversible segmental vasoconstriction of during these episodes led to the detection of a fuso-cillary pleural tumor. This
the cerebral vessels, most commonly occurring in women aged 20-50 yrs. It is asso- stroke-imitating paraneoplastic syndrome was related to hypersecretion of a fraction
ciated with conditions such as migraine, certain drugs and pregnancy. The striking of IGF-II, and was completely cured by resection of the tumor.
presenting feature is TCH, with or without focal signs. CSF is (near) normal, in
contrast to PACNS and SAH. Brain imaging findings vary between normal and
infarction, particularly in the posterior circulation. Segmental vasoconstriction on 11 Interesting cases
DSA does not differentiate between vasculitis and RCVS. One of the hallmarks of
RCVS is the complete reversibility of vasoconstriction on TCD. Treatment is with THREE CASES OF CEREBRAL PEDUNCULAR INFARCTION WITH PURE
calcium channel blockers, in severe cases combined with prednisone. DYSARTHRIA
These patient cases underline that (1) TCH, normal CSF, and MRI or angiographic G.S. Kim, J.H. Lee, S.A. Choi, J.H. Cho
abnormalities may point to RCVS, (2) TCD is helpful in diagnosing RCVS and (3) NHIC Ilsan Hospital, Goyang Shi, Kyungki Do, South Korea
proper diagnosis of RCVS has important therapeutic consequences.
Background: Pure dysarthria can be seen in patients with stroke involving the
corticobulbar tract, usually at the lenticulocapsular, pontine base, or cortical areas.
9 Interesting cases Infarction of cerebral peduncle is rare. Its manifestation is dysarthria-clumbsy
hand or dysarthria-one arm weakness. Pure dysarthria due to cerebral peduncular
BROCA’S APHASIA ELICITED BY WERNICKE’S AREA DAMAGED infarction is extremely rare. We experienced three cases of cerebral peduncular
Y. Zhang, N. Wie, H. Chen, N. Zhang, Y. Wang infarction with pure dysarthria.
Beijing Tiantan Hospital, affiliated with Capital University of Medical Sciences, Cases: All cases showed inaccurate articulation in the labial sound than palatal or
Beijing, China lingual sound. One with left cerebral peduncular infarction showed slight impair
of right sided hopping in neurologic examination. The others with right cerebral
Aphasia is one of the common symptoms in acute and chronic stroke patients, many peduncular infarction showed dysarthria only. There is no severe stenosis of relevant
postmortem and radiologic studies have documented the pattern of associations arterial system in magnetic resonance angiography. In short follow-up period, they
between brain lesions and aphasic syndromes, such as Broca’s aphasia is mainly showed full recovery of symptoms.
due to a lesion damaged of the left inferior frontal area, namely Broca’s area, Discussion: Dysarthria of infratentorial origin has been described in infarctions of

122 Cerebrovasc Dis 2007;23(suppl 2):1–147 16th European Stroke Conference


the basis pontis and cerebellum. We also observed pure dysarthria in patients with 14 Interesting cases
an infarction of the cerebral peduncle. Focal injury to corticobulbar tract within
cerebral peduncle seemed to be a possible cause of pure dysarthria. PRIMARY ANGITIS OF CENTRAL NERVOUS SYSTEM IN A PATIENT OF
ACQUIRED DEFICIENCY SYNDROME (AIDS), A CASE REPORT
A. Al Memar, N. Akhtar, A. Trip
12 Interesting cases Atkinson Morley Wing at St George’s Hospital London, London, United
Kingdom
CEREBRAL INFARCTION IN ACUTE (MYELOMONOCYTIC) LEUCEMIA
AT INITIAL PRESENTATION Background: Cerebral vasculitis in patients infected with human immunodefi-
S. Koskina, A. Tavernarakis, I. Xydakis, E. Mamouzelos, E. Koutra, N. Matikas ciency virus (HIV) is usually secondary to infectious agents rather then HIV
Evangelismos Hospita, Athens, Greece itself. It is extremely rare to have cerebral vasculitis where no other cause can be
found and role of HIV is postulated in genesis of cerebral vasculitis. This is a
Acute leukemia (A.L) is a rare cause of stroke in young adults. We present the case case report of 44-year-old, was diagnosed to have HIV in January 2005, when he
of a patient in whom stroke was the first manifestation of the disease. presented with features of fever headaches, night sweating and hairy leukoplakia.
The patient, a 48 years old woman,was admitted to the hospital to investigate He presented to us in December 2005 with the features of, personality change was
unremitting fever. Few days later, she suffered a stroke (left hemiplegia),and then a hemi paresis and cortical blindness. He had mild leukopenia of 3.7 ANA, ANCA
second one (right hemiparesis and aphasia), and developped thrombosis of the left and other antibodies of vasculitic screen were negative. MRI- was suggestive of
superficial femoral vein. The patient didn’t have any known risk factors other than gross abnormality involving left occipital lobe. Occipital lobe biopsy was consistent
a mild hypertension. Successive computerized tomography scans showed mainly a with clear-cut vasculitis.
hypodense area in the right temporo-parietal region. Methods: We compared the clinical and biopsy results between our case and
Blood tests were performed, that revealed evidence of disseminated intravascular previously published cases.
coagulation (D.I.C.) and positive lupus anticoagulant,while other ancillary inves- Result: PCR and histological findings looking into the possibilities of HSV 1+2,
tigations, including lumbar puncture, thoracic and oesophageal cardiac ultrasound CMV, Adeno virus, VZV, JC virus and HIV were negative there was no evidence
and carotid artery triplex were normal. of cerebral lymphoma. In the view of negative specific viral staining, and absences
Finally,the patient was diagnosed from a bone marrow biopsy,as having acute of antibodies of vasculitic screen suggest the diagnosis of primary angitis of the
myelomonocytic leukemia. Treatment was initiated, but the patient died two central nervous system in a patient infected with HIV.
months later from multiorgan failure and sepsis. Discussion: To our knowledge only eight cases are reported in literature in which
There are several mechanisms causing thrombotic episodes in acute leukemias. primary angitis of central nervous system was suspected to be associated with HIV.
D.I.C.,positive lupus anticoagulant or antiphospholipid antibody in serum, leucosta- This case Illustrates a rarity of condition but does raise the strong hypothetical
sis syndrome in leukemias with leukocytosis, or direct viral damage to endothelial link between HIV and primary vasculitis. In our case histological studies were
cells in virus induced leukemias are mechanisms encountered in the literature. The compatible with a diagnosis of primary angitis of the central nervous system, but
particularity of the present case is the fact that stroke, probably caused by D.I.C., the pathogenic role of HIV in the genesis of the vasculitic process cannot be
was the first manifestation of A.L. elucidated.
Thus, it is of the utmost importance that young adults presenting with stroke, be
investigated thoroughly to diagnose any underlying hematologic malignancy and
initiate, as soon as possible,the apropriate treatment. 15 Interesting cases
FAMILIAL SNEDDON’S SYNDROME
13 Interesting cases S. Llufriu, A. Cervera, S. Amaro, A. Chamorro
Stroke Unit, Hospital Clinic, Barcelona, Spain
ARTERIAL OCCLUSION AND STROKE AFTER CISPLATIN
CHEMOTHERAPY Background: Sneddon’s syndrome is a non inflammatory arteriopathy character-
K.A. Pasco, P. Hart ized by livedo reticularis and cerebrovascular disease. It is an uncommon cause
St George’s Hospital, London, United Kingdom of stroke in young people and it has been associated to the Antiphospholipid
syndrome. It mainly occurs sporadically, although few familial cases have been
Background: Malignancy as a risk factor for cerebrovascular disorders and as a reported. In familial cases the most common pattern of inheritance is autosomal
thromboembolic risk is well described. Cisplatin, used alone or in combination, dominant, although the gene responsible is not known.
has become standard treatment for various solid tumours. Side effects of cisplatin Case report: A 34 year-old woman with right hemiparesis, progressive ataxia
include neurotoxicity and Goldhirsch et al first described the association of acute since early childhood and frequent migraine attacks. In the last year, she had
stroke with cisplatin use in 1983, suggesting this agent increases ones risk of stroke experienced episodes of dizziness, and dysphagia. The neurological exam dis-
above that of the tumour alone. closed mild cognitive impairment, right hemiparesis, horizontal nystagmus and left
Case reports: We describe three cases of acute ischaemic stroke post cisplatin cerebellar signs. On clinical exam, prominent skin lesions -mainly in the thighs-
chemotherapy, all supported by clinical and radiological evidence. The cases are were consistent with livedo reticularis. Global atrophy, multiple and confluent
aged 17, 36 and 44 years, two female; one male and each with different tumour subcortical ischemic strokes and abundant microbleeds were found on brain MRI,
subtypes (neuroendocrine, cervical adenocarcinoma and medulloblastoma). All whereas angio-MRI, carotid ultrasonography and transesophageal echocardiogram
received cisplatin based chemotherapy in conjunction with other treatment. All had were normal. Prothrombotic states and antiphospholipid antibodies were ruled out
Middle Cerebral Artery (MCA) territory infarction 2-10 days post cisplatin therapy. as appropriate. A skin biopsy was non specific. Two sisters and one brother had
All had received more than two treatment cycles. In two cases arterial occlusion livedo reticularis and a history of early-onset stroke (neuroimaging available). The
was confirmed, in the third it was found to be highly likely. remainder sister had 2 abortions and livedo reticularis but not neurological deficits.
Discussion: Cisplatin regimes are implicated in acute stroke and the mechanisms Her father died from a myocardial infarction at the age of 54.
may be multi-factorial. Our cases could be explained by direct cisplatin endothe- Discussion: Sneddon’s syndrome is a devastating cause of stroke in the young with
lial toxicity and enhanced platelet aggregation thus leading to arterial thrombus few cases reported in the literature. We add a new family of this entity which its
formation. Work also suggests that cisplatin predisposes to a hypercoagulable main clinical findings, imaging and immunological traits are reviewed.
state through an acquired protein C deficiency or increased von willebrand factor.
Other reports suggest cisplatin induced vasospasm through hypomagnesaemia. Ad-
ditionally, our cases demonstrate the close temporal relationship between cisplatin 16 Interesting cases
administration and acute stroke onset in the absence of other cardiovascular risk
factors and support the suggestion that stroke tends to occur after several treatment INTRACRANIAL PRESSURE AND CEREBRAL BLOOD FLOW
cycles. A review in 2006 identifying cisplatin use as a stroke risk factor, more CORRELATION
so than other chemotherapeutic agents, also found the MCA territory most often I. Voznjuk, M. Odinak, S. Golokhvastov, N. Tsygan
affected, which lends further weight to our own case findings. Military Medical Academy, Russian Federation

Background: Current imaging methods are unable to differentiate neuroinflamma-


tory processes such as endothelial activation. We imaged activated endothelium in
a mouse model of acute stroke using a novel iron oxide nanoparticle MRI contrast
agent - MNP-Psel - targeted to the adhesion molecule P-selectin.

Poster Session Cerebrovasc Dis 2007;23(suppl 2):1–147 123


Interesting cases
Methods: MNP-Psel was compared to the non-targeted iron oxide MRI contrast (CRP) less than 3 and tests for vasculitis and thrombophilia were negative.
agent Feridex. In ten C57 Black 6 mice the left middle cerebral artery was Electrocardiogram (ECG) showed sinus rhythm with right bundle branch block
transiently occluded for 30 minutes while a body temperature of 36.5 ± 0.5 C was and echocardiogram a hyperechoic myocardium with restricted filling. Cardiac
maintained throughout and after the procedure. 24 hours after reperfusion, six mice MRI showed global wall thickening, oedema suggesting an inflammatory process,
were injected with MNP-Psel and four with Feridex at a dose of 2.8 mg Fe/kg. global subendocardial late enhancement characteristic of amyloid [1], and impaired
MRI scans (T1, T2, and T2*) were obtained at 9.4 T, and infarct was identified diastolic function. There was an IgG lambda paraproteinaemia with partial immune
from T2 maps. Subtraction images (pre-contrast – post-contrast) from T1 maps, T2 paresis and 20% plasma cells in bone marrow. Serum amyloid protein scan showed
maps and T2* were obtained at 1, 36, 72 and 108 minutes after contrast injection. no visceral deposition and rectal biopsy was inconclusive.
Changes in T1 and T2 values in the contralateral hemisphere were subtracted from Discussion: Systemic symptoms preceding amaurosis and a contralateral TIA and
the stroke hemisphere to reveal the infarct tissue-specific contrast accumulation an abnormal echocardiogram gave a clue to a rare cause of cardio-embolic stroke,
effect. After imaging, the mice were euthanized and brain sections through the primary amyloidosis. This was confirmed by cardiac MRI, bone marrow and serum
cortex and striatum were taken for iron histochemical staining by the Prussian blue electrophoresis. Anticoagulation is indicated despite sinus rhythm in view of a 33%
method. risk of cerebral embolism [2] due to impaired cardiac function
Results: MNP-Psel and Feridex had similar T1 effects. T2* images demonstrated References: [1] Maceira AM et al. Circulation. 2005;111:186-93. [2] Hausfater P
a peri-infarct prolonged contrast effect with MNP-Psel but not Feridex. T2 sub- et al. Scand J Rheumatol. 2005;34:315-9.
traction maps revealed a prolonged MNP-Psel infarct-specific contrast effect not
seen with Feridex. Iron staining on vessel walls in the infarct hemisphere indicated
endothelial localization of the MNP-Psel contrast agent. 19 Interesting cases
Discussion: Injection of MNP-Psel, but not Feridex, resulted in a prolonged infarct-
specific iron oxide contrast effect associated with endothelial iron accumulation. POSTERIOR INFERIOR CEREBELLAR ARTERY DISSECTION CAUSING
This suggests that MNP-Psel accumulated in infarct and peri-infarct areas via ANEURYSM AND TRANSIENT ISCHEMIC ATTACK: ANEURYSM
P-selectin-binding on activated endothelium. This demonstrates the feasibility of DISAPPEARANCE AND PREVENTION OF RECURRENT BRAIN ISCHEMIA
using MRI to image specific neuroinflammatory processes that contribute to the WITH CONSERVATIVE TREATMENT. A CASE REPORT
evolution of stroke injury. D. Muentener, A. Mironov, A. Valavanis, R.W. Baumgartner, H. Hungerbuehler
University Hospital of Zurich, Zurich, Switzerland

17 Interesting cases Isolated spontaneous dissection of the posterior inferior cerebellar artery (PICA)
causing aneurysm formation is rare. Up to 70% present with subarachnoid
“PERIPHERAL” VERTIGO OF “CARDIAC” ORIGIN. TWO CASES OF hemorrhage and remaining cases with ischemic events.
CARDIOEMBOLIC PICA INFARCTS, ASSOCIATED WITH PFO, We present a 49 year old man with vertebro-basilar transient ischemic attack (TIA).
PRESENTING AS A MISLEADING ISOLATED VERTIGO Magnetic resonance imaging showed two cerebellar DWI lesions in the territory
S. Beretta, P. Santoro, C. Ferrarese of left PICA with a normal MR angiography (MRA). Transforaminal duplex
University of Milano-Bicocca, Monza, Monza (MI), Italy sonography revealed a stenotic signal, but identification of the affected artery was
not possible. Digital subtraction angiography (DSA) performed 2 days after MRA
Background: Isolated vertigo as a manifestation of acute cerebellar infarct in the showed a stenosis and a fusiform aneurysm of the proximal left PICA likely due to
posterior inferior cerebellar artery (PICA) territory was first reported by about 25 dissection.
years ago. Nonetheless, this presentation of cerebellar strokes still represents a The patient was treated with oral aspirin. One month later another vertebro-basilar
clinical challenge, especially in young patients. TIA occurred. Aspirin was replaced by oral anticoagulation. No further ischemic
Results: We report two cases (man, age 48; woman, age 59) presenting with event was observed in the next 12 months. DSA performed 6 months after symp-
stereotyped-rotatory dizziness, nausea, vomiting, inability to stand unaided and toms onset showed complete resolution of the aneurysm, which retrospectively
nystagmus, which were evaluated in the ER by a ENT and a neurologist and were confirmed the diagnosis of PICA dissection. Anticoagulation was discontinued.
admitted to the ENT department with the diagnosis of “peripheral vertigo”. Such We conclude that dissecting aneurysms of the PICA can resolve spontaneously.
initial manifestation was followed by delayed neurologic signs within 2 days after Anticoagulation may be an efficient and safe treatment in patients with PICA
the onset. An acute, large inferior cerebellar ischemic stroke due to occlusion of dissection causing TIA and aneurysm.
the right PICA was demonstrated by CT scan in both cases. Both patients were
admitted to the acute stroke unit and received treatment with antiplatelet agents and
osmotic diuretics. Both cases demonstrated no evidence of atherothrombosis in the 20 Interesting cases
cerebral arteries, normal heart rhythm and morphology, except from a significant
patent foramen ovale (PFO). Both patients recovered completely within 3 months ISCHEMIC STROKE AFTER CHEMOTHERAPY WITH CISPLATIN,
and underwent a successful percutaneous closure of PFO. ETOPOSIDE AND BLEOMYCIN FOR A TESTICULAR NON-SEMINOMA
Discussion: Early diagnosis of cerebellar infarction simulating vestibular neuritis CARCINOMA: A CASE REPORT
is difficult and these patients are likely to be excluded from rtPA therapy. Carefully M. Vikelis, M. Xifaras, A. Basta, G. Gekas
looking for subtle neurological signs and the eventual use of diffusion weighted General Hospital of Nikea, Nikea, Greece
MRI may overcome this problem in selected patients. Finally, PFO needs to be
investigated as a potential cause of this disorder in young patients. Background: Vascular toxicity associated with cisplatin-containing chemotherapy
for testicular cancer is a side effect that its frequency has not been described
precisely. Nevertheless, major vascular complications such as stroke, myocardial
18 Interesting cases infarction and pulmonary embolism seem to occur infrequently.
Case report: We present the case of a 37-year-old man that was treated with
CARDIAC AMYLOIDOSIS - A RARE CAUSE OF TRANSIENT ISCHAEMIC a combination of cisplatin, bleomycin and etoposide (BEP) for a testicular non-
ATTACK (TIA) seminoma carcinoma. Two days after the first course of BEP he experienced
D.M. Collas sudden-onset right hemiplegia with involvement of the lower facial muscles and
Watford General Hospital, Watford, Hertfordshire, United Kingdom right homonymous hemianopia. A MRI-scan of the brain revealed an extended
infarction in the vascular territory of the right middle cerebral artery. Angiography
Introduction: A 41-year old male with a TIA is presented. of the head and neck arteries revealed a completely thrombotic right internal carotid
Method: After an initial 30 minute episode of motor and sensory loss in the right artery. There was no evidence of coagulopathy, vascular, or endocardial disease that
arm and leg the patient re-presented within 24 hours with a stroke involving face, may have led to a cerebrovascular accident and the patient had no known vascular
arm and leg. Limb weakness resolved within 1 hour and facial weakness within risk factor except for smoking. The time sequence between the chemotherapy
1 day, mild dysarthria persisting. There had been right amaurosis 6 weeks before, and the stroke clearly suggest a causal relationship between them in our patient.
and 1 week of mild confusion, 1 month of lethargy, knee pain, and weight loss Particularly, a cisplatin-related cause is probable, since such adverse effects are
and urticarial rash over a 5 month period. He had a cholesterol of 6 but no other unknown with bleomycin or etoposide.
common risk factors for stroke, being a normotensive non-smoker. Conclusion: Whereas a cause and effect relationship is probable for some vas-
Results: Computed tomography (CT) revealed a left striato-capsular infarct with cular events following chemotherapy, some cases may represent coincidence or
mild mass effect confirmed on magnetic resonance imaging (MRI), with signal may be disease related. Several factors appear to be responsible for cisplatin
increase on diffusion weighting, and normal carotids on duplex scan and MR vascular toxicity, such as an increased thrombogenicity and vascular spasm due to
angiography. Erythrocyte sedimentation rate (ESR) was 40 but C-reactive protein hypomagnesaemia. Potential late vascular toxicity has also to be taken into account.

124 Cerebrovasc Dis 2007;23(suppl 2):1–147 16th European Stroke Conference


21 Interesting cases the second stage of labour. Three hours post delivery she developed left sided
weakness, left homonymous hemianopia and a GCS of 11/15. CT Brain showed a
CEREBRAL LIPIODOL EMBOLISM WITHOUT PULMONARY large intracranial haemorrhage in the right basal ganglia.
INVOLVEMENT DURING TRANSCATHETER ARTERIAL Case 3: A 39 year old woman with a severe headache and systolic blood
CHEMOEMBOLIZATION pressure of 200mmHg eight days post-partum, developed left sided weakness.
B.G. Yoo, J.K. Kim, J.H. Ko, E.G. Kim CT Brain showed infarction in the right middle cerebral artery territory. CT
Kosin University College of Medicine, Busan, South Korea angiogram showed bilateral carotid dissection. Intravenous heparin was started and
subsequently warfarin.
Background: Use of lipiodol in transcatheter arterial chemoembolization (TACE) Five weeks later she had a new headache in her right temple. MR angiogram showed
for hepatocellular carcinoma (HCC) treatment has been found to be associated with further occlusion of the right vertebral artery. Intravenous methylprednisolone was
a number of complications. However, cerebral lipiodol embolism has been rarely started followed by oral prednisolone in view of possible recurrent inflammatory
reported. All of the reported cases of cerebral lipiodol embolism have pulmonary process.
involvement. All 3 women improved. Each patient could walk independently with residual
Case report: A 68- year-old woman with advanced HCC underwent a second weakness to varying degrees. None had speech or swallow difficulties. One patient
course of TACE at the hepatic artery using a mixture of 30 mL lipiodol. During had mild cognitive impairment not evident in everyday function.
the procedure he had dysarthria and deteriorated consciousness, followed by status The challenges in rehabilitation include strategies to cope with infant care, de-
epilepticus and semicoma. There was no breathing difficulty, and skin examination pression in not participating fully in nursing and a fear of not being able to bond
was normal. Two hours later, MRI showed restricted diffusion in the cortex and with the newborn if hospitalised for a long period. It is vital that patients receive
cortical-subcortical junction, both cerebral and cerebellar hemispheres. Two days rehabilitation as soon as possible.
later, a follow-up MRI showed multiple cerebellar and cerebral infarcts with hem-
orrhagic transformation. A transcranial doppler with a bubble study demonstrated
a right-to-left shunt. 24 Interesting cases
Conclusion: We report a patient with cerebral lipiodol embolism without pul-
monary involvement during TACE of HCC. TACE is not an innocent procedure IRON DEFICIENCY ANAEMIA AND STROKE
and clinicians must be alert to complications such as right-to-left shunt. To reduce J.C. Wöhrle, M. Silomon, M. Kaspers, R. Werner
the risk of lipiodol embolism, a smaller lipiodol dose and survey for detection of Katholisches Klinikum Koblenz, Koblenz, Germany
intracardiac shunt before the procedure can be considered.
Background: Stroke is a rare complication of iron deficiency anaemia that may
be related to reactive thrombocytosis with thrombophilia or to impaired oxygen
22 Interesting cases delivery.
Case report: A 45 year-old woman had a severe right-sided hemiparesis upon
CROSSED CONDUCTION APHASIA: A CASE REPORT awakening resolving within 30 minutes. Subsequently, symptoms recurred and
Y. Zhang, Y. Liu, X. Zhao, C. Wang, Y. Wang progressed to hemiplegia and global aphasia on arrival in our stroke unit. She was a
Beijing Tiantan Hospital, affiliated with Capital University of Medical Sciences, cigarette smoker and had felt weak for the last 3 months; she had hypermenorrhagia.
Beijing, China Immediate cranial computed tomography showed early signs of infarction in the
territory of the left middle cerebral artery (MCA). In the presence of ubiquitous
Conduction aphasia is known as a disconnection syndrome, and characterized by a high blood flow velocities, transcranial ultrasound revealed a significant reduction
comparatively reduced ability to repeat spoken language and well comprehension. in the left MCA (systolic/diastolic velocities 89/34 cm/s left vs. 193/77 cm/s
According to Geschwind, conduction aphasia results from damage to the arcuate right). There were small hypoechogenic plaques in both proximal internal carotid
fasciculus, one major pathways connects Broca’s and Wernicke’s areas. Both arteries. Thrombolysis was withheld because of severe microcytic anaemia with
Broca’s and Wernicke’s areas are left intact. We found that not all conduction haemoglobin 5.9 mg/dl and thrombocytosis (698.000/μl). We found iron deficiency
aphasia cases met with these standards. (iron 22 ug/ml, ferritin 4 ng/ml). Screening for thrombophilic factors and cardiac
A 50 year-old highly educated, right-handed man suffered from aphasia after stroke. embolism was negative. The patient received blood transfusions, low dose heparin,
And he had fluent paraphasic expression, severe impairment of repetition and poor and aspirin. Within days, sonography and MR angiography revealed normalized
comprehension without motor impairment. Western Aphasia Battery showed that flow patterns in both MCAs. Hypermenorrhagia remained the only cause of
he was conduction aphasia, and the damaged lesion was right hemisphere, thereby, anaemia. She became ambulatory, but had persistent Broca’s aphasia and a severe
he was crossed conduction aphasia case. We found that he had severe deficits spastic brachial paresis.
in repeating no-words and short memory capacity, although he failed to show Discussion: While extracranial artery thrombosis is recognized as sequelae of
cognitive limitation in phonological output tasks. severe iron deficiency anaemia (e.g. Caplan et al. Neurology 1984), isolated
By diffusion tensor imaging, we found that the fractional anisotropy (FA) values intracranial artery occlusion is exceedingly rare. Intracranial artery obstruction may
of right arcuate fasciculus were smaller than that of the mirror side, that were have been caused by embolism from proximal sites with complete resolution of the
to say the right major pathways connects Broca’s and Wernicke’s areas were original thrombus or by local MCA thrombosis.
damaged. On the other hand, we also found that the FA values of right Wernicke’s
area were smaller than that of mirror area, that means the Wernicke’s area was
also damaged, maybe this damaged can explain why the case had fluent output 25 Interesting cases
and poor comprehension and his language disorders liked Wernicke’s aphasia,
that were to say he was “Wernicke-like” crossed conduction aphasia. The case ISCHEMIC STROKE OR MULTIPLE SCLEROSIS RELAPSE AFTER 44
proved that three supposes of conduction aphasia:Wernicke-Geschwind’s theory YEARS OF REMISSION?
of disconnection, the defect pattern of auditory-speech shorten memory and the Y.-M. Huang, O. Nordmark, M. Lee, H. Naver
Bidirectional pattern. Uppsala University Hospital, Uppsala, Sweden

Background: MS and stroke differ in many ways but share a final common
23 Interesting cases path with neuronal and axonal loss. It is not known how these diseases influence
each other, nor their coincidence or best strategy concerning therapy and stroke
STROKE IN THE PUERPERIUM AND PERI-PARTUM PERIOD prevention.
K.M. Tan, A. Carroll Here we report a patient with 60 years history of MS, complete neurological
National Rehabilitation Hospital, Rochestown Avenue, Dun Laoghaire, Co. remission for >40 years and progressive gait and balance problems with spasticity
Dublin, County Dublin, Ireland for the last 5 years.
Case presentation: Woman born 1923, had at age 24, 27 and 29 right-sided optic
Stroke in the puerperium and peri-partum period, although rare, causes devastating neuritis, at age 31, 32 and 33 episodes of vertigo and diplopia, and at age 33
consequences. The following are 3 cases. an episode of slight left leg weakness and spasticity with minor sequelae. CSF
Case 1: A 28 year old woman with an acute right frontal headache developed at age 31 and 33 showed slight mononuclear pleocytosis, normal protein and
left sided weakness 10 days post caesarean section. CT brain showed right basal glucose. ACTH courses given at age 31 and 33 had beneficial effect. After 1956,
ganglia, internal capsule and parietal infarcts. CT angiogram showed right carotid she remained healthy till 2001 when gait and balance problems and left-sided
dissection. Intravenous heparin was commenced followed by warfarin. spasticity developed insidiously, making unaided walk difficult but she did not
Case 2: A 32 year old woman had a severe headache, nausea and vomiting in consult physician.

Poster Session Cerebrovasc Dis 2007;23(suppl 2):1–147 125


Interesting cases
DWI was performed in three patients. The two asymptomatic patients with DWI did
not show any acute lesion. The other one showed acute lesion in AChA territory.
Conclusion: We suggest that fibrinolysis is a therapy to take into account in CWS.
DWI was normal in treated patients who recovered.

27 Interesting cases
MIGRAINE WITH AURA AS AN ISOLATED PRESENTING SYMPTOM OF
CEREBRAL VENOUS THROMBOSIS
R.E. Petrea, J.R. Romero, S. Seshadri, J. Viereck, V. Babikian, C.S. Kase
Boston University School of Medicine, Boston, MA, USA

Background: Headache is the most common presenting symptom of cerebral


venous thrombosis. In the majority of cases headache is a non-specific symptom
accompanied by other neurological signs.
Methods: Case report. A 27 year old right handed man presented to the emer-
gency department (ED) with a 30 minute headache with visual aura and sensory
symptoms. He reported a generalized, excruciating throbbing headache followed by
bright lights in front of both eyes lasting about 15 minutes. A tingling march from
the right side of his face down to his right upper and lower limbs progressed over
another 15 minutes. All deficits resolved completely in 30 minutes. He had a total
of four episodes only with visual aura and headache, the first one 2 months prior to
the ED presentation. Two of these episodes were evaluated by head CT (computer
tomography) and lumbar puncture both of which were normal. His neurological
examination was entirely normal.
Results: MRI (magnetic resonance imaging) of the brain revealed a hyperintense
Fig. 1. Brain CT: slight bilateral signal changes in capsula externa. signal on T1 and FLAIR sequences in the superior sagittal sinus suggesting
thrombosis. Tiny venous infarcts were seen in the parietal cortex bilaterally. MRV
In May 2005, she was seen in emergency room because of sudden expressive (magnetic resonance venography) confirmed lack of flow in the superior sagittal,
dysphasia and confusion. Symptoms disappeared after 45 min. BP 170/80. When left transverse and sigmoid sinuses, extending to the jugular bulb. Laboratory
83 and having UTI, she had head trauma after fall in Febr, 2006, followed by work-up revealed a nephritic syndrome and an abnormal activated protein C
increase left-sided hemiparesis. Brain CT: unchanged. CSF: >2 oligoclonal IgG resistance. He was treated with anticoagulation with no recurrence of his headache.
bands in CSF absent in serum. MRI showed on T2 multiple pericallosal lesions Conclusions: New onset recurrent migraines with aura can be an isolated pre-
(Fig. 1, A), on T1 no gadolinium enhancement (B) and no fresh ischemic lesions senting symptom of cerebral venous thrombosis. Any headache that progresses
at apparent diffusion coefficient image (C) but leucoaraoisis. After UTI treatment, in an unusual fashion should also prompt the consideration of cerebral venous
she was mentally intact but had severe gait and balance problems and spasticity thrombosis and the appropriate imaging for diagnosis.
persistent at 10 m follow-up.
Questions:
1. Did the patient have stroke in 2001? TIA in May 2005? 28 Interesting cases
2. Cause of left-sided hemiparesis in February 2006, stroke or MS relapse?
3. Best available management both from medical and social aspects? EOSINOPHILIC VASCULITIS: A RARE CAUSE OF DOLICHOECTASIA OF
4. How can imaging help in diagnosis? THE CAROTID AND INTRACRANIAL ARTERIES
M. Labuda, S. Lanthier
Université de Montréal, Faculty of Medicine; CHUM-Hôpital Notre-Dame,
26 Interesting cases Montreal, Canada

THROMBOLYSIS IN CAPSULAR WARNING SYNDROME (CWS): FOUR Background: Present in 12% of strokes, intracranial arterial dolichoectasia (IADE)
CASE-REPORTED is associated with atherosclerosis and elastic tissue diseases, and attributed to
R.M. Vivanco, A. Rodriguez-Campello, A. Ois, M. Gomis, C. Pont, internal elastic lamina disruption. Goals: To clarify pathogenesis of IADE and to
E. Cuadrado, J. Roquer stress the diagnostic challenge of eosinophilic vasculitis (EV).
Stroke Unit, Hospital del Mar, Barcelona, Spain Methods: Case report.
Results: A 46-year-old man presented in 2005 with <2-minute episodes of aphasia
Background: CWS, first described by Donnan in 1993, is characterized by and right limb tremor and weakness without altered vigilance. In 1999, similar
stereotyped episodes of motor or sensory deficit (usually more than 3 episodes episodes were attributed to carotid and IADE and treated with warfarin for 6 months
in 24 hours). It is associated with a high risk of imminent lacunar infarction followed by aspirin. He denied allergies and other neurological, constitutional or
with permanent deficits resembling those of CWS in more than 40% of patients. systemic symptoms, except pruritus since 2003; investigation had shown skin
Pathophysiology of CWS has not been well characterized. Ischemia mechanism is infiltration by lymphocytes and idiopathic blood eosinophilia. Physical exam was
probably due to small vessel penetrating disease and hemodynamic factors associ- normal, as well as brain MRI and 24-hour EEG witnessing episodes. Selective
ated as well as molecular mechanisms. Diffusion-weighted imaging (DWI) shows brain angiography revealed progression of carotid and IADE and no arterial
acute lesions in majority of cases. There are no proven therapies for preventing stenosis. Temporal artery biopsy revealed trans-mural non-necrotic infiltration by
completed stroke in this unstable situation. The use of thrombolytic treatment was lymphocytes and eosinophils, multinucleated cells, and histiocytes forming a single
not described previously in these cases. We report four cases of CWS treated with granuloma. Blood tests showed increased white cell count (14.8 x 109/l; 37%
fibrinolysis eosinophils) and IgE level, negative HIV, aspergillus and hepatitis serologies, and
Patients and methods: Four patients were evaluated between February 2005 and normal inflammatory, prothrombotic and vitamin B12 workups. Echocardiography,
December 2006 (0.5% of ischemic stroke). 3 of them were male (75%). Mean age thoraco-abdominal CT, abdominal CT-angiography, and stool exam were normal.
was 67.5 years. Hypertension was the main vascular risk factor. Stroke symptoms Skin tests indicated pollen and cat hypersensitivity. On bone marrow biopsy, cells
were compatible with lacunar syndrome (motor pure or sensitive-motor), with mean (50% eosinophils) had no chromosomal abnormalities. His neurologic symptoms,
NIHSS 10. Number of episodes varied between 3 and 6 (mean 4). All patients were pruritus and eosinophilia resolved with prednisone (1mg/kg/d for 4 months, tapered
treated with rtPA in the first three hours since last episode. over 3 more months). We did not find previous reports of EV with IADE.
Results: 3 patients remained asymptomatic after treatment (mRS 0) and did not Discussion: EV can cause IADE by disrupting the internal elastic lamina. In this
present any other episode. One patient presented a new episode after the rtPA case, idiopathic blood and tissue eosinophilia is consistent with hypereosinophilic
with left hemiplegia (mRS 4). Blood pressure was monitored in all patients during syndrome, but vasculitis as the sole organ infiltrated by eosinophils is unexpected.
episodes and no decrease coinciding with the clinical worsening was observed. Differential diagnosis includes atypical Churg-Strauss syndrome.
In all patients laboratory tests, CT scan, non-invasive studies for carotid and
intracranial artery disease were normal. Atrial fibrillation was found in one patient.

126 Cerebrovasc Dis 2007;23(suppl 2):1–147 16th European Stroke Conference


29 Interesting cases 31 Interesting cases
MYOCARDIAL INFARCTION DURING STROKE THROMBOLYSIS: A CASE POST-PARTUM CEREBRAL ANGIOPATHY: REPORT OF THREE CASES
REPORT J. Willeit, M. Furtner, M. Knoflach, T. Gotwald, S. Kiechl
M. Herrera, M.E. Erro, J. Gállego, R. Muñoz, B. Zandio, J.A. Villanueva Dept. of Neurology, Innsbruck, Austria
Hospital de Navarra. Pamplona, Pamplona, Spain
Background: The post-partum angiopathy (PPA) is a rare disease of unknown
Background: One potential harm of thrombolytic therapy for brain infarction is etiology characterized by segmental vasoconstriction of medium-sized and large
thrombolytic-induced breakup of thrombi (mostly in the heart or aorta) leading to cerebral arteries. No standard management has been established.
new strokes, myocardial damage or limb ischemia. Methods: We report 3 cases with PPA, in whom serial magnetic resonance
Methods: We report a patient who presented a myocardial infarction during stroke tomography (MRT) and MR angiography were performed.
thrombolysis. Results: All three women delivered a healthy child after an unremarkable preg-
Case report: A 78-year-old man was admitted to the neurology stroke care unit for nancy. They received dopamin agonists to suppress lactation. After hospital
sudden aphasia and right hemiparesis. The NIH Stroke Scale (NIHSS) score was discharge the patients complained of severe headache. Two developed seizures,
15. Brain CT scan was normal. A transcranial doppler revealed left proximal ACM hemianopsia and hemiparesis. Blood pressure monitoring showed intermittent and
oclussion.The ECG showed an atrial fibrilation with normal repolarization pattern. severe hypertension. The cerebral MRT demonstrated high signal intensity lesions
The patient was started on tPA therapy 150 minutes after stroke onset. During drug in the occipito-parietal/frontal region on T2-weighted and diffusion-weighted imag-
infusion, he developed hypotension, oxygen desaturation and bradycardia. He also ing. Most of the lesions showed high signal intensity on ADC maps compatible
suffered neurological deterioration with somnolence, complete right hemiplegia with vasogenic edema, and MRA showed narrowing of large and medium-sized
and left forced gaze deviation. An anaphylactic adverse reaction was suspected and cerebral arteries. The results of extensive tests for cerebral vasculitis were negative.
tPA infusion was stopped. A new CT scan ruled out brain hemorrhage. An ECG In two of the patients, lowering of blood pressure was accompanied by complete
was perfomed with signs of anterior acute miocardial damage. A thoracic CT scan recovery of the neurological deficits and normalization of imaging findings. In the
ruled out an arterial ascending aortic dissection. A coronary angiography confirmed last patient, blood pressure lowering was without any clinical effect. Aggressive
occlusion in distal territories of left anterior descending and circumflex arteries medical therapy including high-dose methylprednisolon and nimodipin resulted in
and mechanical recanalization was unsuccessfully tried. Two days later a trans- a gradual improvement.
esophageal echocardiogram revealed an anterolateral myocardial infarction,dense Conclusion: These cases provide evidence that apart from hypertension, ergot
left atrial spontaneous echo contrast, non complicated atheromatosis in the aortic derivates might act as a trigger of PPA. PPA can be complicated by both va-
arch, and no intracardiac thrombus. sogenic edema and ischemic stroke. The clinical course is highly heterogenous,
Discussion: This patient had an ischemic stroke of a likely embolic origin from ranging from self-limited and fully reversible to vasculitis-like progressive forms.
an intraauricular thrombi; tPA therapy could have favoured the fragmentation of Apart from blood pressure-lowering therapy some patients may require high dose
this thrombi and thus facilitated a second-step coronary embolism. A shock during corticosteroids.
fibrinolytic therapy should raise the possibility of this rare complication, confirmed
by a simple electrocardiographic recording.
32 Interesting cases
30 Interesting cases DISSECTING FUSIFORM VERTEBRAL ANEURYSM IN AN ADOLESCENT:
ENDOVASCULAR TREATMENT
LEFT VENTRICLE NONCOMPACTION, MYOPATHY, DYSMORPHIC C. Semedo, M. Manita, J. Reis, P. Raimundo, P. Esperança, J.M. Cândido
FEATURES AND STROKE IN A YOUNG WOMAN Centro Hospitalar de Lisboa - Zona Central, Lisboa, Portugal
A. Mendes, F. Silveira, M. Garcia, E. Azevedo
Hospital S. João, University of Porto, Porto, Portugal Introduction: Intracranial aneurysms are rare below 18 years old, corresponding
to less than 1% of all the treated aneurysms. Most centres handle no more than 1
Background: Left ventricle noncompaction is a rare congenital cardiomyopathy case a year. Moreover, dissecting fusiform aneurysms of posterior circulation have
characterized by numerous prominent trabeculations and intratrabecular recesses a difficult approach and have been traditionally treated by parent vessel occlusion.
in the ventricles. Heart failure is the most common presenting condition. Other Nowadays aneurysmatic stent placement, with or without coiling, has become a
manifestations include arrhythmia and thromboembolic events. We present a case valuable treatment option.
of stroke associated to noncompaction of left ventricle, unspecific myopathy and Case report: 15 years-old female patient with a right sided cervical and occipital
some dysmorphic features. severe headache, thunderclapping, with nausea and dizziness, holding on for a
Case report: A 20 years old woman was referred to our department for investi- month in spite of oral analgesiae. The patient had no history of previous trauma
gation after having a left middle cerebral artery ischemic stroke with aphasia and and had been otherwise healthy. Neurological examination was normal. The CT
right hemiparesis. At 5 months of age she was diagnosed with a hypertrophic revealed an isodense, calcified lesion in the right lateral-cistern and the MRI showed
cardiomyopathy. Since her 15 years she complained with limbs fatigue and muscle to be probably a displasic aneurysm partially thrombosed with 13mm of diameter,
spasms, and an unspecific myopathy was diagnosed after investigation including with light mass effect over the adjacent medullary side, continuous with the RVA
electromyography and skeletal muscle biopsy. There was no relevant familial (right vertebral artery). The cerebral angiogram revealed a displasic/dissecting
history. She presented some dysmorphic features such as short stature, webbed fusiform aneurismatic formation of the distal RVA (V4), with PICA (posterior
neck, low hairline at the nape of the neck and bilateral cubitus valgus. The inferior cerebellar artery) originating directly from the aneurismatic sac. A Leo
patient had a good mental state and recovered from the aphasia and most of “stent” (4,5mmx20mm) was placed in VA between the two extremities, through all
the right hemiparesis. There was evidence of a distal muscular atrophy in lower the aneurism length, and after that partial occlusion of the remaining aneurismatic
limbs. Stroke investigation disclosed a left internal carotid artery (ICA) occlusion. sac was excluded with coils, with the purpose to induce the progressive thrombotic
Ecocardiography and cardiac catheterism identified left ventricle noncompaction. occlusion of the residual sac, in order to protect PICA and allow collateral circula-
Blood investigations were negative, including for serologic, immunologic and tion. The control angiogram, 2 days after, confirmed the complete exclusion of the
prothrombotic changes, as well as for muscle enzymes. Cariotype was 46, XX. She aneurysm, with the main vessel patency. The patient was discharged asymptomatic.
started anticoagulation. Six months later she remained clinically stable, and there Clinical and transcranial doppler revaluation was normal 3 months after.
was no recanalization of left ICA. Conclusions: This is an interesting case combining an aneurysm in an early
Discussion: Cardioembolism was the probable cause of stroke. Although left age with an fusiform aneurysm difficult approach, turning it into a therapeutic
ventricle noncompaction may be associated with neuromuscular involvement, like challenge. In these situations endovascular stent placement and embolization can
in Barth syndrome, it doesn’t usually affect women. Her dysmorphic features be an effective and safe method.
resemble Turner or Noonan syndromes, which could not be confirmed in this
case. To our knowledge, there is no description in the literature of the congenital
associations found in this patient.

Poster Session Cerebrovasc Dis 2007;23(suppl 2):1–147 127


Interesting cases
33 Interesting cases day. Investigations revealed anaemia (Hb-9.7) and deranged liver function tests
(Bilirubin-29, AST-99, Alkaline phosphatase-388). Initial chest radiograph, abdom-
LEFT VENTRICULAR PAPILLARY FIBROELASTOMA, A RARE CAUSE OF inal ultrasound and CT brain were normal. The epigastrc pain persisted and he
POSTERIOR CIRCULATION INFARCTION developed headache, sweating and nausea, whilst his liver function tests gradually
J. Damásio, R. Almeida, A. Furtado, L. Caiado, A. Tuna deteriorated. On the tenth day as an inpatient, he suffered a brief episode of
Hospital Geral de Santo António, Oporto, Portugal syncope. A repeat ultrasound showed mild intrahepatic duct dilatation. A magnetic
resonance cholangiopancreatogram was performed which suggested a dissection of
Background: Papillary fibroelastoma compromise approximately 7.9% of benign the abdominal aorta. Subsequent CT angiogram confirmed type A dissection of
cardiac tumours. They are most commonly detected on the cardiac valves, being aorta extending from the aortic root to both common carotid arteries and down to
the intra-ventricular localization very rare. Although mostly asymptomatic, their the right common iliac artery. He was commenced on beta blockers and surgical
clinical manifestations may be sudden death, myocardial infarction or cerebral in- repair was undertaken.
farction of cardiogenic embolic source. The embolic mechanism may be explained Aortic dissection can present deceptively and delay in diagnosis can be catastrophic
by one of two mechanisms: dislodgment of tumoral fragments or embolization of especially if thrombolytic treatment is given for treatment of the associated stroke.
fibrin thrombi that arise on the papillary surface. Such an incident has been previously reported. Our case illustrates the need for a
Case report: A 68-year-old male, hypertensive, presented with sudden dysphagia, high degree of suspicion in all stroke patients.
dysarthria, gait disequilibrium, vertigo, nausea and vomiting. On neurologic exami-
nation he had rotatory nystagmus on lateral gaze; decreased right palatal excursion;
broad based stance and gait with right side deviation. Cranial computed tomography
(CT) revealed recent infarct on the right cerebellar hemisphere. The diagnostic Recovery and rehabilitation
studies were normal except the transthoracic echocardiogram that disclosed an
ectopic, mobile mass with the stalk attached deeply in the left ventricular wall.
The patient started anticoagulation. A month later he was submitted to surgical 1 Recovery and rehabilitation
resection of the tumour. The histology revealed a papillary fibroelastoma. One year
later he was symptoms free, had a normal neurologic examination. There was no OPTIMISING REHABILITATION OUTCOMES FOR APHASIA FOLLOWING
evidence of recurrence of the tumour on control echocardiography. STROKE THROUGH NEW LEARNING
Discussion: We report a case of posterior circulation stroke of cardiogenic embolic H. McGrane
origin as a first manifestation of very rare and treatable intra-ventricular papillary Queen Margaret University College, Speech and Language Sciences,
fibroelastoma. Edinburgh, United Kingdom

Many people with aphasia retain residual language impairments to varying degrees
34 Interesting cases of severity following rehabilitation. Currently there is no theory of rehabilitation
that explains the therapeutic process involved in the restoration of a damaged
ISOLATED INFERIOR SAGITTAL SINUS THROMBOSIS (ISST) language system. Therefore it is not possible to discern what approaches/tasks
N. Tran, J. Silva would be most successful at restoring particular language functions. Does rehabili-
Hamilton General Hospital, McMaster University, Hamilton, ON, Canada tation facilitate the accessing of the damaged language system or could it involve
new learning resulting in the creation of new language representations? The main
Background and purpose: The inferior sagittal sinus (ISS) is the rarest affected objective of this study was to investigate whether adults with aphasia could learn
area of cerebral vein thrombosis. Only one previous case of isolated inferior sagittal new vocabulary. The methodology incorporated procedures based on evidence from
sinus thrombosis (ISST) has been reported. We describe a new case of isolated the literature in order to facilitate and promote optimum learning. The novel stimuli
ISST. (20 new words) were taught to 12 adults (<65 years) who presented with varying
Methods: A 70 year-old man presents with a four day history of decreased appetite, degrees of severity of aphasia. The training procedure incorporated learning theory
global weakness followed by decreased level of consciousness. He had a witnessed and a cognitive neuropsychological model of language. The immediate and delayed
right sided focal motor seizure with secondary generalization. He was found with recall of this vocabulary was investigated using a range of assessments to facilitate
right sided weakness, right facial droop, right sided hyperreflexia, drowsiness, the capture of new learning which was measured not only in terms of the accurate
disorientation to time and was febrile (39.9 C). He also had features of frontal production of the stimuli but also the recognition and knowledge of the word
lobe dysfunction including apathy, decreased insight and volitional activity. His forms and meanings. Overall findings of this investigation with the presentation
condition did not change despite empiric treatment with acyclovir, cefotaxime, of select case studies demonstrate the ability of people to learn new language
ciprofloxacin and levofloxacin. representations despite severe language impairment. The findings, which strongly
Results: Initial CT-head showed frontal paramedian hypodensities. CSF demon- suggest that language rehabilitation could incorporate the process of new learning,
strated elevated protein and pleocytosis, primarily lymphocytes. Auto-immune and have significant clinical relevance in terms of developing a theory of rehabilitation
coagulation work-up were negative. Peripheral blood cell count showed leuko- and to the procedures employed in speech and language therapy.
cytosis, mostly neutrophils, which improved spontaneously. No obvious systemic
malignancy was detected by imaging. MRI Head demonstrated high signal in
the superior and medial areas of the frontal lobes in the distribution of the ISS. 2 Recovery and rehabilitation
MR-Venogram showed attenuation of the ISS only. After anticoagulation treatment
the patient improved and managed to go home with some residual frontal lobes EFFECT OF RHYTHMIC AUDITORY CUES ON GAIT OF STROKE PATIENTS
dysfunction. Follow-up MRI showed improved ischemic area and incomplete S.I. Lin
recanalization of the ISS. National Cheng Kung University, Tainan, Taiwan
Conclusion: Primary isolated ISST can present as a febrile non-infectious en-
cephalopathy. In our case, we were unable to demonstrate any particular etiology. Introduction: Sensory regulation is a feature of bipedal locomotion control. For
patients with chronic sensory loss, it is not clear if the way sensory inputs are
used for locomotion control would be altered. This study examined if the use of
35 Interesting cases rhythmic auditory cue (RAC) for locomotion control was affected by the residual
proprioceptive function in patients with chronic stroke.
STROKE AND EPIGASTRIC PAIN: CONSIDER AORTIC DISSECTION Methods: Fourteen chronic stroke patients went through a joint repositioning test
S. Mavinamane, H.G. M Shetty, M. Robinson, K.R. Davis of the knee and ankle, and were classified into intact and impaired joint position
University Hospital Wales, Cardiff, United Kingdom sense (JPS) groups. EMG activity and peak joint angular acceleration of the
affected leg during two walking conditions, normal and with RAC, were recorded
Aortic dissection may rarely present with stroke and the diagnosis can be difficult and compared. In RC, subjects were asked to match their foot-floor-contact with a
with atypical symptoms. Thrombolysing such stroke patients can be disastrous. We beeping tone delivered by a metronome.
report a patient with Aortic dissection who presented initially with an epigastric Results: Walking speeds did not differ significantly between the two conditions
pain and stroke. or the two patient groups. Compared to normal condition, RAC had shorter EMG
A 73 year old hypertensive man, presented with a left hemiparesis and dysarthria activation time in patients with impaired JPS, but not in patients with intact JPS.
for 3 hours. He had epigastric pain for 2 weeks, which worsened significantly on the Stride characteristics did not differ significantly between walking conditions or the
day of admission. Examination revealed epigastric tenderness, dysarthria, and left two patient groups.
hemiparesis. The hemiparesis and dysarthria resolved completely by the following Discussion: Chronic stroke patients were found to use RAC to regulate locomotion.

128 Cerebrovasc Dis 2007;23(suppl 2):1–147 16th European Stroke Conference


However, the effect of RAC was not equal between patients with intact and 5 Recovery and rehabilitation
impaired lower extremity JPS: walking with cues lead to shorter EMG activation
time in patients with impaired JPS, but not in patients with intact JPS, compared to FACTORS PREDICTING EARLY HOSPITAL DISCHARGE FOLLOWING
walking without cues. These findings imply that after chronic sensory loss, changes ADMISSION FOR ACUTE STROKE
in sensorimotor processing for locomotion might have occurred and affected the J. White, L. Dacey, R. Navaratnasingam, M. Wani
use of augmented sensory cues. Thus clinically, instead of using augmented sensory Morriston Hospital, Swansea, Cardiff, United Kingdom
inputs routinely, their use should be planned and effects carefully monitored.
Background: Reducing hospital length of stay following admission for acute stroke
has economic benefits for the healthcare provider. However, identifying patients
3 Recovery and rehabilitation suitable for a reduced length of stay with early supported discharge is difficult at
the time of admission. This study explored the relationship between clinical and
THE EFFECTS OF TYPE AND INTENSITY OF PHYSIOTHERAPY ON social characteristics at the time of admission, with length of hospital stay for acute
LOWER LIMB STRENGTH AND FUNCTION AFTER STROKE stroke inpatients to predict a safe early discharge.
E.V. Cooke, R.C. Tallis, S. Miller, V.M. Pomeroy Methods: A retrospective case control study of all patients admitted with acute
St. George’s University of London, London, United Kingdom stroke to a UK hospital, over a 3 year period. Patients were categorised into two
groups, those requiring a 10 day or less hospital admission and those requiring
Background: Stroke survivors often have permanent residual motor impairment. longer. 23 separate clinical and social characteristics were assessed to evaluate their
This may be due to a sub-optimal dose of conventional physical therapy (CPT) and impact on length of hospital admission.
the discouragement of strength training. However, experimental evidence suggests Results: 359 patients, mean age 76.2 years, mean length of stay 54 days (median
that strength training might be beneficial. Hypothesis: adding functional strength 24 days), mean Barthel Score on admission 10.8.
training (FST) to CPT improves muscle function, gait and functional mobility more Ten factors, on admission, were independently associated with a reduced length
than either CPT alone or CPT plus “neuro-facilitation” (NF). of stay: CT brain scan showing no sign of haemorrhage, (odds ratio (OR) 11.07
Methods: Multi-centred randomised controlled observer-blind trial. Subjects were (95% confidence interval (CI) 1.87 to 65.11)); no receptive dysphasia (OR 7.59 (CI
within 3 months of stroke with the ability to voluntarily move their paretic lower 1.98 to 29.03)); no sensory deficit on admission (OR infinite (CI 5.49 to infinite));
limb. A power calculation estimated sample size as 102. Subjects underwent no hemi neglect (OR infinite (CI 5.72 to infinite)); sinus rhythm (OR 2.72 (CI
baseline measurements before being allocated randomly to; CPT; or CPT + NF; 1.35 to 5.49)); living with support prior to admission (OR 2.52 (CI 1.49 to 4.26));
or CPT+FST for 6-weeks. All additional therapy was provided up to1-hour/day, Functional Ambulation Categories (FAC) score ≥4 (OR 10.68 (CI 6.23 to 18.31));
4 times/week. Outcome measures were made at 6 weeks after baseline. Measure- Barthel Score ≥19 (OR 12.32 (CI 6.63 to 22.88)); and urinary continence (OR
ment battery included: muscle strength; walking speed; and functional mobility 11.98 (CI 5.66 to 25.29)).
(Rivermead). Analysis followed the intention to treat principle. Data, outcome Discussion: This study has identified 10 clinical and social factors present at
minus baseline, was tested for differences between groups using the Kruskal-Wallis admission that may help identify patients who could be potentially discharged early
test. Results: 109 subjects were recruited. Mean age was 68.3 (SD12.03) years. from hospital, allowing prompt referral to early supported discharge teams and
The attrition rate was 8.3%. Only Rivermead data is reported here. Median (IQR) other intermediate care services.
change in Rivermead score following intervention was 5.0 (9.7) for control, 6.5
(14.3) for NF and 7.0 (13.7) for FST. The Kruskal-Wallis statistic was 1.06
(p = 0.59). Discussion: Immediately after intervention no statistically significant 6 Recovery and rehabilitation
differences were found between groups for functional mobility, however there was
a trend towards CPT + FST. Muscle strength (for which the trial was powered) and DIFFERENCES IN VISUAL ATTENTION BETWEEN HEMIPLEGIC SIDES IN
gait data are currently undergoing analysis. POSTSTROKE PATIENTS
S. Shimizu, M. Maeda, Y. Ikeda, H. Nagasawa
Faculty of Rehabilitation, School of Allied Health Sciences, Kitasato
4 Recovery and rehabilitation University, Kanagawa, Japan

MOTOR NETWORK CHANGES AND FUNCTIONAL RECOVERY IN STROKE Background and purpose: We previously reported that visual attention in the
PATIENTS TREATED WITH VERY EARLY MOBILISATION IN AN ACUTE circumferential field in healthy persons was greater in the left lower field than in
STROKE UNIT. A LONGITUDINAL FUNCTIONAL MRI STUDY the right upper field. The present study investigated differences in visual attention
T. Askim, B. Indredavik, S. Mørkved, O. Haraldseth, A. Håberg between left and right hemiplegic sides based on simple reaction times (RTs) to
Norwegian University of Science and Technology, Trondheim University visual stimuli.
Hospital, Trondheim, Norway Methods: Participants were 10 stroke patients with right hemiplegia (RH group),
10 stroke patients with left hemiplegia (LH group), and 20 normal control subjects.
Background: Functional MRI (fMRI) might elucidate mechanisms of brain plas- RTs were recorded using RT estimation software on a personal computer. Fixation
ticity. The aim of this study was to investigate the relationship between functional point and reaction stimuli were presented on a screen. Stimuli were presented at
recovery and brain activation patterns after an acute stroke. one of 16 sites located on circles with radii of 1 cm or 11 cm; visual angles (VA)
Methods: 14 patients (62-75 years) with first ever ischemic stroke and unilateral were 2 degrees (VA2) or 20 degrees (VA20). Stimuli were randomly presented five
hand paresis, but intact language were included. 16 age and gender matched times at each site for a total of 80 trials, and the delay from presentation to the
controls were also investigated. All patients were treated in an acute stroke unit subject pressing a key was recorded as RT. Stroke patients used their unaffected
with very early mobilisation and early supported discharge. They underwent MRI, hand to press the key, while half of the control subjects used their right hand (CR
fMRI and functional tests 4-8 days from onset and after three months. fMRI group) and the other half used their left hand (CL group).
paradigms were 1 Hz and self-paced (SP) index finger tapping. Results and discussion: In the comparison of the LH and CR groups, RTs for the
Results: No patients had infarction involving primary motor cortex (M1). There LH group were slower; however, no significant differences were observed between
was significantly improved hand function as measured by all functional tests. 1 Hz stimuli positions. In contrast, the comparison of the RH and CL groups showed no
task: Patients in the acute phase activated more prefrontal regions than the controls. significant difference in RTs. For the RH and CL groups, RTs to left lower field
There was increased activation in contralateral thalamus, anterior cingulate cortex stimuli were significantly shorter than RTs to upper field stimuli. These results
and ipsilateral prefrontal cortex for patients in the chronic compared to the acute indicate that patients with left hemiplegia may have decreased attention in all visual
phase. SP task: Controls had significantly larger activation in contralateral M1 fields compared to patients with right hemiplegia.
and ipsilateral cerebellum than patients in the acute phase. In the chronic phase
patients had increased bilateral M1 activity compared to the controls. There was
increased activity in contralateral M1 for patients in the chronic compared to the 7 Recovery and rehabilitation
acute phase. Discussion: For the 1 Hz task the difference in activation between the
chronic and the acute phases did not involve increased activation in motor areas, DEPRESSION IN CAREGIVERS OF LONG-TERM STROKE SURVIVORS
but encompassed other cortical regions. This was at great variance to the results D. Varga, E. Boros, J. Kenez, Z. Nagy
from the SP task. These findings indicate that the injured brain adapts to different National Institute for Neurology and Psychiatry, Budapest, Hungary
motor task demands using different networks.
Objective: Caregivers of stroke patients’ may experience high levels of burden,
that can result in deterioration of the caregivers’ mental and/or physical health. Our
aim was to examine the prevalance of depression among caregivers.

Poster Session Cerebrovasc Dis 2007;23(suppl 2):1–147 129


Recovery and rehabilitation
Methods: A sample of 87 stroke survivors and their informal caregivers was rate was calculated and differences between groups were analysed with descriptive
studied. Caregiver burden was evaluated with Beck Depression Inventory and statistics. ARAT data was used to calculate the sample size for a Phase III trial.
Caregiver Strain Index. Patients’ functional, cognitive and behavioural status was Results: 30 subjects were recruited with an attrition rate=0%. No statistically
also assessed with a questionnaire yielding information pertinent to these items. significant differences were found between groups, however there was a trend
Results: 69% of caregivers of long-term stroke survivors suffered some kind for CPT+FST to produce greater improvement at a clinically relevant level: mean
of depression. In 50% the patients’ serious residual functional status, in 77% ARAT change of +13 (CPT) and +22 (CPT+FST). The power calculation estimated
mental-behaviourial symptoms were mentioned as cause of depression. Presence a sample size of 246 for a Phase III trial.
of both caused depression in 87% of caregivers. Patients generate high caregiver Discussion: Results of this pilot study suggest that increased intensity of CPT may
burden are significantly older and had significantly higher volume of cerebral not further enhance motor recovery after stroke but adding FST to CPT might.
infarction. A Phase III trial is feasible using the methods of this study although a large
Conclusion: High percentage of caregivers suffer from depression. The level of multicentre trial will be required.
self-percepted burden was stronger associated to the patients’ mental-behaviourial
symptoms, than to the degree of their disability.
10 Recovery and rehabilitation
8 Recovery and rehabilitation MODIFIED OBSERVATIONAL PERSPECTIVE AND STROKE
REHABILITATION
A PILOT STUDY INVESTIGATING THE COMPARISON BETWEEN L.M. Ewan, T. Haire, K. Kinmond, H. Chatterton, N. Smith, P. Holmes
FAMILIAR AND UNFAMILIAR ENVIRONMENT ON PATIENT’S ABILITIES Manchester Metropolitan University, Alsager, United Kingdom
TO COMPLETE AND PROCESS ACTIVITIES OF DAILY LIVING, POST
BRAIN INJURY Background and purpose: Motor imagery has been questioned as a neuropsy-
J. Scott chological rehabilitation technique for stroke patients with structured observation
Hammersmith Hospitals NHS Trust, London, United Kingdom being proposed as a more valid approach (Holmes, 2006). Similar to imagery
however, observation conditions provide two spatial visual perspectives: first and
Background: Cognitive impairment is common post-brain injury and is associated third person. Since there is evidence that the different perspectives are linked to
with poor long-term outcomes. Environmental context is thought to impact on different brain activity, the use of each perspective may be moderated post-stroke.
cognitive processing, and it is possible that the venue where cognitive abilities are The practical considerations of this change have not been examined experimentally.
assessed will influence the patients’ performance. This research explored observational visual perspective in individuals who had
The Assessment of Motor and Process Skills (AMPS) is an observational tool used experienced stroke to aid the development of observation-based rehabilitation
to measure the quality of a person’s ability to perform activities of daily living, programmes.
based on normative data for age and injury. Method: 21 individuals who had experienced stroke were matched against 19
Hypothesis: Patients’ will perform better in terms of cognitive ability, at home individuals who had not had a stroke. Following ethical approval and full written
compared to in hospital. informed consent, a stroke and observation specific questionnaire was employed to
Objective: To compare the process abilities of patients with brain injury in hospital explore viewing experiences; specifically kinesthisis. Participants viewed DVDs of
and at home using the AMPS, with a same subject design. activities of daily living from both visual perspectives.
Methods: Patients admitted with brain injury, who had cognitive impairment but Results: Non-parametric analysis indicated that individuals who had not had a
were orientated, were assessed in the hospital and at home within 48 hours using stroke showed a statistically greater preference for a first person visual perspective
AMPS. The scores for process skill (the skills needed to organize and adapt actions and reported stronger kinesthisis with this perspective. In contrast, individuals
to complete tasks) were compared at the end of the study. who had experienced stroke showed no preference for either perspective and were
Results: 7 out of the 8 patients assessed performed better within the hospital generally unable to report kinesthisis with either the first or third person perspective.
context. Discussion: Stroke may lead to a change in preferred visual perspective and experi-
ence of observational kinesthisis as a consequence the lesion damage and functional
motor inactivity. Observation-based rehabilitation interventions may support neural
Median AMPS process score Interquartile range P
change. However, further research is required to investigate these changes linked
Home 0.16 0.2-0.54 0.05 to individual differences in stroke aetiology. This study provides evidence that
Hospital 0.94 0.47-1.29 visual perspective should be considered in all imagery and observation-based stroke
rehabilitation interventions.

Discussion/Conclusion: The structure and lack of external stimuli may account


for the improved performance within the hospital context. Patients with cognitive 11 Recovery and rehabilitation
processing deficits performed better within the hospital setting. This implies that
the level of challenge therapists use to assess patients’ cognition through function FUNCTIONAL RECOVERY IN ISCHAEMIC STROKE PATIENTS YOUNGER
may need to be higher in hospital to ensure sufficient process ability at home. OR OLDER THAN 65 YEARS
J. Jansa, Z. Sicherl, K. Angleitner, A. Grad
University Medical centre Ljubljana,Ljubljana, Slovenia
9 Recovery and rehabilitation
Background: To compare duration of occupational therapy (OT), functional out-
THE EFFECTS OF CURRENT PHYSICAL THERAPY AND FUNCTIONAL come and quality of life in group of ischaemic stroke (IS) patients younger or older
STRENGTH TRAINING ON UPPER LIMB FUNCTION AND than 65 years.
NEUROMUSCULAR WEAKNESS AFTER STROKE: A PILOT STUDY Methods: IS patients who were consecutively included into OT within early hospi-
C. Donaldson, R. Tallis, V. Pomeroy tal stay and contacted three months after stroke; 24R-hemiplegia, 26L-hemiplegia;
St George’s, University of London, London, United Kingdom 31 males, 19 females. Assessment tools: Extended Barthel index (EBI), Canadian
Occupational Performance Measure (COPM) and EuroQol (EQ). They were done
Background: Scientific evidence suggests that functional strength training (FST) during OT and at follow up.
might have a better effect than current physical therapy (CPT) on upper limb motor Results: There were 25 patients younger than 65 years (mean 55 yrs, range 39-65)
recovery after stroke. Aim: to assess the feasibility and sample size for a clinical and 25 were older than 65 yrs (mean 73 yrs, range 67-81). Mean duration of OT
trial to compare CPT and FST. in younger group was 15 days (range 4-54); mean duration of OT in older group
Methods: A randomized, single-blinded, clinical trial. Subjects were within 3 was 8 days (range 2-28). This difference was statistically important (p<0,007). The
months of infarction (anterior circulation) with upper limb weakness. Subjects were EBI and EQ were assessed in the whole sample; we were able to follow client’s
randomised into 3 groups. All received routine CPT. Control Group 1 received no priorities with COPM in 32 patients; 15 in younger group and 17 in older group.
extra physical therapy (CPT), Group 2 received increased intensity (CPT+CPT), Difference in EBI was statistically important from the first assessment to follow-up
Group 3 received CPT and FST. Intervention lasted 6 weeks. A treatment recording in both groups (p<0,0001;p<0,0001);there were no statistically important differ-
form, developed by our team and validated in clinical practice, was used to stan- ences among groups in initial or follow-up assessment (p=0.28; p=0.67). Difference
dardise and record CPT. Measurements included: muscle strength, Action Research in EQ was statistically important in both groups (p<0,01;0,002);there were no
Arm Test (ARAT) and 9-Hole Peg Test. Measurements were taken before treatment statistically important difference among groups (p=0,63;p=0,45). Regarding the use
began, after six weeks of intervention, and 12 weeks thereafter. Analysis: Attrition of COPM; 32 patients (64%) of our sample expressed in total 87 activities. There

130 Cerebrovasc Dis 2007;23(suppl 2):1–147 16th European Stroke Conference


were 15 patients from younger group and 17 patients from older group. 14 patients Management and economics
from each group named 58 activities (68%) of basic activities of daily living; 6
younger, 4 older expressed in total 14 (18%) issues of productivity and 5 from each
group named in total 14 (14%) leisure activities. 1 Management and economics
Discussion: Results showed that both groups need less help as measured by EBI.
Equally, the quality of life, as measured with EQ has improved. We were able COMPARISON OF BLOOD PRESSURE MANAGEMENT AFTER STROKE
to follow client functional priorities in both groups, although the younger group AND CORONARY EVENT. THE REDUCTION OF ATHEROTHROMBOSIS
received more OT. Further work is needed to clarify this issue. FOR CONTINUED HEALTH (REACH) REGISTRY
E. Touzé, J. Röther, D. Batt, F. Aichner, M. Alberts, M. Ohman, P. Durieux,
J. Coste, S. Goto, G. Steg
12 Recovery and rehabilitation Hôpital Sainte-Anne, Paris, France

A SERIES OF INVESTIGATIONS INTO SENSORY REHABILITATION POST Background: Management of blood pressure (BP) is not optimal in patients with
STROKE atherothrombotic diseases. We looked for differences in BP control and the use of
S.L Hillier antihypertensive drugs in patients with cerebrovascular disease (CVD, including
University of South Australia, Adelaide, Australia stroke or TIA) and coronary artery disease (CAD).
Methods: 68,236 patients were enrolled in the REACH Registry, an international
Background: Sensory loss post-stroke is well documented, however the role (44 countries worldwide) prospective, observational study of patients with or ≥3
sensation plays in the recovery of motor function is less understood. We have risk factors for atherothrombotic disease. Of these patients 12,153 had isolated
conducted a series of clinical trials investigating different applications of sensory CVD and 33,611 had isolated CAD. At inclusion BP was measured and treatment
input as part of rehabilitation post-stroke. data were collected.
Methods: Firstly we have applied combinations of peripheral and central stimula- Results: There were no major differences in age, previous hypertension and other
tion to either the foot or hand in chronic and acute stroke rehabilitation participants. risk factors between the CVD and CAD patient groups. However, CAD patients
The rationale is that such stimulation will excite the cortex and facilitate positive experienced lower mean BP values, were more likely to have a BP<140/90 mmHg,
neuroplastic responses to subsequent task specific training. The second series of and to receive 3 or more antihypertensive drugs (34.2% vs. 22.7%, p<0.0001).
trials involved training awareness and appreciation of sensory input to the lower The use of 3 or more antihypertensive drugs was also more common in CAD
limb post stroke. The rationale for these experiments was based more on a learning patients with elevated BP (≥140/90 mmHg) (39.4% vs. 26.2%, p<0.0001). After
or attention-training paradigm. adjustment for age, sex, other risk factors, and world regions, the CAD group
Results: Results from these trials offer some functional evidence that afferent input maintained significantly better control of BP (OR=1.4; 95%CI: 1.3-1.5, p<0.0001)
is effective in driving recovery, however data from TMS investigations have been and the use of ≥3 drugs (OR=1.4; 95%CI: 1.3-1.5, p<0.0001). Similar trend was
less convincing. We found sensory appreciation could be improved via specific observed across world regions.
training in chronic stroke participants but not as convincingly in acute. There
was also some preliminary indications that the increased sensory awareness led to
CVD only (12,153) CAD only (33,611)
improved postural control in some participants.
Discussion: Our findings warrant further investigation and current studies are Mean age (SD) 68.9 (10.2) 67.8 (10.2)
exploring the relationship between sensory input in the lower limbs and functional Male, % 56.4 70.8
activity. Previous hypertension, % 80.7 78.7
Mean systolic BP (SD) 140.2 (19.6) 134.5 (18.7)
All P values < 0.0001.
13 Recovery and rehabilitation
Conclusion: Blood pressure management is better after a coronary event than
IS THE BIO-PSYCHOSOCIAL MODEL SUITABLE TO EXPLAIN THE after a cerebrovascular event. This result could be explained by the under use of
DEVELOPMENT OF DEPRESSION AFTER STROKE? combination therapies in stroke patients compared to CAD patients.
T.A. Barskova, G. Wilz
Technical University Berlin, Department of Clinical and Health Psychology,
Berlin, Germany 2 Management and economics
Background: Depression after stroke is common and increases morbidity and US SURVEY OF STROKE NEUROLOGISTS AND
mortality in the first years after stroke onset. Nevertheless little is known about the NEUROINTERVENTIONALISTS ON TREATMENT CHOICES FOR
role of psychosocial factors on the etiology of depression in early as well as in the INTRACRANIAL STENOSIS
late poststroke stages. With reference to the bio-psychosocial model, the aim of T. Turan, M. Lynn, M. Chimowitz
our study was to investigate the influence of stroke survivors’ mental impairment Emory University School of Medicine, Atlanta, GA, USA
as well as the quality of their social relationships on the development of poststroke
depression. Background: We sought to determine the effect of an NIH-sponsored clinical trial
Method: The study used a longitudinal design. Eighty-one German stroke patients on treatment choices of physicians managing patients with intracranial stenosis.
were investigated twice, directly after discharge (on the average three month after Methods: Surveys of treatment choices were sent pre- and 1 year post-publication
stroke onset) and one year later. Hierarchical regression analyses and cross-lagged of the Warfarin vs. Aspirin for Symptomatic Intracranial Disease (WASID) Trial
partial correlation analyses tested direct and indirect mediating effects of potential results. The pre-WASID survey was sent to neurologists and the post-WASID sur-
predictors on poststroke depressive symptoms. vey was sent to neurologists and neurointerventionalists. The post-WASID survey
Results: Time 1 patients’ perceived cognitive and emotional functioning predicted included questions about the minimum benefit that physicians would require to
psychological depressive symptoms at time two. Quality of patients’ social rela- make stenting their treatment of choice. Data was analyzed using the chi-square test.
tionships mediated the effect of the stroke-related emotional deficits on depression. Results: There was a significant difference in the choice of antithrombotic agents
Discussion: In contrast to the previous research the study provided more evidence for the treatment of both anterior circulation (p<0.001) and posterior circulation
for causal influence of different risk factors on PSD. Results support the biopsy- (p<0.001) stenoses after publication of WASID (see Table).
chosocial model of poststroke depression. Early and late poststroke depression There was no significant difference in risk reductions required by neurologists
seem are based on partially different etiological mechanisms. vs. neurointerventionalists for stenting to become their treatment of choice. For

Table 1. Antithrombotic choices before and after WASID


MCA or IC siphon % of MD % of MD Basilar or vertebral % of MD % of MD
pre-WASID post-WASID pre-WASID post-WASID
n=181 n=199 n=181 n=199
Warfarin 41 7 Warfarin 49 15
Antiplatelet 44 85 Antiplatelet 36 74
Combination 11 4 Combination 10 7
Other 4 4 Other 4 4

Poster Session Cerebrovasc Dis 2007;23(suppl 2):1–147 131


Management and economics
a primary endpoint rate of 20%/2 yrs in the medical arm (the rate in WASID 5 Management and economics
for high-risk patients with 70-99% stenosis), 33% of physicians required a 25%
reduction from stenting, 15% required a 33% reduction, 14% required a 40% PRIMARY CARE MEDICINE AND STROKE: THE IRISH NATIONAL AUDIT
reduction, 21% required a 50% reduction, 13% required a 60% reduction, and 4% OF STROKE CARE
would continue to use medical therapy regardless of the stenting rate. D. O’Neill, D. Whitford, F. Horgan, M. Wiley, R. Conroy, S. Murphy,
Discussion: The results of WASID had a significant impact on physician treatment H. McGee, D. O’Neill, on behalf of the Irish National Audit of Stroke Care
practices. For high-risk patients with intracranial stenosis, 40% is the minimum Trinity College Dublin, Dublin, Ireland
relative risk reduction required from intracranial stenting to make it the treatment
of choice for a clear majority (at least 60%) of physicians. Primary care services have a key role in the prevention and management of stroke.
As part of the Irish National Audit of Stroke Care, a survey of general practitioners
(GPs) was performed to document the availability of evidence-based structures for
3 Management and economics supporting stroke care and prevention in general practice and to profile the views,
experiences, and needs of Irish GPs in this context. In a cross-sectional study of
HOSPITAL DISCHARGE CODING UNDERESTIMATES BURDEN OF STROKE randomly selected GPs practising in the Republic of Ireland was surveyed by postal
M. Taylor, C. McAlpine, M. Walters survey.
Stobhill Hospital, Glasgow and Western Infirmary, Glasgow, United Kingdom Of the target sample of 484 GPs, 36 were ineligible and 204 responded (response
rate = 46%). Regarding the acute management of stroke, nearly a fifth of GPs (17%)
Background: Hospital discharge coding is an important process which informs reported initially managing at least a substantial minority (20%) of their patients
health resource planning. During an audit project we noted a discrepancy between at home. The majority of GPs viewed existing rehabilitation services for their
the information services division (ISD) of the Scottish Executive numbers for stroke population as inadequate. Overall, general practice showed little structured
stroke disease workload and the numbers recorded by the local stroke consultants. organisation for long-term follow-up of stroke patients.
Methods: 280 stroke service discharges were reviewed from 2 different stroke units There was little or no organised system of care for the primary prevention of stroke
during different time periods within the health board division. One doctor coded within primary care in Ireland. Three quarters of GPs believed there were barriers
them according to ICD10. The actual coding was then reviewed and compared to to implementing secondary prevention strategies in their practiceJust over 60%
this. reported time as a barrier, 57% of reported staffing issues and almost a third (33%)
Results: 219 out of the 280 (78%) stroke service discharges had a final diagnosis funding as barriers. Other barriers listed included lack of protocols/guidelines
of stroke when coded by the doctor. Of those 219 only 166 (76%) of patients were (17%) and lack of space (almost 10%). The main barriers listed for secondary
recorded as stroke by hospital coding. In particular, of those diagnosed as a lacunar prevention were very similar to those recorded for primary prevention.
stroke (43 patients) only 23 (53%) were coded as stroke on discharge. Of the 61 There was little or no organised system of care for the prevention and management
diagnosed as “not stroke” by the doctor 19 had a “false positive” coding of stroke of stroke within primary care in Ireland. However, there were encouraging signs of
by coders on discharge. development. GPs in practices involved in a national cardiac prevention programme
Discussion: There are several potential sources of error in the coding process. This and those with good or excellent access to practice nurses were more likely to
has major implications for both national stroke statistics and local stroke service engage in evidence-based activities to manage stroke.
planning and resources. Urgent further work is required to identify the extent to
which “false positive” stroke codes are generated and whether this pattern of “false
negative” stroke coding is reproduced elsewhere. 6 Management and economics
EDUCATIONAL MULTIMEDIA CAMPAIGNS HAVE DIFFERENTIAL
4 Management and economics EFFECTS ON PUBLIC STROKE KNOWLEDGE AND AWARENESS OF
INDIVIDUAL STROKE RISK
FIRST IRISH NATIONAL AUDIT OF STROKE CARE J.J, Marx, M. Nedelmann, B. Haertle, M. Dieterich, B.M. Eicke
F. Horgan, A. Hickey, S. Murphy, M. Wiley, R. Conroy, H. McGee, D. O’Neill, Johannes Gutenberg-University Mainz, Mainz, Germany
on behalf of the Irish National Audit of Stroke Care
Trinity College Dublin, Dublin, Ireland Background: Aim of the study was to evaluate the educational effects of different
media in a multimodal educational program on public knowledge of risk factors
Improving services for people with stroke represents a global challenge, espe- and warning signs of stroke.
cially in the light of the proven efficacy of many treatment modalities. The UK Methods: Computer-assisted telephone surveys were conducted among an average
National Sentinel Stroke Audit was a pioneer in developing a national profile of sample of 500 members of the general public, before and immediately after an
hospital services for stroke. We report on the design of a project which builds intense three months educational campaign in a German area of 400.000 inhabi-
on this methodology, but which also profiles nation-wide preventive, community tants. The multimodal educational program comprised of 400 poster advertisements
rehabilitation and long-term care services for people with stroke. on billboards, busses, local emergency transport cars etc. Print media included
The Irish Heart Foundation, in association with the Irish Department of Health flyers dispensed in pharmacies and at the doctors’ office and mail circular to all
and Children, commissioned a national audit of stroke services in March 2006. households. Slogans, stroke interest stories and interviews appeared regularly in
The project involves hospital audits, and community-based surveys of general local newspapers, on television and radio, and several public events focussed on the
practitioners (GP), allied healthcare practitioners (AHPs), patients and carers, and subject.
nursing homes. Results: Before the educational intervention stroke knowledge was generally low,
All 37 public hospitals (100%) providing acute services to stroke patients are especially in men and elderly individuals. General knowledge of the nature of
participating in the.Organisational and Clinical Audit Proformas of the UK Na- stroke (65.7% correct answers before versus 84.9% after the campaign, p<0.01)
tional Sentinel Stroke Audit 2004. A random sample of 484 GPs were surveyed and the awareness of being at risk of stroke (32.7% vs. 41.9%, p<0.01) significantly
by post and 46% responded. The AHP survey, involved interviews with regional, increased due to the campaign, especially in respondents of lower educational
disciplinary and nursing managers, and frontline staff, with 85% response. 200 Background: In contrast, there was hardly any effect on detailed knowledge of
people with stroke and a family member will be interviewed one year after specific stroke warning signs or different risk factors. Mass media were most fre-
discharge using a questionnaire on health status and service needs and utilization, quently reported as the main information source (66.5%). Information flyers were
as well as 200 people with stroke who have been discharged to nursing homes, and also remembered by a high proportion of respondents (59.0%), while widespread
a family member. Final results are due in September 2007. poster advertisements received far less attention (26.7%).
This audit is of interest for two main reasons: it provides evidence of the feasibility Discussion: Our data indicate that educational programs are effective in increasing
of using the UK National Sentinel Audit in another jurisdiction, but also provides general knowledge of stroke in the public. They improve awareness of individual
a methodology which allows for the measurement of availability of the full range stroke risk and this may influence behavior in acute stroke. Especially in indi-
of services for people with stroke across the modalities of primary and secondary viduals of lower educational background repeated information using short-tailored
prevention, acute treatment, rehabilitation and long term care. This global overview messages presented in mass media proved to be effective. It is difficult, however, to
is vital to the delivery of services across the full spectrum of stroke prevention and transfer detailed information by means of a large educational campaign.
care.

132 Cerebrovasc Dis 2007;23(suppl 2):1–147 16th European Stroke Conference


7 Management and economics quality of organization of stroke care and research activity in stroke services in
England.
THROMBOLYTIC THERAPY IN ACUTE ISCHEMIC STROKE IN TAIWAN Methods: The 2006 National Sentinel Audit of Stroke assessed by questionnaire
M. Tseng, K. Chang, J. Liu the quality of stroke service infrastructure and included two questions on research
National Sun Yat-Sen University, Kaohsiung, Kaohsiung, Taiwan activity: (A) “How many stroke research studies are you involved in?”, and (B)
“How many Whole Time Equivalent staff are employed in stroke research?”. Data
Background and purpose: Starting Jan 1, 2004, the use of intravenous recom- were collected by local staff from 235 sites in England in April/May 2006.
binant tissue plasminogen activator (rtPA) in patients with acute stroke becomes Data analysis was performed using SPSS. As research activity formed part of the
available for reimbursement from the National Health Insurance (NHI) Program total score for Organisation of Care, we did not compare with the total score. We
in Taiwan. The purpose of this study was to study the frequency of intravenous examined the association between responses to the 2 questions on research activity
rtPA for stroke treatment in Taiwan the first year after the reimbursement, and to with each of the other 9 domains of Organisation of Care.
examine the characteristics regarding the usages in the health care system. Results: Correlation was shown at the 0.01 level (2-tailed) between responses to
Methods: We studied the administrative claims data of NHI beneficiaries of 2004. the 2 questions research and the following 6 domains: acute care organisation,
The compulsory and universal NHI covers more than 96% of the total population of organisation of care, interdisciplinary services (overall service), TIA/neurovascular
Taiwan since the implementation in March 1995. We identified patients treated with services, team working – agreed assessment measures and communication with
rtPA by searching the database of Details of Inpatient Orders with the rtPA-specific patients and carers. The strongest correlation was with acute care organisation
order code. The associated data of Inpatient Expenditures by Admissions were (Spearman’s rho 0.381 for research question (A) and 0.387 for question (B)). No
examined. significant correlation was found with the domains interdisciplinary services (stroke
Results: Among 90,550 admissions with cerebrovascular diseases in 2004, there unit), team working (records) and team working – team meetings.
were 93 patients treated with rtPA. The mean age was 64.0 ± 11.0 years (range 35.5 Discussion:
to 82.4). Fifty-nine or 63% of patients were men, 69% had a Charlson comorbidity The significant correlation between quality of organization of stroke care and
index of 0, 27% 1, and 4% 2. Neurologists were admitting physicians for 66.7% of research activity suggests that well organized stroke care facilitates stroke patient
patients. About one-forth of patients were treated in medical centers, 57% regional participation in research and/or that participation of stroke services in research
hospitals, and 17% district hospitals. Median length-of-stay (LOS) was 10 days facilitates improved services.
(range 1 -136), and in-hospital death were found in one case (1.1%). Patients cared
for by neurologists as compared to non-neurologists had significantly lower median
LOS (8.5 versus 19 days, P = 0.016). Patients admitted into medical centers had 10 Management and economics
longer median LOS (16 days), as compared to regional hospitals (12) or district
hospitals (6) (Kruskal-Wallis test, P = 0.002). COST EFFECTIVENESS OF STROKE UNIT (SU) CARE FOLLOWED BY
Discussion: Intravenous rtPA was not widely applied within the first year following EARLY SUPPORTED DISCHARGE (ESD)
reimbursement from NHI in Taiwan. Because the analysis was based on NHI Ö. Saka, V. Serra, Y. Samyshkin, S. Merkur, A.J. Mcguire, C. Wolfe
claims data, some important patient-level data, particularly initial stroke severity Kings College, London, Division of Health and Social Care Research, London,
and functional outcomes, were not available. United Kingdom

Introduction: Stroke is the second leading cause of death in England and Wales
8 Management and economics and the leading cause of adult disability. Annual cost of stroke care in the UK
government is over £7bn including. SUs provide improved outcomes for stroke
COST OF STROKE FOR SOCIETY IN YOUNGER PERSONS RECEIVING patients with respect to non-stroke specialised hospital units. In addition to that
REHABILITATION another trend has been ESD of some stroke patients. This allows inpatient beds to
A.K.S. Sunnerhagen, A.A. Björkdahl be available for the care of stroke patients faster, decreases the necessary number
Göteborg University, Göteborg, Sweden of expensive hospital beds to be maintained whilst providing further rehabilitation
care to stroke patients at home. We assessed the cost effectiveness (CE) of SU care
Background and purpose: In recent years a number of costs of stroke studies have followed up by ESD (SUESD).
been conducted based on incidence or prevalence estimating costs a given time. Methods: Data from the South London Stroke Register, and local ESD were
As there still is a need for a deeper understanding of factors influencing the cost utilised for clinical and resource use data. The cost effectiveness of SUESD was
the aim of this study was to calculate the direct and indirect costs for society in compared with with SU without ESD (SUNESD) and general medical ward care
a “younger” (<65) sample of stroke patients and to explore factors affecting the without ESD (GWNESD). We used a Markov model to simulate the care process
costs. for 10 years. Societal perspective was used for costing and included direct care
Methods: 58 patients, included in a study home rehabilitation, were followed 1 costs as well as informal care costs and productivity losses due to mortality and
year and interviewed about use of health care services, assistance, medicine and morbidity.
assistive devices. Costs were calculated. A linear regression of cost and variables Results: SUESD option leads to better outcomes, although it increases total
of functioning, ability, community integration and health-related quality of life was care costs. We found that it costs £9,200 per additional quality adjusted life
undertaken. years (QALY) when SUESD was compared with GWNESD and £8,600 when
Result: Inpatient care contributed substantially to the direct cost with a mean length compared with SUNESD. The incremental cost effectiveness ratio (ICER stayed
of stay of 92 days. Rehabilitation during the first year constituted of in average 28 within accepted limits of £30,000 per QALY gained. The multi-way (+10%) and
days in day clinic, 38 physiotherapy sessions and 20 occupational therapy sessions. probabilistic sensitivity analyses did not have a significant impact on the results.
Total direct mean cost was 33 604 Euro and indirect cost 32 129 Euro. The direct Discussion: This is the only study to date looking at the CE of SU followed by ESD,
costs were influenced by the process skill (the ability to plan and perform a given comparing it with other treatment options. The results of the study suggests that
task and to adapt when needed) and presence of aphasia. Indirect cost for informal treatment in stroke unit followed by early discharge of patients with an enhanced
caregiving increased for patients less health-related quality of life scoring low on outpatient care policy (SUESD) offers the best results in terms of effectiveness,
home integration. with an additional cost within accepted reasonable CE levels. GWNESD, although
Conclusion: Costs are high in this group compared to other studies partly due to cheaper than the other two, appeared the least effective strategy.
length of stay as well as loss of productivity.

11 Management and economics


9 Management and economics
STROKE OCCURRENCE AND DISEASE CLASSIFICATION IN GERMANY- A
DOES ORGANISATION OF STROKE CARE CORRELATE WITH RESEARCH NATIONWIDE ANALYSIS BASED ON THE GERMAN DRG REPORT 2004
ACTIVITY IN STROKE? P.L. Kolominsky-Rabas, B. Griewing, J. Rüthemann
D.F. Jenkinson, G.A. Ford, A.R. Rudd, A. Hoffman, G.D. Lowe Dep. of Health Economics, Institute for Quality and Efficiency in Health Care
UK Stroke Research Network, Leazes Building, Royal Victoria Infirmary, (IQWiG), Cologne, Germany
Newcastle upon Tyne, London, United Kingdom
Background: Data are limited regarding the number of stroke patients and their
Background: It is unclear whether participation of stroke services in research leads fraction in each ICD-10 (International classification of diseases) and DRG (Di-
to improved patient care, or conversely whether better organized stroke services agnosis Related Groups) category in German hospitals since so far data are only
facilitate greater participation in research. We determined the association between available from cohort studies and stroke registers with a limited number of patients.

Poster Session Cerebrovasc Dis 2007;23(suppl 2):1–147 133


Management and economics
Methods: Based on the analysis of more than 1.780 German hospitals transferring factors was performed 6 and 12 months after the initial event by an investigator not
their DRG (B70 A- D) and ICD-10 data to InEK (Institut für Entgeltsystem im involved in the usual follow-up of patients.
Krankenhaus) we compiled a detailed overview of stroke occurrence and disease Results: At 6 months, 41% of patients with diagnosed hypertension at inclusion
classification of all German inpatient strokes in 2004. had BP<140/90 mmHg and 55% of those with diagnosed hypercholesterolemia had
Results: 235.097 stroke patients were reported for 2004. 5.658 (2%) thereof died LDL<1g/L. Compliance to treatment was excellent in 81% of patients. In univariate
within 3 days after admission (B70 C), 189.403 (81%) had a non-hemorrhagic and multivariate analyses, initiation or reinforcement of appropriate treatments was
stroke (DRG B70 B), 20.929 (9%) had a hemorrhagic stroke (B70 A), and 19.107 the main factor associated with BP<140/90 mmHg (OR=2.2; 95%CI: 1.0-4.5)
(8%) stayed in hospital for one day only (B70 D). As categorised with the ICD-10 and LDL<1g/L (OR=3.3; 1.3-8.7) or with decrease in BP (p<0.0001) and LDL
coding system there were 11.500 (4%) patients with subarachnoid haemorrhage (p<0.0001). Patients’ characteristics including sociodemographic characteristics,
(SAH, I60), 33.075 (12%) with intracerebral haemorrhage (ICH, I61), 6.482 (2%) education, income, and knowledge of disease and risk factors were not associated
with other non-traumatic intracranial bleeding (I62), 180.863 (66%) with ischaemic with control of BP or LDL. Among patients with BP≥140/90 mmHg, about 40%
stroke (I63), and 40.882 (15%) with stroke neither defined as haemorrhagic nor received either no treatment or only one drug, and treatment was reinforced in only
ischaemic (I64). This implied an overall ratio of 19% haemorrhagic (I60,61,62) and 20% of them. Results were similar at 12 months with no improvement in the rate
81% non-haemorrhagic (I63,64) strokes for Germany in 2004. of control of risk factors.
Conclusions: This nationwide analysis based on the German DRG report 2004 Conclusion: In-hospital initiation of secondary stroke prevention could influence
gives a detailed overview of stroke occurrence and disease classification in Ger- the long term quality of secondary prevention. Therapeutic inertia is an important
many. Numbers revealed are higher than previous assumptions made by assessing impediment to achieve the BP and LDL control goals after stroke, even in relatively
data available from cohort studies and stroke registers containing a limited sample motivated/compliant patients.
of patients.

14 Management and economics


12 Management and economics
LONGER TERM STROKE CARE: HOW SHOULD SERVICES BE
A NEW METHOD OF ESTIMATING THE TIME USED BY HEALTH CARE DEVELOPED IN THE POST-ACUTE PHASE?
PROFESSIONALS (HCP) FOR ACUTE STROKE CARE IN EUROPE, A.M. Cox, L. Kalra, A.G. Rudd, C.D.A. Wolfe, C. McKevitt
EUROPEAN REGISTERS OF STROKE (EROS) COLLABORATION King’s College London, Division of Health and Social Care Research, London,
Ö. Saka, A.J. Mcguire, P. Heuschmann, A. Rudd, C. Wolfe United Kingdom
Kings College London, Division of Health and Social Care Research, London,
United Kingdom Background: Organised stroke care, such as inpatient stroke units and early
supported discharge, improves outcomes for patients. There is less evidence for
Intro: The EROS project is assessing the provision of stroke care in 8 European the optimal organisation and delivery of stroke care in the longer term. Following
centres. As stroke is a labour intensive disease, time spent by the HCP make up a the MRC Framework for developing complex interventions, we undertook Phase
major part in the resources used. The purpose of our study was to analyse the time 1 work to identify the potential components of an intervention to improve longer
spent by HCP. term stroke care.
Methods: A questionnaire was developed, piloted and used in 7 of the participating Methods: In-depth interviews with a purposive sample of health professionals
centres to the EROS project. The forms included the description of 5 case scenarios (n=25) working in stroke. Participants were asked to describe existing services for
with different severities (case 1 the least, case 5 the most severe according to NIH patients in the post-acute phase, identify successes and shortcomings and propose
scores). In the forms HCP were asked to define the activities they would carry out ways to improve service provision. Interviews were recorded, transcribed and
daily, weekly, on admission and on discharge for each case scenario. The answers analysed using framework analysis.
were recorded in minutes (mins). We analysed the mean and the median time spent Results: Participants highlighted gaps in the available evidence base regarding the
by HCP groups (classified as nurses, doctors and therapists which included speech optimal setting, timing, intensity and focus of therapy delivery.
and language therapists, physiotherapists, occupational therapists) for different case There are theoretical questions that need to be resolved to improve post-acute
scenarios. We used Kruskall Wallis test to test the correlation between the times services. These include whether specialist care is necessary and what specialism
spent by HCP in different countries. means in this context, the nature of multi-disciplinary working, and how to
Results: 145 interviews with HCP were included. The nurses spent more time overcome the structural and professional divisions that currently influence service
with patients than the other HCP (mean total daily time; for nurses 25-305 mins, provision.
for doctors 5-55 mins, for therapists 0-66 mins). For all of the specialists groups Problems relating to the delivery of services include transfer of care between ser-
there was a tendency to spend more time with mid range severity cases (cases 2 & vices, lack of psychology support, capacity to provide intensive therapy, inadequate
3), total time spent increasing steadily from mild to moderate and declining from service provision for the cognitively and perceptually impaired.
moderate to severe. There was statistically significant correlation between the time Conclusion: This interview study identified gaps in the evidence base, theoretical
spent by the nurses and the doctors (p values between 0.0001 and 0.05) but not for questions that underpin the organisation of services as well as practical problems in
the therapists. care delivery. These will need to be addressed in formulating an improved model
Conclusion: The HCP time use questionnaire helped gather data when the forms of post-acute stroke care.
were filled through an interview with the HCP. Although this tool mainly will be
used in costing the stroke service provision we found strong correlation between
the time spent by doctors and nurses in different countries. The lack of such a 15 Management and economics
correlation in the case of therapists can be explained by the differences in the way
the function of therapists are defined in EROS centres. IMPACT OF CHANGES TO THE DRG CLASSIFICATION ON ACUTE
ISCHAEMIC STROKE CARE IN GERMANY
P.L. Kolominsky-Rabas, V. Ziegler, J. Rüthemann
13 Management and economics Dep. of Health Economics, Institute for Quality and Efficiency in Health Care
(IQWIG), Cologne, Germany
IMPORTANCE OF THERAPEUTIC INERTIA IN SECONDARY STROKE
PREVENTION: IMPLEMENTATION OF PREVENTION AFTER A Background: In 2005, the German Diagnosis Related Groups (DRG) classification
CEREBROVASCULAR EVENT (IMPACT) STUDY was modified to allow, for the first time, differentiation between different forms of
E. Touzé, M. Voicu, J. Kansao, R. Masmoudi, B. Doumenc, A. Ferreira, acute ischaemic stroke (AIS) care.
P. Durieux, J. Coste, J.-L. Mas Prior to this, the German DRG system consisted of only one classification for
Hôpital Sainte-Anne, Paris, France AIS: B70B. The new classification distinguishes between complex (B70B) and
non-complex (B70E) neurological treatments for AIS. The advanced category of
Background: Many patients do not receive prevention according to recommen- complex neurological treatment (OPS 8-981) comprises specific diagnostic and
dations after stroke, but the relative importance of patient- and physicians-related treatment features including potential thrombolysis commonly provided in stroke
factors is uncertain. units (SU).
Methods: We prospectively assessed individual factors associated with blood Methods: To assess the influence of the changes made to the DRG system in
pressure (BP)<140/90 mmHg and LDL-cholesterol<1g/L in a cohort of 240 2005 on patient disease management, we analyzed the data, from more than 250
consecutive stroke/TIA patients (Rankin<4; ≤80 years; no major comorbidity) of the 1.750 German hospitals, sent to the InEK (Institut für Entgeltsystem im
from a stroke unit and 3 emergency departments. A standardized assessment of risk Krankenhaus) for the years 2004-2006.

134 Cerebrovasc Dis 2007;23(suppl 2):1–147 16th European Stroke Conference


Results: Prior to the changes in the DRG classification (2004), 6.480 (34%) Conclusion: The PFG identified an under-researched area that they regard as
patients received either plain or contrast MRI (Magnetic Resonance Imaging) as important to understanding the consequences of stroke. Their participation led to
part of their stroke care. After changes made to the DRG system, 1.112 (59%) AIS the development of a cost measure relevant to the population under study. The
patients in the B70B group and 5.971 (34%) patients in the B70E group underwent measure is currently being piloted with people recruited to the South London Stroke
MRI in 2005. The corresponding figures for 2006 were 1.180 (71%) patients in Register.
the B70B group and 4.613 (27%) patients in the B70E group. Concurrently, the
percentage of thrombolytic treatment given to patients increased in the complex
treatment group from 15% in 2005 to 33% in 2006. 18 Management and economics
Conclusions: Distinguishing between complex and non-complex AIS care is rele-
vant and more accurately reflects patient disease management. Thus, the changes MARKET SHARE OF INPATIENT CARE STROKE UNITS FROM THE TOTAL
to the DRG system improve the frequency of appropriate MRI imaging and HOSPITAL CARE MEASURED BY THE DIAGNOSIS RELATED GROUPS
thrombolytic treatment in hospitals providing complex neurological treatment. (DRG) SYSTEM
I. Boncz, A. Sebestyén, J. Betlehem, L. Gulácsi
Department of Health Economics, Policy and Management, University of Pécs,
16 Management and economics Pécs, Hungary

THE APPLICATION OF TELEMEDICINE FOR STROKE IN THE BALEARIC Aim: In the early 1990s, a Diagnosis Related Groups-like financing system was
ISLANDS introduced in Hungary including all the Hungarian acute care hospitals. The aim
S. Tur, I. Legarda, M.J. Torres, C. Jimenez of the study is to analyse the market share of acute stroke units according to DRG
Son Dureta Hospital, Palma de Mallorca, Spain system.
Data and methods: Data were derived from the financial database of the National
Background and purpose: Systemic thrombolysis for acute ischemic stroke is Health Insurance Fund Administration, the only health care financing agency in
administered only in Son Dureta University Hospital (SDUH) in the island of Hungary (1996-2005). All the acute care stroke units were involved into the study.
Mallorca. It is impossible to move a patient from Ibiza or Menorca to Mallorca The following indicators were used for the analysis: number of cases, the number
in time to treat. Our main aim is to extend the use of this treatment to the other of DRG cost-weights, hospital days. Regression lines and Pearson coefficients (R2)
Balearic Islands (Menorca, Ibiza) through telemedic support. were calculated.
Methods: The Department of Neurology of SDUH has Stroke Unit, neurologist Results: Although it was no significant changes in the number of stroke cases
on duty 24 hours per day and experience in thrombolytic treatment. Our hospitals (18.000-20.000 patients/year), the market share of stroke care within in-patients
are connected by a video conference system (red ATM). All hospitals have specific care – measured by the number of cases – decreased continuously from 1,07%
equipment (Tandberg MXP) to allow us to explore a patient at a distance and a CT (1996) to 0,77% (2005). The market share of stroke care within in-patients care
image transferer. measured by the number of DRG cost-weights has been also decreased from 1,06%
After a first phone contact, emergency physicians consult stroke neurologists (1996) to 0,84% (2005). The market share of stroke care from the total in-patients
via a two-way video conference system. Medical history, neurologic examination care hospital days has been also decreased from 1,41% (1996) to 1,01% (2005).
according to National Institute of Health Stroke Scale (NIHSS) and head CT scan The market share of acute stroke care in 2005 compared to 1996 felt to 72,3% in
are reviewed to select a candidate patient for t PA treatment. the number of cases, 79,3% in DRG cost-weights and 71,6% in hospitals days. The
Can Misses Hospital in the island of Ibiza has organized a stroke team. There is Pearson coefficients (R2) for number of cases, DRG cost-weights and hospitals
a specific stroke bed in the Intensive Medical Care Unit and we share the same days are 0,74, 0,72 and 0,55 respectively.
stroke protocol. Both doctors and nurses have been trained. This activity began in Conclusion: The market share and health insurance financial conditions of acute
the island of Ibiza in July 2006. Verge del Toro Hospital in the island of Menorca stroke care units varied significantly between 1996-2005. The overall financial
is developing its own assistance process. effect of DRG system on the Hungarian stroke care seems to be relatively good or
Results: We are registering clinical data, number of contacts, number of thrombol- neutral, but not disadvantageous.
yses, onset to contact and to treatment time, complications, mortality, neurological
deficits and disability at admission, discharge and after 3 months (NIHSS and
modified Rankin Scale) and no treatment reasons.
Conclusions: Telemedicine allows us to extend specialized assistance and throm- Experimental studies
bolytic treatment to underserved areas.

1 Experimental studies
17 Management and economics
AN EXTENDED WINDOW OF OPPORTUNITY FOR
COSTS OF STROKE BORNE BY INDIVIDUALS AND FAMILIES: USER-LED GRANULOCYTE-COLONY STIMULATING FACTOR TREATMENT IN RAT
DEVELOPMENT OF A PATIENT BASED COST MEASURE FOCAL CEREBRAL ISCHEMIA
C. McKevitt, N. Fudge, A. Sriskantharajah, C. Coshall, C. Wolfe, KCL Stroke J. Minnerup, R. Wysocki, R. Laage, A. Schneider, W.R. Schäbitz
Research Patients & Family Group University of Münster, Münster, United Kingdom
King’s College London, London, United Kingdom
Background: Granulocyte-Colony Stimulating Factor (G-CSF) is known as a
Background: The high costs to the state/health service associated with stroke care regulator of white blood cell proliferation and differentiation. We and others have
are documented in several economic analyses. These provide little information shown that G-CSF is effective in treating cerebral ischemia in rodents, both relating
about the costs borne by families/individuals. Our Stroke Research Patients and to infarct size as well as functional recovery. We assessed the hypothesis that
Family Group (PFG) identified personal costs resulting from stroke as a research G-CSF has acute neuroprotective effects and long-term recovery effects in rat focal
priority but methods to assess these costs are not well developed. We report a cerebral ischemia after delayed treatment onset.
user-led study to adapt an existing generic, but untested, cost questionnaire for Methods: Wistar rats (n=24/group) underwent middle cerebral artery occlusion
completion by stroke patients. (MCAO) for 90 min. Four hours after onset of occlusion animals received 60
Method: PFG discussions and 5 individual qualitative interviews were held to μg/kg G-CSF i.v. over 20 min or vehicle. Infarct volumes were determined by TTC
identify preferred research methods and specific cost items. These were used to staining. For evaluation of long-term functional outcome photothrombotic ischemia
develop a topic guide for a novel qualitative method, “guided conversations”, was induced in the parietal cortex. For treatment, animals (n=10/group) were given
between 10 stroke survivors/carers. These were recorded, transcribed and analysed vehicle or 10 μg G-CSF/kg i.v. starting 24 or 72 hours after induction of ischemia
to finalise items for the cost measure. The existing generic questionnaire was and daily repeated for 10 days. Rotarod testing was performed at 1, 2, 3, 4, 5
adapted to incorporate stroke specific items, and reviewed by the PFG to ensure all and 6 weeks after ischemia. Brain sections were immunostained for anti-BrdU and
topics were covered and approve wording. NeuN.
Results: User-led qualitative methods led to identification of items to include in Results: After MCAO we observed a infarct volume reduction by 33% in the total
a questionnaire. These include: payment for adaptations, medications, alternative infarct volume as compared to vehicle-treated rats (334.0 ± 31.5 mm3 vs. 223.3 ±
therapies, diabetic/organic food, nutritional supplements, clothing suitable for dis- 27.3 mm3 , p < 0.05). G-CSF treated rats in both the 24 h and 72 h time-window
ability, transport; direct and indirect loss of family income. The cost measure was performed significantly better in the rotarod test than vehicle-treated animals. The
incorporated into a structured interview questionnaire with content validity, for use number of newly generated neurons (BrdU+/NeuN+) in the dentate gyrus was
in a pilot study. increased (p < 0.01) by G-CSF treatment.

Poster Session Cerebrovasc Dis 2007;23(suppl 2):1–147 135


Experimental studies
Discussion: In Conclusion we demonstrate an infarct reducing effect of a 4 h oxygen therapy. These effects were observed 6 hours after the ischemic stroke.
treatment delay with G-CSF in a severe hemispheric stroke model (MCAO). In Hence further studies are needed to investigate the long term effects of the
the photothrombotic model we have shown that the time window for initiation of combination therapy.
poststroke functional recovery by G-CSF is at least 72 h. This effect correlated with
a profound induction of neurogenesis. G-CSF is therefore thought to activate dual
mechanisms within the brain such as the previously shown neuroprotective effect 4 Experimental studies
plus a substantial recovery/neurogenesis inducing function.
BLOOD-BRAIN BARRIER (BBB) OPENING AFTER TRANSIENT FOCAL
CEREBRAL ISCHEMIA IN RATS
2 Experimental studies I. Marinkovic, A. Durukan, U.A. Ramadan, D. Strbian, M. Pitkonen,
E. Pedrono, L. Soinne, T. Tatlisumak
EFFECTS OF THE TP RECEPTOR ANTAGONIST S 18886 IN A RAT MODEL Biomedicum Helsinki, Helsinki, Finland
OF MIDDLE CEREBRAL ARTERY PHOTOTHROMBOTIC OCCLUSION
T. Hirvonen, V. Blanc-Guillemaud, L. Lerond, J. Jolkkonen Background: It is widely believed that BBB breakdown after transient focal
CNServices, Kuopio, Finland cerebral ischemia occurs in a biphasic pattern. The aim of this study was to evaluate
quantitatively the pattern of BBB damage after transient focal cerebral ischemia and
Background: Platelet activation represents the major source of increase in TXA2 its correlation with the size of the ischemic lesion by the use of contrast-enhanced
biosynthesis after a cerebro-vascular event and plays an essential role in the magnetic resonance imaging (MRI).
pathogenesis of thrombotic stroke. Methods:
S 18886, a TXA2 and prostaglandin endoperoxide (TP) receptor antagonist is being Adult male Wistar rats (n=10) were underwent 90 minutes of transient focal
developed as an anti-atherothrombotic agent and is expected to be effective in cerebral ischemia with the suture occlusion method and imaged with MRI at 4.7
cerebral artery thrombosis. The aim of this study was to investigate the effects of Tesla at 2, 24, 48, 72 hr and 1 week after reperfusion. Diffusion weighted imaging,
S 18886 in comparison to aspirin and clopidogrel, in a rat middle cerebral artery FLAIR (fluid attenuated inversion recovery), and T1-weighted (with and without
(MCA) model of focal thrombosis induced by photochemical reaction. contrast agent gadolinium) sequences were acquired. After calculating lesion area
Methods: S 18886 (10 mg/kg), aspirin (100 mg/kg) and clopidogrel (30 mg/kg) and contrast-enhanced areas, their ratio was obtained. The gadolinium permeability
were orally administered to male Wistar rats (n=10-16/group) 2 hours before (by calculating Ki values via the Patlak plot approach) was estimated for all
thrombosis induction. A group receiving the vehicle served as control. Blood flow imaging time points.
in the distal MCA was monitored by a laser Doppler flowmeter for a 70-min period. Results: In all post contrast images, gadolinium enhancement occurred in a similar
Time to occlusion (TO) and total patency time (TPT), expressed as a percentage of spatial pattern with ischemic lesion and there was no statistically significant differ-
observation period, were measured. ence between ratios (mean ratio was 0.94 for T1-weighted sequence, p=0.06 and
Results: There were no statistical differences in time to occlusion between treat- 0.91 for FLAIR, p=0.6). The Ki values of ischemia regions (cortex and subcortex)
ment groups. However S 18886 and clopidogrel prevented MCA occlusion in 2/10 for all groups were statistically significant (p<0.01) compared with the identical
and 2/11 animals, respectively. S 18886 significantly increased the incidence of re- regions in the contralateral brain hemisphere. The difference in Ki between different
opening (87.5% versus 25% in control group; p<0.05) and the TPT measured when time points was not statistically significant (p=0.38).
MCA blood flow was above 70% of baseline (67.9 ± 8.3% versus 20.9 ± 4.2% Discussion: Our results showed that BBB leakage to gadolinium (molecular weight
in control group, p<0.001). The increases in the incidence of reopening (55.5%) 590 Da) occurs in a monophasic pattern during the period of 2 hr to 1 week after
and the TPT (41.1 ± 12.4%), observed with Clopidogrel were not statistically transient focal cerebral ischemia in rats and BBB damaged brain area is highly
significant. Aspirin had no effect on these parameters. similar to the ischemic area depicted on DWI.
Conclusion: The present study demonstrates that single oral administration of
S 18886 increases incidence of MCA reperfusion and improves MCA blood
flow during reperfusion. The findings suggest that anti-platelet therapy with the 5 Experimental studies
TP receptor antagonist S 18886 can be potentially beneficial in cerebro-vascular
diseases EFFECT OF HIGH-DOSE OESTROGEN THERAPY ON CEREBRAL
PLASTICITYAFTER TRANSIENT FOREBRAIN ISCHAEMIA IN GERBIL
E.A. Wappler, A. Gal, G. Szilagyi, J. Vajda, J. Skopal, K. Felszeghy, C. Nyakas,
3 Experimental studies Z. Nagy
National Institute of Psychiatry and Neurology, National Stroke Center,
HYPERBARIC OXYGEN TREATMENT COMBINED WITH THROMBOLYTIC Budapest, Hungary
THERAPY REDUCES INFARCTION SIZE IN EXPERIMENTAL ISCHEMIC
STROKE Background: After ischaemic injury repair mechanisms in the brain tissue reduce
L. Küppers-Tiedt, A. Manaenko, A. Günther, D. Michalski, A. Wagner, the functional deficit. Neuroprotective effect of oestrogen is well documented,
D. Schneider however its effect on repair mechanisms are still not elucidated. In our work
Klinik und Poliklinik für Neurologie; Universität Leipzig, Leipzig, Germany we focused on the expression of plasticity genes and functional recovery after
oestrogen treatment in transient ischaemic model.
Background: In acute ischemic stroke effective treatment is still limited. The only Methods: 3 month-old ovariectomized femail gerbils (n=40) were subjected to 10
approved therapy is thrombolysis with rtPA within the first three hours, but this min transient forebrain ischaemia or sham procedure. Half of the ischemic animals
therapy is only an option for a small number of patients due to the time window were pre-treated i.p. with 4 mg/kg body weight oestrogen 20 min previous to
and the risk of hemorrhage. This study investigated the effects of thrombolysis in surgery. From one series of animals brain samples were collected on postoperative
combination with hyperbaric oxygen therapy (HBOT) in acute ischemic stroke in day 4 for histological and molecular biological examinations. Paraffin-embedded
rats. brain slices were stained with TUNNEL-caspase double labelling fluorescent anti-
Methods: In 22 male Wistar-Rats an ischemic stroke was induced by embolic sera. Marker mRNA levels were determined with real-time PCR. Gene expression
occlusion of the middle cerebral artery using clots of 20 mm length. After stroke levels were assessed by ddCT method using TaqMan gene expression assays. On
induction the animals were randomized to one of three groups: 1) Control (room air other series of animals attention and learning behaviour were tested in spontaneous
and placebo), 2) Thrombolysis (room air and rtPA), 3) HBOT (hyperbaric oxygena- alternation, novel object recognition and spatial learning paradigms beginning from
tion (2.5 ATA) and rtPA). rtPA was given intravenously two hours after the embolic postoperative day 7.
stroke. The animals were exposed to room air/HBOT before or during thrombolysis Results: Oestrogen significantly decreased the number of apoptotic and necrotic
for one hour. 6 hours after the stroke the animals were sacrificed and brain slices cells in CA1 region. Oestrogen treatment resulted in a significant increase in
stained with Triphenyltetrazoliumchloride to calculate the infarct volume. Bcl-XL, nestin and GAP-43 mRNA expression. In ischaemic insult inpaired atten-
Results: The ischemic infarctions calculated 6 hours after the embolic stroke tion and working memory in all behavioural tests, while oestrogen pre-treatment
extended to 50% of the hemisphere. Thrombolysis alone did not reduce the improved attention and prevent or decreased memory deficit.
infarction size (about 43% of the hemisphere), but the combination of throm- Discussion: Our novel finding is that oestrogen is not just neuroprotective in our
bolysis and HBOT lead to a significant decrease of infarction size to about model, but augmented the expression of plasticity genes and these correlate well to
20% of the hemisphere (HBOT before rtPA p=0.01; HBOT during rtPA p=0.02, better outcome in behaviour tests.
Student-Newman-Keul-Test). This work was supported by OTKA T037887, GVOP-3.1.1.-2004-05-0389/3.0.
Discussion: In this study we could demonstrate a significant reduction of infarction
size in an embolic stroke model in rats by combining thrombolytic and hyperbaric

136 Cerebrovasc Dis 2007;23(suppl 2):1–147 16th European Stroke Conference


6 Experimental studies 8 Experimental studies
S 18886, A THROMBOXANE A2 RECEPTOR ANTAGONIST, PREVENTS ULTRASOULD-THROMBOLYSIS WITH 488KHZ - SAFETY-STUDIES WITH
OCCURRENCE OF SPONTANEOUS BRAIN DAMAGE IN STROKE-PRONE AN MRI-BASED RAT STROKE MODEL
RATS VIA ANTI-INFLAMMATORY ACTIVITIES M. Walberer, M. Nedelmann, D. Schiel, K. Volk, P. Reuter, M. Kaps,
P. Gelosa, E. Nobili, A. Gianella, V. Blanc-Guillemaud, L. Lerond, U. Guerrini, T. Saguchi, G. Bachmann, H. Furuhata, T. Gerriets
E. Tremoli, L. Sironi University Giessen, Germany; Kerckhoff-Clinic Bad Nauheim; Jikei University
Dept. Pharmacol. Science, Univ. Milan; Italy; Inst. Recherches Internationales Tokyo, Giessen, Germany
Servier, Courbevoie, Milan, Italy
Objective: Ultrasound can enhance the effect of i.v.-thrombolysis in acute stroke.
Background and aim: Spontaneously Hypertensive Stroke-prone rats (SHR-SP) First clinical trials with 2MHz-ultrasound revealed an improved recanalisation rate
are an established model of human cerebrovascular disease. In this rat strain, the but yet no convincing clinical benefit. Lower ultrasound frequencies might be
development of hypertension and inflammation precedes the appearance of brain more effective. However, clinical trials as well as animal experiments have shown
abnormalities. The aim of the present investigation was to assess the efficacy of S severe side-effects. Safety of new therapeutic ultrasound devices thus needs to be
18886, an orally active antagonist of TP-receptors (the receptors for thromboxane determined.
A2), in protecting the brain of SHRSP and whether this effect was related to its Methods: Male Wistar rats were subjected to middle cerebral artery-occlusion
anti-inflammatory properties. for 90 minutes followed by reperfusion (suture technique). Rt-PA (Actilyse® ) was
Methods and results: Male SHR-SP (n=10 per group), fed with a high-salt diet, injected intravenously thereafter. Then transcranial ultrasound treatment (488kHz;
received by gavage vehicle or S 18886 (3 or 30 mg/kg/day). In vehicle-treated sweep: 10%; 0.7W/cm2 ; continuous wave) was started and continued for 60
animals, brain lesions, as detected by magnetic resonance imaging, developed spon- minutes. Sham treated animals were used as controls. Intracerebral temperature
taneously after 40 ± 2 days (mean ± SEM). Treatment with S 18886 had no effect was recorded during ultrasound application in a sub-study.
on arterial blood pressure, significantly delayed the appearance of brain damage, MRI (Bruker PharmaScan, 7.0 Tesla) was performed after 24h. Ischemic lesion
at the dose of 30 mg/kg/d (p<0.001), and increased survival, in a dose dependent volume (T2-WI and DWI) and vasogenic brain edema (T2-relaxation time) were
manner (p<0.001 and p<0.0001 at the dose of 3 and 30 mg/kg/d respectively). quantified. T2*-WI was used to determine hemorrhagic complications.
In comparison with vehicle-treated SHRSP, treatment with S 18886 (30 mg/kg/d; Results: 488kHz-ultrasound treatment did not noteworthy affect brain temperature.
n=5), preserved brain tissue by preventing macrophage infiltration (ED1 positive Ultrasound did not increase lesion volume or edema formation. No hemorrhagic
cells) (p<0.05), and reduced the accumulation of perivascular macrophages (ED2 complications could be detected on T2*-weighted imaging.
positive cells) and lymphocytes T helper (CD4+ positive cells) as assessed by Conclusion: The 488kHz-device did not exert any side-effects in our MRI-based
immunohistochemistry. Furthermore, S 18886 attenuated the transcription of the rat stroke model. Further safety- and efficiency-studies are required prior first
pro-inflammatory cytokines IL-1beta, TNF-alpha, IL-6, and MCP-1, as assessed by clinical applications.
RT-PCR.
Conclusion: These data indicate that S 18886 prevents the occurrence of sponta-
neous brain damage in SHRSP by reducing inflammation, suggesting that S 18886 9 Experimental studies
may exert a beneficial anti-inflammatory effect in cerebrovascular disease.
GW3965, AN AGONIST OF THE LXR NUCLEAR RECEPTORS, IS
NEUROPROTECTIVE IN EXPERIMENTAL STROKE
7 Experimental studies M.A Moro, J.R Morales, M.P. Pereira, J.R. Caso, O. Moldes, J. Vivancos,
C. Gubern, J. Serena, A. Davalos, I. Lizasoain
CDP-CHOLINE INCREASES EAAT2 ASSOCIATION TO LIPID RAFTS AND Facultad de Medicina, Universidad Complutense Madrid, Madrid, Spain
AFFORDS NEUROPROTECTION IN EXPERIMENTAL STROKE
I. Lizasoain, O. Hurtado, J.M. Pradillo, D. Fernández-López, T. Sobrino, Background and purpose: Liver X receptors alpha (LXR-alpha) and beta (LXR-
T. Gasull, M. Castellanos, F. Nombela, J. Castillo, M.A. Moro beta), also known as NR1H3 and NR1H2, respectively, are ligand-activated
Facultad de Medicina, Universidad Complutense Madrid, Madrid, Spain transcription factors that belong to the superfamily of nuclear receptors. Apart from
their role in the regulation of cholesterol homeostasis and fatty acid metabolism,
Background: EAAT2 is responsible for up to 90% of all glutamate transport LXR receptors have been described to inhibit the expression of inflammatory medi-
and has been reported to be associated to lipid rafts. In this context, we have ators such as inducible nitric oxide synthase (iNOS), cyclooxygenase-2 (COX-2) or
recently shown that CDP-choline induces membrane translocation of EAAT2. Since matrix metaloproteinase-9 (MMP9). Since these anti-inflammatory actions might
CDP-choline preserves membrane stability by recovering sphingomyelin levels a be useful in stroke, we have investigated the effects of the LXR agonist GW3965
glycosphingolipid present in lipid rafts, we have decided to investigate whether on stroke outcome in a rodent model of cerebral ischaemia by permanent occlusion
CDP-choline increases association of EAAT2 transporter to lipid rafts. of the middle cerebral artery (MCAO).
Methods and results: For lipid rafts isolation, brain homogenates from each group Methods: Male Fischer rats were used. Infarct size: 48 after MCAO, animals
were subjected to a discontinous sucrose gradient in the presence of Brij-58 and 8 were sacrificed with an overdose of pentobarbitone and a serial of 2 mm thick
fractions were collected. Flotillin-1 was used as a marker of lipid rafts due to its coronal slices were made and stained with 2,3,5-triphenyltetrazolium chloride 1%
known association to these microdomains. We have found that flotillin-1 was found in 0.2 phosphate buffer. Infarct size was determined using a computer image
mainly in fractions 2 and 3 and their levels were similar in all the groups studied. analysis system. Experimental groups were control, permanent middle cerebral
EAAT2 protein was predominantly found colocalised with flotillin-1 in the fraction artery occlusion (MCAO), and MCAO+GW3965 (20mg/kg). GW3965 or vehicle
2, and CDP-choline increased EAAT2 levels in fraction 2 at both times examined (DMSO) were administered i.p. 10 min after MCAO. Stroke outcome was assessed
(3 and 6 hours after 1g/Kg CDP-choline administration). Furthermore, exposure to by measurement of infarct size. Protein expression of iNOS, COX-2 and MMP9
middle cerebral artery occlusion also increased EAAT2 levels, an effect which was in cerebral cortex were studied by Western blot and data were expressed as % of
further enhanced in those animals receiving 2 g/Kg CDP-choline 4 hours after the densitometry of bands in the MCAO group.
occlusion. Infarct volume measured at 48 h after ischemia showed a reduction in Results: The administration of the LXR agonist GW3965 reduced infarct volume
the group treated with CDP-choline 4 h after the ischemic occlusion. (180.4 ± 7.7 mm3 vs. 150.2 ± 5.5 mm3 in MCAO and MCAO+GW3965,
Conclusions: We have demonstrated that CDP-choline induces a re-localisation respectively, n=6-10, p<0.05). Furthermore, GW3965 reduced MCAO-induced
of EAAT2 into lipid raft microdomains in rat brain. This effect is also found expression of iNOS (41 ± 1% of MCAO, n=4, p<0.05), COX-2 (43 ± 3% of
after experimental stroke, when CDP-choline is administered 4h after the ischemic MCAO, n=4, p<0.05) and MMP-9 (43 ±1% of MCAO, n=4, p<0.05) was reduced
occlusion. We have also shown that this delayed post-ischaemic administration of in animals treated with GW3965.
CDP-choline induces a potent neuroprotection. Conclusions: Activation of LXR receptors induce neuroprotection in experimental
stroke, very likely due to anti-inflammatory mechanisms.

Poster Session Cerebrovasc Dis 2007;23(suppl 2):1–147 137


Experimental studies
10 Experimental studies risk can only be estimated by invasive diagnostics, which themselves bare the risk
of cerebrovascular accidents. Therefore we searched for a reliable non-invasive
ENHANCEMENT OF SENSORIMOTOR RECOVERY UNDER diagnostic tool for preoperative risk estimation.
CEREBROLYSIN TREATMENT IN A RAT MODEL OF FOCAL CEREBRAL Methods: A computer model of the brain supplying arteries was designed, whose
INFARCTION parameters can be determined by non-invasive measurements and picture-giving
M. Hitzl, J.M. Ren, D. Sietsma, S.M. Qiu, H. Moessler, S.P. Finklestein procedures to fit the model to the individual physiological state of the patient.
EBEWE Pharma GmbH Nfg.KG, R&D Neuro Products, Unterach, Austria Comparing time series generated by the model with those measured at the patient
the model can be evaluated and in the case of insufficient results its parameters can
Background: Many efforts have been made to find drug products having the po- be changed by an optimization process based on evolutionary algorithms.
tential to reduce infarct volume and/or promote neurological recovery after stroke. Results: The patient adapted models behaved physiologically and showed good
Cerebrolysin a unique drug product composed of neurotrophic and neuroprotective agreement between the modelled data and those recorded from the subjects. The
peptides from biological origin seems to fit perfectly into this specification. It has reaction of individual cerebrovascular systems in critical situations similar to the
therefore been tested in an rodent model of stroke. occlusion of the internal carotid artery was investigated by special scenarios. Even
Methods: Focal cerebral infarction was produced in mature male Sprague-Dawley though in this first step of examination the optimization process was only related
rats by occlusion of the proximal right middle cerebral artery. Animals have to a few parameters, it became obvious that evolutionary algorithms are suitable
subsequently been treated with Cerebrolysin at a daily dose of 1.0, 2.5, or 5.0 ml/kg provided that some physiological laws are considered.
body weight starting 24, 48 or 72 hours after stroke onset for 21 days. Behavioral Discussion: Although some difficulties remain concerning the parameter estimation
assays were performed before and during Cerebrolysin treatment (forelimb and and optimization we hope, that this flexible, time saving, cheap and non-invasive
hindlimb placing and body swing tests). At the end of Cerebrolysin treatment the method makes a valuable contribution to avoid complications of induced vessel
infarct volume has been determined using a computer-interfaced imaging system. occlusion during medical treatment by an improved operation planning.
Results: Cerebrolysin treatment of rats after focal cerebral infarction resulted
in enhanced recovery of sensorimotor function compared to vehicle-treated ani-
mals. Enhancement of sensorimotor recovery has been found when Cerebrolysin 13 Experimental studies
treatment at a dose of 2.5 ml/kg was started 24 or 48 hours after stroke onset.
Discussion: These findings clearly demonstrate that administration of Cerebrolysin NATURAL REGULATORY CD4+CD25+FOXP3+ T-LYMPHOCYTES (TREG)
after stroke can enhance neurological recovery. PREVENT DELAYED INFARCT GROWTH BY AN INTERLEUKIN-10
DEPENDENT MECHANISM
R. Veltkamp, E. Suri-Payer, C. Sommer, C. Veltkamp, H. Doerr, T. Giese,
11 Experimental studies A. Liesz
University Heidelberg, Heidelberg, Germany
RHEOENCEPHALOGRAPHY: A NON-INVASIVE METHOD TO ASSESS THE
ELECTRICAL IMPEDANCE CHANGES RELATED TO THE PULSATILITY OF Background and aims: Inflammatory cascades contribute to secondary ischemic
THE CEREBRAL BLOOD FLOW brain damage. Tregs are important anti-inflammatory modulators in various inflam-
J.M. Pons, J.J. Pérez, P. Ortiz, E. Guijarro, A. Navarré, J. Sancho matory diseases. We studied the role of Tregs in ischemic stroke.
1
Consorcio Hospital General Universitario Valencia; 2 Centro de investigación e Methods: Focal ischemia was induced by transtemporal MCAO. Tregs were
innovación en bioingeniería Universidad Politécnica de Valencia, Valencia, eliminated either by preischemic depletion with mAb (clone PC61) in C57Bl/6
Spain mice or by adoptive transfer of CD4+CD25- into rag2-/- mice. Infarct volume and
cerebral cytokine expression (RT-PCR) were measured at various time points after
Objective: Rheoencephalography (REG) measures the electrical impedance MCAO. Effect of IL-10 was tested by intraventricular injection or by transfer of
changes of the head caused by the pulsatility of the cerebral blood flow (CBF). Tregs from IL -10 -/- mice.
However, the use of REG in the clinical practice is limited because signal is buried Results: Treg depletion had no effect 24h after MCAO, but Treg-depleted
by the extracranial component. Our research group has formulated a mathematical mice had significantly larger infarct volumes 7d after MCAO (control: 7.4mm3 ;
algorithm that allows the extraction of the intracranial component from the REG antibody-treated: 12.1mm3 ). Correspondingly, transfer of CD4+25- T cells into
signal. The main goal of this work is to validate the separation method. For this lymphocyte-deficient rag2-/- mice resulted in larger infarcts (12.9mm3 ) than trans-
purpose, an experimental model that arrests mechanically the extracranial blood fer of CD4+ cells (6.8mm3 ; p<0.05). Intraventricular IL-10 reversed this effect.
flow is used. Treg derived IL-10 was particularly important as adoptive transfer of CD4+CD25+
Material and methods: REG signal was acquired in healthy volunteers in two cells derived from IL-10 -/- failed to prevent infarct growth. In mice lacking
conditions: (i) normal and (ii) during the arrest of the scalp blood flow by means the Tregs, RNA levels of proinflammatory cytokines were significantly more elevated
scalp compression with a pneumatic cuff. Subsequently, the intracranial component in ischemic hemisphere compared to control (6h after MCAO: TNFa 4x; IL-1b 2x;
extracted with our algorithm was statistically compared with the REG traces 72h after MCAO: IFNg: 5x). Cerebral invasion of Tregs became first detectable
recorded in scalp compression condition. 72h after MCAO by FACS and immunohistochemistry.
Results: Intracranial component extracted by our algorithm matches well with Conclusions: Tregs are master anti-inflammatory modulators in ischemic stroke
the REG trace recorded in scalp compression condition. Additionally, the mor- which reduce secondary infarct progression by downregulating proinflammatory
phology of the extracted intracranial component agrees with the intraparenchymal cytokine –induced cell death. Based on our findings, this effect is probably mediated
impedance traces previously described in the literature. by early humoral IL-10 signalling and by delayed Treg invasion.
Conclusions: Our results suggest that the intracranial REG component can be
reliably extracted from the raw REG signal by cancelling the scalp blood artifact.
This method could provide a new non-invasive technique to assess the cerebral 14 Experimental studies
blood flow. Nevertheless, additional works would be necessary to check and to
assess the diagnostic capability of our REG technique. NONLINEAR ANALYSIS OF BRAIN SPIROGRAPHY SIGNALS - THE WAY TO
This work was supported by grant PI04/0303 from the Instituto de Salud Carlos A NEW NON-INVASIVE DIAGNOSTIC TOOL (A PILOT STUDY)
III (Fondo de Investigación Sanitaria) in the framework of the “Plan Nacional de M. Swierkocka-Miastkowska, G. Osinski
Investigación Científica, Desarrollo e Innovación Tecnológica (I+D+I)”. Department of Neurology for Adults, Medical University of Gdansk, Gdansk,
Poland

12 Experimental studies Background: Ischaemic stroke is associated with disturbances of respiration


rhythm. The purpose of this study was to analyze breathing patterns of acute phase
FIRST EXAMINATIONS WITH AN AUTOMATICALLY OPTIMIZED stroke patients in comparison to healthy subjects.
COMPUTER MODEL FOR INDIVIDUAL SIMULATIONS OF CEREBRAL Methods: Brain spirography (BSG) as a new method of experimental clinical
HEMODYNAMICS breath research was deviced and tested in Medical University of Gdansk. It has a
F.C. Roessler, V. Metzler, R. Grebe, G. Siegel detecting system coupled with pressure sensors. Signals from the sensors through
Clinic for Neurology, UK-SH, Campus Lübeck, Lübeck, Germany the analog-digital converter are transferred to the computer for making visual
representation of respiration activity on a screen. Data from 55 patients with
Background: During the medical treatment of some cerebrovascular diseases it first-ever supratentorial ischaemic stroke and a control study of 25 volunteers were
is necessary to occlude brain supplying arteries. Sometimes these interventions obtained. In patients the respiration curves were measured 3 times during first
cause a cerebral ischemia and the patient will suffer from strokes. Until now this 5 days of hospitalization. All patients were assessed with the National Health

138 Cerebrovasc Dis 2007;23(suppl 2):1–147 16th European Stroke Conference


Institues Stroke Scale and (if needed)Glasgow Coma Scale. The curves were anti-apoptotic factors and IL-1, while the expression pro-apoptotic bax remained
analyzed with 3 nonlinear methods: Return Map Plot (RMP), calculation of Fractal unchanged.
Dimension (FD) with Higutchi algorithm and graphical representatiom of Visual Discussion: These data suggest that deprenyl is neuroprotective in an in vitro
Map Plot (VMP). model of ischemia. Although deprenyl upregulates the expression of Bcl-2 under
Results: We analyzed 25 physiological and 165 pathological data sets. As a result basal conditions, its effect on anti-apoptotic factors is not significantly manifested
we obtained average values of FD for both groups: in the group of volunteers during OGD.
FD=1.599 ±0.072, in stroke patients FD=1.873±0.076. The values analyzed with
ANOVA test are significantly different (p<0.003).
Discussion: As a number of stroke patients is instantly high, it is very important 17 Experimental studies
to develop quick, easy-to-use and non-invasive methods to monitor acute phase of
stroke. A set of graphical interpretation of RMP and VRP together with value of BCL-2 AND BCL-XL GENES THERAPY INCREASES PLASTICITY AND
FD and estimation of trends in groups of signals could give us clinically important CELL CYCLE GENES EXPRESSION AFTER HYPOXIA IN PC12 CELLS
information by visual representation of the analysis of dynamic status of respiratory A. Gal, G. Szilagyi, E. Wappler, Z. Bori, J. Vajda, J. Skopal, Z. Nagy
pattern. National Institute of Psychiatry and Neurology, National Stroke Center,
Budapest, Hungary

15 Experimental studies Introduction: Hypoxia induces cell necrosis and/or apoptosis. Antiapoptotic gene
therapy could be an option to prevent the cell death and activate the repair mecha-
MRI AND BEHAVIOR EFFECTS OF EARLY INTRAVENOUS DELIVERY OF nisms. In this study we measured the expression of plasticity and pro/antiapoptosis
MESENCHYMAL STEM CELLS AT EXPERIMENTAL CEREBRAL INFARCT genes (Bcl-2, Bcl-XL, Bax, synapsin-1, nestin and c-fos) in PC12 cell culture
IN RATS system after adenovirus containing Bcl-2 or Bcl-XL gene delivery. We found pre-
L. Gubskiy, K. Yarygin, O. Povarova, Yu. Pirogov, R. Tairova, A. Dubina, viously that the gene transfer has a cytoprotective effect, protects the mitochondrial
I. Cheblakov, D. Kupriyanov, V. Skvortsova function and augmented repair protein GAP-43 expression after hypoxic insults.
Fundamental and Clinical Neurology Department, Russian State Medical Materials and methods: The cells were treated by Argon gas (1 hr) for induction
University, Moscow, Russian Federation hypoxic cell injury followed by 24 hrs of restored oxygen. The cells were infected
with adenovirus constructs contaning Bcl-2 or Bcl-XL gene utilized before or
Background: To measure the effect of early intravenous delivery of mesenchymal after hypoxia. We examined the selected mRNA levels with real-time PCR. The
stem cells (MSCs) on neurological and neurobehavioral functional deficits and gene expression levels were determinated by ddCT method using TaqMan gene
MRT volume of experimental cerebral infarct in rats. expression assays.
Methods: 3-month-old 19 male Wistar rats (weight 180 to 250 g) were subjected to Results: Hypoxia and reoxygenization increased the pro-apoptotic Bax gene ex-
focal ischemia in the region of MCA by electrocoagulation before bifurcation into pression while the c-fos mRNA level was decreased. Gene transfers of Bcl-2 or
frontal and parietal branches under intraperitoneal anesthesia by chloral hydrate Bcl-XL resulted in a significant increase of Bcl-2, Bcl-XL, synapsin-1, nestin and
(300 mg/kg). The rats were randomized into three groups: sham (3), control (8) c-fos mRNA expression levels after hypoxic insults.
and experimental (8 animals with intravenous delivery of 6 million of MSCs on the Conclusions: In our in vitro model, Bcl-2 or Bcl-XL anti-apoptotic gene delivery
1 - 2nd days after operation). MRT was performed on 1-2 and 7 days at BioSpec was not only cytoprotective but it augments repair genes expressions after hypoxic
70/30, neurological and behavior functional tests (elevated cross - maze, open-field insults. The double actions of these genes appear to be beneficial in preventing
tests) also where performed. hypoxic cell injury. However, the link between the augmented anti-apoptotic and
Results: Neurological severity scores in experimental and control groups on 1, 7 repair mRNA expression is not clear at the moment.
and 14 days after operation were equal but lower than those in the sham-operated Keywords: PC12, hypoxia, Bcl-2, Bcl-XL gene transfer, plasticity genes
group. At open-field test the horizontal activity of control rats was higher than
experimental animals. There were no significant differences between control and
MSC groups on the cross-maze on 10 but not 20 day. Before delivery of MSCs 18 Experimental studies
volumes of cerebral infarct (at T2-weighted imaging) were without significant
difference between control and experimental groups. There was significant decrease (-) DEPRENYL-N-OXID IS NEUROPROTECTIVE AFTER TRANSIENT
of the volumes in both groups on 7 day. HIPPOCAMPUS ISCHEMIA IN GERBILS
Discussion: Early intravenous delivery of MSCs did not change the rate of decrease G. Szilágyi, K. Magyar, Z. Nagy
of the volume of cerebral infarct at the first 7 days of experimental cerebral infarct National Stroke Centre, Budapest, Hungary
in rats. There were no difference between groups at neurological and behavior
functional tests except for more high activity of control rats at open field test. Introduction: As we reported previously, (-)deprenyl-N-oxid (DNO) has signifi-
cant cytoprotective effects in PC12 cell culture. Decreased cell death and reactive
species production and increased mitochondria trans-membrane potential were
16 Experimental studies demonstrated after hypoxic injury. In this paper we tested the neuroprotective effect
of DNO on hippocampus in a model of transient, bilateral common carotid artery
OXYGEN-GLUCOSE DEPRIVATION-INDUCED CELLULAR CHANGES IN occlusion in Gerbils.
ORGANOTYPIC SLICE CULTURES OF THE HIPPOCAMPUS: PROTECTIVE Methods: We performed transient, bilateral carotid artery occlusions for 10 min-
EFFECT OF (-)DEPRENYL utes. The treated group was injected 0.4 mg/kg/day of N-oxid-deprenyl intra
B. Bali, Z. Nagy, K.J. Kovács peritoneal for 4 days. The control rats were injected with the vehicle only. The
Semmelweis University, Budapest, Hungary gerbils were killed after 4 days. On the formaldehyde fixed sections TUNEL and
caspase-3 immuno-histochemistry were performed and NIKON/BIORAD confocal
Background: (-)Deprenyl is an irreversible inhibitor of type B monoamine oxidase microscope was used for analysis. Consecutive images were taken from the hip-
(MAO-B), which is now used as a neruoprotective compound for treatment of pocampus. The TUNEL and caspase-3 positive cells were counted automatically
Parkinson’s or Alzheimer’s diseases. Evidence suggests that the therapeutic efficacy with Image J 1.37 software (NIH, USA).
of deprenyl may not be related exclusively to the inhibition of the enzyme MAO-B, Results: All the caspase-3 positive cells were TUNEL positive too. In the CA2
however the cellular mechanisms underlying its neuroprotective effect remained regions we found significantly less caspase positive neurons az there were found in
unknown. the controls. Similarly in the same region significant decrease in number of TUNEL
Methods: To test the impact of deprenyl on ischemia-induced changes in vitro, we positive cells were counted.
followed the time course of propidium iodide (PI) uptake as an indicator of neuronal Discussion: In our previous study we demonstrated the neuroprotective effect of
cell death in organotypic hippocampal slice cultures exposed to oxygen-glucose deprenyl. This drug decreased significantly the TUNEL labelled and TUNEL-
deprivation (OGD) for 45 min. The expression of apoptotic factors (Bcl-2, Bcl-xl caspase-3 double labelled neurons in the penumbra region after permanent MCA
and Bax) as well as of the proinflammatory citokine interleukin-1 (IL-1) was occlusion in rat. In the present experiment one of the deprenyl metabolite DNO
measured by polymerase chain reaction (PCR) decreased similarly the number of TUNEL positive cells in the CA2 hippocampus
Results: The first signs of neuronal death were detected 2 hours after OGD and region. DNO cytoprotective effect was previously documented in PC12 cell culture.
were extended to all subfields of the hippocampus by 24 hours post-injury. Presence The neuroprotective effect of the highly polar molecule in the in vivo model could
of deprenyl (10-9 M) significantly delayed the cell death induced by the insult. be related the transient opening of BBB in this model.
Exposure of control cultures to deprenyl significantly increased the abundance of Grant: OTKA T037887.
Bcl-2 and Bcl-xl mRNAs as revealed by RT-PCR. OGD resulted in an elevation of

Poster Session Cerebrovasc Dis 2007;23(suppl 2):1–147 139


Experimental studies
Vascular surgery and neurosurgery/Interventinal 3 Vascular surgery and neurosurgery/Interventinal
neuroradiology neuroradiology
CAROTID ENDARTERECTOMY: COMPLICATIONS AND CLINICAL
1 Vascular surgery and neurosurgery/Interventinal OUTCOME
neuroradiology R. Martinez, Y. Silva, J.A. Amado, O. Andres, J. Puig, S. Pedraza,
M. Castellanos, J. Serena
INTRA-ARTERIAL AND INTRAVENOUS THROMBOLYSIS IN ACUTE Hospital Universitari Dr. Josep Trueta, Girona, Spain
ISCHEMIC STROKE FROM CAROTID “T” OCCLUSION
P. Nencini, S. Mangiafico, M. Nesi, I. Romani, G. Cagliarelli, M. Pratesi, Background: To investigate the rate of perioperative complications and the clinical
V. Palumbo, M. Cellerini, A. Rosselli, D. Inzitari outcome of endarterectomy in patients with symptomatic carotid-artery stenosis of
Careggi Hospital, Florence, Italy at least 70% in daily clinical practice. High risk patients were included.
Method: Ninety-five patients consecutively diagnosed as having symptomatic
Background: Outcome in acute ischemic stroke from internal carotid artery oc- carotid stenosis >70% were included over a 4 year period up to 2006. The
clusion is poor with high mortality or severe long-term disability. We evaluated if therapeutic decision was taken collectively by a multidisciplinary team from the
intra-arterial (IAT) or intravenous thrombolysis (IVT) may influence outcome. neurology, neurosurgery and neuroradiology departments. Vascular risk factors,
Methods: From February 2004 to August 2006, twenty-nine patients with acute neurological examination, neuroimaging findings, carotid and transcranial colour
internal carotid artery “T” occlusion were admitted to two Hospitals in Florence, duplex study, intra- and post-operative complications (local and systemic), stroke
Italy. All patients underwent screening for IVT (SITS-MOST protocol), colour recurrence and mortality at 3 months were recorded. Patients were admitted to
duplex sonography or cerebral angiograph, and had a 3-month follow-up with the neurology department both on the occurrence of stroke and for immediate
mRankin scale (mRS). postoperative attention.
Results: Eleven patients (male 64%, mean age 66 years, mean NIHSS 20) were Results: Seventy-six percent of patients were men, mean age 70±8.5 years. Hyper-
treated with IATwithin 6 hours from symptom onset; 11 patients (male 27%, mean tension had a frequency of 72.6%; hypercholesterolemia, 51.6%; diabetes, 31.6%;
age 72 years, mean NIHSS 18) with IVT within 3 hours from symptom onset; and smoking, 29.5%; and ischaemic cardiac heart disease, 23.2%. Sixty percent had suf-
7 patients (male 86%, mean age 64 years, mean NIHSS 18) had standard treatment. fered a stroke and 40% a TIA. Forty percent of patients had a symptomatic stenosis
Recanalization was achieved in 8/29 (27.6%) patients (6 TIMI 3 and 2 TIMI 2), all >90% and 24% had a contralateral asymptomatic stenosis >70% or occlusion.
treated with IAT. Four out of 11 (27.3%) IAT patients had a 3-month good (mRS The occurrence of stroke or death within 3 months of carotid endarterectomy was
0-2) outcome compared with no patients in both the IVT and standard treatment 4.2%. Two patients died perioperatively (2.1%), one as a result of a hyperperfusion
group. The 3-month mortality rate was 36% in IAT, 27% in IVT, and 43% in syndrome and the other due to a brain infarction. Two patients (2.1%) suffered
the standard group, respectively. Symptomatic haemorrhage occurred only in IAT stroke recurrence.
group (27% of patients). Minor haemodynamic alterations were detected in 42.1% of patients during the
Conclusions: The prognosis of ischemic stroke due to internal carotid artery first days after endarterectomy (hyper or hypotension) and 43.2% had local
“T” occlusion remains severe. Our data may suggest a favourable effect on the complications (XII or VII minor pareses).
intra-arterial approach. More data are needed to confirm this hypothesis. Conclusions: Among patients with severe carotid-artery stenosis and coexisting
conditions, carotid endarterectomy in clinical practice, including high risk patients,
has a low perioperative risk although minor complications are frequent, which may
2 Vascular surgery and neurosurgery/Interventinal be attributable to the close neurological control.
neuroradiology
RETROSPECTIVE VALIDATION OF THE ABCD SCORE IN PATIENTS 4 Vascular surgery and neurosurgery/Interventinal
PRESENTING WITH TRANSIENT ISCHAEMIC ATTACKS UNDERGOING neuroradiology
CAROTID ENDARTERECTOMY
S. Shaikh, J. Brittenden, E. MacAulay, M.J. Macleod CAROTID ENDARTERECTOMY AUDIT OF GREAT BRITAIN & IRELAND
University of Aberdeen, Aberdeen, United Kingdom A. Rudd, T. Lees, A. Halliday, P. Rothwell, A. Hoffman, D. Kamugasha
Royal College of Physicians, London, United Kingdom
Introduction: Patients who have experienced a transient ischaemic attack are at
risk of developing a stroke especially within the first two weeks after a TIA. The Background: A prospective two-year audit involving all hospitals that offer
ABCD score aims to predict an individual patient’s risk, thus facilitating the ability Carotid Endarterectomy (CEA), aiming to capture data on all CEA cases performed
to fast-track investigation and treatment of the high-risk group who have a score of between Dec 05 & Dec 07, to assess quality of process of care & outcomes against
5 or 6. We aimed to assess the ABCD score of patients who had undergone carotid the available evidence base. Main reporting spring 2008. A firm evidence base
endarterectomy. supports the role of CEA & its urgency in the prevention of stroke. In the UK
Method: 194 of patients who underwent CEA between January 2001 and December 110,000 patients per annum suffer first stroke & 30,000 suffer TIAs. 10%-15% of
2005 were identified from a prospectively collected database. the stroke patients should have CEA. The Healthcare Commission commissioned
Results: 90 (46.4%) patients undergoing CEA presented with a TIA. The remaining the audit following a pilot funded by the Stroke Association.
operations were performed for cerebrovascular accident (n=59), amaurosis fugax Methods: All surgeons who undertake CEA are eligible to participate and un-
(n=36) and asymptomatic carotid disease (n=9). All patients had an ipsilateral dertake to contribute to: Organisational Survey (2 rounds) describing individual
high-grade internal carotid artery stenosis (>70%). Of the 89 patients with TIAs surgeon routine practice: investigations, case selection criteria, surgical technique
(case-notes of 1 patient were destroyed), the median age was 71years (range & post-operative assessment and Clinical Audit to collect patient level data
45-83) with a male to female ratio of 1.6:1. Post-operative complications included (indications, investigation, surgical technique & 30-day morbidity/mortality).
2/89 (2.22%) TIAs, 2/89 (2.24%) lingual nerve paraesthesia, and 4/89 (4.5%) Results: Organisational Survey (Round 1): Median number of CEAs performed
haematomas none of which required drainage. The ABCD scores were as follows: per annum overall is 17 (IQR 10-25) - 90% of these done for symptomatic disease
1, n=4 (4.49%); 2, n=15 (16.85%); 3, n=19 (21.34%); 4 n=22 (24.71%); 5 n=17 Over 70% of surgeons say they are able to see patients referred by letter within 2
(19.10%); 6 n =12 (13.48%). weeks
Conclusions: All patients undergoing CEA for TIAs were treated as per the 99% of surgeons would not operate on symptomatic carotid stenoses <50% and
recommendations of the European carotid trial, yet according to the ABCD score 53% would not operate <70%.
two thirds of these patients would be considered to be at low risk of a subsequent 62% of surgeons would be prepared to undertake CEA within 2 weeks following
neurological event. These patients would not have been fast-tracked for treatment a non-disabling stroke if the CT scan showed no infarct and 39% if the CT scan
and thus further validation of this score is urgently required. showed a small infarct
Vascular surgeons perform nearly all CEA but about one quarter of surgeons
perform fewer than 10 cases per year. There are significant variations across the
country in access to CEA services.
Discussion: Recruitment is still open. 86% of eligible surgeons have registered and
so far contributed 1300 cases for the Clinical Audit for which data collection will
continue until end of December 2007. The first round of the Organisational Survey
completed May 2006 and the second is currently Round 2 is underway will report
April 2006

140 Cerebrovasc Dis 2007;23(suppl 2):1–147 16th European Stroke Conference


Venous diseases 3 Venous diseases
INCIDENCE OF INHERITED THROMBOPHILIA IN GREEK PATIENTS
1 Venous diseases WITH CEREBRAL VENOUS THROMBOSIS
K. Lysitsas, I. Gravas, G. Papaioannou, P. Kyriakidis, E. Dermitzakis, J. Rudolf
DEVELOPMENT OF A RISK SCORE TO PREDICT THE PROGNOSIS OF Papageorgiou General Hospital, Thessaloniki, Greece
CEREBRAL VEIN AND DURAL SINUS THROMBOSIS (CVT)
J.M. Ferro, T. Rodrigues, L. Bacelar-Nicolau, H. Bacelar-Nicolau, P. Canhão, Background: Hereditary thrombophilia has been reported to be present in approx-
I. Crassard, A. Dutra, A. Massaro, M.A. Mackowiak-Cordiolani, D. Leys, J. imately 30% of all patients with cerebral venous thrombosis (CVT). However, data
Fontes on the incidence of inherited thrombophilia in Greek CVT patients are scarce.
Department of Neurosciences, Hospital de Santa Maria, Lisboa, Portugal Methods: We report the results of the diagnostic work-up including a full throm-
bophilia screening in a consecutive case series of 27 patients (8 males, 19 females,
Background: Although cerebral vein and dural sinus thrombosis (CVT) has an age range 17 – 59 years) with CVT from a Greek tertiary healthcare facility.
overall favourable prognosis, a variable proportion of patients die or became Results: Cephalalgia was the leading symptom in 85% of the patients (n=23),
dependent after CVT. It is relevant to identify such high-risk patients. focal neurological signs were present in 48% (n=13), and epileptic seizures in 22%
Method: We used the ISCVT sample (624 patients) with a median follow-up time (n=6). Multiple thrombosis of cerebral sinus was a common finding in MRI and
of 478 days to develop a Cox proportional hazards regression model. Because of MRV: Thrombosis of the superior sagittal sinus was found in 78% (n=21), of the
non proportional hazards, the used model was stratified by the median age of 37 transverse sinus in 41% (n=11), the sigmoid sinus in 7% (n=2), of the sinus rectus
years. A treatment of influential observations (dfbeta analysis) led us to not include in 18% (n=5) and of the cavernous sinus in one patient only. Elevated D-dimers
9 outlier subjects. The model was tested in the whole ISCVT sample and in two were found in 48% (n=13, hyperhomocysteinaemia in 30% (n=8), heterozygous
validation samples 1) the VENOPORT (91 patients), 2) of 169 consecutive CVT mutation of the MTHFR gene in 44% (n=12) and homozygous MTHFR mutation
patients admitted to 5 ISCVT participating centres after the end of the ISCVT in 18% (n=5). Other hereditary thrombophilias (e.g. FV-Leiden mutation, n=1, or
recruitment period. the prothrombine G20210A mutation, n=2) were found in single cases only.
Results: In the ISCVT sample the model (HR - CNS infection 5.11; malignancy Conclusion: In this consecutive open case series of Greek patients with CVT, the
3.96; deep system 3.32; coma 3.17; mental 2.25; haemorrhage 1.57; male 1.76) incidence of inherited thrombophilia was considerably higher than reported from
accurately predicted 89% of good and 47% of bad outcomes (accuracy: 85%) at 6 other comparable study populations.
months, for a cut-off of 83% in the estimated survival probability. Area under the
ROC curve was 0.79 (p=0.000). In the VENOPORT validation sample the model
accurately predicted 91% of good and 25% of bad outcomes (accuracy: 84%). Area
under the ROC curve was 0.69 (p=0.077). In the 5 ISCVT centres validation sample Heart & brain
the model accurately predicted 93% of good and 24% of bad outcomes (accuracy:
86%). Area under the ROC curve was 0.79 (p=0.000).
Conclusion: The prognostic model presents a good external validity. The model 1 Heart & brain
accurately predicts the majority of favourable outcomes and 1/4 to 1/2 of un-
favourable outcomes. It can be used to avoid dangerous interventions in low-risk DIAGNOSING PATENT FORAMEN OVALE(PFO) IN CRYPTOGENIC
patients and to select patients for intensive monitoring and aggressive interventions. STROKE:TRANSCRANIAL DOPPLER VS TRANS OESOPHAGEAL ECHO
From hazard ratios a prognostic score and estimated survivor probability at 6 S. Kumar, M.S. Randall, L.O.’ Toole, J.N. West, G.S. Venables
months can be computed. Sheffield Teaching Hospitals NHS Trust, Sheffield, United Kingdom

Background:
2 Venous diseases PFO is associated with cryptogenic stroke in young patients (<55 years). Trans
Oesophageal Echo (TOE) has been the standard for diagnosing PFO. Contrast en-
DURAL ARTERIOVENOUS FISTULAS AND PREMATURE hanced Trans Cranial Doppler (TCD) is a simpler, easier & less invasive technique
ANTICOAGULATION CESSATION AFTER CEREBRAL VENOUS that detects a right to left shunt (RLS).The aim of this study was to compare the
THROMBOSIS utility of the two techniques in the management of young patients with stroke.
P. Cardona, H. Quesada, P. Sanchez, M.A. Fong, A. Escrig Methods:
Bellvitge Hospital, Hospitalet de Llobregat, Barcelona, Spain TCD & TOE were performed in 100 consecutive patients with ischaemic stroke
or TIA (< 55 years; mean age 40years). Statistical analysis was performed using
Dural arteriovenous fistulas (DAVF) rarely are associated with cerebral venous SPSS software.
thrombosis (CVT). We report five cases of symptomatic intracranial dural arteri- Results:
ovenous fistulas during follow-up of CVT. 51% of patients had RLS on TCD and only 41% on TOE. After a positive result
Methods: We retrospectively review forty patients with intracranial venous throm- on ce TCD 2 patients who had a negative TOE on the first occasion were shown
bosis between 1996-2006. In five cases DAVFs were developed during follow-up to have a shunt on repeat TOE. Other structural abnormalities detected by TOE
period 1 year after anticoagulation stopping (after 6 -9 months of period treatment); were inter atrial septal aneurysm (19), aortic atheroma (7), atrial thrombus (2), left
leptomeningeal drainage were present in all the cases. ventricular hypertrophy (2) & mitral valve abnormalities (3). Using TOE as the
Results: Symptoms as pulsatile tinnitus or headache appeared 3-12 months interval standard, TCD sensitivity was 90% and specificity was 76%.With the combination
after anticoagulation cessation. All five patients where the initial angiogram studies of the two tests as the standard, the sensitivity of TCD & TOE was 93% & 75%
had showed abnormalities of the venous transverse or sigmoid sinuses, persistent respectively. The negative predictive value of TCD was 92%,while that of TOE
abnormalities were seen on the later angio-MR previous to stopping oral anticoag- was only 76%.McNemar’s test showed a significant difference between TCD &
ulant (6-12 months period) as occluded or filiforme sinus. Two of five patients had TOE(P=0.03).
factor V Leiden previously unknowned. Embolization of DAVF was performed in Discussion:
three cases with good outcome. This study reveals the added value of TCD in combination with TOE. The higher
Discusion: DAVF appeared over previous ocluded or filiforme transverse sinus sensitivity and negative predictive value of ceTCD may be due to an extracardiac
demonstrated in angio-MR. All fistulaes were on the transverse or sigmoid sinuses.It shunt or inadequate valsalva during TOE. The size of the shunt on TCD may
was hypothesized that factor V Leiden and other inhereted deficiencies of coagula- assist in the risk assessment for stroke recurrence in young people with stroke.
tion factors, might be involved in the pathogenesis of DAVFS secondary to venous TOE is useful to exclude other sources of cardiac emboli. TCD has been shown
thrombosis predisposition over damaged venous wall. Also the anticoagulation to be reliable, more sensitive, less invasive and easy to use in a clinical setting
cessation may predispose to DAVF formation. making it the ideal screening tool. All young cryptogenic stroke patients should
Conclusion: The longterm anticoagulant therapy in occluded or partial thrombosed have both TCD & TOE; undergo risk stratification based on degree of shunt on
sinus might be important for prevention of thrombosis and DAVF formation TCD, the presence of intra cardiac abnormalities and other concomitant risk factors
although patients were asymptomatic. Due to a potential risk of intracranial hemor- to facilitate appropriate management.
rages, embolisation previous to prompt anticoagulation may be developed in these
cases.

Poster Session Cerebrovasc Dis 2007;23(suppl 2):1–147 141


Heart & brain
2 Heart & brain 4 Heart & brain
MODERATE HYPOTHERMIA FOR ANOXIC ENCEPHALOPATHY AFTER THE ROLE OF THE MORPHOLOGICAL CHARACTERISTICS OF PATENT
IN-HOSPITAL AND OUT-OF-HOSPITAL CARDIAC ARREST: RESULTS IN FORAMEN OVALE IN CRYPTOGENIC STROKE: AN MRI STUDY
ROUTINE CLINICAL PRACTICE C. Bonvin, K.O. Lovblad, H. Müller, R. Sztajzel
R.A. Bernstein, K. Dewan, A.M. Naidech, M.J. Alberts, D. Fintel, D. Bergman, University Hospitals of Geneva, Genève, Switzerland
R. Oakley
Northwestern University, Chicago, IL, USA Background and purpose: Patent foramen ovale (PFO) is an established cause of
cryptogenic stroke in young patients. The aim of our study was to evaluate, in pa-
Background and purpose: Randomized trials have shown that induced moderate tients admitted for a cryptogenic stroke or transient ischemic attack (TIA), whether
hypothermia (MH) improves neurological outcomes after out-of-hospital cardiac the number and distribution of ischemic lesions on MRI differed according to the
arrests due to ventricular fibrillation/tachycardia (VF/VT). However, the effective- morphological characteristics of the PFO including size and degree of interatrial
ness and safety of this treatment for other arrhythmias or for in-hospital arrests is right-to-left shunting (RLS) and presence of atrial septal aneurysm (ASA).
less clear. In addition, the prognostic significance of early brainstem dysfunction Patients and methods: We included 220 consecutive patients less than 60 years old
after hypothermia is unknown. We devised a standard protocol for MH in patients admitted from 2000 to 2006 for a cryptogenic stroke or TIA (absence of any other
with anoxic encephalopathy after cardiac arrest of any type, including both in determined stroke etiology following TOAST criteria after complete diagnostic
hospital and out-of hospital arrests. workup). Hypercoagulable state was not an exclusion criterion, since it may play
Methods: For this retrospective case series, we collected demographic, clinical, a role in the paradoxical embolism. Demographic data have been analyzed from
and outcome data on our first 21 consecutive patients treated with MH for anoxic the patients’ personal records. MRI scans and echocardiographies were evaluated
encephalopathy after cardiac arrest. Target temperature was 33o C for 24 hours by independent experienced investigators, blinded to the patients’ history. Two
from start of cooling, with controlled re-warming over 8 hours. Neurological out- different methods were systematically assessed to diagnose PFO and ASA: contrast
comes were dichotomized based on discharge disposition as “good” (discharge to transcranial Doppler (c TCD) and transesophageal echocardiography (TEE) as well
home or rehabilitation) or “poor” (discharge to nursing home or death). Brainstem as transthoracic echocardiography (TTE) in most patients.
dysfunction was defined as any of the following: pupillary non-reactivity, absent Results: Recruitment of patients is completed and neurologists, cardiologists and
caloric or oculocephalic reflexes, absent corneal reflexes, or absent gag reflex. neuroradiologists are currently working intensively on the data. We will especially
Results: Of the 21 patients who underwent MH after cardiac arrest, 62% were determine (i) the prevalence of PFO and ASA in cryptogenic strokes, (ii) compare
male, and the mean age was 60 [range 35-88]. In hospital arrests (n=16, 76%) out- c-TCD, TEE and TTE methods in their ability to detect and quantify the PFO,
numbered out-of-hospital arrests (n=5, 24%). Arrest arrhythmias included pulseless (iii) correlate the number and size of MRI lesions with size of PFO, ASA and
electrical activity (44%), asystole (24%), VF/VT (19%), primary respiratory arrest degree of RLS in univariate and multivariate analysis (logistic-regression model
followed by cardiac arrest (10%) and unknown (5%). The mean time to return and ANCOVA). To our knowledge, this study is the first to compare simultaneously
of spontaneous circulation was 16 minutes [95% CI 9.7-22.7 min]. Discharge c-TCD, TEE and TTE findings with MRI lesions in patients with cryptogenic
dispositions were to home (10%), rehabilitation (19%), nursing home (14%) and stroke. This study may help to better assess the risk of stroke in these patients and
dead (57%). Good outcome (discharge to home or rehabilitation) occurred in 3 of thus have critical impact on treatment options.
5 (60%) of out-of-hospital arrests, and 3 out of 16 (18%) of in hospital arrests.
Among patients surviving 3 or more days, all of those with brainstem dysfunction
had poor outcomes (n=8); of those without brainstem dysfunction on day 3, 6 out
of 7 (86%) had good outcomes. Large clinical trials (RCTs)
Conclusions: Moderate hypothermia after cardiac arrest is feasible in routine clin-
ical practice. Good neurological outcome may be more common in out-of-hospital
arrests; only a randomized trial can determine if this therapy is effective for 1 Large clinical trials (RCTs)
in-hospital arrests. Consistent with experience in the pre-hypothermia era, patients
with brainstem dysfunction on or beyond day 3 have poor outcomes. DELAYS IN TREATMENT FOR SYMPTOMATIC CAROTID STENOSIS AT
RESEARCH ACTIVE CENTRES
R.L Featherstone, J. Ederle, M.M. Brown
3 Heart & brain UCL Institute of Neurology, London, United Kingdom

IS HEART DISEASE A PROGNOSTIC FACTOR FOR ACUTE STROKE Background: Treatment of symptomatic carotid artery stenosis is an effective
OUTCOME? A PROSPECTIVE STUDY secondary prevention measure for stroke. The earlier endarterectomy is performed
I. Ybot, M.J. Abenza, B. Fuentes, B. San José, M.A. Ortega-Casarrubios, after symptoms, the better the long-term outcome. We have used baseline data from
P. Martínez, E. Díez-Tejedor the International Carotid Stenting Study (ICSS), an ongoing multicentre study of
University Hospital La Paz, UAM, Madrid, Spain symptomatic patients randomized between carotid endarterectomy and stenting, to
assess delays in treatment.
Background: Heart disease in ischemic stroke (IS) may be the cause of stroke, Methods: The interval between the most recent TIA or non-disabling stroke,
a coexistent illness, or even a consequence of stroke, but its presence means a recorded at randomization, and the date of procedure (carotid endarterectomy or
higher risk for vascular death. Objective: To analyse the presence of cardiopathy in stenting) was calculated for all ICSS patients where data on the procedure was
patients with acute IS and its impact on stroke outcome. returned by December 2006. Data came from 36 centres in the UK, Europe, North
Methods: Prospective study with inclusion of consecutive IS patients in a 4-month America and Australia.
recruitment period. Previous or current cardiopathy, vascular risk factors, stroke Results: The median delay between event and treatment was 55 days (n=854). Most
severity on admission, in-hospital complications and modified Rankin Scale (mRS) of the delay occurred before randomization, median delay between randomization
at discharge were analysed. and treatment was 14 days. The three centres with the shortest average delay
Results: 91 patients included, 33% with known heart disease. Most frequent between event and treatment were compared with the three that had the longest.
entities were arrhythmia, including atrial fibrillation (AF) (53.3%) and ischemic The median delay at the fastest centres was 14 days (N=42 patients) compared
cardiopathy (36.7%). They were older (72 vs 63 years old; p<0.05), had greater to 123 days in the three slowest centres (N=72 patients), a significant difference
frequency of hypertension (80% vs 42%; p<0.05), hypercholesterolemia (60% vs (p<0.001).
19%; p<0.05) and peripheral artery disease (20% vs 4,9%; p<0.05), had more Discussion: Significant differences exist in treatment delays between centres. Even
severe strokes on admission (p<0.05) and worse outcome at discharge (mRS>2: the most efficient research active centres are failing to treat many patients with
48.1% vs 18.2%;p<0.05) than patients without previous history of heart disease. symptomatic carotid stenosis within 2 weeks of the presenting symptoms, when
It was diagnosed cardiopathy in 11 among 61 patients without known heart the benefit is greatest. Such treatment delays result in a substantial proportion of
disease (18%), being AF the most frecuently diagnosis (6 patients). In the logistic patients being left at high risk of a recurrent event while awaiting investigation
regression analysis, the only independent factor of poor outcome was the stroke and treatment. The results emphasise the need to reorganize stroke services to
severity on admission, without significant influence of heart disease. investigate and treat carotid stenosis urgently.
Discussion: Although previous cardiopathy seems to be associated to higher stroke
severity on admission and worse recovery at discharge, when adjusting for other
prognostic factors it was not independently associated to poor outcome.

142 Cerebrovasc Dis 2007;23(suppl 2):1–147 16th European Stroke Conference


2 Large clinical trials (RCTs) Behavior and mood
THE SAFETY AND EFFICACY OF CLOPIDOGREL VERSUS TICLOPIDINE
IN JAPANESE STROKE PATIENTS — COMBINED RESULTS OF TWO PHASE 1 Behavior and mood
III MULTICENTRE RANDOMISED CLINICAL TRIALS
S. Uchiyama, T. Yamaguchi, Y. Fukuuchi SYMPTOMS AND DIAGNOSIS OF DEPRESSION IN APHASIC STROKE
Tokyo Women’s University, Tokyo, Japan PATIENTS
A.C. Laska, B. Mårtensson, T. Kahan, M. von Arbin, V. Murray
Background: Compared with aspirin, both ticlopidine and clopidogrel have demon- Karolinska Institutet, Department of Clinical Sciences, Stockholm, Sweden
strated superior efficacy in preventing recurrent vascular events, but adverse drug
reactions (ADRs) are more common with ticlopidine. For the first time, the safety Background: We investigated the feasibility of assessing depression, and symptom
and efficacy of these agents have been compared directly among Japanese stroke occurrence, in patients with aphasia.
patients in a combined analysis of 2 phase III randomised, controlled studies. Methods: 89 acute stroke patients with aphasia of all types were followed for six
Methods: Patients aged 20–80 years with a history of noncardioembolic stroke months. The diagnosis of depression was made in accordance with DSM-IV criteria
were randomised to receive clopidogrel 75 mg once daily (n=941) or ticlopidine at baseline, 1, 3, and 6 months. A standard aphasia test was performed. A battery
200 mg once daily (n=928) for 26 or 52 weeks. The primary endpoint was of “yes and no” capability questions from the comprehension part of the aphasia
safety (incidence of ADRs; n=1869). The major secondary endpoint was efficacy test were selected for depression diagnostic purposes.
(combined incidence of cerebral infarction, myocardial infarction, and vascular Results: In 60 patients (67%) at baseline, and successively increasing to 100%
death; n=1862). at six months, comprehension allowed reliable DSM-IV diagnosis. The possibility
Results: Baseline characteristics of each group were similar (mean age, 64.7 to undertake a DSM-IV interview was related to the degree of aphasia (p<0.01),
years; 71.3% males). The clopidogrel group had significantly fewer ADRs than the and was least in patients with global and mixed non-fluent types of aphasia. A
ticlopidine group (35.0% vs 48.7%; p<0.0001) and a significantly lower incidence comparison at one month between patients reliably fulfilling the criteria for a
of hepatic dysfunction (13.4% vs 25.6%; p<0.001). The frequency of hemorrhagic depression (D) and those who did not (Non-D) revealed: none of the two cardinal
ADRs was similar in the two treatment groups (clopidogrel group, 11.9%; ticlo- symptoms occurred among the Non-D. Of the other symptoms, weight loss (36% in
pidine group 10.1%; p=0.612). Both drugs were equally effective in preventing D, 16% in Non-D); insomnia (50% in D, 33% in Non-D); loss of energy (25% in D,
vascular events (clopidogrel group, 3.6%; ticlopidine group, 3.8%; p=0.510). 20% in Non-D); and impaired concentration (27% in D, 19% in Non-D) occurred
Conclusions: In Japanese patients with a history of noncardioembolic stroke, both (all n.s.). At six months weight loss, insomnia, and loss of energy still occurred in
clopidogrel and ticlopidine are equally effective in the prevention of recurrent above 10% in Non-D. In all, criteria for depression were fulfilled in 24%.
vascular events. Discussion: It is possible to verify the presence or absence of a depression accord-
However, clopidogrel is safer than ticlopidine. Now that clopidogrel is available ing to DSM-IV criteria in two thirds of aphasic stroke patients in the acute setting.
in Japan, it should be considered as the preferred treatment choice, as occurs for Some depression symptoms occur irrespective of depression diagnosis. Hence, if
Western patients. a cardinal symptom is fulfilled depression may possibly be over-diagnosed in the
individual stroke patient with aphasia.

3 Large clinical trials (RCTs)


2 Behavior and mood
ETHNICITY DOES NOT AFFECT THE HOMOCYSTEINE-LOWERING
EFFECT OF VITAMIN THERAPY IN SINGAPOREAN STROKE PATIENTS SYMPTOM PROFILES IN MAJOR AND MINOR POSTSTROKE DEPRESSION
K. Kasiman, J.W. Eikelboom, G.J. Hankey, H.M. Chang, M.C. Wong, C.P. Chen V. Murray, P. Gustavsson, B. Mårtensson
National Neuroscience Insititute, Singapore General Hospital Campus, Karolinska Institutet Danderyd Hospital, Dept. Clin. Sciences, Stockholm,
Singapore Sweden

Background: Increased plasma total homocysteine (tHcy) levels are a risk factor Background: Findings on clinical profiles in poststroke depression are conflict-
for stroke and can be reduced with vitamin therapy. However, data on the tHcy- ing. Meta-analysis is difficult due to different methodologies. Hence, new data
lowering effects of vitamins are limited largely to white populations. Thus, we are needed. Symptom profiles in major and minor poststroke depression were
aimed to determine in Singaporean patients with recent stroke: (1) the efficacy compared. For clarity, or basis for hypotheses, the symptom profiles of the major
of vitamin therapy (folic acid, vitamin B12, and B6) on lowering tHcy, and (2) depressed stroke patients were compared with those of major depressed psychiatric
whether efficacy is modified by ethnicity (Chinese, Malay & Indian). patients.
Methods: A total of 506 eligible patients (420 Chinese, 41 Malays and 45 Indians) Methods: Stroke patients fulfilling DSM-IV diagnostic criteria for major or minor
were recruited after presenting with ischemic stroke within the past 7 months. depression (n=127), and “psychiatric” in-patients with a major depression (n=40)
Patients were randomized to receive either placebo or vitamins as part of a were assessed by the Montgomery-Åsberg Depression Rating Scale (MADRS).
large multi-centre double-blinded clinical trial. Fasting blood samples collected at Results: The MADRS profiles of major and minor depressed stroke patients were
baseline and at 1 year were assayed for levels of plasma tHcy. similar, with lower scores in minor depression but for “inner tension”; “pessimistic
Results: Mean baseline tHcy was similar in the 2 groups, At 1 year, mean tHcy thoughts”; and “suicidal thoughts” where scoring was equally high. No basic
was significantly higher in the placebo group compared with the vitamin group. clinical or neuroradiology differences were identified. Stroke patients with lesions
Ethnicity was not an independent determinant of tHcy
levels at baseline. The magnitude of the reduction in tHcy levels at 1 year with
vitamin therapy was similar, irrespective of ethnicity: mean change in tHcy Chinese
(-3.2 vs 0.6 micromol/L); Malay (-3.5 vs 1.5 micromol/L) and Indians (-3.0 vs 0.2
micromol/L).
Discussion: Vitamin therapy reduces mean tHcy levels in the Singaporean stroke
population studied. Ethnicity did not impact on the tHcy-lowering effect of vitamins
used in this study, despite possible differences in dietary intake and genetic makeup.
This suggests the generalisability of vitamin therapy efficacy in lowering tHcy
across Asian populations.

Poster Session Cerebrovasc Dis 2007;23(suppl 2):1–147 143


Behavior and mood
involving the cortex rated higher for “sadness”, while in those with a central lesion impairment, delirium, catastrophic reaction and self-referred apathy in elderly. The
only, “inner tension” (anxiety) was more pronounced. In the comparison of profiles identification of those neuropsychiatric disturbances is clinically relevant for their
between major depressed stroke patients and “psychiatric” patients, the items on functional state recovery.
“sadness” and “reduced sleep” were similarly pronounced.
Discussion: Given the similarity in “sadness” i.e. depressed mood, equivalent to
cardinal criterion 1 in the DSM classification of a depression, it is striking that
“inability to feel”, the equivalent of the DSM cardinal criterion 2, was much less Stroke and movements disorders
pronounced in stroke than among the “psychiatric” patients.
Conclusions: The difference between major and minor poststroke depression may
be more quantitative than qualitative, while the difference between poststroke and 1 Stroke and movements disorders
“psychiatric” major depression could be more qualitative.
MYOCLONUS AFTER ACUTE STROKE
L. Idrovo Freire, F. Vivancos Matellanos, M. Lara Lara, E. Diez-Tejedor
3 Behavior and mood Hospital Universitario La Paz, Madrid-Spain

ENDOREACTIVE POST-STROKE DEPRESSIONS ARE ASSOCIATED WITH Introduction: Hyperkinetic abnormal movements during acute stroke are uncom-
POORER MOTOR RECOVERY mon, with an estimated prevalence of 1%. Myoclonus is a clinical manifestation
V. Kontzevoj, V. Skvortsova, M. Savina, E. Petrova defined as a sudden, brief, involuntary and shock-like movements caused by
Russian Medical State University, Russian Federation muscular contraction (positive) or inhibitions (negative).
Methods: We report 3 patients that on examination during the acute phase of
Background: The majority of recent studies showed that poststroke depression stroke showed hemi-asterixis (two of them) and a positive myoclonus in the other
(PSD) influence the recovery of neurological deficit and daily activities. However, (videos).
some studies didn’t take into account the clinical heterogeneity of PSD. Some of Results: The patients with asterixis had similar clinical features and both suffered
PSD are known to have endogenic structure. cardioembolic ischaemic infarcts of the posterior cerebral artery territory. The
Objective: We hypothesized that PSD with different psychopathological structure patient showing a positive myoclonus had a thalamo-mesencephalic haemorrhage.
would influence differently on motor recovery. On all cases, neuroimaging studies revealed that the postero-lateral thalamus was
Methods: 115 subjects with first stroke (57 males, 58 females, the mean age 65 involved. The patients who showed asterixis, in addition to the thalamic compro-
years) were observed in fixed terms. Depression was diagnosed using criteria of mise, also had temporo-occipital lesions (one of them the cerebellar hemisphere was
ICD-10. The elaborate psychopathological analysis of their clinical features was also affected). On the other hand, in the patient with the haemorrhagic stroke the
made. The degree of neurological impairment was assessed by the Orgogoso Scale. rostral mesencephalus was also affected. In all cases, these abnormal movements
The recovery was assessed by criterion of Wilxoson. had a good outcome.
Results: During first year after stoke depressions were observed in 38 patients Discussion: Hyperkinetic abnormal movements during stroke are unusual neurolog-
(33%). 6 cases with manifestation of depression before stroke were not included ical manifestations and acute-onset hemi-asterixis is even less frequently reported.
in further analysis. In 21 patient were diagnosed reactive PSD. In 12 patients Asterixis is usually associated with thalamic lesions (ventral and posterolateral)
were diagnosed endoreactive PSD that had both reactive and endogenic features though any lesion of the cerebellar-rubrothalamic-cortical pathway can enhance
(vitalized affects, circadian rhythmus with worsening of depressive symptoms at myoclonic activity.
the morning etc.). In patients without PSD (n = 77) Orgogozo scale total score
changed significantly from 1–3 days to 2. week (p = 0,005), from 2. to 4. week (p
= 0,000), from 4. week to 3 month (p = 0,000) and from 3. month to 6. month (p
= 0,017); changes from 6 to 12 month after stroke were insignificant. In patients Intracranial aneurysms and vasospasm
with reactive PSD changes of Orgogozo scale total score were significant from 2.
to 4. week (p = 0,001) and from 4. week to 3. month (p = 0,002). In patients with
endoreactive PSD Orgogozo scale scores changed insignificantly in all defined time 1 Intracranial aneurysms and vasospasm
intervals.
Conclusions: Endoreactive PSD compared with reactive ones are associated with LOCAL LEVELS OF ENDOTHELIN-1 AND NITRIC OXIDE METABOLITES
poorer motor recovery. IN BASILAR ARTERY AND CEREBROSPINAL FLUID AFTER
EXPERIMENTAL SUBARACHNOID HEMORRHAGE IN RABBITS
V. Neuschmelting, S. Marbacher, A.R. Fathi, R.W. Seiler, S. Jakob, J. Fandino
4 Behavior and mood University Hospital Berne, Berne, Switzerland

NEUROPSYCHIATRIC PROFILE OF ELDERLY ACUTE STROKE PATIENTS Objective: The genesis of Endothelin-1 (ET-1) and Nitric Oxide (NO) as two
C.O. Santos, L. Caeiro, J.M. Ferro, M.L. Figueira important mediators in the development of cerebral vasospasm (CVS) after sub-
Serviço de Neurologia e Serviço de Psiquiatria, Department of Neurosciences, arachnoid hemorrhage (SAH) is controversially discussed. The objective of this
Hospital de Santa Maria, Lisboa, Portugal study was to determine whether local levels of ET-1 and NO in cerebral arterial
plasma and/or in cerebrospinal fluid (CSF) are associated with the occurrence of
Background: Neuropsychiatric disturbances after acute stroke are relatively fre- CVS after SAH.
quent. Elderly stroke patients have a high proportion of concomitant diseases, a Methods: CVS was induced using the one-hemorrhage-rabbit-model and confirmed
worse recovery and an aging brain. We aim to describe the neuropsychiatric profile by digital subtraction angiography of the rabbits’ basilar artery (BA) on day 5. Prior
of a sample of elderly acute stroke patients. to sacrifice local samples of CSF and basilar arterial plasma (BAP) samples were
Methods: Consecutive acute stroke patients (≤4 days after stroke onset) hospi- assessed by transclival approach to the BA in addition to systemic arterial plasma
talised in a Stroke Unit were assessed with a standardized protocol including: (SAP). ET-1 levels were determined by an immunometric technique (in pg/ml ±
MMSE, Delirium Rating Scale, Montgomery Asberg Depression Rating Scale, De- SEM) and total nitrate/nitrite level spectrophotometricly (in μmol/L ± SEM).
nial of Illness Scale, Catastrophic Reaction Scale, Mania Rating Scale, Apathy Scale Results: Angiographically detectable CVS could be documented in animals with
and Apathy Evaluation Scale. Neuropsychiatric profile of patients aged </≥65 induced SAH (n=12, p<0.05). The ET-1 level in CSF was significantly elevated by
years old (younger vs elderly) was compared. Bivariate analysis was performed to 27.3% to 0.84 ± 0.08 pg/ml in SAH animals (n=7) in comparison to control (0.66
find associations between neuropsychiatric disturbances and demographic, clinical ± 0.04 pg/ml, n=7, p<0.05). There was no significant difference of ET-1 levels in
and imaging data in the elderly patients. SAP and BAP samples of SAH animals compared to controls. Highly significant
Results: We studied 55 elderly patients (mean age of 72.5 years old), 13 (24%) lack of local NO metabolites could be documented in BAP of SAH animals (36.8
of them presenting an acute cognitive impairment, 7 (13%) delirium, 27 (49%) ± 3.1 μmol/L, n=6) compared to controls (61.8 ± 6.2 μmol/L, n=6, p<0.01).
acute depression, 27 (49%) denial, 8 (15%) catastrophic reaction, 1 (2%) mania, Decreasing tendency of local NO level remained insignificant in CSF and SAP
9 (39%) were identified as clinically apathic and 8 (35%) considered themselves (n=6, p>0.05).
as apathic. Elderly patients presented a higher frequency and severity of acute Conclusions: This study demonstrates elevated ET-1 level in CSF and local lack of
cognitive impairment (p=.01), a higher severity of delirium (p=.04) and catastrophic NO in BAP samples to be associated with CVS after experimental SAH. Possible
reaction (p=.02) and they considered themselves as more apathic (p=.02). genesis of local changes of ET-1 and NO level after SAH are discussed in respect
Discussion: Although the frequency of neuropsychiatric disturbances was similar to controversial data reported to date.
to that presented by younger patients, we found a higher severity of cognitive

144 Cerebrovasc Dis 2007;23(suppl 2):1–147 16th European Stroke Conference


2 Intracranial aneurysms and vasospasm 4 Intracranial aneurysms and vasospasm
SHARED EXPERIENCE IN THE ACUTE TREATMENT OF PATIENTS WITH INTEREST OF PERFUSION AND DIFFUSION MR IMAGING TO FOLLOW
CEREBRAL ANEURYSM PATIENTS WITH CEREBRAL VASOSPASM AFTER ANEURYSMAL
M. Carvi y Nievas, J. Hattingen, H. Höllerhage, M. Müller-Schimpfle SUBARACHNOID HEMORRHAGE
Neurosurgery, Frankfurt am Main/Höchst, Germany E. Le Bars, H. Brunel, M. Moynier, G. Boubotte, A. Bonafé
CHU Hôpital Gui de Chauliac, Montpellier, France
Objective: evaluation of our shared endovascular-microsurgical experience treating
cerebral aneurysms. Objective: study the potentiality of Diffusion and Perfusion MRI to improve the
Method: An interventional neuroradiologist and a neurosurgeon administered vasospasm diagnosis sensitivity in case of aneurysmal subarachnoid bleeding.
the emergent treatment of 97 consecutive SAH-patients harboring 108 cerebral Methods: Thirty cases of aneurysmal SAH were evaluated with TCD, DWI and
aneurysms. Decisions were based on the patient-clinical-condition, aneurysm mor- PWI within the first three days and the following sixth and tenth day after the
phology and location, degree of ICP and on CBF distribution patterns. The benefits bleeding. The fourth MRI examination is done at 6 months to evaluate brain
of joined case-assessment were retrospectively analyzed evaluating the rate of damages. For each patient, the apparent diffusion coefficient, the cerebral blood
aneurysm occlusion, the employment of complementary treatments, the patient volume, the cerebral blood flow, the tissue mean transit time, the Time to Peak
clinical evolution and number of observed complications. (TTP), the time inflow of contrast agent were evaluated for each exam. Two
Results: Initially, 39 aneurysms in 34 patients were endovascular (EV) and 65 methods for the evaluation of DWI and PWI analysis were carried out: a qualitative
aneurysms in 63 patients were surgical (S) treated. Four non-ruptured aneurysms analysis for the thirty cases; a longitudinal quantitative analysis of PWI based on
remain under control. Three patients in the surgical group died without angio- two groups of patients. The control group showed no modification of PWI during
control. Complete radiological aneurysm occlusion was achieved in 35 (89.5%) the study. In the other group variations of PWI time data outside the ischemic area
EV- and 60 (95.2%) S treated aneurysms. Complementary treatments included were found.
24 CSF-drainages and 7 decompressive surgeries in the EV-group as well as 5 Results: We found in two patients a complete reversibility in DWI anomalies.
EV-procedures to treat severe vasospasm in the S-group. Four aneurysms-remnants Three patients showed PWI anomalies without DWI modification. The amplitude
(2 EV and 2 S-treated) remain unchanged. One EV-treated-aneurysm grew and of relative perfusion time data at the acute stage of vasospasm is statistically
was surgically occluded. Favorable evolution was observed in 27 (79.4%) EV and significant between the two groups. The evolution of relative perfusion time data
52 (82.5%) S treated patients. CT-documented rebleedings (7 - 1), angiographic for the group with altered perfusion is statistically significant compared to the
vasospasm (3 - 5), occlusion of main vessels (1 - 2) were the method related control group. The relative TTP evolution is correlated with the clinical symptoms
complications in EV and S-groups respectively. during the acute stage of vasospasm, MRI lesion and with the neurological deficits
Conclusion: After comparing literature data, shared decisions in the emergent at 6 months. The longitudinal analysis of the rTTP value was the most sensitive
aneurysm-treatment increases the rate of aneurysm-occlusion, improves patient’s parameters witch was correlated with the deficit and with a risk of a lesion at six
evolution and allows appropriated complementary treatments reducing the number month.
of complications. Conclusion: The DWI and PWI appear to be sensitive imaging techniques for
cerebral vasospasm evaluation. According to these preliminary results, perfusion
appears to be an important tool for the evaluation of symptomatic or asymptomatic
3 Intracranial aneurysms and vasospasm vasospasm and for the follow up of those patients.

NOREPINEPHRINE INDUCES DILATION IN THE RABBIT BASILAR


ARTERY DUE TO ALPHA ADRENOCEPTOR DEPENDENT MECHANISM 5 Intracranial aneurysms and vasospasm
AFTER EXPERIMENTAL SUBARACHNOID HEMORRHAGE IN VIVO
V. Neuschmelting, A.R. Fathi, S. Marbacher, R.W. Seiler, S. Jakob, J. Fandino PILOT STUDY OF NON-INVASIVE MEASURES OF ENDOTHELIAL
University Hospital Berne, Berne, Switzerland DYSFUNCTION IN ACUTE ISCHAEMIC STROKE
S.L. Soiza, I. Ford, H. Clark, M. Bruce, K.K. Kalal, D.J.P. Williams
Objective: Norepinephrine (NE) is routinely administrated for prevention and University of Aberdeen, Aberdeen, United Kingdom
treatment of cerebral vasospasm (CVS) after subarachnoid hemorrhage (SAH).
The aim of this study was to determine mechanisms responsible for angiographic Introduction: Endothelial dysfunction (ED) is believed to be important in the
dilation and hypertension observed during continuous NE infusion in the rabbit pathogenesis of ischaemic stroke. Studies show serum markers of endothelial
basilar artery (BA) after SAH. activation are acutely raised after stroke. A direct, non-invasive measure of global
Methods: CVS was induced using the one-hemorrhage-model. On day 5 the ED has recently been developed.1 The method relies on pulse wave analysis
animals underwent control angiography prior to continuous intravenous adminis- (PWA) before and after administration of endothelium-dependent (salbutamol) and
tration of NE. Alpha-1 adrenoceptor antagonist (prazosine) and alpha-2 antagonist independent (glyceryl trinitrate (GTN)) vasodilators. We believe this is the first
(rauwolscine) were added for partial inhibition. Changes in diameter of the BA study employing this technique in stroke patients.
were digitally calculated in μm and expressed in percentages ± SEM. Prior to Methods: 29 patients with recent ischaemic stroke, 21 controls matched for risk
sacrifice, local samples of cerebrospinal fluid (CSF) and BA blood were obtained factors, and 9 healthy controls underwent PWA at the right radial artery using
by transclival approach. Endothelin-1 (ET-1) and nitric oxide (NO) levels were SphygmoCor. ED was assessed by the ratio of the change in augmentation index
determined in random samples of both groups. after 400mcg inhaled salbutamol via spacer over the change after 400mcg of
Results: SAH induced CVS in the BA (-13.9% ± 2.0, n=36, p<0.0001). NE sublingual GTN.1 Serum markers of ED (vonWillebrand factor, E-selectin and
caused hypertension from 83.2 ± 0.8 mmHg to 170.3 ± 0.9 mmHg (p<0.001). sVCAM-1) were obtained simultaneously. One-way ANOVA was used to look for
A dilation of 12.4% ± 2.6 (p<0.0001) of the BA during NE administration could significant differences between the groups.
be documented. Alpha-2 adrenoceptor inhibition partially reversed NE-dependent Results: See Table 1. Correlation between the various measures of ED was poor.
blood pressure plateau and significantly narrowed BA diameter by 11.3% ± 1.7
(n=12, p<0.05). Additional alpha-1 inhibition instead showed similar antihyper- Table 1. Mean values of measures of endothelial function
tensive effect while its narrowing effect on the dilated BA was less (-4.8% ± Healthy Controls Matched Controls Acute Stroke P
0.9, n=12) and remained insignificant (p>0.05). ET-1 and NO levels in CSF, BA
Augmentation Index (AIx), % 9.7 32.7 32.6 <0.001
and systemic plasma remained unchanged after NE administration and were not
AIx drop after Salb/GTN 0.57 0.23 0.30 0.02
affected by additional alpha antagonism (n=7 each, p>0.05). vonWillebrand Factor, U/ml 0.91 1.01 1.30 0.05
Conclusion: This study demonstrates the novel finding that NE causes dilation of E-selectin, ng/ml 36.2 50.9 49.9 0.43
the BA in the SAH rabbit model due to alpha adrenergic dependent mechanism, sVCAM-1, ng/ml 274.2 361.7 353.4 0.40
independently, however, from ET-1 and NO system.

Conclusions: Patients who have suffered an acute ischaemic stroke have evidence
of endothelial dysfunction, but this was not significantly different from that found
in a population matched for risk factors for stroke.
Reference: [1] Hayward et al. J Am Coll Cardiol 2002;40:521-528.

Poster Session Cerebrovasc Dis 2007;23(suppl 2):1–147 145


Intracranial aneurysms and vasospasm
Vascular biology 3 Vascular biology
IMPAIRED FLOW MEDIATED DILATATION IS ASSOCIATED WITH POOR
1 Vascular biology OUTCOME IN ISCHEMIC STROKE
D. Santos, M. Blanco, N. Perez de la Ossa, S. Arias, J. Serena,
POTENTIAL OF ERYTHROPOIETIN IN TREATMENT OF SPINAL CORD X. Rodriguez-Osorio, F. Nombela, M. Rodriguez-Yañez, R. Leira, A. Davalos
INJURY AND VASCULAR FAILURE Hospital Clinico, University of Santiago de Compostela, Santiago de
I. Voznjuk, M. Odinak, N. Tsygan Compostela, Spain
Military Medical Academy, Russian Federation
Background: Brachial arterial flow-mediated dilatation (FMD) reflects endothelium-
Nowadays the use of cytokines that promote neuron survival and growth is a dependent vasodilator function. FMD is diminished in patients with atherosclerosis,
promising trend in the treatment of spinal cord injury and vascular failure. One of is a marker of low nitric oxide bioavailability, and is associated with an increased
the few nerve growth factors which are used in clinical practice is erythropoietin. risk of vascular or cardiac events. Our aim was to investigate the relationship
The purpose of the study was to evaluate the potential of erythropoietin in the between FMD and outcome in patients with acute ischemic stroke.
treatment of spinal cord injury and vascular failure. Methods: In 120 consecutive patients (58.3% male, median age 73 years) with
The experiment involved 48 male adult rats. The rats were subject to spine acute ischemic stroke within the first 24 hours of evolution we measured FMD by
compression at 20 N for 30 sec at level L3-L4. The animals were divided into high-resolution ultrasonography. FMD was calculated as the relationship between
three groups: intact rats (8 animals); the rats that received sodium chloride (0.9%, basal diameter of the brachial artery before (d1) and after (d2) transient vascular oc-
0.5 ml) intraperitoneally 10 min after the trauma (20 animals); the rats that clusion (300 mmHg for 4 minutes) with a sphygmomanometer (FMD= d2 – d1/d1).
received erythropoietin (5,000 units/kg) intraperitoneally 10 min after the trauma The intima-media thickness (IMT) >0.9 mm, extracranial carotid atherosclerosis,
(20 animals). All the rats underwent daily neurological examination (the assessment stroke severity (NIHSS score) at baseline and discharge, and modified Rankin Scale
of hind limb and tail muscle strength, the pain sensitivity of the hind part of the (mRS) at 3 months were also evaluated. Poor outcome was defined as mRS >2.
body, and pain reflexes of hind limb flexion and tail withdrawal). The results of the FMD was categorized according to ROC analysis.
examination were assigned numerical scores. Histological spinal cord examination Results: Median [quartiles] FMD was 8.9 [4.3, 13.9]. Median FMD values were
was carried out on the 1st and 21st day after the trauma. significantly lower in patients with IMT >0.9 mm (p<0.0001), and extracranial
The lifetime of the rats that received erythropoietin (4.63±1.69 days) was reliably carotid atherosclerosis (p<0.0001). FMD negatively correlated to stroke severity,
(p<0.05) higher than in rats that received sodium chloride (2.75±1.28 days). On the both at baseline (p=0.038) and discharge (p=0.034). Median FMD was significantly
11-16th day after the injury, the muscle strength in rats that received erythropoietin lower (4.5 [2.3, 10.3] vs 9.4 [5.6, 15.1], p=0.003) in patients with poor outcome
was reliably (p<0.05) higher than in rats that received sodium chloride. The speed (n=38). The adjusted odds ratio of poor outcome for FMD >4.5% was 9.69 (1.97,
of the recovery of the muscle strength was reliably (p<0.025) higher in rats that 47.68; p=0.005).
received erythropoietin. Histological examination showed a smaller number of Conclusions: Impaired FMD in patients with acute ischemic stroke is associated
damaged neurons and a smaller area of spinal hemorrhage in rats that received with poor outcome.
erythropoietin.
The data proves that erythropoietin increases the lifetime, extent and rate of
neurologic recovery after spinal cord injury in rats. This may be due to the 4 Vascular biology
neurotrophic and vascular-protective effect of erythropoietin. Thus, erythropoietin
may have high potential in the treatment of spinal cord injury and vascular failure. A SYSTEMATIC ASSESSMENT OF THE GENETIC INFLUENCES ON
CAROTID INTIMA MEDIA THICKNESS (CIMT)
L. Paternoster, N. Martínez-González, M. Chung, R. Charleton, S. Lewis,
2 Vascular biology C. Sudlow
University of Edinburgh, Division of Clinical Neuroscience, Edinburgh, United
REDUCED ADAMTS-13 (VON WILLEBRAND FACTOR-CLEAVING Kingdom
PROTEASE) ACTIVITY IN THE EARLY PHASE AFTER TIA OR ISCHAEMIC
STROKE Background: CIMT is a measure of subclinical atherosclerosis, associated with
D.J.H. McCabe, R. Starke, P. Harrison, P.S. Sidhu, M.M. Brown, S.J. Machin, increased risk of stroke and myocardial infarction, and a heritability of around 50%.
I.J. Mackie It should be informative in studying the genetics of vascular disease, particularly
The Adelaide and Meath Hospital, Trinity College Dublin, Dublin, Ireland large artery ischaemic stroke.
Studies of the association between various genes and CIMT have produced con-
Background: Reduced ADAMTS-13 (von Willebrand factor-cleaving protease) flicting results. We aimed to identify genes whose association with CIMT has been
enzyme activity is well described in patients with thrombotic thrombocytopenic studied in >5000 subjects, and to perform meta-analyses to evaluate reliably the
purpura (TTP), and may lead to the accumulation of very large von Willebrand evidence for an association.
factor (VWF) multimers. Large VWF multimers may promote platelet activation Methods: For each relevant study, we extracted information on subjects, methods
and thrombus formation in vivo and could exacerbate ischaemia or infarction in and mean (&SD) CIMT per genotype. We calculated study-specific and pooled
patients with TIA or ischaemic stroke who do not have TTP. mean difference in CIMT between genotypes.
Methods: Using a collagen binding assay, we performed a pilot study to measure Results: 8 genes were studied in >5000 subjects: angiotensin converting enzyme
ADAMTS-13 activity in platelet poor plasma in 56 patients in the early phase (≤4 (ACE); apolipoprotein E (APOE); beta 2 adrenergic receptor; methylenetetrahy-
weeks) and 46 patients in the late phase (≥3 months) after a TIA or ischaemic drofolate reductase; endothelial nitric oxide synthase; factor V; interleukin 6;
stroke while they were on treatment with aspirin (75-300 mg daily). We compared paraoxonase 1.
these data with those obtained from 22 controls subjects who were not on aspirin. Several relevant studies (accounting for 19% of subjects studied across all genes)
The results were expressed in percentages relative to pooled normal plasma. had insufficient published data for inclusion.
Results: Mean ADAMTS-13 activity was significantly lower in the early phase 2 genes (ACE and APOE) showed a significant association with CIMT. The DD
(70.3%, P = 0.002) but not in the late phase (80.1%, P = 0.07) after TIA or stroke genotype of ACE had a mean CIMT 0.02mm greater than the II genotype. e4
compared with controls (94.5%). allele-containing genotypes of APOE had a mean CIMT 0.07mm greater than e2
Discussion: We have shown that ADAMTS-13 activity is significantly reduced in allele-containing genotypes. For both genes, we found larger associations among
the early phase after TIA or ischaemic stroke. Studies in larger cohorts of patients smaller studies, Asian subjects and subjects at high vascular risk.
are required to assess the importance of this finding, and further work is ongoing Discussion: We have identified 2 genes likely to influence CIMT, but methodolog-
to assess the impact of reduced ADAMTS-13 activity on platelet function ex vivo ical issues such as small study bias and missing data make it difficult to estimate
under high shear stress conditions. the true size of the associations. To increase the reliability of our results, we are
seeking additional data from studies with insufficient published data.

146 Cerebrovasc Dis 2007;23(suppl 2):1–147 16th European Stroke Conference


5 Vascular biology 7 Vascular biology
THE EFFECT OF ACUTE HYPERHOMOCYSTEINAEMIA ON CEREBRAL ASSOCIATION BETWEEN STROKE SUB-TYPES AND INTERLEUKIN-1
BLOOD FLOW OF HEALTHY ELDERLY VOLUNTEERS GENE POLYMORPHISM WITHOUT SALIVA INTERLEUKIN-1 BETA
S.R. Hart, A.A. Mangoni, C. Swift, C. Deane, R. Sherwood, A. Wierzbicki, IMPLICATION
S.H. Jackson M. Caillier, Y. Bejot, G.V. Osseby, F. Contegal, D. Minier,
Div. of Clinical Neuroscience, University of Edinburgh, United Kingdom R.M. Gueant-Rodriguez, M. Giroud
Stroke registry of Dijon, Dijon, France
Background: Mildly increased plasma homocysteine is an independent risk factor
for ischaemic stroke. However, the underlying fundamental causal arterial mecha- Background: Ischemia-induced inflammation is characterised by early infiltra-
nisms in vivo linking hyperhomocysteinaemia with cerebrovascular disease remain tion of leucocytes in the ischaemic region and development of brain oedema.
unclear. Interleukin-1 (IL-1) is one of the key modulators of the inflammatory response.
Objective: To test the hypothesis that acute increases in plasma homocysteine The IL-1 gene cluster on chromosome 2q14 contains three related genes (IL-1
produced by methionine are associated with an acute decrease in cerebral arterial alpha, IL-1 beta and IL-1 receptor antagonist, IL-1 ra). Clinical studies suggest an
blood flow velocity (CABFV) measured by transcranial Doppler (TCD) ultrasound. early intrathecal IL-1 beta production and IL-1 beta mRNA expression in blood
By contrast, the simultaneous response of peripheral arterial distensibility was mononuclear cells during stroke. We aimed to investigate the association between
measured by pulse wave velocity (PWV) and digital volume pulse (DVP). ischemic stroke sub-types and IL-1 gene polymorphism as well as production of
DESIGN: A double-blind, cross-over, placebo controlled design was used and saliva IL-1 beta.
cerebral blood flow velocity and peripheral arterial distensibility and plasma homo- Methods: The -889C/T IL-1A, -511C/T IL-1B and IL-1RN (VNTR) polymorphism
cysteine concentrations were measured between 12 and 20 hours after methionine was genotyped in patients with stroke due to large vessel disease (n=22), car-
loading or placebo. dioembolism (n=33), lacunar stroke (n=24), other determined mechanism (n=17),
Results: Between 13 and 16 hours after initial exposure to a methionine loading undetermined cause (n=21), transient ischemic attack (n=19) and in control group
test, mean CABFV showed a significant 5.1% decrease in mean blood flow velocity (n=19) by PCR. IL-1 beta concentration was determined in saliva using ELISA.
(34.1±0.3 m/s vs 36.0±0.3 m/s, p <0.01) compared to placebo (Sample size = 8). Results: There was no significant rise in the concentration of salivary IL-1 beta
However, between 17 and 20 hours after methionine exposure, CABFV showed no in acute stroke compared to the control group’s results. Studied polymorphisms
significant sustained change, compared to placebo (36.1±1.0 m/s vs 35.3±0.3 m/s, did not influence concentration levels. Genotypes frequency of IL-1A CT and TT
p < 0.1). There was no significant change in peripheral arterial distensibility mea- were significantly higher in lacunar stroke with respect to the control group (62,5%
sured by PWV during hyperhomocysteinaemia compared to placebo (9.9±0.2m/s and 31,6%, respectively; p=0,04), but not T allele. For IL-1RN (VNTR), IL-1RN
vs 10.1±0.2m/s, p<0.5) and no difference in DVP, stiffness index (83.7±1.8% vs 4-4 genotype frequency was higher in cardioembolic stroke than in control group
83.7±1.6%, p<0.1). (85,7% and 46,2%, respectively; p=0,04). This result was also confirmed for the
Conclusion: In healthy elderly volunteers, acute hyperhomocysteinaemia resulted allele 4 (35,4% and 21,1% respectively, p=0,02).
in a significant initial decrease in CABFV but no sustained reduction in cerebral Discussion: This study suggests than IL-1A and IL-1RN gene polymorphism is
blood flow velocity. There was no significant simultaneous change in periph- related with respectively lacunar and cardioembolic stroke onset.
eral arterial distensibility suggesting that elderly cerebral arterial response to
hyperhomocysteinaemia is different to that of peripheral arteries.

6 Vascular biology
SUBMICROSCOPIC FEATURES OF SMALL VESSEL DISEASE IN SKIN
BIOPSIES OF PATIENTS WITH CHRONIC KIDNEY DISEASE AND
EARLY-ONSET (<50 YEARS) COGNITIVE IMPAIRMENT. PRELIMINARIES
RESULT
G. Arismendi-Morillo, M. Fernandez-Abreu, A. Castellano-Ramirez
Laboratory of Electron Microscopy, University of Zulia. Nephrology and
Pathology Department HGS, Maracaibo, Venezuela

Background and aims: Decline in cognitive function has been reported in patients
with advanced renal disease. In addition, end-stage renal disease has been associated
with accelerated vascular disease of the cerebral circulation. Cerebral small vessel
disease is frequent in patients with cognitive impairment. Skin biopsy is hire in the
study of leukoaraiosis since permit establish the responsible vascular pathology of
possible brain disease. The aim of this study was illustrate the small vessel disease
in skin biopsies of patients with chronic kidney disease and early-onset cognitive
impairment in Maracaibo city - Venezuela.
Patients and methods: Two female patients with chronic kidney disease and early-
onset (< 50 years) of cognitive impairment that showed signs of Leukoaraiosis were
studied. Punch skin biopsy was prepared for conventional transmission electron
microscopy study and for haematoxylin/eosin, PAS and Red Congo stain.
Results: Small vessels study by means electron microscope revealed an increase in
media-lumen ratio, endothelial cells with hyperplasic nucleus, clear cytoplasm and
scarce organelles, thickened and multilayered basal membrane with focal degener-
ative changes and deposition of amorphous and electron-dense materials as well
as proliferation of collagen fibers. Smooth muscular cells exhibited hypertrophy.
Pericytes showed phagocytoced material and residual bodies. In adventitia was
thickened with abundant collagen fibers, amorphous and electron-dense materials
and cell debris.
Conclusion: The morphological changes in subcutaneous small vessel correspond
to small vessel disease of type degenerative microangiopathy and, possibly corre-
spond to the microvascular pathology in the brain. Added patients with chronic
kidney disease and early-onset cognitive impairment are needed to establish a
complete characterization of small vessel disease.

Poster Session Cerebrovasc Dis 2007;23(suppl 2):1–147 147


Vascular biology