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