Stroke

Poster Session II
Cerebrovasc Dis 2007;23(suppl 2):1147
Thursday 31 May 2007
Risk factors of stroke 1 Risk factors of stroke
the signicant difference in BMI between the two examined groups suggests that clopidogrel therapy should be weight-adjusted.
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LUNG FUNCTION AND LONG-TERM FATAL STROKE
Risk factors of stroke
U. Goldbourt, D. Tanne Tel Aviv University Department of Epidemiolgy and Preventive Medicine, Tel Aviv, Israel
Background: Research on lung function and incidence of stroke has yielded conicting results. Participants and methods: For 10,232 men of diverse countries of origin, civil servants and municipal employees, who participated in the Israeli Ischemic Heart Disease (IHD) study in 1963, extensive demographic, biochemical, socioeconomic and clinical information was collected in 1963, 1965 and 1968. Of these men, 4330 underwent an assessment of forced vital capacity (VC) and 1.0 sec forced expiratory volume (FEV). Results: Over a 23-yr follow up, 1297 men died, among whom for 136 the recorded underlying cause of death was stroke. For quartiles of VC, as % of age and height predicted level, there was a modest gradient of fatal stroke (18,16,14 and 13 per 10,000 person-years) which was erased upon age-adjustment. The corresponding rates declined from to 23 to 18, 10 and 8 per 10,000 person years for FEV, or 19,15,14 and 10 for FEV as percent of FVC, in the 1st,2nd,3rd, and 4th quartiles, respectively (P for trend=0.02 for the former and 0.55 for the latter by Mantel-Cox trend test after age-adjustment and exclusion of baseline IHD and cancer). Further adjustment for height which was markedly, inversely related to stroke mortality eliminated both associations. There was no appreciable interaction between smoking habits and lung function with respect to long-term fatal stoke. Conclusions: In this cohort, low FEV, whether in absolute terms or in relation to FVC, did not appear to be an independent marker of risk for fatal stroke beyond age and height.
ASSOCIATION OF METABOLIC SYNDROME WITH ISCHEMIC STROKE IN PATIENTS WITH INTRACRANIAL ATHEROSCLEROSIS
J.H. Park Myongji Hospital, Kwandong University, College of Medicine, Goyang-si, South Korea
Background and purpose: Metabolic syndrome (MetS) is associated with intracranial atherosclerosis. Patients with more severe MetS components were reported to be more likely to have intracranial atherosclerosis. To elucidate the association between MetS and ischemic stroke, we attempted to demonstrate the association of MetS and its individual components with frequency of ischemic stroke lesions and investigated the independent associations between them in acute ischemic stroke patients. Methods: We evaluated 370 acute ischemic stroke patients who underwent brain magnetic resonance (MR) imaging and MR angiography. The stroke subgroups were categorized as intracranial large artery atherosclerosis (IC-LAA, n=151), extracranial large artery atherosclerosis (EC-LAA, n=29), and nonatherosclerosis (NA, n=190). MetS was dened using the criteria of the National Cholesterol Education Program Adult Treatment Panel III. Results: Patients with IC-LAA group showed a higher rate of previous ischemic lesions and MetS than those with EC-LAA and NA (all P<0.001). The number of previous ischemic lesions showed a tendency to increase as the number of MetS components increased in the IC-LAA group (P=0.002). In the IC-LAA group, MetS was independently associated with previous ischemic lesions (OR, 3.80 P<0.001) which was prominent with more severe MetS components after adjustment for risk factors (P<0.001). Among the component conditions, high blood pressure, impaired fasting glucose, and abdominal obesity were predominantly associated with previous ischemic lesions (all P<0.001). Conclusions: MetS was associated with ischemic stroke with IC-LAA. Controlling the MetS components is mandatory with the aim of preventing from advanced intracranial atherosclerotic vascular damage and ischemic stroke. Further studies of different ethnics need to be performed to conrm whether MetS is more associated with those with IC-LAA.
CLOPIDOGREL RESISTANCE: ROLE OF BODY MASS AND CONCOMITANT MEDICATIONS
G. Feher, K. Koltai, B. Alkonyi, L. Szapary, G. Kesmarky, S. Komoly, K. Toth University of Pecs, Medical School, Pecs, Hungary
Introduction: Platelets have a central role in the development of arterial thrombosis and subsequent cardiovascular events. An appreciation of this has made antiplatelet therapy the cornerstone of cardiovascular disease management. Recent studies have described the phenomenon of clopidogrel resistance but the possible mechanisms are still unclear. Patients and methods: The aim of this study was to compare the characteristics (risk prole, previous diseases, medications, hemorheological variables and plasma von Willebrand factor and soluble P-selectin levels) of patients in whom clopidogrel provided effective platelet inhibition with those in whom clopidogrel was not effective in providing platelet inhibition. 157 patients with chronic cardio- and cerebrovascular diseases (83 males, mean age 6111 yrs, 74 females, 6313 yrs) taking 75 mg clopidogrel daily (not combined with aspirin) were included in the study. Results: Compared with clopidogrel-resistant patients (35 patients (22%), patients who demonstrated effective clopidogrel inhibition had a signicantly lower BMI (26.1 vs. 28.8 kg/m2 , p<0.05). Patients with ineffective platelet aggregation were signicantly more likely to be taking benzodiazepines (25% vs. 10%) and selective serotonin reuptake inhibitors (28% vs. 12%) (p<0.05). After an adjustment to the risk factors and medications BMI (OR 2.62; 95% CI: 1.71 to 3.6; p<0.01), benzodiazepines (OR 5.83; 95% CI: 2.53 to 7.1; p<0.05) and SSRIs (OR 5.22; 95% CI: 2.46 to 6.83; p<0.05) remained independently associated with CLP resistance. There was no signicant difference in the rheological parameters and in the plasma levels of adhesive molecules between the two examined groups. Conclusion: The background of ineffective clopidogrel medication is complex. Drug interactions may play a role on clopidogrel bioavailability, on the other hand,
DEATH AND DEPENDENCE ONE YEAR AFTER THE FIRST TRANSIENT ISCHAEMIC ATTACK: A POPULATION-BASED STUDY IN RURAL AND URBAN NORTHERN PORTUGAL
M. Correia, M.R. Silva, E. Moreira, R. Magalhes, M.C. Silva Institute for Molecular and Cell Biology, University of Porto, Porto, Portugal
Background and purpose: Information about prognosis of transient ischaemic attacks (TIA) is scarce, particularly in population-based studies. Recent data showed a high early risk of stroke after a TIA, reaching 12.7% at seven days. In this study prognosis of a rst TIA is evaluated in terms of risk of death and dependence, taking into account the occurrence of stroke after the index event. Methods: The 141 patients with a rstever-in-a-lifetime TIA occurred between October 1998 and September 2000 in a rural population of 18677 and an urban population of 86023 were entered a registry. A neurologist observed these patients soon after the episode and also at three and twelve months after the TIA. Previous dependence and dependence after the episode was determined by the modied Rankin scale (score 3 or more). Results: One year after the TIA, 10 out of 105 patients (9.5%) in the urban area were death, compared to 6 out of 36 (16.7%) in the rural area. Amongst the survivors 23.7% were dependent one year after the episode, 25.8% in the urban area and 17.2% in rural area (excluding seven that were lost to follow-up). In the urban area this proportion reduces to 22.8% taking into account those previously dependent. Comparing the Rankin score before and one year after the episode, 77
Poster Session Risk factors of stroke
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(57.5%) become more dependent or died, 53 (39.6%) kept their score and only four patients improved their score (Wilcoxon test, z=7.5, p<0,001). As expected the occurrence of stroke during the follow-up period worsened the prognosis at one year (Mann-Whitney, z=2.7, p=0.007). Discussion: The occurrence of a rst TIA carries out not only an early risk of stroke, but most of the patients showed an increased degree of dependence one year after the episode. The occurrence of stroke after a TIA is partially responsible for this prognosis. Study supported by: FCT/FEDER project POCI/SAU-ESP/59885/2004
consistent and robust in a variety of sensitivity analyses. Notably, soluble RANKL was not associated with carotid or femoral artery atherosclerosis assessed and monitored by high-resolution ultrasound. Conclusions: Our study lends large-scale epidemiological support to a role of RANKL in CVD. In the absence of a signicant association between RANKL and atherosclerosis the view that RANKL promotes plaque destabilization and rupture is a highly appealing concept.
7 5 Risk factors of stroke
AGE PREDICTS DELAYED TRANSIENT ISCHAEMIC ATTACK INVESTIGATION AND MANAGEMENT
INCREASED PREVALENCE OF VASCULAR RISK FACTORS BUT EQUAL ACCESS TO HOSPITAL SERVICES IN A DEPRIVED TRANSIENT ISCHAEMIC ATTACK POPULATION
T.J. Quinn, J. Dawson, K.R. Lees, M.R. Walters Gardiner Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
Introduction: Cerebrovascular events increase in frequency and severity with age. Recent studies suggest that elderly UK patients diagnosed with transient ischaemic attack (TIA) are inappropriately denied evidence based intervention. Similar examples of ageism have been reported in many other areas of hospital medicine. Due to the frequency of events immediately following TIA, urgent assessment and initiation of treatment is essential. We examined if age inuenced referral to a fast-track TIA clinic. Methods: Our TIA clinics assess all suspected cerebrovascular events referred. Patient details are prospectively recorded in a comprehensive database. Data were collated for patients seen between August 1992 and January 2005. Patients were categorised according to age: 0-40; 41-65; 66-75; 76+. Associations between age and: mode of referral (letter; phone call; other); time to referral; time from referral to appointment and initiation of treatment prior to clinic were analysed using the Kruskal-Wallis test. Results: Full data were available for 3495 of 3596 patients assessed during the study period, median age 67 (range 16-95). There was no signicant association between increasing age and delay from symptom onset to referral time (P=0.014); mode of referral (P=0.131) or time to appointment (P=0.652). The youngest patients were less likely to be prescribed antiplatelet (P<0.001).
Age (years) 040 (n=188) 4165 (n=1431) 6675 (n=1035) Over 75 (n=805) Median Referral Time (days) 6 8 7 6 Median Appointment Time (days) 8 9 9 9 Number of Phoned Referral 28 (14.9%) 191 (13.3%) 164 (15.8) 120 (14.9) Number on Anti-platelet 35 (18.6%) 511 (35.7%) 337 (32.6%) 271 (33.7%)
T.J. Quinn, J. Dawson, K.R. Lees, M.R. Walters Gardiner Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
Introduction: Cerebrovascular disease is over represented in socially deprived communities but traditional vascular risk factors do not account for all the variation. Unequal access to and uptake of specialist management could contribute. We analysed data on TIA clinic attendance, seeking effects of socioeconomic deprivation. Methods: We serve an urban population including the most afuent and deprived areas of the city. We prospectively record structured details of patients seen at clinic. Socio-economic deprivation was measured from postcodes and the 2001 census, using the Depcat ordinal hierarchical scale, ranging from 1=least deprived to 7=most deprived. We analysed the association between social deprivation, referral and vascular risk factors by ANOVA. We interpreted delay from symptom onset to clinic referral as a marker of access to specialist care. Results: We assessed 3462 patients between August 1992 to January 2005. The most deprived areas were over represented, with 1711 patients in Depcat 6 - 7. There was no association between clinic referral or attendance and Depcat. There were signicant associations between Depcat and lifestyle factors of smoking and alcohol excess (each p<0.005).
Depcat1 Delay to clinic (days) Smoking % Hypertension % Diabetes % Dyslipidemia % Alcohol % 16.5 6.1 39 5.1 16.9 2.3 Depcat2 35.2 13.9 27.9 3.7 8.9 1.2 Depcat3 28.9 24.7 44.1 7.8 16.3 4.8 Depcat4 33.9 34.6 42.3 18.6 18.7 3.7 Depcat5 37.5 24.8 46.3 7.5 14.2 3.8 Depcat6 89.6 40.1 44.4 9.3 19 4.3 Depcat7 55.3 46.3 44.1 7.7 17.9 5.2
Discussion: The effect of deprivation on cerebrovascular health inequality is partly explained by certain vascular risk factors but not by access to hospital services.
Discussion: We have found no evidence of ageism in access to TIA services. However, delays to clinic assessment remain substantial. Public education strategies to promote early presentation with TIA symptoms are required.
DO CONVENTIONAL VASCULAR RISK FACTORS INFLUENCE BRAIN ARTERIOVENOUS MALFORMATIONS? PROSPECTIVE, POPULATION-BASED COHORT AND CASE-CONTROL STUDIES
SOLUBLE RECEPTOR ACTIVATOR OF NUCLEAR FACTOR-KB LIGAND (RANKL) AND RISK FOR CARDIOVASCULAR DISEASE
S. Kiechl, G. Schett, J. Schwaiger, K. Seppi, P. Eder, G. Egger, P. Santer, A. Mayr, Q. Xu, J. Willeit Innsbruck Medical University, Innsbruck, Innsbruck, Austria
Background: Overexpression of RANKL is a prominent feature of vulnerable atherosclerotic lesions prone to rupture and was suggested to contribute to the transition from a stable to an unstable plaque phenotype in both human and murine atherosclerosis because of its ability to promote matrix degradation, monocyte/macrophage chemotaxsis and vascular calcication. Methods and results: The Bruneck Study is a prospective population-based survey of men and women 40-79 years old at the 1990 baseline examination. Levels of soluble RANKL and other variables were assessed in 909 subjects (1990) and up-dated every ve years. All cases of cardiovascular disease (CVD) were carefully recorded between 1990 and 2005. During follow-up, CVD (dened as ischemic stroke and TIA, myocardial infarction and vascular death) manifested in 124 subjects. The level of soluble RANKL emerged as a highly signicant predictor of vascular risk (adjusted hazard ratio [95%CI] 1.27 [1.16-1.40]; P<0.001). Predictive signicance was independent of that afforded by classic vascular risk factors, C-reactive protein and osteoprotegerin concentration and severity of carotid atherosclerosis. Findings were internally
T.M. Brock, R. Al-Shahi Salman Division of Clinical Neurosciences, University of Edinburgh, Edinburgh, United Kingdom
Background: Conventional risk factors for cerebral infarction and haemorrhage are thought to play little if any role in either causing brain arteriovenous malformations (AVMs), or inuencing their behaviour. Methods: We extracted data on vascular risk factors from the medical records of 229 adults newly-diagnosed with a brain AVM, who were enrolled between 1999-2003 in a prospective, population-based cohort study in Scotland (SIVMS). A sample of 36 adults with brain AVMs were sex-matched and age-matched (to within 5 years) with 36 controls. Results: In the case-control study, adults with brain AVMs were more likely than controls to have smoked at some stage in their life (75% versus 50%, p=0.028; odds ratio [OR] 3.0, 95% condence interval [CI] 1.1 to 8.1), but this relationship did not hold for current smokers, nor was it found for hypertension, ischaemic heart disease, alcohol consumption, hyperlipidaemia, or diabetes mellitus. In the whole cohort, 116 (72%) had smoked sometime in their life, and 29 (14%) had hypertension prior to the rst presentation of their brain AVM. There was no signicant difference between adults who did (n=114) and did not (n=115) present with intracranial haemorrhage in pre-presentation hypertension, smoking, or any other vascular risk factors.
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16th European Stroke Conference
Discussion: Smoking appears to be associated with the occurrence of brain AVMs, but this nding needs conrmation in other cohorts, and larger studies. Vascular risk factors do not appear to inuence whether a brain AVM rst presents with a haemorrhage or not, but their inuence on the occurrence of haemorrhage after AVM diagnosis requires further investigation.
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DEPRESSIVE SYMPTOMS AND RISK OF STROKE: THE ROTTERDAM STUDY
M.J. Bos, T. Lindn, P.J. Koudstaal, A. Hofman, I. Skoog, H.W. Tiemeier, M.M. Breteler Erasmus Medical Center, Rotterdam, Rotterdam, The Netherlands
Background: Results from previous studies that assessed whether self-reported depressive symptoms predispose to stroke in the general elderly population are controversial and they did not distinguish between men and women, nor did they perform psychiatric workups in those who reported depressive symptoms. We examined the association between depressive symptoms, depressive disorder, and risk of stroke in the general population. Methods: This prospective population-based cohort study was based on 4424 participants of the third Rotterdam Study survey (1997-1999), who at that time were 61 years of age, free from stroke, and underwent Center for Epidemiological Studies Depression Scale (CESD) interview. Depressive symptoms were considered present if CESD score was 16. Participants with depressive symptoms underwent diagnostic workup for depressive disorder. Follow-up for incident stroke was complete until January 1, 2005. Data were analyzed with Cox proportional hazards models with adjustment for relevant confounders. Results: Men with depressive symptoms were at increased risk of stroke (adjusted hazard ratio (HR) 2.15; 95% condence interval (CI) 1.10-4.22) and ischemic stroke (adjusted HR 3.25; 95% CI 1.62-6.50). In women there was no association between presence of depressive symptoms and risk of stroke. The associations that we found were at least partly attributable to persons who reported depressive symptoms but who did not full DSM-IV diagnostic criteria for depressive disorder. Discussion: Presence of depressive symptoms is a strong risk factor for stroke in men but not in women.
NO INCREASED RISK OF RECURRENT STROKE IN PFO CARRIERS
H. Poppert, A. Bockelbrink, M. Morschhaeuser, J. Schwarze, P. Heider, L. Esposito, D. Sander Munich University of Technique, Munich, Germany
Background: Contrast-enhanced transcranial Doppler ultrasonography (cTCD) is a sensitive noninvasive screening method for detection of a patent foramen ovale (PFO). We aimed to investigate the relationship between a suchlike detected right-to-left shunt (RLS) and subtypes of cerebral ischemia as well as the risk of stroke recurrence. Methods: The records of 763 patients with denite diagnosis of cerebral ischemia at discharge were analyzed retrospectively. All patients had undergone TCD based RLS detection. Stroke origin was subtyped using the TOAST classication criteria. For follow-up all patients were contacted by mail. In case a patient did not answer, we tried to contact the patient or the patients relatives and the family doctor by telephone. Results: A RLS was detected in 140 (28%) male and in 114 (42%) female patients. These patients were younger (p<0.001) and in male patients presence of RLS was associated with stroke of unknown origin (p=0.001). In female patients this association was not signicant (p=0.076). After adjustment for age no signicant association was found in either group. Complete follow-up data with a median follow-up period of 4 years could be collected in 639 patients (83.7%). 10 shunt-carriers (4.7%) and 32 patients (7.6%) without RLS (p=0.180) had suffered a recurrent stroke. Logistic regression adjusting for age, gender and stroke subtype conrmed the lack of a positive correlation (OR 0.7 (95%CI 0.33-1.48)). Conclusion: We found age and gender to be important confounders in the often cited association of PFO and cryptogenic stroke. This has not been taken into account in most previous studies. Furthermore, RLS did not correlate with stroke recurrence, thus weakening the thesis of a PFO generally being an important risk factor for stroke.
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ASPIRIN RESISTANCE: POSSIBLE ROLES OF CARDIOVASCULAR RISK FACTORS, PREVIOUS DISEASE HISTORY, CONCOMITANT MEDICATIONS AND HAEMORRHEOLOGICAL VARIABLES
G. Feher, K. Koltai, B. Alkonyi, L. Szapary, G. Kesmarky, S. Komoly, K. Toth University of Pecs, Medical School, Pecs, Pcs, Hungary
Introduction: The aim of this study was to compare the characteristics (risk prole, previous diseases, medications and haemorrheological variables) of patients in whom aspirin provided effective platelet inhibition with those in whom aspirin was not effective in providing platelet inhibition. Patients and methods: 599 patients with chronic cardio- and cerebrovascular diseases (355 men, mean age 64 11 years; 244 women, mean age 63 10 years) taking aspirin 100-325 mg/day were included in the study. Blood was collected between 8:00am and 9:00am from these patients after an overnight fast. The cardiovascular risk proles, history of previous diseases, medication history and haemorrheological parameters of patients who responded to aspirin and those who did not were compared. Platelet and red blood cell (RBC) aggregation were measured by aggregometry, haematocrit by a microhaematocrit centrifuge, and plasma brinogen by Clauss method. Plasma and whole blood viscosities were measured using a capillary viscosimeter. Results: Compared with aspirin-resistant patients, aspirin sensitive patients had a signicantly lower plasma brinogen level (3.3 g/L vs 3.8 g/L; p < 0.05) and RBC aggregation values (24.3 vs 28.2; p < 0.01). In addition, signicantly more patients with effective aspirin inhibition were hypertensive (80% vs 62%; p < 0.05). Patients who had effective platelet aggregation were signicantly more likely to be taking beta-adrenoceptor antagonists (75% vs 55%; p < 0.05) and ACE inhibitors (70% vs 50%; p < 0.05), patients with ineffective platelet aggregation were signicantly more likely to be taking HMG-CoA reductase inhibitors (statins) [52% vs 38%; p < 0.05]. Use of statins remained an independent predictor of aspirin resistance even after adjustment for risk factors and medication use (odds ratio 5.92; 95% CI 1.83, 16.9; p < 0.001). Conclusions: Impaired hemorheological parameters are associated with aspirin resistance. It is also possible that drug interactions with statins might reduce aspirin bioavailability.
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TYPE 3 PHOSPHODIESTERASE INHIBITORS MAY BE PROTECTIVE AGAINST CEREBROVASCULAR EVENTS IN PATIENTS WITH CLAUDICATION
W.M. Stone, S.R. Money, R.J. Fowl Mayo Clinic Arizona, Phoenix, AR, USA
Objective: The risk of cerebrovascular events in patients with mild to moderate peripheral vascular disease is signicant. Cilostazol is a phosphodiesterase type 3 (PDE3) inhibitor that is effective in the treatment of symptoms of peripheral arterial occlusive disease. The method of action includes antithrombotic, vasodilatory, and antiproliferative effects. Methods: The CASTLE trial was a prospective randomized double blinded trial to establish the safety of this PDE3 inhibitor use in 1435 patients with mild to moderate peripheral arterial occlusive disease. A post-hoc analysis of the CASTLE trial was undertaken to evaluate Cilostazol usage on cerebrovascular events. Blinded adjudication of all cerebrovascular events (stroke, TIA, and carotid revascularization) in this trial was performed. Kaplan Meier analysis was used for statistical evaluation. Results: The overall rate of cerebrovascular events was 4.6% (66 of 1435 patients) with a mean followup of 515 days. Ischemic vascular events were more common (2.5%) than hemorrhagic events (0.3%), (p<0.05). The placebo group demonstrated a greater risk for events, 5.8% (42 of 718 patients) vs. the Cilostazol treated group, 2.9% (21 of 717 patients), (p<0.05). Cerebrovascular risk factors were similar in both groups. Conclusion: The risk of cerebrovascular events in patients with mild to moderate peripheral arterial occlusive disease is 4.6% with a mean followup of 515 days. Treatment with PDE3 inhibitors may reduce this risk. Further evaluation of the use of PDE3 inhibitors for prevention of cerebrovascular events should be considered.
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PSYCHO-SOCIAL FACTORS INFLUENECE STROKE OUTCOME
G. Szab, L. Molnr, C. vry, Z. Nagy National Stroke Centre/Budapest, Balassagyarmat, Hungary

Background: Factors inuencing stroke outcome are subject of interest. The aim of present study was to compare the impact of traditional risks factors and psychosocial factors on modied Rankin scale. Methods: In the stroke unite of a county hospital, 646 consecutive stroke patients were include in this study. Determining disease outcome we used the modied Rankin scale after 28 days of stroke onset. Stroke risk factors were recorded and psychosocial data (Beck depression scale, coping skills, educational attainment, and isolation) were collected using the standardized questionnaires. For statistics we used a multiway contingency tables with log linear modelling. Results: A log linear model ts well (p=0.786) to our data. Patients suffering form repeated stroke showed signicantly worse outcome (p<0.001). Hypertension, diabetes mellitus, hyperlipidemia and smoking were not signicant factors on stroke outcome. On the other hand close relationship could be described in the 3-factors interaction among depression, isolation and stroke outcome, furthermore among coping skills, depression, and stroke outcome, nally among coping skills, educational attainment, and stroke outcome. The 2-factors interaction between educational attainment and isolation, and between educational attainment and depression could be also proved. Discussion: The signicant effects of depression, insufcient coping skills, low educational level, and isolation on stroke outcome were documented. Better managing of these factors may improve the quality of life after stroke.
All participants, who at baseline were free from previous stroke, were subsequently followed for occurrence of stroke (average follow-up time 5.1 years). We calculated hazard ratios (HRs) with 95% condence intervals (CIs) for the association between hemodynamic parameters and risk of stroke using Cox proportional hazards models with adjustment for age, sex, systolic blood pressure, antihypertensive drug use, diabetes mellitus, ever smoking, current smoking, carotid intima-media thickness, and carotid distensibility. Results: Risk of stroke (n=122) and ischemic stroke (n=89) increased with increasing middle cerebral artery ow velocity: when comparing the tertile with highest velocity to the tertile with lowest velocity, the HR was 1.74 (95% CI 1.09-2.77) for the association between mean ow velocity and stroke, 1.63 (95% CI 1.03-2.58) for end diastolic ow velocity and stroke, and 1.33 (95% CI 0.86-2.08) for peak systolic ow velocity and stroke. These estimates increased 10-26% when only ischemic strokes were included. We found no associations between vasomotor reactivity and risk of stroke. Discussion: Risk of stroke increased strongly with increasing middle cerebral artery ow velocity as measured with TCD in the general population.
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A PROSPECTIVE STUDY OF PREVALENCE AND PROGNOSIS OF PVD IN PATIENTS ADMITTED WITH ISCHAEMIC STROKE
V. Paranna, A. Gupta, R. Prakash, L. Bachegowda, G. Shankar, K.K. Manda, A. Watkins West Wales Hospital, United Kingdom
Introduction: Atherosclerosis is a multisystemic,asymtomatic disease which is divided into Cerebrovascular disease,Peripheral Vascular disease & Coronary Artery disease.Patients presenting with acute stroke are likely to have PVD which may be unrecognised.Presence of PVD increases the risk of Myocardial Infarction & stroke by 2 fold.Early detection & management of PVD can avoid complications.Ankle Brachial Pressure Index is simple bedside test useful in this process. Objective: The aim of the study was to evaluate the prevalence of PVD in stroke patients,to assess whether symptomatic or asymptomatic PVD,severity of the disease & to evaluate whether PVD is an independent prognostic factor in the outcome of stroke. Method: Prospective comparative group study which was carried out in West Wales Hospital,Carmarthen,UK.A total of 100 patients have been included in this ongoing study.This includes 55study group and 45 control group.Patients admitted with ischaemic stroke were included in the study group & age and sex matched non stroke general medical acute admission were included in control group.Etical committee approval obtained. Intervention:The data collected included demographics,barthel index,abbreviated mental test,associated vascular risk factors,whether symptomatic PVD in the past,ABPI during hospitalisation,discharge destination & follow up 3months after discharge.Ankle BP was measured using handheld Doppler & ABPI was calculated as systolic ankle BP/systolic arm BP.Pvalue was determined from by unpaired t test for continuous variables & chi square test for discrete variables. Results: Average age of patients was 80yrs & 78yrs in the study & control group respectively.The average length of stay varied from 40 days (control group) to 59 days(trial group) with no statistical difference.Average Barthel Index though similar at admission(14),at discharge average BI was 14(trail gr) and 17(control gr) with statistical signicance(p=0.001).More number of pt had AMT<7 in study gr with statistical signicance(p=0.011).Study population had higher prevalence of Hypertension(69%) & hypercholesterolaemia(18%) which was statistically signicant(p=0.002 & p=0.011).67-80% of study population had mild to moderate degree of PVD based on ABPI which is statistically signicant(p=<0.001 & p=0.001) which was previously undetected and asymptomatic. Conclusions: The results of this study favoured PVD as a common asymtomatic and unrecognised condition in patients with stroke.Early detection of PVD could prevent compilcations in high risk patients.There is also a need to educate,identify & treat associated risk factors.The study is ongoing to include larger sample size for multiple regressional analysis to evaluate the role of PVD as an independent prognostic factor following stroke.
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STROKE IN CHRONIC KIDNEY DISEASE: PATTERNS OF STROKE, FACTORS AFFECTING DEVELOPMENT OF STROKE
S. Jung, S.H. Hwang, S.B. Kwon, K.H. Kwon, I.S. Koh, K.H. Yu, B.C. Lee Hallym University College of Medicine, South Korea
Background: Patients with chronic kidney disease (CKD) have increased risk for stroke. Although they share conventional stroke risk factors, not all CKD patients suffer stroke. We analyzed the pattern of stroke and tried to elucidate the factors affecting development of stroke in patients with CKD. Method: We used data from Hallym Stroke Registry (HSR) for enrolling patients with stroke and chronic renal failure (CRF) or end stage renal disease (ESRD) as CKD. Forty patients were included from total 55 patients with acute stroke within 7 days of onset who were diagnosed as CKD from July 1996 through June 2005. 35 patients with CKD who did not develop stroke were selected as the control group. We classied patients according to the modied TOAST classication and evaluated their neurologic manifestations. We also compared the properties including stroke risk factors and laboratory ndings between two groups. Results: 29 patients had ischemic stroke and 11 patients had hemorrhagic stroke. The percentage of hemorrhagic stroke was higher than general population in HSR (5.3%). The most common ischemic stroke subtype was small artery occlusion (25.0%) and followed by large atherosclerosis (20.0%). The hypertensive nephropathy was most common cause of CKD (47.5%) and duration of causative disease was 13.1910.24 years. As compared to the control group, stroke patients with CKD showed higher rate of hypertension, prolonged activated prothrombin time, lower level of triglyceride and lower LDL cholesterol level. Conclusion: Strokes in CKD differ from general population in their pattern and the risk factors. There is relatively larger incidence of hemorrhages compared to non-kidney disease patients. Low lipid prole in CKD patients may suggest the protective effect of hyperlipidemia against the development of stoke as preventing of malnutrition which is one of the most important cause of mortalities in CKD patients.
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TRANSCRANIAL DOPPLER HEMODYNAMIC PARAMETERS AND RISK OF STROKE: THE ROTTERDAM STUDY
M.J. Bos, P.J. Koudstaal, A. Hofman, J.C. Witteman, M.M. Breteler Erasmus Medical Center, Rotterdam, Rotterdam, The Netherlands
Background: We explored the association between transcranial Doppler (TCD) hemodynamic indices and risk of stroke in the general population. Methods: At baseline we assessed mean ow velocity, peak systolic ow velocity, end diastolic ow velocity, and vasomotor reactivity (VMR) with TCD in 2022 Rotterdam Study participants of age 61 years and over in both middle cerebral arteries.
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MIGRAINE MEDIATES THE INFLUENCE OF C677T MTHFR GENOTYPES ON ISCHEMIC STROKE RISK WITH A STROKE-SUBTYPE EFFECT
A. Pezzini, M. Grassi, E. Del Zotto, A. Giossi, R. Monastero, G. Dalla Volta, S. Archetti, C. Camarda, R. Camarda, A. Padovani Dipartimento di Scienze Medico-Chirurgiche, Neurologia Vascolare, Spedali Civili di Brescia, Brescia, Italy
Background: To investigate the role of C677T MTHFR polymorphism in migraine pathogenesis and in the migraine-ischemic stroke pathway. Methods: A rst genotype-migraine association study was conducted on 100 patients with migraine with aura (MA), 106 with migraine without aura (MO), and 105 subjects without migraine, which provided evidence in favour of association of the TT677 MTHFR genotype with increased risk of MA compared to both control subjects (odds ratio [OR], 2.48; 95% CI, 1.11 to 5.58) and patients with MO (OR, 2.21; 95% CI, 1.01 to 4.82). Based on these ndings, mediational models of the genotype-migraine-stroke pathway were tted on a group of 106 patients with spontaneous cervical artery dissection (sCAD), 227 young patients whose ischemic stroke was unrelated to a sCAD (non-CAD), and 187 control subjects, and a genotype-migraine partial mediation model was selected. Results: Both migraine and the TT-genotype were more strongly associated to the subgroup of patients with sCAD (OR, 4.06; 95% CI, 1.63 to 10.02 for MA; OR, 5.45; 95% CI, 3.03 to 9.79 for MO; OR, 2.87; 95% CI, 1.45 to 5.68 for TT genotype) than to the subgroup of patients with non-CAD ischemic stroke (OR, 2.22; 95% CI, 1.00 to 4.96 for MA; OR, 1.81; 95% CI, 1.02 to 3.22 for TT genotype) as compared to controls. The prevalence of migraine sufferers carrying the TT677 MTHFR genotype turned out to be higher among patients with multiple-vessel dissection (3/16; 18.8%) than among those with single-vessel dissection (12/90; 13.3%) and control subjects (5/187; 2.7%) and the log-odds trend statistically signicant (2 (df) for log-odds trend = 11.2 (1); P = 00008). Discussion: Migraine may act as mediator in the MTHFR-ischemic stroke pathway with a more prominent effect in the subgroup of patients with sCAD.
assess the prevalence and incidence of risk factors for vascular disease. We also assessed the control of known risk factors. Methods: All adult patients admitted with recurrent stroke in the year 2005 were included in the study. The Royal College of Physicians guidelines 2004 on secondary prevention for stroke were used as the gold standard. We used our local diabetic guidelines to dene the control of Diabetes Mellitus with a haemoglobin A1C level of less than 8 as acceptable control. Results: 81(24%) of 331 stroke inpatients in 2005 had a recurrent ischemic stroke. 52(64%) patients had known hypertension of which 17(33%) were well controlled while 35(67%) patients had uncontrolled hypertension despite being on medication. 12(15%) patients had newly diagnosed hypertension. 19(23%) patients were known to have diabetes mellitus of which 7(37%) had acceptable glycemic control and 12(63%) patients had poor control. There were no new diabetics. 37(45%)patients had hypercholesterolemia despite being on statins. 10(12%) patients had untreated hypercholesterolemia.12(14%) patients had new hypercholesterolemia. Signicant carotid artery stenosis was known in 3 patients and diagnosed in 2 new patients following admission. 47(58%)patients had not had carotid dopplers after their previous stroke. 13(16%) patients were current smokers and 39(48%) were ex smokers. 12(15%) patients had known atrial brillation and 5 patients had newly diagnosed AF. Conclusions: Most patients with recurrent ischemic stroke had multiple risk factors identied at their rst stroke but a majority of these risk factors were either under treated or untreated. There was evidence of substantial under-investigation with carotid dopplers. A smaller number of patients had newly identied vascular risk factors at their admission with recurrent stroke. Better identication of risk factors after a stroke and more aggressive control could reduce the burden of recurrent ischemic stroke.
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ANEMIA AND CHRONIC KIDNEY DISEASE ARE RISK FACTORS FOR MORTALITY IN STROKE PATIENTS
P. Del Fabbro, J.-C. Luthi, P. Michel, E. Carrera, M. Burnier, B. Burnand CHUV Lausanne, Lausanne, Switzerland
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Background: Chronic kidney disease (CKD) has been linked to higher stroke risk. Anemia is a common consequence of CKD, and recent evidence suggests that anemia is a risk factor for cerebrovascular disease. The purpose of this study was to examine among stroke patients, the association between CKD, anemia, hospital mortality and one year mortality. Methods: We performed a retrospective cohort study with consecutive stroke patients over a 3 year period hospitalized in the stroke unit of a single university hospital. We recorded demographic characteristics and risk factors for stroke. Reduced kidney function was dened as a serum creatinine 80 mol/L for women and 106 mol/L for men. Glomerular ltration rate (GFR) was also calculated. Anemia was dened when hemoglobine was below 12 g/dl on admission. The main outcome measures were hospital mortality and one year survival. Results: 963 patients aged between 16 and 97 years were included. Fifty-vepoint-ve percent had CKD according to our denition, and 12.1% had anemia. Thirty-three (3.7%) patients died during their hospitalization; among those, 27 (81.8%) had CKD (p=0.002). 82 (9.6%) patients died during the rst year after discharge from hospital, among them 54 (65.9%) had CKD (p=0.035). Anemia on admission to the hospital was associated with an increased risk of death during hospitalization and at one year after discharge. After adjustment for other factors, hemoglobine was independently associated with an increased risk of death at the hospital and one year survival. Conclusion: Both CKD and anemia are frequent among stroke patients and are associated with an increased risk of hospital and one year survival.
PATENT FORAMEN OVALE, THROMBOPHILIC DISORDERS AND MIGRAINE IN YOUNG PATIENTS WITH ISCHEMIC STROKE
P. Martnez-Snchez, B. Fuentes, M.V. Cuesta, J. Domnguez, L. Idrovo, L. Gabaldn, M.A. Ortega-Casarrubios, E. Dez-Tejedor La Paz University Hospital, UAM, Madrid, Spain
Background: Patent foramen ovale (PFO) has been associated to inherited thrombophilic disorders, stroke and migraine separately. Our goal is to asses the relationship between PFO atrial septal aneurism (ASA), thrombophilic disorders and previous history of migraine in young patients with cryptogenic stroke. Methods: Observational study with inclusion of consecutive patients from the Stroke Unit Data Bank (January 1995-October 2005). Patients under 55 years with an acute cryptogenic cerebral infarction were selected. We analyzed: demographic data, vascular risk factors, stroke subtype, previous migraine and the presence of thrombophilic disorders by a battery of hematological test. The presence of PFO ASA was assessed by transcranial Doppler sonography monitoring and echocardiography. Results: 235 patients, mean age 42.97 9.353 years. 16.6% had a PFO, 7.7% had previous migraine and 7.2% were diagnosed of a thrombophilic disorder. Patients with PFO had less traditional risk factors such as hypertension, current smoking or coronary arterial disease (P<0.05). PFO+ASA was more common in women (9.3% vs 2.9%; P=0.044) and in patients with previous migraine (22.2% vs 4.1%; P=0,011). Thrombophilic disorders were more frequent in PFO patients (15.4% vs 5.6%, P=0.043; OR 3.058: 95% CI 1.058-8.839) as well as in previous migraine patients (22.2% vs 6%; P=0.031; OR 4.484: 95% CI 1.291-15.565). The frequency of thrombophilic disorders was the highest in migraine + PFO patients (60% vs 6.1%, P= 0.003; OR 23.143: 95% CI 3.570-150.017). Conclusions: In patients under 55 years, thrombophilic disorders are diagnosed more frequently in PFO-related cerebral infarcts, especially in migranous patients.
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SUBCLINICAL HEMODYNAMIC ABNNORMALITIES IN SYMPTOM-FREE HYPERTENSIVE PATIENTS DURING HEAD UP TILT TABLE TEST
L. Csiba, Z. Bajk, K. Csap, P. Soltsz Debrecen University, Debrecen, Hungary

The dysregulation of the autonomic nervous system plays an important role in the development of hypertension. The heart rate variability and baroreex sensitivity are established methodes for the evaluation of the cardiac autonomic activity and provide the assessment of the sympathetic and vagal activity. Our purpose was to measure the cardiac parameters of the autonomic nervous system in essentiel, non-treated hypertensive patients and later the efcacy of the antihypertensive treatment by non-invasive technique. Heart rate variability calculated with spectral analysis and baroreex sensitivity
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RISK FACTOR ANALYSIS IN PATIENTS ADMITTED WITH RECURRENT ISCHEMIC STROKES
P.K. Shibu, S.H. Guptha, P. Owusu-Agyei Peterborough District Hospital, Peterborough, United Kingdom
Background: We studied patients admitted with recurrent ischaemic stroke to
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obtained by the sequence technique were measured in 28 healthy persons (age: 48,298,14 yrs, m/f rate: 1) and 28 hypertensive patients (age: 46,116,54 v, m/f rate: 1,1) by Task Force Monitor during head-up tilt table test. The number of the baroreex sequences was signicantly higher (66,9 vs 51,1; p=0,031), the baroreex effectiveness index was signicantly lower (67,3 v 58; p=0,027) and also signicantly lower heart rate variability was measured in the low frequency (LF-RRI) range(213 ms2 vs 468,2 ms2, p=0,018) in the hypertensive group. The decreased baroreex sensitivity and heart rate variability proved the autonomic dysfunction, the lower sympathetitc activity indicated long-standing systemic hypertension in the hypertensive group. The authors will also show the changes after 6 months antihypertensive therapy (nished April, 2007).
of undetermined cause (IUC). Statistical analyses were performed using uni- and multi-variate logistic regression models Results: FHOS was identied in 17 (11.4%) out of the 149 rst-ever IS patients (mean age 387 years, male gender 58%). The distribution of FHOS among the TOAST subgroups was as follows: LAA 21% (4/19), CE 9% (2/22), LAC 17% (4/24), IOE 13% (5/38) and IUE 4% (2/46). FHOS was more prevalent (p=0.045) in the combined group of IS of vascular etiology (LAA/LA/IOE, 16%) than in the group of patients with CE and IUE (6%). After adjusting for stroke risk factors and demographic characteristics FHOS was independently (p=0.052) associated with IS due to LAA, LAC or IOE (OR:3.1; 95%CI:1.0-10.1). Discussion: Our ndings indicate that young adults with IS of vascular etiology are more likely to have a positive FHOS than patients with CE or IUE.
24 22 Risk factors of stroke

PREVALENCE OF CONVENTIONAL VASCULAR RISK FACTORS IN STROKE PATIENTS UP TO 45 YEARS OLD. A COMPARISON WITH GENERAL STROKE POPULATION
METABOLIC SYNDROME IN SYMPTOMATIC AND ASYMPTOMATIC PATIENTS WITH SEVERE CAROTID STENOSIS
J. Lopez-Fernandez, A. Gonzalez-Hernandez, O. Fabre-Pi, J.A. Suarez-Muoz, M. Vazquez-Espinar, S. Diaz-Nicolas, V. Araa-Toledo, A. Cubero-Gonzalez Hospital de GC Dr Negrin, Spain
Introduction: Ischemic stroke is considered a heterogeneous entity that presents differences in relation to aetiology, pathology and prognosis, which can vary according to age groups. We have analysed the presence of conventional vascular risk factors in a series of stroke in the young patient, which has been compared to another series including the general population in our area. Material and methods: We performed a retrospective revision of the clinical history of all patients admitted in our service in the interval 01/01/2001-31/12/2005. All ischemic strokes (ISs) or transient ischemic attacks (TIAs) in patients up to 45 years-old were included. We recorded parameters related to the presence of conventional vascular risk factors high blood pressure (HBP), diabetes mellitus (DM), dyslipemia (DLP), tobacco smoking, ischemic cardiopathy (IC), peripheral arteriopathy and atrial brillation (AF) and compared them to the number of total strokes in 2004 and 2005. Results: We included 536 patients (60,4% men and 39,6% women) in our period of study; 70 of them (51,4% men and 48,6%) were up to 45 years-old. The prevalence of HBP was 37,7% in the group <46 years-old and 62,9% in the total of strokes; of DM, it was 7,24% vs. 34,9%; of DLP, it was 46,7% vs. 32,5%; of active tobacco smoking, it was 59,4% vs. 42,4%; of IC, it was 8,6% vs. 14,1%; of FA, it was 1,5% vs. 20%; and of peripheral arteriopathy, it was 0 vs. 4,3%. Conclusions: In our series, the prevalence of some conventional vascular risk factors (HBP, DM, IC, peripheral arteriopathy and AF) is evidently minor in the up to 45 year-old stroke population, meaning that different etiopathogenic mechanisms are involved. However, some conventional vascular risk factors (DLP and tobacco smoking) show a higher prevalence in this group, which, associated to other predisposing factors, could favour ischemic events. For this reason, both primary and secondary prevention is highly necessary to avoid the conjunction of prothrombotic disorders in the patient.
L. Tuskan-Mohar, I. Strenja-Linic, K. Blazina, I. Antoncic, S. Dunatov, M. Bucuk, A. Jurjevic University Hospital Center Rijeka, Croatia
Background: Metabolic syndrome (MS) is a constellation of interrelated abnormalities that increase the risk for the development of cerebrovascular disease. The aim of this study was to analyze a group of symtomatic and asymptomatic patients with severe occlusive disease of extracranial internal carotid artery (ICA) and the presence of MS in these patients. Methods: One hundred and forty seven patients with severe carotid stenosis, treated at Department of Neurology, Rijeka University Hospital Center, Croatia, were included into the study. Sixty two (42%) patients were asymptomatic and eighty ve (58%) were symptomatic. We analized a combination of vascular risk factors such as obesity, diabetes mellitus, dyslipidemia and hypertension, which are known elements of MS, in these patients. Results: There were 147 patients with severe carotid stenosis, 101 (69%) men (age 65.5) and 46 (31%) women (age 68.3). MS with all its elements was documented in 20% patients. The frequency of individual components of the MS: hypertension 79%; diabetes mellitus 29%; abnormal lipid prol 67%; BMI>25 in 20% (BMI>30 in 12%). The combination of hypertension and abnormal lipid prol was the most common risk factor (43%). The all risk factors equally occurred in both sexses. MS was more common in symptomatic than in asymptomatic patients (p=0.001). Discussion: In our series one fth of patients with severe carotid stenosis had MS which was prevailing in symptomatic patients. The combination of hypertension and atherogenic dislipidemia was the most frequent risk factor. Focusing on the most prominent risk factors, which are modiable, and treating them is the most effective way to prevent stroke.
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THE MOST FREQUENT RISK FACTORS FOR ISCHEMIC STROKE IN YOUNG ADULTS
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M. Jovicevic, I. Divjak, A. Jovanovic Institute of Neurology, Clinical Centre Novi Sad, Univeristy of Novi Sad, Novi Sad, Yugoslavia
Background: The objective of the study was to investigate risk factors for ischemic stroke in young adults. Methods: The study included 100 patients with ischemic stroke of both sexes aged 15-45 years treated at the Institute of Neurology in Novi Sad. All patients 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 following risk factors were studied: family history, diabetes, cardiac disease, patent foramen ovale, hypertension, previous stroke(s), smoking, hyperlipidemia, obesity, alcohol abuse, migraine, oral contraception, immunological diseases, pregnancy and puerperium. Results: Cardiac disease was found in 26% of all patients, of which none was in the youngest group, while it was most frequent in the group 26-35 years (p=0.011). Patent foramen ovale was found in 6% of all patients and it was more frequent in younger patients. Arterial hypertension was present in 51% of all patients and the percentage of patients with this risk factor was signicantly higher in older age groups (8.3%:25%:63.9%) (p<0.001). Smoking was the most frequent risk factor, present in 55.6% and equally distributed in all age groups (p=0.918). Hyperlipidemia was the second most frequent risk factor (53.5%). Most patients with hyperlipidemia were in the oldest group, however there was no signicant difference (p=0.406). Oral contraception was used by 4% of patients. Five female patients were pregnant or in puerperium (2:1:2).
ASSOCIATION BETWEEN FAMILY HISTORY OF STROKE AND ISCHEMIC STROKE SUBTYPE IN YOUNG ADULTS
K. Spengos, S. Vassilopoulou, M. Papadopoulou, A. Konstantinopoulou, P.P. Zis, E. Koroboki, G. Tsivgoulis Eginition Hospital, University of Athens, Athens, Greece
Background: Recent data have indicated that ischemic stroke (IS) subtype may be associated with the family history of stroke (FHOS). Both population-based and hospital-based studies have shown that FHOS is more prevalent in IS patients. However, the potential relationship between the etiopathogenic mechanism of cerebral infarction and FHOS has not been studied in the former stroke subgroup. Methods: Consecutive rst-ever stroke patients, aged between 15 and 45 years and hospitalised in the stroke wards or referred to the stoke outpatient clinic of our tertiary care University Hospital over a 5-year period, were prospectively included in a computerized observational data bank. Demographic characteristics, stroke risk factors and FHOS among any rst-degree relative were documented in all patients. According to the TOAST criteria, ischemic stroke was classied based on etiopathogenic mechanisms into the following groups: large artery atherosclerotic stroke (LAA), cardioembolic stroke (CE), small artery occlusion or lacunar infarction (LI), infarction of other determined origin (IOE) and infarction
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Discussion: Smoking was the most frequent risk factor, registered in 55.6% of all study patients. Study of risk factors is essential for adequate prevention and treatment of ischemic stroke.
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THE RATE OF STROKE ASSOCIATED WITH THE USE OF THORATEC VENTRICULAR ASSIST DEVICE IN OLDER PATIENTS
26
M.B. Vijayappa, B. Clemson, M. Alsorogi, S. Al-Hawarey, D. Joseph, A. Talkad, M. Mathews, D. Wang University of Illinois College of Medicine at Peoria, OSF, INI, Peoria, IL, USA
Background: Because of the shortage of heart donors, ventricular assist devices (VAD) are used to provide mechanical circulatory support in patients with heart failure awaiting planned heart transplant or in patients who are not candidates for heart transplant. The use of VADs has been increasing due to the growth of the aging population. However, it is unclear if there is an increased risk of developing stroke relative to age. Our study was to determine the effect of age on the risk of stroke after VAD implant. Methods: This is a retrospective study exempted by the community IRB. From 1996-2006, we reviewed records of all patients who received VADs as a bridge to transplant. Demographic data, clinical and radiographic ndings were collected. Descriptive statistics were applied. The patients were categorized according to age; Group I, less than 55 and Group II, 55 or older. Results: From 1996-2006, 45 patients received VADs. The number of patients in group I was 24 (53%) and group II was 21 (47%). Group I had 8 (33%) strokes; 6 (23%) were ischemic and 2 (8%) hemorrhagic. Group II also had 8 (30%) strokes, 7 (32%) were ischemic and 1 (5%) hemorrhagic. In Group I; 4 (17%) had diabetes, 13 (54%) hypertension and 7 (29%) left atrial cannulation. In Group II; 11 (52%) had diabetes, 11 (52%) hypertension and 6 (29%) left atrial cannulation. The overall mortality in group I was 11 (46%) and 10 (48%) in group II. One (4%) death in each Group was associated with stroke. Conclusion: Regardless of patients age, the occurrence of stroke associated with the implantation of a VAD was similar. There was no signicant increase in stroke related mortality. Given the known benet of VADs support to improve the rate of successful transplantation and the absence of an increased risk of stroke in older patients, the use of VAD support in appropriate patients should be carefully considered regardless of age.
HEREDITARY TROMBOPHILIAS AND NEUROLOGICAL COMPLICATIONS
J. Szilasiova, B. Benova, D. Kozakova, E. Kahancova, E. Antolova, Z. Gdovinova Faculty of Medicine P.J. Safarik University and Faculty Hospital Kosice, Slovakia
In patients with unknown etiology of stroke hereditary coagulation disorders can be the reason of stroke. There are also other neurological disorders which can be caused by thrombophilias. Studies have shown that trombophilia testing inuences less than 25% of physicians treatment of stroke. The authors present small study consists from 10 patients (8 women, 2 men), mean age 28.5 years, with different types of hereditary coagulation disorders affecting cerebral circulation. In 5 patients (50%) isolated and in the next 5 patients (50%) combined hereditary coagulation deffect were found. Decit of antithrombin (AT) III, mutation of gene for methylenetetrahydrofolate reductase (MTHFR), hyperhomocysteinemia, high factor VIII, factor V Leiden, protein S and C decit, increased level of plasminogen activator inhibitor (PAI) webe detcted. In four patients thrombosis of cerebral arteries and thrombembolic events were preceded by delivery or using contraceptives. In four patients coagulopathy was found also in family members. In 9 cases neurological complications were the rst manifestation of thrombophilia, in one stroke was preceded by phlebothrombosis of lower extremities. In ve patients brain infarcts, in two cases thrombosis of brain venous sinuses were found and in the last three patients magnetic resonance revealed demyelinating lesions. After therapy two patients have mild hemiparesis, next two vascular epilepsy and last six patients are without any consequences. In patient with AT III decit was in the same time present thrombembolia of pulmonal, radial, axillar and cerebral arteries with numerous brain infarcts. Hereditary thrombophilias are rare reasons of stroke, but with higher frequency in younger patients. Their detection may provide prognostic information of the risk of recurrent events as well as determine the most appropriate treatment.
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ASSOCIATION OF CAROTID INTIMA MEDIA THICKNESS AND PLAQUE WITH AORTIC ARCH CALCIFICATION
27
INFLUENCE OF VASCULAR RISK FACTORS ON OXIDATIVE STRESS, ASSESSED BY MEASUREMENT OF SERIC MDA LEVELS, IN ACUTE ISCHEMIC STROKE SUBTYPES
B.-S. Shin, E.S. Lim Chonbuk National University Hospital and Medical School, Jeonju, South Korea
Introduction: Atherosclerosis is a generalized process and is the major cause of cerebrovasculardisease. The more advanced atherosclerotic lesions contain calcium deposits. Aortic arch calcication may represent a manifestation of generalized atherosclerosis. The carotid intima media thickness (IMT) is also recognized as independent predictors of adverse cerebrovascular outcomes. The purpose of this study is to examine the relationship between the degree of aortic arch calcication and carotid IMT and plaque. Materials and methods: A total of 56 patients (31 men and 25 women) were included. All patients had chest radiography in the posteroanterior view. Severity of aortic arch calcication was graded as follows: grade 1 (small spots of calcication or single thin calcication of the aortic knob), grade 2 (one or more areas of thick calcication), grade 3 (circular calcication of the aortic knob). The degree of carotid atherosclerosis was evaluated by measuring the maximum IMT of the common carotid artery, carotid bulb, and internal carotid artery by duplex carotid ultrasonography. Results: The mean age of patients was 70.0 9.1 years and the numbers of male patients was 31. (55.4%). Severity of aortic arch calcication was grade 1 in 26 patients (46.4%), grade 2 in 18 patients (32.1%), grade 3 in 12 patients (21.4%). Aortic arch calcication was observed more commonly in elderly patients. There was no signicant difference between aortic arch calcication and gender. There was no signicant relationship between severity of aortic arch calcication and carotid IMT. But there was signicance between severity of aortic arch calcication and plaque number (p=0.012).
A. Simion Faculty of Medicine and Pharmacy Oradea/Clinical Hospital of Neurology and Psychiatry, Oradea, Romania
Background: Oxidative stress has been involved in the pathogenesis of several diseases considered as risk factors for ischemic stroke. Material and method: A consecutive series of ischemic stroke patients admitted were evaluated clinically, with brain CT and/or MRI, Duplex sonography, electrocardiography, transthoracic echocardiography, and biochemically (measurement of lipid fractions and fasting glucose levels).Strokes were divided into large artery disease (LAD), small vessel disease (SAD) and cardioembolism (CE) according to the TOAST criteria.Risk factors were diagnosed according to the international criteria (JNC 7 for hypertension, ADA for diabetes, BMI>30 kg/m2 for obesity).Smoking and alcohol intake were recorded as admitted by the patient.We recorded the NIHSS score on admittance and Barthel index (BI) at discharge.Malondialdehyde (MDA) levels were measured on admittance(day 1, viewed as baseline levels)and on day 3 and 7. Results: Patients with fewer risk factors had lower baseline-MDA levels.Smoking raised the MDA levels in LAD signicantly(p<0,001)and lowered BI(2,43 to 4,6; 4,18 to 5,9; 3,13 to 5,3).In SAD only baseline-MDA level was signicantly higher (1,83 to 4,5, p<0,001).Diabetes signicantly increased oxidative stress at rst determination and worsened outcome in SAD(1,83 to 4,1, p<0,001).In CE the MDA values were not as high as in microangiopathy, but outcome was even poorer. Dislipidemia, obesity and hypertension raised the baseline-MDA levels nonsignicantly, except obesity in CE in which both MDA(2,17 to 3,5, p<0,001)and outcome were signicantly altered.Alcohol intake raises (p<0,001) MDA level in LAD (2,43 to 5,1; 4,18 to 5,9; 3,13 to 5,3). Conlusions: Based on our results preventive antioxidant therapy would be most benecial in diabetes.
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Stroke and diabetes
ISCHEMIC STROKE IN PATIENTS UNDERGOING DIALYSIS
S. Jung, S.H. Hwang, S.B. Kwon, K.H. Yu, I.S. Koh, B.C. Lee Hallym University College of Medicine, National Medical Center, Seoul, South Korea
Background: When we evaluated the patterns of stroke and risk factors in patients with chronic kidney disease, it was difcult to analyze those results because the included patients were not homogenous. In that study, we included ischemic and hemorrhagic stroke patients with either chronic renal disease or end stage renal disease (ESRD) undergoing dialysis. We performed this study in patient with ischemic stroke with ESRD so as to elucidate the factors that affect developing ischemic stroke in chronic kidney disease. Methods: We enrolled patients with acute ischemic stroke in ESRD patients undergoing dialysis using the data from Hallym Stroke Registry (HSR). Twenty patients were included from July 1996 through June 2006. Thirty patients with hemodialysis who did not develop stroke were selected as control group with age and sex matching. We compared the demographic features, stroke risk factors, laboratory ndings in ESRD patients with or without ischemic stroke. Results: The mean age of acute ischemic stroke patients was 60.7510.19 and male to female ratio was 0.82. The most common ischemic stroke subtype was small vessel occlusion (SVO, 9 of 20 patients) and followed by large artery atherosclerosis (LAA, 7 of 20). Ischemic stroke patients showed longer duration of causative disease of ESRD, higher rate of hypertension history, and low serum LDL cholesterol level compared with the patients with control group. Discussion: Although low serum LDL level in stroke with CKD in our previous study could be affected by relatively high frequency of hemorrhagic stroke, low serum LDL was also observed in ischemic stroke patients undergoing dialysis. These nding shows that serum cholesterol level can reects the status of malnutrition rather than atherosclerosis at least in CKD patients.
THE TEMPORAL PATTERN OF POST-STROKE HYPERGLYCAEMIA IS A PREDICTOR OF LONG-TERM SURVIVAL
M. Koufali, R. Durairaj, R. Kumar, A.K. Sharma Aintree Stroke Team for Audit and Research, Aintree University Hospitals NHS Foundation Trust, United Kingdom
Background: Recent work has shown that persistent post-stroke hyperglycaemia (PHG) affects infarct size and clinical outcome. The purpose of this study was the detailed investigation of the association between blood glucose levels (BGL)obtained over 24 hours and survival at 12 months following a stroke. Patients & Methods: 1496 patients, admitted during 2000-2005, with a conrmed diagnosis of ischemic stroke and not previously known to be diabetic were included in this retrospective analysis. Only Caucasian patients with conrmed onset, admission, discharge and death dates were included in the study. BGL values were obtained upon admission and at 24 hours. Results: Median admission BGL was 6.3 mmol/L, while median BGL at 24 hours post admission was 5.5 mmol/l. 987(66%) of patients survived at 12 weeks, 568 (38%) survived at 12 months, while 284(19%) patients died in hospital. 807 patients (54% of total) were hyperglycaemic upon admission (glucose >6.1 mmol/L) with 256 of them (32%) remaining hyperglycaemic at 24hours postadmission. Multiple regression analysis demonstrated that 24 hour PHG is independently associated with: Death in hospital (p=0.017), survival at 12 months (p=0.009) and increased lengths of stay (p=0.005). Conclusion: Evidence is presented that patients with persistent hyperglycaemia over 24 hours have poorer outcomes. Further research is thus warranted which would allow us to target this group of patients for aggressive therapy for blood sugar control following a stroke.
3 Stroke and diabetes 1 Stroke and diabetes
Stroke and diabetes
POST-STROKE HYPERGLYCAEMIA IS NOT AN EPIPHENOMENON OF ISCHAEMIC STROKE SEVERITY
M.T. McCormick, T.A. Baird, K.W. Muir University of Glasgow, Glasgow, United Kingdom
Introduction: Post stroke hyperglycaemia (PSH) is common and is associated with a worse outcome. It is postulated that hyperglycaemia reects the stress response of a severe stroke. We sought to establish the prevalence of PSH within 48hours of ictus and describe its association with stroke severity. Methods: Patients presenting within 24hours of a suspected stroke (April 2004January 2006) underwent 4 hourly capillary blood glucose (CBG) monitoring for 48hours. Baseline demographics, NIHSS, OCSP and time of stroke onset were collected. Stroke severity was described as severe (NIHSS > 15); moderate (NIHSS 715) or mild (NIHSS 06). Hyperglycaemia was dened as a CBG > 7mmol/l, Results: 353 patients underwent CBG proling. Median Age 72 (IQR 62,80); Median NIHSS 6 (3,13). 17% had diabetes. At presentation 29% of patients had PSH; Median time to CBG was 238 minutes (IQR 165,494). Over the 48hour monitoring period 75% developing Hyperglycaemia, with 25% euglycaemic throughout. Glycosylated Haemoglobin was statistically lower in patients with euglycaemia compared to hyperglycaemia (p = 0.001). Stroke severity was not predictive of admission hyperglycaemia whereas glycosylated haemoglobin was (OR 2.97; 95%CI 1.84-4.78; p < 0.001). There was no statistically signicant difference between mean blood glucose on initial monitoring between groups. However at 48 hours, blood glucose was signicantly lower in more severe strokes (NIHSS > 15), CBG = 5.8mmol/l compared to milder strokes (NIHSS 06), CBG = 6.6mmol/l (p = 0.015). Discussion: Post stroke Hyperglycaemia is common. Overall prevalence for the 48hour period was 75%. Stroke severity was not predictive of post stroke hyperglycaemia with more severe strokes having a statistically lower blood glucose compared to milder strokes at 48hours.
THE EFFECT OF STATIN PRE-TREATMENT ON INFARCT VOLUME AND DISCHARGE DISPOSITION IN ISCHEMIC STROKE PATIENTS WITH DIABETES
J.S. Nicholas, J.C. Thomas, Z. Rumboldt, P. Tumminello, S.J. Patel Medical University of South Carolina, Charleston, SC, USA
Background: Studies have indicated reduced rates of stroke among patients with diabetes treated with statins. In contrast to stroke prevention, the purpose of this analysis was to examine post-stroke outcomes (infarct volume, discharge disposition) among patients with diabetes who were taking a statin at onset of ischemic stroke relative to those who were not. Methods: Study design was a retrospective cohort analysis of all veried ischemic stroke patients admitted to our university hospital 2002-2006 with magnetic resonance diffusion weighted imaging (DWI). Of these patients, 131 presented with diabetes or were newly diagnosed at admission. Infarct volume was calculated from DWI, blinded to statin status. For patients with multiple infarcts, volume recorded was the sum of all infarcts. Discharge disposition and clinical data were abstracted from hospital records. Statistical comparisons between statin and no-statin groups were made using 2-sided t-tests for continuous variables, chi-square for categorical, and Mann-Whitney for nonparametric. Variables pre-specied as potential confounders of infarct volume were time to imaging, location and type of stroke. Results: Patients with diabetes who were taking a statin on admission had a statistically signicant 55.1% decrease in median infarct volume relative to the no-statin group (1.02 cm3 statin versus 2.27 cm3 no-statin, Mann-Whitney p=.039, N=131, 46.6% on statins). While differences in discharge disposition were not statistically signicant, 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 signicantly between groups in univariate analysis, nor did age, gender, or race (all p values >.05). Discussion: In this study, statin-pretreated patients with diabetes experienced signicantly smaller median infarct volumes following ischemic stroke than those not pretreated. Given the potential importance to treatment practices, this nding and its implications for clinical outcome should be further investigated.
Stroke and diabetes
DIABETES MELLITUS AND THE EARLY RISK OF STROKE AFTER TRANSIENT ISCHEMIC ATTACK: A HOSPITAL-BASED CASE SERIES STUDY
G. Tsivgoulis, S. Vassilopoulou, E. Manios, P.P. Zis, K. Spengos Eginition Hospital, University of Athens, Athens, Greece
Background: California- and ABCD-scores reliably predict short-term risk of stroke after TIA. Both scores contain similar components. However, diabetes
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mellitus (DM) is only included in the California Score. Aim of the present study was to evaluate the potential relationship of DM with the early risk of stroke in a cohort of hospitalised TIA patients. Methods: All patients hospitalised in our Department with denite TIA during a 5-year period were identied and their medical charts as well as their Emergency Room records were retrospectively reviewed by two investigators blinded to followup. Patients with previous history of stroke and those who missed their follow-up evaluations at the outpatient clinic of our Department at 1 month after admission were excluded. DM was specied as fasting serum glucose 7.0 mmol/L, nonfasting serum glucose 11.1 mmol/L, or use of oral blood sugar-lowering drugs or insulin. The outcome events of interest in all TIA patients were subsequent strokes during the 1-month follow-up period. Statistical analyses were performed using the Kaplan-Meier product-limit method and stepwise Coxs proportional hazards model. Results: The 30-day risk of stroke in the present case series (n=226) was 9.7% (95%CI:5.8-13.6%; 22 events). The 30-day risk of stroke was higher in patients with DM (17.3%; 95%CI:7.6-27.0%) than in non-diabetic patients [(7.1%; 95%CI:3.211.0%); log-rank test=5.20; df=1; p=0.0225]. After adjustment for demographic characteristics, stroke risk factors, history and number of prior TIAs, duration and symptoms of TIAs, as well as secondary prevention treatment strategies during hospitalisation, DM was independently (p=0.015) associated with a three-fold greater 30-day risk of stroke (HR:2.98; 95%CI:1.28-6.94). Discussion: DM is an independent predictor of subsequent stroke in patients presenting with TIA. It should be taken into account by prognostic scores that stratify the risk of early stroke in TIA patients.
groups. Detected differences were adjusted for age and sex by multivariable logistic regression. Results: Between Jan 1995 and Dec 2004, diabetes was identied in 419 patients (16.9%). The mean age of black diabetic patients was signicantly lower than that of whit patients (68.9y versus 73.4y, respectively; p<0.001); no differences were found for sex. Among black diabetic patients, the prevalence of atrial brillation (OR 0.2; 95% CI 0.1-0.4) and of smoking (OR 0.5; 95% CI 0.3-0.7) was lower, and presence of hypertension higher (OR 2.7; 95% CI 1.5-4.8) compared to white; no other statistically signicant differences for vascular risk factors were found. Distribution of stroke pathology and of clinical subtypes showed no statistically signicant variation between the two ethnic groups. Conclusions: Substantial ethnic differences were found in the prevalence of vascular risk factors between black and white diabetic stroke patients. These differences might reect different risk factor proles and possibly point to 2 clusters with different interactions between risk factors
Etiology of stroke 1 Etiology of stroke
CEREBRAL HEMODYNAMIC FEATURES OF ALCOHOLIC ABSTINENT SYNDROME AND OPIATE ABSTINENT SYNDROME
I. Voznyuk, N. Artemyeva, S. Scherbak Military Medical Academy, Russian Federation
Stroke and diabetes

Background: Chronic alcoholization and heroinism are characterized by various hemodynamic disorders, that promote the development of the cerebral pathology. Methods and materials: The research involved 55 patients with the alcoholic abstinent syndrome (26-59 years old) and 40 patients with the opiate abstinent syndrome (25-41 years old). The control group included 34 men and women (18-47 years old). The clinical data and results of the Doppler sonography were investigated. Results: The similar decrease of the linear blood ow velocities in both middle cerebral arteries was registered in 60% of the patients with the alcoholic abstinent syndrome and in 54,5% of the patients with the opiate abstinent syndrome; in both anterior cerebral arteries in 56,4% and 43,8% correspondingly; in both posterior cerebral arteries in 47,3%, in both vertebral arteries in 32,7% of the patients with the alcoholic abstinent syndrome. The decrease of the linear blood ow velocities in the basilar artery was detected in 58,2% of the patients with the alcoholic abstinent syndrome and in 20,7% of the patients with the opiate abstinent syndrome; the diffuse increase of the vascular tone in 54,5% and 48,5%; the decrease of the integrated index of the cerebrovascular reactance in 85,5% and 68,8% correspondingly. Restriction of the cerebrovascular reactivity was registered in 41,8% of the patients with the alcoholic abstinent syndrome (vasodilatation) and in 28% of the patients with opiate abstinent syndrome (vasodilatation and vasoconstriction). Conclusion: The decrease of the linear blood ow velocities in the intracranial arteries, the diffuse increase of the vascular tone and the decrease of the integrated index of the cerebrovascular reactance occurs reliably more often in the patients with the alcoholic abstinent syndrome and opiate abstinent syndrome, than in the control group. The similar bilateral decrease of the linear blood ow velocities was predominantly registered in the middle cerebral arteries and in the anterior cerebral arteries.
PATIENTS WITH STROKE HAVE A HIGH PROBABILITY OF DYSGLYCAEMIA AS ASSESSED USING AN ORAL GLUCOSE TOLERANCE TEST
S.H. Naqvi 1 , J.D. Lee 2 , V. Patel 3 , K.M. Sharobeem 1 Sandwell General Hospital, Rowley Regis; 2 Department of Cardiology, George Eliot Hospital NHS Trust, Nuneaton; 3 Warwick Medical School, United Kingdom
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Background and aims: In the UK, the recently published Joint British Societies Guidelines on the Prevention of Cardiovascular Disease recommend performing an oral glucose tolerance test (OGTT) on subjects with an acute cardiovascular event. In this study, we report our experience of performing an OGTT in those suffering a recent acute stroke in a district general stroke unit. Methods: An OGTT was performed in clinically stable consecutive patients admitted to the stroke unit with a diagnosis of acute stroke. The study was conducted over a period of 3 months. Those with known diabetes mellitus were excluded. Results: Data on 71 patients were available. Mean age of subjects was 70 years (Range 24-96). 49% were male. 86% suffered a non-haemorrhagic stroke. The mean time of admission to OGTT was 8.5 days. Only 43% had a normal OGTT. The proportions of those with impaired fasting glycaemia, impaired glucose tolerance and diabetes mellitus were 3%, 34%, and 20% respectively. Conclusions: Our data suggests that, based on the results of an OGTT, patients suffering an acute stroke have a high probability of having dysglycaemia. The gold standard OGTT for diagnosing dysglycaemia should be employed as there is data supporting the prevention of diabetes mellitus in those with impaired glucose tolerance. Furthermore, early treatment of diabetes mellitus can potentially offset the appearance of classic diabetes complications.
Stroke and diabetes
Etiology of stroke
ETHNIC DIFFERENCES IN COMORBIDITIES AND STROKE SUBTYPES OF DIABETIC STROKE PATIENTS: THE SOUTH LONDON STROKE REGISTER (SLSR)
INTERPRETATION OF COMPUTED TOMOGRAPHY AND DIFFUSION-WEIGHTED IMAGING DURING ACUTE NEUROLOGICAL EVENTS IN MITOCHONDRIAL RESPIRATORY CHAIN DISORDERS
A. Elmarimi, T. Rashid, J. Adie, O. Wood, P.U. Heuschmann, A.M. Toschke, A.G. Rudd, C.D.A. Wolfe Kings College London, London, United Kingdom
Background: Major differences in underlying risk factors of stroke have been identied between ethnic subgroups, which may have implications in directing secondary preventive strategies. Data are lacking about differences in comorbidities and stroke subtypes between black and white diabetic stroke patients. Methods: Data were collected from the South London Stroke Register (SLSR), a population-based stroke register covering a multiethnic source population of 271.817 inhabitants (2001). Analysis was restricted to those with known diabetes and to patients of black or white ethnic group. Demographics, major vascular risk factors and stroke subtype were compared between black and white ethnic
S. Mittal, W. Watson, M. Aribandi, J.P. Hosey Geisinger Medical Center, Danville, PA, USA
Sudden neurological events are common and mimic acute stroke in mitochondrial respiratory chain disorders characterized by disruption of intracellular metabolic pathways and energy failure. We had the opportunity to examine four separate sets of computerized tomography (CT), diffusion-weighted imaging (DWI) and apparent diffusion coefcient (ADC) data collected during acute neurological events from two patients with defects in the mitochondrial respiratory chain function. Both had prior histories of mental retardation and seizures but no known mitochondria disorder. Clinically the events were characterized by acute onset hemispheric symptoms suggesting stroke. Initial evaluation with CT brain showed hypodensity involving the temporoparietal region of the symptomatic hemisphere
Poster Session Etiology of stroke
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with effacement of sulci and surrounding edema indicative of subacute stroke. DWI and ADC map were obtained within the rst 48 hours; there was a delay of 168 hours in one event. All four DWI/ADC data were strikingly similar and showed restricted diffusion mixed with increased ADC in the temporoparietal area indicating a combination of cytotoxic and vasogenic edema. One patient had A3243G mutation and the other a deciency of cytochrome c oxidase activity and partial deciency of NADH dehydrogenase. Though presented acutely CT scans in all four events suggested subacute stroke. With newer treatment modalities for ischemic stroke widely available it is important to distinguish them from acute events in mitochondrial encephalopathies. DWI helps distinguish between cytotoxic and vasogenic edema. Membrane ion pump failure and ingress of sodium into the cell during acute ischemia cause restriction of movement possibilities of water molecules. Resultant uniformly reduced values of ADC are seen in infracted area conned to a vascular territory. In our observation restricted diffusion was notably conned to the cortical areas while the adjacent white matter showed increased ADC which was felt to be unique to patients with mitochondrial encephalopathy presenting as acute neurological events.
patient had an ICH into a germinative cell tumor metastases and the other three had ischemic strokes- two had identied intracardiac emboli source (a fungi and a nonbacterian thrombotic endocarditis). Discussion: Patients with CVD and cancer in our hospital seem to receive a less thorough investigation of stroke etiology. Autopsy data seem to differ from clinical ones, maybe due to the severity of patients evaluated. A better investigation of these patients could help identify preventable causes of stroke recurrence.
Etiology of stroke
EMBOLIC LESION PATTERN ON DIFFUSION WEIGHTED BRAIN IMAGING AND AETIOLOGY OF STROKE
J.N.E. Redgrave, A. Chandratheva, D. Briley, P.M. Rothwell Stroke Prevention Research Unit, Department of Clinical Neurology, Oxford University, Oxford, United Kingdom
Background: Diffusion-weighted MR-imaging (DWI) is highly sensitive to acute cerebral ischaemia and may help to determine the likely underlying aetiology. For example, several studies have reported an association between multiple acute ischaemic lesions and ipsilateral 50% carotid stenosis, although none has quantied the predictive value. Methods: Consecutive patients referred to a specialist clinic with TIA or minor stroke had DWI and carotid MR-angiography. Ipsilateral 50% carotid bifurcation stenosis was related to the presence of solitary and multiple acute ischaemic lesions on DWI. Results: 500 patients (278 men) were studied. DWI showed acute ischaemic lesion(s) in 179/280 (63.9%) patients with minor stroke vs. 33/220 (15%) with TIA (p<0.0001). 52 (10.4%) patients had symptomatic 50% carotid stenosis. A solitary DWI lesion was not associated with symptomatic carotid stenosis (OR 1.00, 0.51-1.99, p=0.99) but multiple acute DWI lesions in the ipsilateral carotid territory was strongly associated (OR 5.87, 2.68-12.86, p<0.001) with carotid stenosis, particularly the presence of >3 lesions (OR 8.87, 3.26-24.15, p<0.001). However, the corresponding sensitivities for prediction of the presence of 50% ipsilateral carotid stenosis were nevertheless low (25% and 15% respectively) and the imaging appearance was also associated with cardioembolic aetiology. Conclusion: Multiple acute ischaemic lesions on DWI are strongly associated symptomatic 50% carotid bifurcation stenosis, but the appearance is likely to be of limited use in aetiological classication.
Etiology of stroke
STROKE PATTERNS IN PATIENTS WITH INTERNAL CAROTID ARTERY DISSECTION THE SIGNIFICANCE OF VESSEL PATENCY
L.H. Bonati, S.G. Wetzel, J. Gandjour, R.W. Baumgartner, P.A. Lyrer, S.T. Engelter University Hospital Basel, Basel, Switzerland
Background: Spontaneous dissection of the internal carotid artery (ICAD) is an important cause of stroke in young and middle-aged patients. ICAD may lead to a complete vessel occlusion or residual ow through a stenotic artery. Diffusionweighted imaging (DWI) has the potential to highlight differences in the pattern of cerebral ischemia between occlusive and non-occlusive ICAD. Methods: DWI, Doppler and color duplex sonography, and angiographic studies were assessed in 40 consecutive patients (median age 47 years, interquartile range [IQR] 39-56) with ischemic stroke caused by spontaneous ICAD, referred to two university hospitals. Number, size and location of hyperintense lesions on DWI were correlated with vessel patency. Results: Patients with non-occlusive ICAD (n=15) presented with more ischemic lesions (median 5, IQR 1-10) than patients with complete ICA occlusion (n=25) (2, 1-3; p=0.014). In contrast, ischemic lesions were larger in occlusive ICAD (62, 50-99 mm) compared to non-occlusive ICAD (25, 10-50 mm; p=0.007). Stroke patterns differed signicantly between the two groups (p=0.002). Non-occlusive ICAD was associated with disseminated lesions involving borderzone territories, whereas most patients with occlusive ICAD had large territorial infarcts. Conclusions: Our data suggest different stroke patterns in ICAD patients with occluded ICA compared to those with stenotic ICA. These ndings may be of relevance in the ongoing controversy about the acute treatment of stroke in ICAD.
Etiology of stroke
PREVALENCE OF FABRYS DISEASE IN YOUNG MALE PATIENTS WITH STROKE OR TRANSIENT ISCHEMIC ATTACK
A. Viguier, T. Levade, V. Larrue CHU de Toulouse, Toulouse, France

Background: Fabrys disease is a rare inherited, X-linked storage disease that may 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 patients with stroke or TIA. Methods: Peripheral blood leukocyte alpha-galactosidase A activity was determined in male patients aged 18-55 years, consecutively admitted to a tertiary stroke unit for acute stroke or TIA. Causes of stroke or TIA were classied using the TOAST classication. Results: 108 patients were recruited from January 2004 to June 2005. The mean age SD was 45 years 9. There were 71 ischemic strokes, 27 TIAs, 8 cerebral hemorrhages and 2 venous cerebral thrombosis. Causes of stroke or TIA were undetermined in 51/98 (52%) patients. No patient had a decient alpha-galactosidase A activity. Discussion: These ndings conrm the rarity of Fabrys disease among unselected young male patients with stroke and TIA.
Etiology of stroke
STROKE IN PATIENTS WITH CANCER IN A GENERAL HOSPITAL: DIFFERENCES BETWEEN CLINICAL AND AUTOPSY SERIES
G.S. Silva, D.L. Gomes, M.M. Alves, J.A. Fiorot Jr, A.R. Massaro UNIFESP- Universidade Federal de So Paulo, So Paulo, Brazil
Background: Cerebrovascular disorders (CVD) are frequent causes of neurological symptoms in cancer patients. Clinical and autopsy series differ in the importance of cancer specic conditions as causes of CVD in these patients. Our aim was to describe the clinical features of patients with CVD and cancer admitted to a general hospital, and to compare them to autopsied patients with the same diagnosis. Methods: A retrospective analysis of patients with the diagnosis of CVD and cancer in their discharge summaries from July 2005 to July 2006 was performed. 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 of CVD and cancer. Intracerebral hemorrhages (ICH) (55%- 9% subdural and 46% intraparenchimal) were more frequent than ischemic strokes. Primary cancers were: leukemia (36.4%), lung (18.2%), primary intracerebral cancer (18.2%), colon, prostate and genitourinary tract (9.1% each). TOAST classication was cardioembolic in 50% of the patients and undetermined in 50%. Oxfordshire classication was partial anterior circulation in 66.7% and posterior circulation 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 resonance imaging in 9% and Doppler in 9%. From 350 necropsy studies, four patients had a diagnosis of CVD and cancer (mean age 48 63, 3 women). One
Etiology of stroke
WHITE MATTER LESION LOAD IDENTIFIED BY MAGNETIC RESONANCE IMAGING IS NOT RELATED TO IPSILATERAL CAROTID ARTERY STENOSIS
F.N. Doubal, J.M. Wardlaw, M.S. Dennis University of Edinburgh, Edinburgh, United Kingdom
Introduction: Cerebral white matter hyperintensities (WMH) on T2-weighted magnetic resonance (MR) are common but their aetiology is unknown. They are associated with hypertension, diabetes and atherosclerosis, and may be caused by
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small vessel disease or microemboli (e.g. from the heart, aortic arch or carotid artery stenosis). Studies have linked the severity of any carotid stenosis to the severity of whole brain WMH load but have not specically examined brain ipsilateral to a stenosis. We hypothesised that if microemboli cause WMH, e.g. from carotid stenoses, more WMHs would be found in the cerebral hemisphere ipsilateral to a stenosis than in the hemisphere distal to a non-stenosed carotid. Methods: We prospectively recruited patients with lacunar or mild cortical stroke from a tertiary hospital. Patients were imaged with a 1.5T MR scanner (T2/DWI/GRE/FLAIR) and carotid doppler ultrasound. We dichotomised carotid stenosis as >or <50% NASCET. MRI scans were scored for deep and periventricular WMHs in each hemisphere using the Fazekas method, blind to carotid stenosis. We compared hemispheric Fazekas scores between patients with or without uni or bilateral carotid stenosis. Results: Of 79 patients, 14 had asymmetrical carotid stenosis (one > and one <50%), 1 had bilateral >50% stenoses and 64 had bilateral <50% stenoses. In the 14 with asymmetrical stenoses there was no difference in deep or periventricular WMHs between the ipsilateral (mean deep Fazekas 1.78; mean periventricular Fazekas 1.42) or contralateral hemisphere (1.78;1.36) to the stenosis. In the 64 with no stenosis bilaterally there was no difference in mean deep and periventricular Fazekas scores between the left (1.64;1.03) and right (1.62;1.08). The patient with bilateral stenoses had identical scores in each hemisphere. Conclusions: We found no link between cerebral hemisphere WMH score and ipsilateral carotid artery stenosis, suggesting that microemboli, at least from carotid stenoses, are unlikely to cause most WMHs.
Results: A total 404 lesions were present in 224 patients. Among these patients, single lesions were found in 64 (15.8%) and multiple lesions in 160 (84.2%). Of the single lesions 24(37.5%) were intracranial stenosis and 50(62.5%) were extracranial. Lesions were located in the anterior circulation in 42 patients (65.62%) and in the posterior circulation in 22 (34.37%). Among the 340 stenoses in the 160 patients with multiple lesions, 38 (23.75%) patients had 88 lesion in the intracranial, and 92 patients (57.5%) had 186 lesions in the extracranial vessels solely and both intra and extracranial in 30(18.75%) patients harboring 66 lesions. Overall 142(35.1%) lesions were intracranial and 262(64.9%) were extracranial. Conclusion: Intracranial atherosclerosis is common in Indian patients with atherosclerotic stenosis involving extracranial carotid artery disease.
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Etiology of stroke
HOMOCYSTEINE IN STROKE SUBTYPES IN THE SOUTH LONDON BLACK POPULATION
U. Khan, C. Crossley, P. Collinson, H. Markus St. Georges University of London, London, United Kingdom
Introduction: Cerebral small vessel disease (SVD) is increased in black populations but the underlying mechanisms are poorly understood. In Caucasians elevated serum homocysteine (Hcy), and genetic variants causing increased Hcy levels, have been associated with SVD particularly in cases which have accompanying leukoaraiosis where pathological studies suggest an underlying small vessel arteriopathy and endothelial dysfunction is a proposed disease mechanism. We compared Hcy levels from black strokes enrolled in the in the prospective South London Ethnicity and Stroke Study with community controls. Methods: Hcy, B12, folate and creatinine were measured in black strokes (N=483) from three South London hospitals and controls recruited by random sampling of family practices (N=276). All patients were subtyped by one rater using modied TOAST criteria based on investigations. In SVD patients, leukoaraiosis was graded according to severity (modied Fazekas scale) and patients divided into two groups: isolated lacunar infarction (ILI) and lacunar infarction in the presence of conuent leukoaraiosis (ischaemic leukoaraiosis (ILA)). Results: Hcy (mol/L) was increased in black stroke patients (14.22 (8.80)) vs. controls (11.13 (5.34)) (OR: 4.63 (2.50-8.58), P<0.001) after adjusting for age, gender, vascular risk factors, B12, folate and creatinine. Hcy levels were significantly raised in the following groups: SVD (OR: 7.16 (3.32-15.44), P<0.001), intracerebral haemorrhage (OR: 5.53 (2.07-14.72), P=0.001), cardioembolism (OR: 7.85 (2.87-21.42), P<0.001) and unknown aetiology (OR: 2.28 (1.15-4.52), P=0.018) with highest levels seen in SVD (16.19 (11.48)). Within the SVD group Hcy was higher in the ILA subgroup (19.63 (14.61)) vs. ILI (13.41 (7.06)) (OR: 4.75 (1.53-14.69), P=0.007) and correlated with radiological leukoaraiosis severity (R=0.265, P=0.001). Conclusions: Hcy is a risk factor for cerebral SVD in blacks, especially in conuent leukoaraiosis. This is consistent with a role for endothelial dysfunction in SVD pathogenesis in this ethnic group.
Etiology of stroke
VASCULAR RISK FACTORS IN TRANSIENT ISCHAEMIC ATTACKS AND LATE-ONSET EPILEPSY
M.O. McCarron, A. Hunter, M. Watt Altnagelvin Hospital, Derry, United Kingdom

Background: There is emerging evidence that late onset seizures may be the rst manifestation of occult cerebrovascular disease. We sought to compare the vascular risk proles in patients with transient ischaemic attacks and patients with late-onset epilepsy for which no other cause was identied. Methods: Consecutive patients attending a neurovascular clinic with a diagnosis of transient ischaemic attack (TIA) or epilepsy were eligible for study. Vascular risk factors were prospectively recorded and compared in each group with the chi square test. Results: One hundred patients were enrolled in each group. The distribution of vascular risk factors was as follows: atrial brillation (2 in seizure group versus 0 in TIA group, NS), hypertension (59 versus 52, NS), diabetes (9 versus 10, NS), cigarette smoking (52 versus 45, NS), heart failure (1 versus 0, NS), hyperlipidaemia (35 versus 33, NS), ischaemic heart disease (18 versus 23, NS), previous cerebrovascular disease (33 in seizure group versus 7 in TIA group, p<0.001), excess alcohol (19 versus 16, NS), and family history of stroke (52 versus 50, NS). Discussion: Vascular risk proles are very similar among TIA and late-onset epilepsy patients. This study also supports existing evidence that previous cerebrovascular disease is a risk factor for late-onset epilepsy.
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Etiology of stroke
PATTERN OF INTRACRANIAL VERSUS EXTRACRANIAL ATHEROSCLEROTIC CEREBROVASCULAR DISEASE IN INDIAN PATIENTS WITH STROKE- AN ANGIOGRAPHY STUDY
DETECTION OF RIGHT-TO-LEFT SHUNTS IN PATIENTS WITH HEPATOPULMONARY SYNDROME IS POSSIBLE USING TRANSCRANIAL DOPPLER
S. Husain, S. Sukumaran, A. Vajpayee, S.U. Khan, K.M. Rahman, S. Chaturvedi Gopal, S. Sharma Sir Ganga Ram Hospital, New Delhi, New Delhi, India
Objective: To evaluate the intracranial atherosclerosis among patients of atherosclerotic stenos-occlusive extracranial carotid artery disease undergoing cerebral DSA for the evaluation of the cerebral haemodynamic. Material & methods: Between May 1999 to March 2005, 224 cerebral DSA were performed in symptomatic patients referred to us with evidence of extracranial large vessel disease, either on Doppler, CTA or MRA. The percentage diameter stenosis for extracranial vessel was calculated by NASCET method and for intracranial vessels as per WASID method. They were categorized as nonsignicant stenosis (0% to 49%), signicant stenosis (50% to 99%), and total occlusion. The intracranial vessels were involved when a lesion was distal to the ophthalmic artery. For the vertebral artery, the distinction was made at the point where the artery pierced the dura at the level of foramen magnum. The intracranial extent of the stenosis was included in this study up to the M2 and A2 segments in the anterior circulation and the P1-P2 segments of the posterior cerebral artery.
G.S. Silva, D.L. Gomes, M.G. Vasconcelos, J.A. Fiorot Jr, M.M. Alves, C.H. Fischer, A.R. Massaro UNIFESP - Universidade Federal de So Paulo, So Paulo, Brazil
Background: Patients with liver failure can present with a large spectrum of neurologic symptoms. Cerebrovascular disease has been described as one of the most frequent neuropathology ndings after liver transplantation. Right-to-left shunts (RLS) were described in patients with hepatopulmonary syndrome, related to intrapulmonary vascular dilatations. We assessed the hypothesis that intrapulmonary RLS in patients with hepatopulmonary syndrome can be detected by transcranial Doppler (TCD). Methods: Patients with liver failure and hepatopulmonary syndrome, selected from the gastroenterology outpatient clinic of our hospital, and with a conrmed intrapulmonary RLS on transesophagealechocardiography (TEE) were evaluated. A group of patients with intracardiac RLS on TEE was also studied. All patients were submitted to middle cerebral artery TCD monitoring by transtemporal approach after the injection of saline solution (9ml) and air agitated, in the right antecubital vein. Monitoring was performed during normal breathing and after Valsalva maneuver. The presence of microembolic signs (MES) was evaluated by three examiners, blinded to the patients diagnosis.
Poster Session Etiology of stroke
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Results: Eight patients with hepatopulmonary syndrome (mean age 53,2 12,3 years, 6 men) and 20 patients with intracardiac shunts (mean age 47 16,8 years, 8 men) were evaluated. MES were detected by TCD with a sensitivity of 87,5% in patients with intrapulmonary shunts and 90% in those with intracardiac shunts. Time delay to rst MES detection was higher in patients with intrapulmonary shunts (15s X 10 s in patients with intracardiac shunts) (p=0,04). Discussion: TCD can detect intrapulmonary shunts in patients with hepatopulmonary syndrome, with a sensitivity slightly lower than for the detection of intracardiac shunts. Time delay for intrapulmonary shunts detection is higher when compared to intracardiac shunts. Paradoxical emboli should be investigated as a potential cause of neurologic symptoms in patients with liver failure and TCD can be a useful screening method for this evaluation.
renal FMD;III (n:12), isolated cervical FMD;IV (n:33) without FMD. Renal FMD, bilateral in half of the cases,was signicantly associated with an age over 40 years.Two out of patients with renal FMD had arterial hypertension. Conclusion: The prevalence of combined cervical and renal artery FMD is 9% in patients with CAD.More FMD cases(7%)are detected by cervical and renal DSA than by cervical DSA alone.The diagnosis of renal FMD could help in identifying patients at risk of renal artery dissection and renovascular hypertension.The presence of an arterial hypertension is not predictive for renal FMD.
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Etiology of stroke
CAUSES HETEROGENEITY OF LACUNAR STROKE
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Etiology of stroke
O. Vinogradov, A. Kuznetsov National Pirogov Centre of Therapy and Surgery, Moscow, Russian Federation
Background: Cerebral microangiopathy owing to hypertension or diabetes mellitus is considered to be main cause of lacunar stroke (LS). But other causes of LS are known too. The purpose of this study was to determine etiologies of LS other than small-artery disease. Material and methods: We have examined 105 patients with acute LS. We used: diffusion-weighted MRI (Giroscan INTERA NOVA, Holland), transthoracic or transesophageal echocardiography, carotid duplex sonography (VIVID 7, USA), transcranial Doppler sonography with microemboli detection (Sonomed-300, Russia); scale evaluation was performed according to NIHSS. Results: Patients with LS according to diffusion MRI were divided in 3 groups: group I single small (less than 15 mm) lacunar focus 59 patients (56,5%); group II large focus (more than 15 mm) or multiple small foci at the same vascular territory 24 patients (22,9%), group III multiple foci in different vascular territory 22 patients (20,9%). LS caused by small-artery disease was revealed in 69 patients (65,7%). Stroke mechanism different from small-artery disease was revealed in 36 patients (34,3%). Signicant differences in potential sources of cerebral embolism were revealed in group I in comparison with group II (p<0,05) and group III (p<0,001). Multiple lacunas or combination of lacunas and cortical strokes is reliable cerebral embolism marker. Neurological deciency was more severe in LS patients with embolism (p<0,01). Conclusions: Causes of LS are heterogeneous. Choice of secondary prevention regime demands of determination true cause of LS.
RELATIONSHIP OF CAROTID ATHEROSCLEROSIS WITH LEUKOARAIOSIS IN ISCHEMIC STROKE PATIENTS
E. Ben-Assayag, M. Mijajlovic, S. Shenhar-Tsarfaty, I. Bova, L. Shopin, S. Berliner, I. Shapira, N.M. Bornstein Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
Background: Previous studies have shown that white matter lesions are associated with increasing age, hypertension, diabetes and history of stroke. Although several lines of evidence suggest a role of atherosclerotic processes in atherothrombotic vascular events, their involvement in leukoaraiosis (LA) remains to be determine. Our study examines the association between atherosclerosis, reected as intimamedia thickness (IMT) and carotid plaques and LA in a group of ischemic stroke patients. Methods: One hundred sixty four consecutive ischemic stroke patients were included (mean age 66.7 3.4 years, 61% males). All patients underwent brain computed tomography (CT) and carotid dupplex with measurements of IMT in the common carotid artery. The extent and number of white matter lesions (WML) were recorded by 2 independent readers. Results: Seventy two patients (44%) were found to have 1 or more WML on CT images located in frontal, parietal or occipital region. Of whom, 30% were recorded to have advanced LA. Mean IMT was signicantly higher in stroke patients with LA (p=0.004) compared to those without it. Also, carotid plaque occurrence was associated with LA (2 =6.154, p=0.013) and advanced LA (2 =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; 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). Discussion: Stroke patients with LA present strong relationship with increased carotid IMT and plaque occurrence. Association was independent of gender, body mass index and all vascular risk factors. This suggests that advanced atherosclerotic process in LA.
Stroke and lipids 1 Stroke and lipids
DEPLETION OF THE LIPID RAFT COMPONENTS CHOLESTEROL AND SPHINGOMYELIN PREVENTS NMDA-INDUCED NEURONAL DEATH
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Etiology of stroke
J. Ponce, N. Perez de la Ossa, O. Hurtado, M. Dolade, M. Millan, J. Arenillas, A. Davalos, T. Gasull Fundacio Institut dInvestigacio en Ciencies de la Salut Germans Trias i Pujol, Badalona, Spain
Background and purpose: Excess brain extracellular glutamate in cerebral ischemia leads to neuronal death through overactivation of N-methyl-D-aspartate (NMDA) receptors. The cholesterol lowering-drugs statins have been reported to protect from NMDA-induced neuronal death but, so far, the mechanism underlying this protection is unknown. Since NMDA receptors have been reported to be associated with the cholesterol- and sphingomyelin-rich membrane domains known as lipid rafts, we have investigated the effect of treatments that deplete cholesterol or sphingomyelin levels on NMDA-induced neurotoxicity. In addition, we have investigated the effect of simvastatin on the percentage of NMDA receptors associated to lipid rafts. Methods: Primary neuronal cultures were pre-treated with simvastatin, the inhibitor of cholesterol synthesis AY9944, or the inhibitor of sphingomyelin synthesis fumonisin B1. Cell death was determined 24 h after the addition of NMDA. Lipid rafts from control and simvastatin-treated neurons were isolated, and Western blots were performed using an antibody specic for the subunit 1 of NMDA receptors (NMDAR1). Results: Sustained treatment with either simvastatin, AY9944, or fumonisin B1, protected neurons from NMDA-induced neuronal death by 70%, 56% and 30%, respectively. Simvastatin (250 nM) reduced by 40% the association of NMDAR1 to lipid rafts and did not change total expression of NMDAR1. Discussion: The inhibition of the synthesis of main components of lipid rafts protects from NMDA-induced neuronal damage. This protection might be mediated by a reduced association of NMDA receptors to lipid rafts. Taken together these
FIBRO MUSCULAR DYSPLASIA AND CERVICAL ARTERY DISSECTIONS: VALUE OF RENAL ARTERY ANGIOGRAPHY
J.M. de Bray, A. Pasco, F. Dubas, B. Vielle, J.F. Subra University Hospital, France
Fibro muscular dysplasia (FMD) is a potential cause of cervical artery dissection(CAD).Moderate forms of FMD are undiagnosed by magnetic resonance angiography.The use of renal intra-arterial digital subtraction angiography(DSA)in identifying FMD in CAD has not yet been validated. An ancillary study from a prospective study was performed to determine the prevalence of the association of cervical and renal artery FMD in CAD assessed by DSA and to dene the diagnostic impact of renal DSA in these patients. Methods: A prospective study on symptomatic recurrence of CAD was performed from 1994 to 2004 and is in press in Cerebro.Vasc.Dis.103 patients were consecutively included for a CAD diagnosed by cervical MRI or suggested by 2 concordant cervical imaging methods.FMD(17 patients)was dened as a string of beads image located in a non dissected vessel.The design of the ancillary study consisted in including patients with CAD investigated by both cervical and renal artery DSA.Population:54 patients fullled our subgroup criteria were 31 women and 23 men.The Chi square test and Fishers exact test were used for assessing the association between renal FMD and vascular risk factors. Results: According to the presence of FMD,4 sub-groups of patients were identied.I (n:4),showed renal FMD but no cervical FMD;II(n:5), had cervical and
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ndings suggest that lipid raft integrity is necessary for signalling to death through NMDA receptors.
Stroke and lipids
STATIN USE, LIPID PROFILE AND SYMPTOMATIC INTRACEREBRAL HAEMORRHAGE FOLLOWING IV THROMBOLYSIS
M.W. Koch, M. Uyttenboogaart, P.C. Vroomen, J. De Keyser, G.J. Luijckx University Medical Centre Groningen, Groningen, The Netherlands
Background: Intravenous thrombolysis with tissue plasminogen activator (tPA) improves outcome of acute ischaemic stroke, but increases the risk of symptomatic intracerebral haemorrhage (sICH). It has been suggested that lower cholesterol levels may be associated with higher incidence of primary ICH as well as with sICH following tPA treatment. Methods: From a prospective hospital based tPA registry comprising 309 patients, we selected all patients with known serum concentrations of total cholesterol (TC), HDL, LDL and triglycerides (TG), modied Rankin Scale (mRS) scores at three months and statin use (n=214). Lipid proles were compared between patients with and without sICH following tPA treatment and between patients with and without favourable outcome (mRS 0-2). Results: Patients with sICH (n=10) had signicantly higher TG (2.6 SD 1.9 vs 1.8 SD 1.0 mmol/l, p=0.049) and lower HDL levels (1.0 SD 0.3 vs 1.2 SD 0.4 mmol/l, p=0.049) Neither LDL (3.0 SD 0.8 vs 3.2 SD 1.0 mmol/l, p=0.59), TC (5.0 SD 1.0 vs 5.1 mmol/l SD 1.2, p=0.78) levels nor statin use (2 vs 30 patients, p=0.65) were signicantly different between patients with and without sICH. There were no signicant differences for any of these variables between patients with favourable and unfavourable outcome: TC (5.2 SD 1.3 vs 5.0 SD 1.1), HDL (1.2 SD 0.4 vs 1.2 SD 0.4), LDL (3.2 SD 1.1 vs 3.1 SD 0.9), TG (1.9 SD 1.2 vs 1.7 SD 1.0), statin use (15 vs 17 patients). Conclusion: Although patients with sICH had marginally higher TG and lower HDL levels, statin treatment or overall lipid prole seem unrelated to functional outcome at 3 months.
Methods: The cohort included all patients presenting to the Emergency Department with an acute ischemic stroke over a 22-month period (March 04 to December 05). The lipid prole (cholesterol, triglyceride, LDL and HDL levels) measured prior to or following admission was abstracted. Measurement of the panel ranged between 15 days prior to the stroke to 17 days after the event (Mean 0.79 days SD 2.53). Daily statin intake prior to the event and prescription on discharge was also recorded. The primary outcome variable, functional disability, was determined using the modied Rankin scale (mRs, 0-2=good outcome, 3-6=bad outcome), which was calculated for each patient at the time of discharge. A Pearsons chi-square test was performed analyzing the relationship between the functional outcomes at discharge and statin intake at the time of the event. Results: Of 508 patients, 207 (40% female) presented with an LDL of 100 mg/dL. This group was divided into those who were on a statin on admission (n=100) and those who were not (n=107). There was no signicant difference in the admission stroke severity measured by the NIHSS (p=0.18), age (p=0.31) and gender (p=0.06) between the 2 groups. The patients on a statin were signicantly more likely to have a good functional outcome, (OR 0.5; 95% CI 0.29-0.95; p=0.033). Following adjustment for age and NIHSS, statin intake still predicted a better functional outcome (p<0.0001). Conclusion: Daily statin intake appears to be associated with a better functional outcome following an acute ischemic stroke despite ideal LDL levels (100) and similar stroke severity on admission. Other mechanisms of action of statins like plaque stabilization, improved endothelial cell function, anti-inammatory, antiplatelet, anti-oxidant and antithrombotic effects may play a role in a better functional outcome.
Stroke and lipids
SERUM CHOLESTEROL LEVELS AND SHORT TIME OUTCOME IN STROKE PATIENTS
P. Milia, M. Paciaroni, V. Caso, S. Biagini, M. Venti, A. Billeci, F. Palmerini, A. Alberti, A. Baldi, G. Agnelli University of Perugia, Perugia, Italy
Background: Although cholesterol and stroke disorders has been extensively studied, the relationship between serum cholesterol levels and short time outcome after stroke has not been widely investigated. Objective: To identify if serum cholesterol levels measured at admission after stroke have any prognostic value on outcome at discharge. Methods: Patients consecutively admitted to our stroke unit suffering of any type of stroke were analysed. Fasting serum cholesterol was measured at 24 hours after admission. Outcome was evaluated using mRS: we identied adverse outcome as mRS 3 at discharge. Data were analysed by univariate and logistic regression analysis. Results: We collected 935 patients suffering of stroke (mean age 74.6511; 789 ischemic, 146 hemorrhagic; mean NIHSS 8.676.5). Mean values of cholesterol at admission was 195.251 in the overall group with no differences between all types of stroke (I 195.6550; H 192.4338). Functional outcome at discharge (mRS&3) was not inuenced by levels of cholesterol in all the population after logistic regression analysis (OR 0.99 CI 0.99-1.0, p 0.4) and also in either ischemic (OR 0.99 CI 0.99-1.0 p 0.7) and hemorrhagic strokes (OR 0.99 CI 0.98-1.0, p 0.2). Conclusions: Serum levels of cholesterol are not associated with outcome in the early phase after ischemic and/or hemorrhagic stroke, suggesting that it doesnt need to be treated in the acute phase as negative prognostic risk factor. Still remains uncertainty about its role at early and medium time on stroke patients.
Stroke and lipids
HIGH TRIGLYCERIDE LEVELS IN SINGAPOREAN ACUTE ISCHEMIC STROKE PATIENTS REDUCES THE RISK OF POOR OUTCOME AT 1 YEAR AFTER STROKE
J.L. Pascual, H.M. Chang, M.C. Wong, C.P. Chen National Neuroscience Institute, Singapore General Hospital Campus, Singapore, Singapore
Background: Cholesterol reduction lowers risk for recurrent vascular events in stroke patients. However, low total cholesterol (TC) and low triglyceride (TG) levels have been linked to increased risk for hemorrhagic stroke, and poorer outcomes after stroke, respectively. We investigated the effect of lipid-lowering therapy on the outcomes of Singaporean acute ischemic stroke patients. Method: Consecutive acute ischemic stroke patients had fasting TC, high-density lipoprotein(HDL), low-density lipoprotein (LDL) and TG determinations. Elevated lipids were dened as follows: TC 5.2 mmol/L, LDL 2.6 mmol/L, and TG 1.7 mmol/L. Prior lipid-lowering therapy was documented. At 1 year follow-up, functional outcome was assessed using the modied Rankin score (MRS). Results: 805 patients gave informed consent for fasting lipid proles and 1 year follow-up. The mean TC was 5.66 mmol/L, mean LDL was 1.31 mmol/L, and mean TG was 1.73 mmol/L. Patients with prior stroke, ischemic heart disease or lipid therapy had lower TC and LDL levels (p < 0.05). At 1 year after stroke, 28% of patients had mRS 3 or worse. Elevated TG independently predicted for good functional outcome (HR = 0.41, 95% CI: 0.23 0.75). Discussions: In agreement with previous studies, high TG is associated with better outcomes after stroke. Whether elevated TG is itself protective or is associated with a higher probability of receiving lipid-lowering drugs remains to be elucidated.
Acute stroke: clinical patterns and practise 1 Acute stroke: clinical patterns and practise
EVALUATING THE USE OF HAND MITTENS IN POST STROKE PATIENTS WHO DO NOT TOLERATE NASO-GASTRIC FEEDING
Stroke and lipids
Y.-Y.K. Kee, W. Brooks, R. Dhami, A. Bhalla Epsom and St. Helier University Hospitals NHS Trust, United Kingdom
Background: Early naso-gastric (NG) and consistent feeding in acute stroke patients has been shown to improve patient morbidity and mortality. However, after an acute stroke, patients can be agitated and may frequently pull out NG tubes. Recurrent NG tubes placements are associated with complications such as trauma and chest infections. The use of restraints such as hand mittens may improve nutrition and reduce complications of NG placements. This practice although uncommon in the UK, is used commonly in other countries. Few studies have been
ROLE OF STATINS IN FUNCTIONAL OUTCOME FOLLOWING AN ACUTE ISCHEMIC STROKE
L. Vaidyanathan, G. Kumar, D. Nash, W.W. Decker, L.G. Stead Mayo Clinic, Rochester, USA
Hypothesis: Similar to the benecial effect in acute coronary syndrome, daily statin improves functional outcome following acute ischemic stroke by mechanisms other than lowering LDL levels.
Poster Session Acute stroke: clinical patterns and practise
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done to evaluate the use of such restraints in acute stroke patients. This study aims to evaluate the use of hand mittens in such patients. Methods: We carried out a retrospective case control study with 18 patients over a period of one year period (8 with, 10 without mittens). The following data was collected: number of NG tubes inserted during the patients admission, number of aspiration pneumonias treated with antibiotics, number of chest x-rays the patient received, amount of feed received, weight loss/gain during admission, length of stay. Results were analysed using GraphPad Prism 4 software Results: The median age in both groups was 81.5 years. 89% of patients had total anterior circulation stroke. Patients in the mitten group needed fewer ng tubes; 7 vs 10 p<0.05. There were less episodes of aspiration pneumonia, p<0.05. Patients with mittens experienced less weight loss; 0.7kg vs 5.2kg, p<0.05. There were fewer deaths in the mitten group, 2 vs 7, p<0.05. There was a small reduction in the length of stay 40 vs 48.5 days, p=0.15. Discussion: The use of physical restraint is not universally accepted in the UK. The decision to use mittens in our patients was taken after discussions with the patient or next of kin. The use of mittens resulted in better nutrition in our patients, as well as a reduction in mortality and should be considered in patients who do not tolerate their NG tubes.
level of the midbrain. Only 1 arterial territory was involved in 7/14 cases and which corresponded to the antero-medial territory in 6/7 cases. Antero-medial infarcts were always present in patients with diplopia and controlateral cerebellar ataxia. Among patients with III nerve palsy, infarct affected the nuclear (2/3) or fascicular bers (1/3). Motor decit was associated with anterolateral infarct (5/6 patients). Discussion: The link between diploplia and controlateral cerebellar ataxia seemed to relate specically to a midbrain infarct located in the antero-medial territory and with no predictive value for an antero-posterier extension of the infarct. A brachiofacial motor decit clearly implied the involvement of the anterolateral territory, as expected by the somatotopy of the corticospinal tract. The use of a practical tool to determine location of pure midbrain infarct enables the establishment of a good correlation.
Acute stroke: clinical patterns and practise
PURE DYSARTHRIA AND DYSARTHRIA-FACIAL PARESIS SYNDROME
K. Yonemura, Y. Hashimoto, M. Uchino Kumamoto City Hospital, Kumamoto, Japan

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

Background: The origin of acute vertigo often remains undetermined after neurological, otological, and CT examination in the emergency room. We investigated the diagnostic yield of magnetic resonance imaging (MRI) in these patients. Methods: Patients were included in the study if they had presented with sudden onset of vertigo to our Department between 01/2002 and 06/2005, and complete neurological, otological and cranial CT investigation allowed no denite allocation to peripheral or central origin of the vertigo. Results of cranial MRI including diffusion-weighted imaging (DWI), clincal, and epidemiological information were taken to compare the patients with (group 1) and those without (group 2) acute lesions on MRI using univariate statistics. Results: In the 108 patients with acute vertigo (mean age 61 years, 62% women), acute ischemic lesions were detected in 12% on DWI. Affected regions were medulla oblongata, cerebellum, pons, thalamus, corpus callosum, temporo-occipital lobe, parietal lobe, both periventricular areas, and frontal lobe. Higher prevalence of vertigo-unrelated ischemic CT changes (p=0.01) and non-signicant trends towards elevated serum cholesterol (p=0.06), older age (0.07) and higher blood glucose levels (0.09) were observed in group 1 compared with group 2. All other clinical and epidemiolgical variables were similar in both groups. Conclusion: In patients with acute vertigo and inconclusive clinical and CT examinations, the diagnostic yield of cranial MRI is low. Patients with old ischemic lesions on CT are more likely to have a central vertigo origin. Clinical and epidemiological characteristics are not associated with higher detection rates of acute brain lesions.
PURE MIDBRAIN INFARCTION: CLINICAL RADIO ANATOMY CORRELATIONS
R. Allibert, F. Vuillier, L. Tatu, T. Moulin University Hospital Besanon, Besanon, France

Background: Clinical anatomical correlation in pure midbrain infarct has not been widely established in a standardised manner. The aim of the study was to analyse patients with pure midbrain infarcts using standardised protocols (clinical and imaging analyses). Method: Using a previously published arterial territories mapping, a correlation between the clinical patterns, arterial territories and anatomical structures involved was established. Patients with pure midbrain infarct were selected from all patients admitted with rst-ever stroke in our stroke unit. Clinical and imaging data were standardised according to Besanon stroke registry criteria. All MRI images were retrospectively reviewed by 2 neurologists to conrm infarct location, vascular arterial territories and brain stem structure. Results: 14 pure midbrain infarcts were included. Clinical manifestations included gait ataxia in 2/14 patients, dysarthria in 4/14, limb ataxia in 10/14, sensory symptoms in 1/14, third nerve palsy in 9/14, denitive limb weakness in 6/14 and internuclear ophthalmoplegia. In most cases (9/14), the infarct was located in the high
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COURSE OF CEREBROVASCULAR INCIDENTS IN PATIENTS WITH PERMANENT AND PAROXYSMAL ATRIAL FIBRILLATION
ISCHEMIC STROKE REVEALING SMALL INTRACRANIAL ANEURYSM. NATURAL HISTORY, MANAGEMENT AND RECOMMENDATION
J. Staszewski, J. Kotowicz, A. Stepien Military Medical Institute, Warsaw, Poland

Permanent atrial brillation (pAF) is an important risk factor for cerebrovascular incidents (CVI). The frequency and prognosis of CVI in patients with paroxysmal AF (plAF) is not well known. The aim of this single center study was to assess the course and risk factors of unfavorable outcome of CVI in ptAF and plAF. Patients with established AF and acute, ischemic CVI were included to prospective study with 6-months follow-up. The patients were classied on admission, discharge and after 6-month as non-dependent (mRS 2) or dependent (mRS 3 5). The course of CVI was categorized as favorable (non-dependence) or unfavorable (dependence or death). The risk of embolic complication in AF was assessed in CHADS2 scale. Of 178 included patients 70 (39%) had plAF and 108 (61%) had ptAF. Groups were similar in vascular risk prole. Cardioembolic strokes were more common in ptAF than in plAF group (56% vs 44%, p=0.03). The proportions of dependent patients at admission, discharge and at 6-month visit in ptAF were higher than in plAF (50% vs 19%, 81% vs 45%, 71% vs 40%; p<0.001). In-hospital and 6-month mortality rates were higher in ptAF than in ptAF group (13% vs 3% and 32% vs 13%, p<0.001). Unfavorable risk factors for short- and long-term outcome were: ptAF (OR 2.05, p=0.01), lack of chronic anticoagulation treatment (OR 3.48, p=0.02), chronic heart failure (OR 2.54, p=0.05), diminished left ventricular ejection fraction (LVEF) (OR 2.15, p=0.01), non-lacunar cerebral infarction (OR 1.74, p=0.001) and increased (moderate to very high) risk of embolic complications (OR 1.92, p=0.004). Results suggest signicantly different course of CVI in patients with ptAF and plAF. Those with plAF had more favorable short- and long-term prognosis of CVI. Risk factors for unfavorable stroke outcome were: ptAF, chronic heart failure, lack of chronic anticoagulation, diminished LVEF, non-lacunar cerebral infarction and presence of increased risk of embolic complications.
H. Desal, B. Daumas-Duport, F. Herisson, E. Auffray-Calvier, B. Guillon Hopital Laennec, Centre Hospitalier Universitaire de Nantes, Nantes, France
Background: Ischemic stroke may be the rst manifestation of small intracranial aneurysm, secondary to clot embolization from the aneurysmal sac. Pathophysiology, clinical characteristics and outcome are not clearly identied leading to undetermined management. Methods: Patients admitted over a 6-year period in our stroke unit with ischemic stroke distal to small (< 25 mm) sacciform intracranial aneurysm, in the absence of other causes for the infarctions, were selected. Patients demographics, characteristics of aneurysms, outcome and management were analysed. Results: Eight patients fullled our selection criteria (5 women; mean age 50, range 38-58). Ischemic stroke and intracranial aneurysm involved the anterior circulation in 3 patients and the vertebrobasilar system in 5. The mean size of the aneurysms was 11 mm (range 3-18). Digital angiography showed partial or complete aneurysm thrombosis in 4 patients with occlusion of the parent artery in 2. An unexpected subarachnoid haemorrhage was diagnosed in 3 patients. Two patients died during the 72-hours period following their admission because of severe subarachnoid haemorrhage. In the other cases, prognosis was excellent after early endovascular embolisation (3 patients) or spontaneous thrombosis (3 patients) of the aneurysm. However, in these last 3 patients, 2 had a late partial recanalisation of the aneurysm that justied endovascular treatment. Discussion: Our results suggest that ischemic strokes revealing intracranial aneurysm might be associated with an asymptomatic subarachnoid haemorrhage, that should be ruled out by CSF analysis (with spectrophotometry). Antithrombotics should also be used cautiously in these high risk patients for haemorrhage. Early endovascular or surgical treatment could prevent subsequent subarachnoid haemorrhage or stroke recurrence. Radiological follow up is required to detect further recanalisation, particularly in cases with early spontaneous aneurysm thrombosis.
9 7 Acute stroke: clinical patterns and practise

COMPARISON BETWEEN THE OCSP AND TOAST CLASSIFICATION SYSTEMS IN THE DIAGNOSIS OF CEREBRAL SMALL VESSEL DISEASE IN THE SOUTH LONDON BLACK AND WHITE POPULATIONS
CEREBRAL MICROEMBOUS DETECTION IN PATIENTS WITH ACUTE ISCHEMIC STROKE
J. Lee, S.J. Lee Yeungnam University College of Medicine, South Korea

Background: Microembolic signals(MES) detected by transcranial Doppler(TCD) have been considered as an independent predictor of recurrent ischemic stroke. However, the association between the presence of MES and the risk of stroke has predominantly been studied on small and selected patients. To evaluate the clinical signicance of MES in patients with acute ischemic stroke, we investigated the prevalence of MES and analyzed the relationship between MES and stroke subtype. Methods: We intended to perform TCD monitoring for 30 minutes to detect MES from the bilateral middle cerebral arteries in patients within 15 days of stroke onset. The strokes were subtyped using the TOAST classication criteria. Results: Of a total of 884 consecutive ischemic stroke patients admitted to our stroke unit within 7 days of stroke onset, TCD study performed 590 patients, and 65 were excluded because there was a long interval between onset of symptoms and examination, an articial heart valve, and inadequate temporal bone window. MES were detected in 23(4.2%) despite the fact that all patients were receiving an antiplatelet or an anticoagulant treatment. Among patients with positive MES detection, 7(31.8%) had recurrent MES during follow-up TCD monitoring within 3 days after the rst examination. MES were detected in 3.1% of patients with large-artery atherosclerosis stroke, 4.1% of cardioembolic stroke, 2.1% of lacunar stroke, 9.1% of cryptogenic stroke, and 4.1% of undetermined stroke(p=0.241). In 6 of the 8 patients(75%) with the anterior circulation infarct, MES were observed ipsilateral to the affected territories. Discussion: During antithrombotic treatment in patients with acute ischemic stroke, the prevalence of MES is low and MES detection dose not improve ischemic stroke subtype classication. The MES are frequent in the territories of symptomatic arteries in the anterior circulation stroke and recurrent MES are common during a short follow-up.
U. Khan, P. Jerrard-Dunne, L. Kalra, A. Rudd, C. Wolfe, H. Markus St. Georges University of London, London, United Kingdom
Background: Stroke classication systems based on clinical criteria, such as the Oxfordshire Community Stroke Classication (OSCP), have been widely used in epidemiological studies to diagnose lacunar stroke but may be inaccurate compared with systems based on investigation results. We compared OSCP with a pathophysiological classication (modied TOAST) in diagnosis of lacunar stroke in blacks and whites in the South London Ethnicity and Stroke Study. Methods: African and African-Caribbean strokes presenting to three South London hospitals were prospectively recruited (N=600). 600 consecutive Caucasian strokes presenting to the same three centres were also recruited. All cases underwent standardised clinical assessment, demographic and risk factor data collection and investigations (brain imaging (CT 65.4%, MRI 8.3%, both CT and MRI 26.3%), imaging of the extracranial cerebral vessels (97%), echocardiography (56.7%)). All cases were subtyped using modied TOAST criteria (excluding the use of hypertension as a criterion for diagnosis) by one observer with review of original imaging. Cases were also subtyped using the OCSP classication. Results: Using TOAST, lacunar stroke was more prevalent in blacks (OR 2.94(1.974.39)p<0.001) compared to whites. Similarly, OCSP-dened lacunar infarction was increased in blacks but the association was weaker (OR 1.94(1.39-2.73)p<0.001). Taking TOAST classication as the gold standard the sensitivity of OCSP for detection of lacunar stroke was 84% (76% specicity). Positive predictive value (PPV) for lacunar stroke detection was 56.5% (negative predictive value (NPV): 92.8%). Accuracy of OSCP for lacunar stroke diagnosis was worse in black patients: PPV 66.7% (NPV: 88.6%) compared to a PPV of 41.4% (NPV: 96.0%) in whites. Conclusions: Lacunar stroke is increased in blacks compared to whites but use of OCSP underestimates the difference. OCSP is less accurate at lacunar stroke diagnosis in blacks, and this may introduce bias in studies comparing subtype differences between ethnic groups if OSCP is used.
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FIRST-DAY BODY TEMPERATURE DYNAMICS A CLINICIANS TOOL FOR MONITORING PENUMBRAL TISSUE TRANSFORMATION AND UPDATING PROGNOSIS AFTER ISCHEMIC STROKE?
ALBUMIN TO CREATININE RATIO (ACR) IS ASSOCIATED WITH THE SEVERITY OF ACUTE STROKE AND PREDICTS THE OUTCOME OF ACUTE STROKE AND TRANSIENT ISCHEMIC ATTACK (TIA)
J. Mau, S.D. Jayavel Heinrich Heine University Hospital, Duesseldorf, Germany

Background: Early normal but later rising body temperature (BT) was recently shown to robustly and independently reduce the likelihood of complete dependency or death after hemispheric ischemic stroke. To substantiate this unexpected nding, rst-day BT dynamics were to be studied in data from the rst European Cooperative Acute Stroke Study (ECASS) and explained within a model of progressive stroke. Methods: The ECASS had randomized and treated 615 patients to either 1.1mg/kg rt-PA or placebo IV within 6 hours from symptom onset; 461 patients had complete 0-2-24h proles of 3 BT measurements. BT proles were grouped into 37(10%) "ever constant", 34(7.4%)"early only rising", 123(26.7%) "late only rising", 107(23.2%) "ever rising", 49(10.6%) "decreasing", 35(7.6%) "convex", and 76(16.5%) "concave", their association with baseline covariates tested with stratied chi-squares and dichotomized 90-day modied Rankin scores (mRS) logistically regressed on known predictors and trial medication. Results: Prole groups were equally distributed between rt-PA and placebo and all baseline covariates but for initial BT (P<0.0001), initial stroke severity (P=0.0298), hypo-density extent in infarct territory (P=0.0164), and presence of infarct signs (P=0.0033) on baseline computed tomography. Specic interactions were significant for the latter (P=0.041) and in BT > 37C (P<0.0001) and BT<36C (P=0.0025). "Ever rising" proles increased 90-day fatality and "ever constant" proles reduced risk of long-term dependency (mRS 4-5) among survivors after 24h, independently. Hence, associations of BT proles were found for only the lesion parameters and for specic long-term outcomes. Discussion: A dynamic model of progressive stimulation of metabolic and apoptotic regulation after focal ischemia explains that BT dynamics appear closely correlated with evolving transformations in the ischemic penumbra. Conclusion: Beyond clinically updating baseline prognosis after 24 hours, monitoring BT might also be used for timing neuro-protective interventions.
K. Koniari, E. Gialouri, K. Makris, I. Drakopoulos, O. Glezakou General Hospital KAT, Athens, Greece
Background: Although microalbuminuria is associated with clinical risk factors for stroke, there is surprising little information regarding it as an independent risk factor for stroke or as a predictor of stroke outcome. Methods: In our study we investigated the prevalence of microalbuminuria in acute stroke patients and its association with the patients clinical status at admission and outcome. We studied 60 patients (mean age 75 years) who were admitted in our hospitals ER within 6 hours of their rst neurological symptom. A urine sample was collected at the time of admission, along with morning collections at 24, 48, 72 hours and at the 7th day of hospitalization. ACR was measured on a POCT instrument (Bayer DCA-2000). CT-scan was performed on all patients. Neurological decit and clinical status was assessed by the Glasgow Coma Scale (GCS) on admission and on days 1, 2, 3 and by Glasgow Outcome Score (GOS) on discharge from the hospital. Results: The mean value of ACR, on the admission sample, in patients with severe clinical status (GCS<8) was 354 mg/g, signicantly higher than in patients with better clinical status (GCS 9-13 and GCS 14-15) 114 and 122 mg/g respectively (p<0,01). The mean value of ACR on the last day of hospitalisation was highly correlated with the outcome (reected by GOS). It was 348 mg/g in patients with GOS=1, 209 mg/g in patients with GOS 2 -4 and 53 mg/g in patients with GOS=5 (p<0,01). In addition concerning the question if ACR levels can predict the outcome, only in non-diabetic patients with poor outcome (GOS=1), the mean value of ACR of the 24 hours measurement was signicantly higher than in those with better outcome (GOS 2-4 and GOS=5) 262, 199 and 58 mg/g respectively (p<0,01). Discussion: Our preliminary results from this ongoing study suggest that this marker, when determined on admission and within 24 hours might be useful in determining the severity of the stroke independently of the type of stroke, and that these early measurements can be of value in predicting outcome in non-diabetic patients.
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DOES ACUTE STROKE UNIT CARE CHANGE DURING A REHABILITATION CLINCIAL TRIAL (AVERT PHASE II)?
J. Collier, J. Bernhardt National Stroke Research Institute, University of Melbourne, Heidelberg West, VIC, Australia
Objectives: During A Very Early Rehabiliation Trial (AVERT) Phase II, we randomised recruited stroke unit patients from two hospitals to receive either a very early mobilisation (VEM) protocol or standard (usual) care. Both patient groups were treated on the same ward. Given the potential for contamination effects using this design, we aimed to investigate whether levels of physical activity for non-recruited patients changed as a response to the trial embedded within each stroke unit. Methods: Prior to the trial, behavioural mapping procedures were used to evaluate the proportion of the day patients were in bed, sat out of bed, and were standing or walking. Behavioural mapping requires structed observation and recording of patient activity over a single day. During AVERT, mapping procedures were repeated to determine activity levels of patients receiving standard care. All patients <14 days post stroke were eligible, with the exception of those requiring palliative care. We excluded clinical trial participants. Ten-minute observations were conducted between 0800 to 1700 with patient activity documented, who was present and where patients were located. Stepwise binomial logistic regression was used to assess difference in activity between time periods (2001/2; 2004/5), controlling for differences in patient characteristics. Results: 51 patients (mean age 74.0 years, 51% male) were recruited at Austin Health and St. Vincents Hospital, Melbourne. Patients spent 65% of the day resting in bed and 9% of the day in standing/walking activities. This was similar to the activity patterns of patients in the pre-trial sample (60% of day in bed, 13% standing/walking). No statistical differences between time periods was found (bed: CI 95%-1.02.0, P=0.926; stand/walk: CI 95% -6.22.1, P=0.315). 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 nding supports the feasibility of conducting an individually randomised rehabilitation clinical trial.
RATE OF INTRACEREBRAL HAEMORRHAGE IN PATIENTS WITH MINOR STROKE: A CLINICAL RULE TO REDUCE CT MISDIAGNOSIS
C.E. Lovelock, J.N. Redgrave, D. Briley, P.M. Rothwell University of Oxford, Oxford, United Kingdom
Background: Most studies of acute stroke management focus on the initial hours following symptom-onset. However many patients with non-disabling strokes present late. In a recent clinic-based Scottish study of patients presenting late (>4 days after the event) with minor stroke, around 4% had intracerebral haemorrhage (ICH) on MRI, 75% of which appeared as infarcts on CT brain imaging. MRI was recommended when patients could not be CT scanned within one week of a minor stroke. We aimed to determine the frequency of ICH in two cohorts of patients with minor stroke, and to identify clinical predictors for ICH, which might be used to prioritise patients for MRI where resources were limited. Method: We studied 343 consecutive patients with minor stroke (NIHSS3) in patients ascertained in the Oxford Vascular (OXVASC) Study (scanned using CT after a median delay of 4 days) and 245 consecutive patients presenting to a hospital-based stroke clinic, all of whom had MRI. Results: The rates of ICH were 4.1% (95%CI: 2.5-6.8%) on CT in OXVASC and 4.5% (95% CI 2.5-7.9%) on MRI in the clinic cohort. In a pooled analysis (25 ICH in 588 patients), severe hypertension (BP 180/110 mmHg) on assessment (OR 5.4, 95%CI 2.3-12.3, p<0.001), vomiting (OR 9.9, 3.7-26, p=0.001), confusion at onset (OR 8.2, 3.1-21.4, p=0.001), and premorbid anticoagulation (OR 6.1, 2.1-17.7, p=0.01) were predictive of ICH. The 178 (30%) patients who had at least one of these risk factors included 92% of patients with ICH. Conclusion: The rate of ICH in minor strokes in our cohorts is consistent with that in the only previous study. Several clinical variables were predictive of ICH, and if independently validated could form the basis of a simple rule to select patients who require MRI.
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MRI PERFUSION-DIFFUSION MISMATCH IN PATIENTS WITH ACUTE ISCHEMIC STROKE
TRANSIENT ISCHEMIC ATTACK IN ADULT ONSET MOYAMOYA DISEASE
S. Di Legge, M. Diomedi, F. Sallustio, S. Napolitano, G. Koch, B. Rizzato, R. Floris, P. Stanzione University of Tor Vergata, Rome, Italy
Background: The MRI perfusion-diffusion mismatch is viewed as a marker of still-salvageable tissue amenable to reperfusion therapies. Whether its presence is an independent predictor of clinical outcome in non-thrombolytic series has not been extensively investigated. Objectives: To evaluate the occurrence, evolution, and clinical correlates of MRI perfusion-diffusion abnormalities in patients with acute ischemic strokes not treated with thrombolytics. Methods: Patients with acute ischemic stroke (AIS) admitted to our emergency room (ER) within 12 hours of symptom onset were screened for MRI eligibility. The MRI protocol included DW, PW MRI and intracranial MR angiogram (MRA). All patients were admitted to a stroke unit and managed according to the current guidelines. Stroke severity was assessed by the NIH Stroke Scale (NIHSS) score at scheduled times. Patients with and without PW-DW mismatch were compared for demographic, clinical and imaging variables. Results: Over a 12-month period 189 patients with symptoms suggestive of AIS were seen by the stroke team. Of them, 116 (61%) had an MRI study within 12 hours. Thirty (26%) patients did not complete the MRI study for lack of compliance or clinical instability. A perfusion-diffusion mismatch (M+) was detected in 29/86 (34%) patients. The presence of PW-DW mismatch was associated with higher baseline NIHSS scores (p=0.02), intracranial stenosis (p=.001), lesion enlargement on follow-up MRI (p=.001) and higher three-month mRS (0.04). At logistic regression analysis the only independent predictor of poor outcome (mRS 3-6) at 3 months was onset NIHSS (OR 1.7, 95% CI 1.1-2.8; p=0.02). Conclusions: Up to one third of our AIS patients who completed the MRI protocol within 12 hours of stroke onset had a PW-DW mismatch. Its detection was associated with more severe strokes, intracranial artery occlusion, lesion growing, and worse outcome. This information may help in establishing the efcacy of thrombolitic therapy beyond the 3-hour window based on MRI parameters.
J.-M. Kim, S.-H. Lee Seoul National University Hospital, Seoul, South Korea
Background and objective: There have been few reports about initial manifestations in adult onset moyamoya disease. In this study, we described the initial manifestations of adult onset MMD including TIA symptom characteristics, and investigated the relationship between the initial manifestation and intracranial stenosis. Method: Between 1999 and 2006, total of 65 patients who are older than 14 years were admitted and diagnosed as moyamoya disease at Seoul National University Hospital. The patients were categorized into TIA, ischemic stroke, hemorrhagic stroke, and nonspecic group due to the initial symptoms. The outcome after surgical revascularization was evaluated in terms of two domains, which are the number of TIAs and stroke recurrence after surgery. Result: Out of 65 subjects, the numbers of patients who had initial manifestation as TIA, ischemic stroke, hemorrhagic stroke and nonspecic symptom were 29 (44.6%), 11 (16.9%), 15 (23.1%), and 10 (15.4%), respectively. TIA manifestations were variable among subjects. Twenty subjects out of 29 experienced motor dominant symptoms, whereas only two had sensory dominant symptoms. Isolated cognitive dysfunctions such as language dysfunction occurred in four subjects. The means of Suzuki grade in TIA group and ischemic stroke group were 2.90 0.9 and 3.64 0.8 (p=0.022), showing signicantly severe stenosis in ischemic stroke group compared to TIA group. There was no statistically signicant difference in the surgical outcome in terms of TIA numbers and stroke recurrence between the TIA and stroke groups. Discussion: This study demonstrated that TIA is frequent as initial symptom among adult onset MMD, and TIA manifestations are variable among subjects. Patients whose initial manifestation is TIA have lower intracranial arterial stenosis than stroke group, implying that TIA is earlier manifestation in the disease process than ischemic or hemorrhagic stroke.
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INSULAR INVOLVEMENT IN ACUTE MIDDLE CEREBRAL ARTERY TERRITORY INFARCTION
SYSTEMIC THROMBOLYSIS WITH RT-PA IN POSTERIOR CIRCULATION STROKE
B.G. Yoo, J.K. Kim, J.H. Ko, E.G. Kim Kosin University College of Medicine, Busan, South Korea
Background: The frequency and extent of insular involvement in middle cerebral artery (MCA) territory infarction and its relationship with stroke severity and clinical relevant disorders are not well established. The purpose of this study is to determine insular involvement in MCA territory infarction and its relationship with clinical and laboratory parameters. Methods: We analyzed a total of 73 consecutive patients with acute non-lacunar MCA territory stroke proved by an MRI scans. Results: Insular involvement were present in 52 patients (73%); 34 (65%) had major insular lesions and 18 (35%) had minor lesions. The major insular involvement was associated with elevated serum CK-MB (p=0.044) and brinogen (p=0.024), and size of MCA infarction (p=0.018) than minor insular lesion. The anterior insular alone was involved in 14 (27%) patients, and the posterior insular alone was involved in 4 (7.7%) patients. Among patients with insular involvement, twenty-three patients (44%) had lenticulostriate territory infarction. Insular involvement was associated with larger MCA territory infarctions, more severe clinical decits, and mortality. Isolated anterior insular infarcts were often accompanied by other infarcts in the superior territory, whereas posterior insular infarcts were often accompanied by inferior division infarction. Conclusions: The insular involvement is a common in patients with acute nonlacunar MCA territory infarction. Major insular involvement is associated with large MCA territory infarction, proximal MCA occlusion, elevated serum CK-MB, and greater neurologic severity than minor and no insular infarction.
B. Dimitrijeski, A. Villringer, H.C. Koennecke, A. Hartmann Charit Campus Benjamin Franklin, Berlin, Germany
Objectives: Ischemic stroke in the posterior circulation (PCS) accounts for 10-15% of all strokes, representing a major cause for disability and death in stroke patients. Treatment with rt-PA for acute ischemic stroke within a 3-hour time window has been proven to be effective and reduces signicantly disability. However, most data on systemic thrombolysis refer to stroke in the anterior circulation (ACS). We compared the clinical outcome at 3 months in patients with PCS and ACS treated with rt-PA. Methods: 242 patients were treated between 1998 and 2006 within a 3-hour time window according to the NINDS-trial protocol, 216 (89%) with ACS, 26 (11%) with PCS, 3 (1%) with basilar occlusion. Infarct localisation was n=11 brain stem, n=6 occipital lobe, n=2 thalamic, n=2 cerebellar and n=5 combined. Neurological status was measured at admission and at 3-month follow-up using the NIH-Stroke-Scale (NIHSS) and the modied Rankin Scale. Results: A total of 26 patients suffered from PCS (42% female, Mean NIHSS at admission 13, mean age 68y). Good functional outcome dened as Rankin 2 occurred in 16 patients (62%) with PCS compared to 107 patients (50%) with ACS (p=0.25). The mortality rate was n=4 (15%) in PCS and n=30 (13%) in ACS (p=0.51) and symptomatic intracranial hemorrhage occurred in n=1 (4%) in PCS and in n=7 (3%) in ACS (p=0.60). Conclusions: In our study population clinical outcome at 3-month follow up, mortality and intracranial hemorrhage rates are similar in patients with ACS and PCS after treatment with systemic thrombolysis. It seems to be a safe and effective treatment in patients with posterior circulation stroke.
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COMPARATIVE ELIGIBILITY FOR ACUTE HEMORRHAGIC AND ISCHEMIC STROKE TREATMENTS IN A DISTRICT GENERAL HOSPITAL
M.O. McCarron, M. Armstrong, P. McCarron Altnagelvin Hospital, Derry, United Kingdom

Background: Thrombolysis treatment fot acute ischemic stroke (AIS) benets patients. Recombinant activated factor VII (rFVII) is emerging as a similar time-dependent treatment for acute intracerebral hemorrhage (ICH). We sought to
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determine the relative proportions and absolute numbers of patients eligible for acute stroke treatments in an Irish district general hospital. Methods: In a prospective observational study delays in admissions, demographic details, and stroke severity were recorded in consecutive stroke patients admitted to a district general hospital over a 12 month period. The eligibility criteria for acute treatments were adapted from the NINDS study group for ischemic stroke and a phase two study of rFVII treatment, which excluded patients with any history of thrombotic or occluusive disease. Results: 171 patients (96 men, 75 women, mean age 69.912.7 years) were assessed. Multiple logistic regression showed that less severe strokes, living alone and attending a general practitioner all independently delayed hospital admission. Patients with ICH arrived in hospital faster than AIS patients, p=0.03. ICH patients had more severe strokes than AIS patients (median NIHSS 8 versus 4, p=0.006). Nineteen of 152 or 12.5% of AIS patients were in hospital within 2.5 hours of stroke onset with a NIHSS>4 and fullled the NINDS thrombolysis criteria. Seven of 19 or 37% of ICH patients were admitted within 3.5 hours and were eligible for rFVII treatment. Discussion: Although proportionately more ICH patients may potentially avail of acute treatment than AIS patients, almost three times as many AIS patients were eligible for acute treatment in this district general hospital. There may be less potential to decrease admission delays for ICH patients.
3 month period was 66.9 [72.0] days. The mean wait for fast-track assessment of patients (n=62) from initial TIA to review was 4.5 [6.9] days. This decreased the overall wait (n=168) in the 2nd 3 months to 29.6 [33.2] days, p<0.005. Conclusion: The urgent daily assessment of TIAs provides signicantly faster assessment, investigation and treatment compared with weekly one-stop clinics. This is essential to decrease the risk of recurrent stroke in patients with TIAs, in particular those with high grade carotid stenosis that may need subsequent Carotid Endarterectomy.
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ATRIAL FIBRILLATION IN ISCHEMIC STROKE PATIENTS: EVALUATION OF THE USAGE OF ORAL ANTITHROMBOTICS IN EUROPE
B.M. Hamad, P. Nasuti, E. Yeung IMS Health, London, United Kingdom

Background: It is clinically known that atrial brillation (AF) is associated with higher in-hospital mortality in ischemic stroke patients. The purpose of this study is to assess the use of oral antithrombotics among patients with AF and to illustrate the diffusion of recommended guidelines into clinical practice. Methods: We conducted a patient-diary study in 296 hospitals in France, Germany, Italy, Spain and UK. They treated total of 2,659 ischemic stroke patients, during the period of July 2005 and December 2005, with a mean of 9 patients per hospital. Hospitals were selected to be representative by geographic regions, size and stroke unit facilities in each country. Results: Among the 2,659 patients, 478 (18%) pts were found to have chronic AF of whom 123 (26%) also developed AF acute event during the stroke hospitalisation. Also, 70 (3%) patients had experienced an acute event of AF for the rst time. We report data from 548 ischemic stroke patients with AF, 75% were classied as cardioembolic, 20% non-cardioembolic and 5% of uncertain cause. On-therapy analysis showed that 54% of pts received aspirin, 46% oral anticoagulants (OAC), 13% clopidogrel, 3% dipyridamole and 1% Aggrenox. We also analysed mono and dual therapies; 31% pts had aspirin only, 26% OAC only, 16% aspirin+OAC, 6% clopidogrel only, 6% aspirin and clopidogrel only, and interestingly 10% didnt receive any oral antithrombotic therapy. In-hospital mortality accounted for 12% of the patients, 27% discharged home independently, 15% discharged home dependently and 43% transferred to rehab and long term care facilities. Conclusion: European guidelines recommend oral antithrmobotic therapy for ischemic stroke associated with AF for secondary prevention and this has been adopted widely in European hospitals treating ischemic stroke patients, however still 10% of patients are not receiving any form of oral antithrombotic therapy to prevent recurrent stroke, and only 45% are receiving OAC.
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A LINK BETWEEN LUNAR PHASE AND MEDICALLY UNEXPLAINED STROKE SYMPTOMS
F. Ahmad, T.J. Quinn, M. Walters, J. Dawson Gardiner Institute of Medical and Cardiovascular Sciences, Glasgow, United Kingdom
Background: Possible lunar effects on health have been postulated for centuries. Association between phase of the moon and vascular; neurological and psychiatric disease have been reported. There are no published studies on the effect of lunar phase on cerebrovascular disease. A consistent proportion of stroke unit admissions remain medically unexplained despite extensive investigation. This cohort of Medically Unexplained Stroke Symptoms (MUSS) patients have been previously described and show a high rate of psychiatric comorbidity. We hypothesised that admission to an acute stroke unit, with true stroke or MUSS, may be inuenced by lunar cycle. Methods: All admissions to our Acute Stroke Unit are recorded in a comprehensive database. Those admitted between 1st January 1993 and 30th September 2006 (MUS) were included in the study. The association between admission rate and phase of the moon was calculated using a X2 test across the groups. We observed admission rate for conrmed stroke and MUSS. Results: There were 7219 admissions during the study period, which comprised 167 complete lunar cycles. Stroke admissions were evenly spread throughout lunar phases (p=0.72). Admission with medically unexplained stroke-like symptoms was signicantly increased during full moon phases (p=0.023). Discussion: There was a statistically signicant association between full moon lunar phase and diagnosis of medically unexplained stroke-like symptoms. There was no association with other stroke diagnoses. This study adds to the growing literature regarding lunar effects on health.
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TRANSIENT ISCHEMIC ATTACK IN ADULT MOYAMOYA DISEASE
J.-M. Kim, S.-H. Lee, J.-K. Roh Seoul National University Hospital, Seoul, South Korea
Background: Transient ischemic attack (TIA) is a frequent initial manifestation in adult onset moyamoya disease (MMD). However, clinical characteristics of TIA in adult MMD have not been fully understood, as compared with the numerous reports on child MMD. In this study, we investigated the initial manifestations of adult MMD including TIA symptom characteristics, and the relationship between the initial manifestations and the extent of the disease progression. Method: We recruited 65 MMD patients of adult onset between 1999 and 2006, who visited and diagnosed at the Seoul National University Hospital. We obtained their basic demographic data, imaging les, and clinical information. The study groups were categorized into TIA, ischemic stroke (IS), hemorrhagic stroke (HS), and nonspecic (NS) according to the initial manifestations. Symptoms of TIA were described via detailed interview. The outcomes after surgical revascularization were evaluated in terms of stroke or TIA recurrence during the follow up. Result: Out of 65 subjects, there were 29 (45%) TIA, 11 (17%) IS, 15 (23%) HS, and 10 (15.4%) NS patients. TIA manifestations were variable among subjects. Twenty subjects out of 29 experienced motor dominant symptoms, whereas only two had sensory dominant symptoms. Isolated cognitive dysfunctions such as language dysfunction occurred in four subjects. Stages of MMD evaluated by Suzukis method were signicantly higher in IS group (3.64 0.8) than in TIA group (2.90 0.9; p=0.022). There was no signicant difference in the surgical outcome in terms of TIA and stroke recurrence among the groups. Conclusion: We showed that TIA is very frequent initial manifestation among adult MMD and that involvement of intracranial arteries are less extensive in TIA group. Our results suggest that TIA as initial manifestation mainly occurs in the earlier stage of the MMD.
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IMPLEMENTATION OF FAST-TRACK ASSESSMENT OF PATIENTS WITH TRANSIENT ISCHAEMIC ATTACKS IS MORE EFFECTIVE THAN WEEKLY ONE-STOP CLINICS
S. Goode, N. Altaf, J. Riley, J. Gladman, S. MacSweeney Queens Medical Centre, United Kingdom
Introduction: The risk of stroke is highest immediately after an initial transient ischaemic attack (TIA). Current guidelines highlight the need for the rapid assessment of patients with TIA. There is, however, a signicant delay in the assessment of patients with TIA in a weekly one-stop clinic. The aim of this study was to ascertain the impact of an urgent daily TIA clinic on waits for assessment and treatment. Methods: Retrospective analysis was performed on the delay between initial TIA, referral and clinic dates. This data was collected for a 3 month period during which the weekly one stop clinic was used to assess patients with suspected TIA. In addition, data was also collected during the 3 month period during which the pilot fast-track TIA assessment as well as the weekly one-stop clinic was functional. Results: 288 patients with suspected TIA were assessed over the study period. The mean age of the patients was 68 years (SD 10) and 51% were male. The mean interval between TIA (n= 120) and review in the weekly TIA clinic in the initial
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THE ULTRASOUND SIGNS OF ENDOTHELIAL DYSFUNCTION IN ACUTE ISCHEMIC STROKE
M.A. Domashenko, A.O. Chechetkin, Z.A. Suslina Institute of Neurology, RAMS, Moscow, Russian Federation
Background: The aim of the study was to evaluate the ultrasound signs of endothelial dysfunction in patients with acute ischemic stroke [IS]. Methods: The ultrasound evaluation of the endothelium-derived vasodilatation of the brachial artery [BA] was performed in 27 patients (age 67 [55; 79] years; 14 males, 13 females) with IS in the rst 48 hours of stroke onset. The maximal increase of BA diameter after cuff test [CT] with the transient occlusion of BA by the cuff of manometer was evaluated. 20 patients (age 64 [51; 72] years; 10 males, 10 females) with the chronic ischemic cerebrovascular diseases were investigated in the control group. Results: The neurological decit in IS patients was 79 [58,5; 90] on ESS and 4,5 [2,5; 9] on NIHSS. The initial linear speed of the blood ow [LSBF] on BA was 62 cm/s [54; 65] and 58 cm/s [50; 65] and the initial diameter of BA was 4,6 mm [4,0; 5,1] and 5,1 mm [4,6; 5,4] in patients with IS and control group accordingly. After the CT the LSBF on BA increased on 121% [103; 219] and 184% [126; 223] in patients with IS and control group (p=0,07). The increase of BA diameter after the CT was 5,4% [4,3; 9;5] and 8,5% [6,8; 11,5] in patients with IS and control group (p=0,035). The increase of BA diameter was directly correlated with ESS score (R 0,35; p=0,047) and indirectly correlated with NIHSS score (R -0,33; p=0,049). Conclusion: The BA dilatation after CT in patients with IS was decreased compared to patients with the chronic cerebrovascular diseases. The ultrasound signs of endothelial dysfunction in patients with IS and their correlation with the stroke severity were demonstrated.
stroke patients to a general hospital. HIPE identied patients with acute stroke presenting to our hospital from 01-01-05 to 30-06-05. Data was collected from the emergency services and hospitals records. Time intervals from initial contact with the emergency services to medical assessment in hospital were recorded. Data on time of symptom onset was available for patients who arrived via personal transport. Forty-six patients presented with an acute stroke (84.78% infarcts). Thirty-one patients arrived by ambulance [12 by 999 call= (1), 19 non-999 call= (2)],15 via personal transport (3). Mean interval from the time of the ambulance call to arrival at scene was 24 mins (1) vs 28 mins (2) [NS]. Mean interval from time of call to arrival in the emergency department was 66.3 mins (1) vs 74.4 mins (2) [NS]. Mean interval from time of emergency department arrival to medical assessment was 95 mins(1), 105 mins(2) and 43 mins(3) [(1)/(2) vs (3) p=0.01/p=0.002].The average time from symptom onset to arrival in the emergency department was 861.6 mins for patients arriving by personal transport. The rapid ambulance response contrasts with the delayed medical response to acute stroke at our institution. Better public and medical awareness of the urgency of acute stroke management is necessary. This study has provided useful baseline data on our current performance regarding the transport and medical assessment of acute stroke patients. We plan to put in place an integrated response for acute stroke in order to maximise patient outcomes.
Acute stroke: complications and early outcome 1 Acute stroke: complications and early outcome
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THE RELATIONSHIP BETWEEN THE LOCATIONS OF DEEP-VEIN THROMBOSIS AND MOTOR IMPAIRMENT IN ACUTE ISCHEMIC STROKE PATIENTS
S100B AS A BIOMARKER: ITS OPTIMAL ROLE IN STROKE
P. Dassan, G. Keir, R. Jager, M.M. Brown UCL, Institute of Neurology, London, United Kingdom
Background: Blood biomarkers may be important in three areas of acute stroke: diagnosis; as a surrogate marker for severity of brain damage; and predicting prognosis. The S100B protein has been studied in each area individually in selected patients but there are no studies directly comparing its utility in these areas. We correlated all three measures with serial measurements of S100B in an unselected series to determine its optimal role. Method: Blood samples and National Institute of Health Stroke Scale (NIHSS) scores were taken on arrival to hospital and daily, where possible, for up to 6 days after onset of symptoms in 40 consecutive patients with suspected ischaemic stroke (26 acute infarcts and 14 stroke mimics). Serum S100B was measured by enzymelinked immunosorbent assay. Infarct volumes were measured on diffusion-weighted images. Results: In patients venesected within 24 hours of symptom onset there was no signicant difference in S100B levels between acute infarction and stroke mimics (mean 0.19 ng/ml vs 0.12 ng/ml). Peak S100B levels after 24 hours however, correlated well with both infarct volume and maximum NIHSS scores (r = 0.89, P<0.001 and r = 0.81, P<0.001 respectively). The highest level was seen in a patient with malignant middle cerebral artery infarction. Peak S100B level was a good predictor of dichotomised outcome after discharge (independent mean 0.14ng/ml vs dependent mean 0.36ng/ml, P<0.05). Conclusion: Serum S100B measurements are not helpful in distinguishing infarction from stroke mimics in the emergency room. Measurement of blood S100B levels after cerebral infarction is a useful measure of the severity of brain damage and predicts prognosis. It may also be a useful predictor of malignant infarction.
D.G. Sherman, G.W. Albers, C. Bladin, C. Fieschi, A.A. Gabbai, C.S. Kase, W. ORiordan, G.F. Pineo, for the PREVAIL Investigators University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
Introduction: Studies of major orthopaedic surgery have shown that deep-vein thromboses (DVT) do not always occur on the same side of the body as the surgical intervention suggesting that reduced mobility is not the only factor triggering thrombus formation. We assessed the relationship between the side of the body affected by motor impairment and the side with DVT in PREVAIL, a study of VTE prophylaxis in acute ischemic stroke patients. Methods: Patients with acute ischemic stroke, conrmed by CT scan or MRI, and unable to walk unassisted due to motor impairment of the leg were randomized within 48 h of stroke symptoms to enoxaparin 40 mg SC qd or UFH 5000 IU SC q12h for 104 days. DVT was conrmed by venography, or ultrasonography when venography was not practical. PE was conrmed by VQ or CT scan, or angiography. Results: The PREVAIL study showed a 43% relative reduction in the risk of symptomatic or asymptomatic deep-vein thrombosis (DVT), symptomatic pulmonary embolism (PE), or fatal PE with enoxaparin compared with UFH in acute ischemic stroke patients (10.2% vs 18.1%; p=0.0001), with no increase in clinically important bleeding. A post-hoc analysis showed that 7.0% of patients developed a DVT on the same side as the motor impairment, and 3.5% developed a DVT on the contralateral side. Conclusion: Although more DVT events occur on the same side as the motor impairment, about one third occur in the contralateral leg. This suggests that while ow-dependent thrombogenic factors (i.e. stasis) are triggers for thrombus formation, some other factors may also be important. Rehabilitation and nursing care should focus on mobilization of the patient as well as providing VTE prophylaxis.
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Acute stroke: complications and early outcome
PREHOSPITAL TRANSPORT OF ACUTE STROKE PATIENTS AND TIME TO INITIAL MEDICAL ASSESSMENT IN AN IRISH GENERAL HOSPITAL
R. Purcell, G. Bergin, C. Cooney, E. Farrelly, R. Morton, H. Logan, R. Lynch, S. Murphy Midland Regional Hospital, Mullingar, Co. Westmeath, Dublin, Ireland
The aims of acute stroke management are to minimise neurological impairment and maximise functional recovery. Rapid patient transfer to acute stroke units is essential to achieve these aims. In Ireland, there is no nationally agreed policy on acute stroke care. A retrospective study was performed to examine prehospital transport of acute
PREVALENCE AND RISK FACTORS OF FAECAL INCONTINENCE IN STROKE PATIENTS ADMITTED TO THE ACUTE STROKE UNIT AND TO REHABILITATION WARDS (PILOT STUDY)
U. Khan Oxford Redcliff, Abingdon, United Kingdom

Background and purpose: Faecal incontinence [FI] commonly affects patients after stroke. This is an observational study to assess the prevalence of and risk factors for FI in stroke patients admitted to the acute stroke unit & to rehabilitation wards. Methods: 50 patients admitted in Oxford Radcliffe Hospital stroke unit from May
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2006 for a period of 10 wks were enrolled and followed up in rehabilitation wards and in the community. The prevalence of FI was assessed over a time period of 3 months and risk factors were assessed in the1st wk after admission. The main comparative statistical tool used was the Chi squared test or Fishers exact tests. Results: Pre-stroke FI was 2%.Post-stroke FI at wk1 was 34%, at wk 4 was 26% & at wk 12 was 21%. The characteristics of 17 FI patients were compared with 33 without FI.Total anterior circulation stroke syndrome was strongly associated with FI (P<0.0001) as was stroke severity, measured by NIHSS >14; GCS<15 (P<0.0001).There was a signicant association between poor cognition [MMSE score <25] and FI (P=0.009). Disability [Barthel Index<15] was also signicantly associated with FI (P=0.002). Concurrent urinary incontinence [UI] (P<0.0001) and diarrhoea (P=0.027) were but constipation (P=0.70) and faecal impaction (P=0.327) were not associated with FI. Enteral feeding was strongly associated with FI (P<0.0001). Advanced age (>80) was not a signicant factor when adjusted for gender (P=0.061) but showed a positive trend. Conclusion: FI is common in older stroke patients & resolves in <50% within 3 months. Stroke severity, conscious state, level of disability, co-existing UI, diarrhoea and enteral tube feeding are signicant risk factors. This pilot provides data to plan future larger studies of FI in stroke patients.
recommended (2000) in all groups, particularly those on modied diet (normal diet mean 1311; SD 520, modied diet 765 SD 464, NG diet 1633 SD 780: all p values<0.0001). Median daily protein intake was signicantly lower in those on a modied diet (39.2g) compared with NG feeding (56.9g, p=0.012) a normal diet (50g, p=0.02) and recommended levels (50grams). Mean seven day total calorie intakes were signicantly lower than recommended levels (14000) in patients on a normal diet (8854 p=0.023), and modied diet (5052 p=0.001) but not in those being fed with NG (11436p=0.32). This interim analysis was not powered to demonstrate reductions in weight, but patients on a modied and normal diet lost 3.5 kg in 7 days while those on NG lost 0.3kg. There was a strong negative correlation between weight loss and both calorie and protein intake (Pearson -0.79, and 0.-0.89 p= 0.001). Conclusions: Patients on modied diet are at risk of malnutrition. Consideration of feeding supplementation should be given to patients with swallowing difculties
THROMBOLYSIS WITH RT-PA DOES NOT PROMOTE EDEMA FORMATION IN ACUTE ISCHEMIC STROKE
V. Sachsenmaier, I. Dzialowski, C. Disque, G. Gahn Technical University of Dresden, Dresden, Germany

Background: There is ongoing controversy whether recombinant tissue plasminogen activator (rt-PA) treatment is associated with excessive edema formation following acute ischemic stroke. Possible mechanism might be the toxic disruption of the blood brain barrier and subsequent reperfusion injury. We studied the hypothesis that patients with large middle cerebral artery (MCA) infarctions treated with rt-PA develop larger cerebral edemae than controls. Methods: We retrospectively studied patients with large MCA infarctions from 07/2001-10/2006 dened by an Alberta Stroke Program Early CT Score (ASPECTS) < 5 on day 1 7 follow-up imaging. Exclusion criteria were spaceoccupying secondary hemorrhage, hemicraniectomy, and thrombolysis with non-tPA agents. We recorded baseline characteristics and rt-PA treatment status from the patient chart. We prospectively assessed the extent of cerebral edema applying a 5scale grading system (0, no edema, 1, compression of external subarachnoid spaces, 2, compression of lateral ventricle, 3, midline deviation, 4, obstructive dilatation of opposite lateral ventricle, Borovich scale). We compared Borovich scores among rt-PA treated patients and controls using non-parametric statistical testing. Results: We identied 90 patients for our study with a mean age of 66 13 years, 42% female, mean onset-to-imaging-time of 59 40 hours, median ASPECTS of 2 (iqr2-4). Of the 90 patients, 30 were thrombolysed and 60 were controls. Baseline characteristics did not differ across the two groups. Distribution of Borovich scale scores for the treatment (and control) group was 0 (0) % for grade 0, 0 (8) % for grade 1, 43 (40) % for grade 2, 37 (33) % for grade 3, and 20 (18) % for grade 4. Median Borovich scores among both groups did not differ signicantly (median 3, p=0.48). Conclusion: In our retrospective study, t-PA treatment did not exacerbate cerebral edema in patients with large MCA infarctions. Further prospective evidence is needed to conrm this result. 1723/1800 characters
COMPARISON OF 2 TYPES OF PROGRESSION AFTER ACUTE ISCHEMIC STROKE: CONTINUOUS DETERIORATION VS. FLUCTUATION OF STROKE SEVERITY
Y.-J. Cho, K.-S. Hong, J.-.S. Koo, K.-H. Yu, H.-J. Bae, M.-K. Han, M.-K. Jeong, D.-W. Kang, J.-M. Park, B.-C. Lee Inje University Ilsan Paik Hospital, Goyang-si Gyeunggi-do, South Korea
Background: To investigate the frequency, possible attributable factors and the prognosis of 2 types of progression after acute ischemic stroke. Methods: All consecutive patients with rst-ever ischemic stroke within 24 hours from onset were recruited prospectively, who admitted 4 university hospitals in Seoul metropolitan region. Baseline demographics, stroke subtypes, past medical history, medical complications after stroke, and modied Rankin Scale at 3 months were assessed by predetermined protocol. Stroke severity was assessed by NIH Stroke Scale (NIHSS) at admission, on hospitalization days 1, 2, 3, and week 1 and 2. Clinical deterioration was dened as decrease of 2 points in total NIHSS score or 1 point in motor scale score. Results: Among 566 patients recruited, 142 (25.1%) worsened. One hundred thirty patients (91.6%) were deteriorated within 3 days after stroke onset. Continuous deterioration (CD) was found in 94 (66.2%), and returning to initial status after uctuation (F) was found in 48 (33.8%). CD patients are older (68.611.2 vs. 62.012.4), and more likely to have higher initial NIHSS (median=7.5 vs. 6.0), preceding systemic infection (24.5% vs. 12.5%), and worse functional outcome (mRS 3-6=78.7% vs. 56.2%) at 3 months than F patients. After adjusting sex, hypertension, diabetes, and stroke subtypes, age was the only signicant independent predictor of CD (OR=1.04, 95% CI=1.01-1.08) by logistic regression analysis. Discussion: Continuous deterioration of stroke severity after acute ischemic stroke results in poor functional outcome. Age, initial NIHSS, and preceding systemic infection might predict further decline.
6 4 Acute stroke: complications and early outcome
ACUTE MORTALITY PREDICTION IN STROKE PATIENTS
COMPARISON OF NUTRITIONAL INTAKE IN POST STROKE PATIENTS ON NORMAL, MODIFIED AND NG DIET
M. Delobel, A. Viguier, M.C. Turnin, V. Larrue CHU de Toulouse France, Toulouse, France
We examined the use of the Simplied Acute Physiology Score II (SAPS II) for the prediction of in-hospital mortality in a large number of stroke patients managed in a neurological intensive care unit. Data on SAPS II were prospectively collected in patients with ischemic stroke, cerebral hemorrhage, transient ischemic attack, or subarachnoid hemorrhage, consecutively admitted to a tertiary neurological intensive care unit. We constructed receiver operating characteristic curves (ROC) to determine the ability of SAPS II to predict in-hospital mortality. 2214 patients were included in this analysis. 321 (14.5%) patients died in hospital. The area under ROC curve [95% condence interval] was 0.83 [0.81-0.86]. With a cut-off point of 30 the positive predictive value of SAPS II was 38.3%, and the negative predictive value 94.8%. Findings were similar in an analysis restricted to patients older than 40 years. The ndings indicate that SAPS II is a reliable tool to predict acute mortality in patients managed for stroke in a neuroligical intensive care unit.
T. Nagarajan, A. Addison, M. Winder, A.G. Dyker Freeman Hospital, Newcastle upon Tyne, United Kingdom
Patients with swallowing problems after stroke are at risk of developing nutritional deciencies. Methods: Three groups of patients were studied: Normal diet (n=4), modied thickened diet (n=5), and naso-gastric feeding(n=4). Patients were studied for seven days. Full records were kept of patients nutritional intake. Patients were weighed on day one and day 7. Results were tabulated using Excel (2003) and statistical analysis was carried out using MINITAB (14). Test for normality was carried out on all analysed data and students T test was used to compare normally distributed data while MannWhitney Tests and Wilcoxon Signed Rank test were used to compare non-normally distributed data. Results: Mean daily calorie intake was signicantly lower in those being fed a modied diet compared with NG (difference 546, p<0.0005) and normal diet (difference 868, p<0.0005).There was no difference in daily calorie intake between NG and normal diet. Average daily calorie intake was signicantly less than
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A NOVEL POLYMORPHISM IN THE PROMOTER REGION OF THE SURVIVIN GENE IS RELATED TO HEMORRHAGIC TRANSFORMATION IN PATIENTS WITH ACUTE ISCHEMIC STROKE
EARLY HEMORRHAGIC EVENTS AFTER INTRAVENOUS THROMBOLYSIS OF HEMISPHERIC AND BASILAR ISCHEMIA: RESULTS OF THE HELSINKI STROKE THROMBOLYSIS STUDY
M. Castellanos, C. Gubern, J. Serena, J. Castillo, M.A. Moro, M. Milln, R. Rodrguez, F. Nombela, O. Hurtado, J. Mallolas Hospital Universitari de Girona Doctor Josep Trueta, Girona, Spain
Background: The expression of survivin, a member of the inhibitor antiapoptotic proteins family, has been shown to increase after cerebral ischemia in response to the release of angiogenic growth factors. This protein has been mainly located at the microvaculature within the infarcted and peri-infarterd area, and so we aimed to investigate whether survivin gene polymorphisms were associated with hemorrhagic transformation (HT) of cerebral infarction. Methods: DNA was isolated from peripheral blood samples of 97 patients with a hemispheric ischemic stroke and 38 controls. Polymorphism screening of the survivin gene was performed by polymerase chain reaction, single-strand conformation polymorphism and sequencing analysis. DWI sequences were obtained within 12 hours from symptoms onset and at 7212 hours by using a 1.5-T MRI. The presence of HT was determined on the second DWI sequence and classied according to ECASS II criteria. Results: Forty-seven patients (48%) had HT: 27 patients had hemorrhagic infarction and 20 had parenchymal hemorrhage (PH). Thirty-two patients (32%) received rt-PA. A novel polymorphism was identied in the promoter region of the survivin gene which corresponded to an C-to-T transition at -241 bp from the transcription start site. The prevalence of the mutant allele (T) was similar in patients and controls (14% vs. 16%, respectively; p=0.985). Seven patients (26.9%) with allele T had HT compared to 40 (56.3%) of wild-type (p=0.009). Logistic regression analysis showed that the presence of the polymorphism was associated with a lower risk of HT (OR 0.28; 95% CI, 0.08 to 0.97; p=0.045) independently of age, 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 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 secondary down-regulation of the angiogenic process.
T. Bogoslovsky, O. Hppl, L. Soinne, O. Salonen, P.J. Lindsberg, M. Kaste Helsinki University Central Hospital, Biomedicum, Neuroscience Program, Helsinki, Finland
Early cerebral hemorrhages after ischemic stroke are the most feared adverse event following the theapeutic use of recombinant tissue plasminogen activator. The reason for bleeding is not known, but their incidence has been associated with various premorbid factors, such as diabetes, the use of antithrombotics, the duration and extent of cerebral ischemia as well as the perithrombolytic levels of blood glucose and blood pressure (BP). Onset-to-treatment times tend to be longer in basilar occlusions, but it is not known, if their bleeding tendency is different. We aimed to asses the rate of hemorrhagic events within 24 hours after thrombolysis and the associated factors in consecutive anterior and posterior circulation stroke patients treated in Helsinki University Central Hospital during years 2003 to 2005. Of 335 strokes 304 were hemispheric (HS) and 31 basilar occlusions (BAO). BAO patients had more severe strokes (median NIH Stroke Scale 20 vs. 10, p<.001) and longer onset-to-treatment times (8731453 min vs. 12743 min, p<.0001) and less antiaggregatory treatment (22.6% vs 43.1%, p=.03), but similar age (6417 vs. 6912 years, p=.14) and prevalence of diabetes [4(15%) vs. 33(12%),p=.72]. BAO patients had comparable prethrombolytic glucose (7.0 vs 7.1 mmol/l) and BP levels (systolic 152 vs 156 mmHg, diastolic 81 vs 82 mmHg). Overall incidence of postthrombolytic hemorrhages was 64 (21%) in HS and 5 (16%) in BAO (p=.52). There was no difference in distribution into subgroups of hemorrhagic events according to ECASS II classication or extraischemic or subarachnoidal bleeding. Despite 7-fold longer treatment delay and 2-fold stroke severity, thrombolysis of BAO is not associated with more major hemorrhages than that of HS.
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ENDOTHELIAL DYSFUNCTION IN ACUTE ISCHEMIC STROKE IS 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, R.M. Umarova, A.S. Suslin, M.V. Krotenkova, Z.A. Suslina Institute of Neurology, RAMS, Moscow, Russian Federation
Background: The aim of the study was to evaluate the concentration of von Willebrand factor [vWf] in acute ischemic stroke [IS] compared with the stroke severity and the size of the brain infarction. Methods: The concentration of serum vWf was investigated in 40 patients (age 65 [57; 74] years; 22 males, 18 females) with IS in the rst 48 hours and on 21 day of IS onset. The size of the brain infarction was measured on diffusion-weighted (DWI) MRI images (in the rst 48 hours of IS) and on T2 MRI images (on 21 day of IS). Correlation analysis of vWf concentration, NIHSS score and the size of brain infarction was performed. Results: The vWf concentration was 158% [130; 181] and 170% [147; 200] in the rst 48 hours and 21 day of IS accordingly (p=0,03). The neurological decit on NIHSS was 4,5 [2,5; 9] and 1,5 [0; 4] in the rst 48 hours and 21 day of IS accordingly. The vWf concentration in the rst 48 hours of IS was directly correlated with NIHSS score (R 0,33; p=0,049). The size of the brain damage on DWI was 16,1 sm3 [4,7; 40,4] in the rst 48 hours of IS and was directly correlated with vWf concentration (R 0,59; p=0,046). The size of brain infarction on T2 MRI was 11,2 sm3 [6,8; 32,2] on the 21 day of IS and also was directly correlated with vWf concentration (R 0,71; p=0.009). Conclusion: The serum vWf level is correlated with the stroke severity and the size of the brain infarction in patients with IS.
STROKE PATIENT PROGRESSION IN DIJON FROM 1985 TO 2004
P. Decavel, Y. Bejot, G.V. Osseby, B. Parratte, T. Moulin, M. Giroud Besanon University Hospital, Besanon, France
Background: Development of stroke management over a number of years has changed the vital and functional prognosis of patients. Method: The main aim was to test the outcome of patients with rst-ever stroke over a long period among a random population. A study was carried out into the progression of the number of deaths over 20 years, handicap development according to the modied Rankin scale and the clinical state of patients coming into the department with a rst-ever stroke identied in an ongoing registry of the population between 1985 and 2004. Results: The distribution of stroke type was as follows: 3142 infarctions, 341 hematomas and 74 subarachnoid hemorrhages. Over 20 years, mortality has declined by 0.94% per year (p<0.01), the number of patients able to walk 28 days after stroke has increased by 0.78% (p=0.02) per year, with no increase in the number of patients severely handicapped (p=0.43). If the age at which the rst-ever stroke took place has risen, the number of patients initially comatosed has not changed (p=0.06). Discussion: The decline in mortality observed in Dijon conrms the tendency observed in the majority of other registries. The Dijon registry is, however, the only one to be ongoing. The improvement in stroke patient progression is signicant despite the increase in the age at which the rst event took place. Over a period of 20 years, a 50% decrease in stroke patient mortality with no rise in severe handicap has been observed in Dijon.
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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 Inrmary, University of Glasgow, Glasgow, Airdrie, Scotland, United Kingdom
Introduction: Early progression of ischaemic stroke is common, occurring in around 25% of patients. This complication is associated with poor outcome. We have demonstrated that progression is associated with elevation of markers of coagulation activation. We aimed to determine whether the association of progressing
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stroke with haemostatic activation is due to an underlying enhanced acute phase inammatory response. Methods: Consecutive ischaemic stroke patients were recruited. Progressing stroke was dened by deterioration in components of the Scandinavian Stroke Scale over the rst 72 hours. Measures of Interleukin (IL)-6, IL-18 and tumour necrosis factor-alpha (TNF-A) were made in addition to highly sensitive C-reactive protein (hsCRP). Results: We studied 150 patients of whom 35 (23%) had progressing stroke by European Progressing Stroke Study criteria. IL-6 levels [11.3 (6.0-16.6) v. 7.0 (3.3-13.8), p=0.02] and hsCRP [8.66 (3.69-30.4) v. 5.26 (1.64-18.4), p=0.05] were higher in the progressing group. IL-18 [median 295 (216-452) v. 280 (212-375), p=0.42] and TNF-A levels [2.53 (1.86-3.67) v. 2.24 (1.58-3.10), p=0.18] were similar in progressing and non-progressing cases. In binary logistic regression none of the acute phase markers were independent predictors of progressing ischaemic stroke; thrombin-antithrombin complexes (odds ratio (OR) 7.74), admission mean arterial blood pressure (OR 1.4 for each 10mmHg rise) and age (OR 1.05) were independent predictors of progressing stroke. Conclusions: Circulating levels of IL-6 and hsCRP are elevated in subjects with progressing ischaemic stroke. However, these inammatory markers are not independent predictors of stroke progression. The acute phase inammatory response is unlikely to be a major contributor to haemostatic activation in progressing ischaemic stroke.
6 h and hemorrhagic transformation (HT) on MRI at 24-48 h. mRS score was used to assess 3-month outcome. Results: 66 (45.5%) patients had RHS. Baseline NIHSS was lower in RHS (median 17 vs 19, p=0.0001). Time to MRI was similar between both hemispheres. RHS patients presented with larger DWI volume (73.9 vs 38.5 cc; p=0.004) and smaller PWI/DWI mismatch (63% vs 79%, p=0.011). Only 13 (16.5%) patients with LHS did not meet MRI criteria for thrombolysis, compared to 21 (31.8%) of those with RHS (p=0.03). 85 (58.6%) patients were treated with tPA (34 RHS, 51 LHS; p=0.112). Among those treated with tPA, baseline NIHSS was lower in RHS (16 vs 19; p=0.0004), whereas DWI and PWI/DWI mismatch volumes were comparable. Recanalization rates (RHS 53.1% vs 52.2%, p=0.934) did not differ between both hemispheres. Only 1 patient had symptomatic HT. At 3 months, good clinical outcome (mRS 0-2, RHS 33.3% vs 39.1%, p=0.609) and mortality (RHS 15.2% vs 23.9%, p=0.339) were similar between RHS and LHS. Conclusion: Patients with a RHS present with larger infarct volumes and lesser salvageable penumbral tissue, suggesting a possible less efcient pattern of collateral circulation in the right hemisphere. A MRI-based screening for thrombolysis, irrespective of the time window, may improve the selection of patients with RHS likely to benet from tPA.
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IS RENAL FAILURE A PREDICTOR FACTOR OF POOR EVOLUTION IN ACUTE STROKE?
THE EFFECT OF DYSPHAGIA ON COMPLIANCE AND OUTCOME IN THE EFFICACY OF NITRIC OXIDE IN STROKE (ENOS) TRIAL
L. Gabaldn, B. Fuentes, J. Fernndez, L. Idovro, P. Martnez, E. Dez-Tejedor University Hospital La Paz, UAM, Madrid, Spain
Background: Previous studies have pointed out that renal failure is an independent factor of poor outcome in patients with cardiac failure, myocardial infarction and coronary surgery. However, no studies analysing its possible inuence on stroke outcome are available. Methods: Observational study including consecutive rst-ever acute stroke inpatients with a two-years recruitment period. Renal failure was dened as creatinine level 3 1.2 mg/dl on admission or previous diagnosis of it. In-hospital mortality and outcome at discharge (modied Rankin Scale) were the main outcome measures. Results: 445 patients were included, mean age 69.713.2. In the univariate analysis creatinine >1.2 mg/dl was associated to more in-hospital mortality (31.7 vs 20.7%; p=0.04) but not to poor outcome at discharge. In multivariate logistic regression analysis the predictive factors independently associated to in-hospital mortality were: stroke severity on admission (OR 0.49; 95% IC 0.39-0.63) and the development of systemic (OR 17.97; 95% IC 5.47-59) or neurologic complications (OR 23.49; 95%IC 7.25-76.01) without any inuence of renal failure. Conclusions: Renal failure measured by creatinine serum level does not significantly inuence in-hospital mortality or outcome at discharge in acute stroke patients. However, new studies analysing other parametres of renal function such as creatinine clearance are need to get denite conclusions.
G.M. Sare, L. Gray, T.J. England, P.M.W. Bath, for the ENOS Investigators Institute of Neuroscience, University of Nottingham, Nottingham, United Kingdom
Introduction: About 50% of stroke patients have dysphagia at presentation and this may result in the discontinuation of pre-stroke medical therapy and delay the initiation of acute oral therapy. Enteral access is unreliable since naso-gastric tubes can be difcult to insert and are often pulled out. Here we examine the relation between the administration of oral and transdermal medication in patients with acute stroke. Methods: ENOS is an international, randomised controlled trial in 5,000 patients with acute ischaemic or haemorrhagic stroke which is investigating the safety and efcacy of lowering BP with transdermal glyceryl trinitrate (GTN, given for 7 days). Patients taking pre-stroke antihypertensive therapy are also randomised in a partial-factorial design to continue or temporarily stop this. We compared treatment compliance and outcome (Modied Rankin Scale (mRS) at 90 days post randomisation) between those with and without dysphagia. Results: As of 10 January 2007, 559 patients (28 centres, 9 countries) had been recruited into ENOS. 283 (51%) of these patients had dysphagia. In analyses blinded to treatment assignment, 87% of dysphagic patients received all of their randomised treatment between days 1-4 in the GTN patch versus No GTN arm of the trial compared to 76% in the stop versus continue arm (p=0.01). Those with dysphagia had more severe strokes at baseline and signicantly worse outcome at 90 days compared to those without: median mRS 3 (inter quartile range, IQR 2-5, n=283) compared to median 2 (IQR 1-3, n=276) (p<0.0001). Discussion: Stroke patients with dysphagia were more likely to receive transdermal treatment than oral antihypertensive medication. These data highlight the potential benets of transdermal medications in this high risk population.
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SIGNIFICANCE OF COMMON COMPLICATIONS DURING THE FIRST WEEK POST STROKE: IMPACT ON FUNCTIONAL OUTCOME AT 90 DAYS
G. Rohweder, E. Naalsund, P. Oksnes, B. Indredavik St. Olavs University Hospital, Department of Neuroscience, NTNU, Trondheim, Norway
Background: Little is known about the prognostic impact of acute post-stroke complications. The aim of this study was to dene the longterm functional outcome in patients who experienced a common (>2.5%) complication during the rst week after a stroke, while admitted to an acute comprehensive stroke unit and followed up by an early supported discharge service. Methods: 244 patients consecutively admitted to our stroke unit and with a modied Rankin Scale (mRS) of < 2 were included on admission and followed with assessment for 8 complications: fever, diffuse pain, progressing stroke, urinary tract infection (UTI), isolated Troponin T elevation (Trop T), chest infection, non-serious falls, and acute myocardial infarction (AMI). After discharge, the patients were followed up for 90 days with weekly telephone assessments and a home-visit and functional assessment after 3 months. Results: The mean age of patients was 77 yrs., 56% were women. The frequency of complications were as follows: fever 26%, diffuse pain 25%, progressing stroke 18%, UTI 17%, Trop T 13%, chest infection 12%, non-serious falls 7%, AMI 6%. 48% of all patients had an improvement >1 on the mRS. Frequencies of mRS > 1 were as follows: In pts with a chest infection: 18%, without 52% (p=0.001). In pts with Trop T: 34%, without 50% (p=0.089). In pts with AMI: 30%, without
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SIDE DIFFERENCES ON THE EXTENT OF SALVAGEABLE ISCHEMIC TISSUE IN HYPERACUTE STROKE
R. Delgado-Mederos, M. Ribo, A. Rovira, J. Alvarez-Sabin, M. Rubiera, J. Munuera, E. Santamarina, P. Delgado, O. Maisterra, C.A. Molina Hospital Vall dHebron, Barcelona, Spain
Background: Previous research has suggested that right hemisphere stroke (RHS) may achieve worse outcome after thrombolysis. We aimed to evaluate the inuence of the side of affected hemisphere on the extent of baseline MRI abnormalities in acute stroke and to assess the value of MRI-based selection approach for tPA treatment in RHS. Methods: We prospectively studied 145 acute stroke patients due to proximal MCA occlusion imaged with MRI within the rst 6 h from symptoms onset. Those with unclear onset time were excluded. DWI and time-to peak (PWI) lesion volumes were measured. MRI inclusion criteria for tPA were PWI/DWI mismatch>20% and DWI volume<50% of MCA territory. Recanalization was assessed by TCD at
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49% (p=0.229). In pts with UTI 46%, without 48% (p=0.777). In pts with fever 49%, without 48% (p=0.876). In pts with progressing stroke 60%, without 46% (p=0.080). In pts with diffuse pain 62%, without 44% (p=0.012). In pts with non-serious falls 81%, without 46% (p=0.006). Discussion: This study suggests that the occurrence of chest infection during the rst week after a stroke leads to a worsened outcome, while the occurrence of Troponin T elevation and acute myocardial infarction may do so. Frequent falls and diffuse pain are indicators of improved functional outcome at 90 days after a stroke. Progressing stroke does not confer a worsened outcome under the current management.
screening for aspirin resistance after a stroke might identify a sub-group of people who may benet from higher doses of aspirin and/or combination therapy.
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WHAT FACTORS INFLUENCE EARLY RECANALISATION DURING THROMBOLYSIS IN ACUTE ISCHEMIC STROKE?
L. Sekoranja, H. Yilmaz, K. Lovblad, R. Grandjean, P. Temperli, R. Sztajzel University Hospital of Geneva, Geneve, Switzerland
Purpose: We evaluated the factors determining rcanalisation after thrombolysis. Patients and methods: Patients with acute ischemic stroke (AIS) of < 3 h underwent either IV or combined IV-IA lysis, if no recanalisation after 30. CT-angiography was done in all p and monitoring with TCCD during 60 in case of IV and during 30 in case of IV-IA lysis. TIBI was used to assess the residual MCA ow before the lysis and to evaluate presence or absence of early recanalisation (TIBI >1 at 30). Results: 54 patients, 30 M, mean age 68.1 y. 33 p had IV and 21 IV-IA lysis. 43 (80%) p had an MCA and 11 (20%) a T occlusion. Hypertension had 30 (55%), DM 8 (15%), and AF 23 p (43%); 18 (33%) were on ASA and 11 (20%) on statins. Thrombolytic was given within 60 to 230. NIHSS ranged from 5 to 21. Fifteen (27%) p had a TIBI 0 before lysis, 9 a grade of 1(16%), 12 (22%) grade of 2 and 18 (33%) grade of 3; 17 (31%) p received contrast because of insufcient temporal window. After lysis 25 (46%) p improved > 4 points on NIHSS. Factors increasing the early recanalisation in univariate analysis: TIBI 1 to 3 respectively OR 8.1, 95% CI 1.1 to 59, p= 0.039; OR 8.7, CI 95% 1.3 to 59, p= 0.021 and OR 15.6; 95% CI 2.7 to 103, p= 0.002. The factors decreasing the early recanalisation: T occlusion OR 0.02, 95% CI 0.003 to 0.20, p 0.001; M1 occlusion OR 0.11 95% CI 0.02 to 0.6, p 0.011. In a multivariate analysis factors increasing the likelihood of early recanalisation: TIBI grades 1 to 3 respectively OR 11.9 95% CI 0.4 to 4.1, p= 0.025; OR 13.8, CI 95% 1.3 to 105, p= 0.014 and OR 24.7; 95% CI 0.07 to 1.1, p= 0.075 and atrial brillation OR 0.28, 95% CI 0.07 to 1.1, p 0.075. Conclusion: Presence of a residual ow of the MCA on TCCD (TIBI 1 to 3) was the best predictor of early recanalisation; presence of T or M1 segment occlusion on Angio-CT were associated with a lower one, however only on univariate analysis.
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EARLY PULMONARY EMBOLISMS IN PATIENTS TREATED WITH FACTOR VIIA FOR INTRACEREBRAL HEMORRHAGE. CHANCE OR SAFETY CONCERN?
W. Vadot, A. Jaillard, P. Bedouch, C. Chevallier, K. Garambois, O. Detante, B. Hommel, M. Hommel University Hospital of Grenoble, Grenoble, France
Introduction: Intracerebral hemorrhage (IH) was the least treatable type of stroke. Activated Factor VII (rFVIIa) IH Trial (FIHT) suggested that treatment of IH with rFVIIa within 4 hours improves outcomes despite thromboembolic adverse events (Mayer et al. 2005). Our aim was to evaluate feasibility and safety of rFVIIa in a stroke Unit. Methods: We consecutively included patients with IH admitted during years 2005 and 2006, who met criteria for inclusion in FIHT. Patients admitted in 2006 were administered 80 g of rFVIIa per kilogram of body weight and were compared with the historical controls admitted in 2005. Clinical outcome were NIHSS, Rankin score and mortality. Safety was assessed using serum troponin and D-dimer at baseline, 6 hours and on day 1, 2, 3 and later when necessary. Lower limb Doppler and thoracic CT scan were performed in patients with high D-dimer levels in order to assess deep venous thrombosis (DVT) and pulmonary embolism (PE). Results: Among the 30 patients included (NIHSS=14), 15 received RFVIIa. In this group, none had myocardial infarction, one died of cerebral edema, and two suffered PE. The rst PE occurred at day one and the other at day 2 with re-bleeding at day 3. Both patients with EP recovered. Because each received 7.2 mg of RFVIIa in relation to high weight and had no other risk factor, we limited later on the highest dose at 4,8 mg. None of the next patients suffered PE but one had PVT. In the control group, 2 patients died, 3 had DVT but none had PE. Clinical outcome was not different in the two groups. Discussion: At our knowledge, early PE was not reported as thromboembolic complications in patients treated by RFVIIa for IH. A dose effect relation was suggested by the high total dose received the two patients with PE.
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THE IMPACT OF HYPERTHERMIA AND INFECTION ON THE ACUTE ISCHEMIC STROKE PATIENTS ADMITTED TO INTENSIVE CARE UNIT
W. Seo, S. Yu, J. Kim, S. Koh Korea University College of Medicine, Seoul, South Korea
Background: Despite well recognized deleterious effect of the hyperthermia on critically ill neurological patients, few investigations were performed for the issue about the fever after ischemic stroke in intensive care unit (ICU) setting. We tried to prove the effect of hyperthermia on in-hospital outcome and the role of infection on hyperthermia in the acute ischemic stroke patients admitted to ICU. Methods: We reviewed medical records retrospectively for the acute ischemic stroke patients admitted to ICU within 24 hours from the onset between March 2004 and December 2006. The patients were assigned into normothermia, mild hyperthermia (MH, 37.6C and <38.0 1;, at least one time during ICU stay) and severe hyperthermia (SH, 38.0 1;). Causes of hyperthermia were divided into infection and non-infectious cause. Outcomes were measured by in-hospital mortality or long ICU stay (4 days). The logistic regression tests with factors presumed to be related with hyperthermia were performed to predict the outcomes. Result: Among the 150 patients included (63.38 12.13 years old, male 57.3%), MH and SH were observed in 15 and 40 patients, respectively. SH was independently related to in-hospital mortality (OR 10.3, p < 0.01) and long ICU stay (OR 7.8, p < 0.01). MH was related with long ICU stay (OR 4.2, p = 0.03). Among the other factors, Glasgow coma scale was associated with in-hospital mortality (OR 0.77, p = 0.02) and long ICU stay (OR 0.82, p < 0.01). The patients with infection (39 patients) was more prevalent in SH than in MH (p < 0.01) and had longer ICU stay than non-infectious group (p = 0.01). Discussion: Careful concern for the infection as well as effort for lowering body temperature per se is needed to the acute ischemic stroke patients admitted to ICU.
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ASPIRIN RESISTANCE IS ASSOCIATED WITH INFLAMMATION, ISCHEMIC STROKE SEVERITY, AND POORER FUNCTIONAL OUTCOME AT 6 MONTHS
N.A. Englyst, G. Horseld, C.D. Byrne University of Southampton, Southampton, United Kingdom
Background: Stroke is the largest cause of disability in the UK but little is known about which factors inuence recovery. Aspirin is used in primary and secondary prevention of stroke. Aspirin resistance is associated with a higher risk of developing stroke but its relationship with severity of stroke and functional outcome after stroke is unclear. The aim of this study was to investigate the relationship between aspirin resistance and inammatory cytokines, stroke severity and functional outcome at 6 months. Methods: Aspirin resistance was assessed by thrombelastography in 100 people with ischemic stroke and 100 community-based controls. Stroke outcome (degree of disability) was assessed using the Rankins Stroke Scale within 72 hours of stroke and at 6 months. Plasma interleukin IL-6 was measured by Enzyme Linked Immunosorbent Assay (ELISA). Results: Aspirin resistance was associated with a higher Rankins scale at baseline (p=0.013), suggesting that aspirin resistance is associated with more severe strokes. Aspirin resistance at baseline was also associated with higher Rankins scale at 6 months (p=0.048). Aspirin resistance was associated with increased IL-6 (p=0.034) and higher levels of IL-6 were associated with poorer outcome from stroke (p=0.017). IL-6 was independently associated with aspirin resistance in multivariate analysis. Discussion: Aspirin resistance in conjunction with increased plasma IL-6 may indicate a high risk of poor functional outcome from stroke. These data suggest that
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MAJOR NEUROLOGICAL IMPROVEMENT AFTER STROKE THROMBOLYSIS IN A FRENCH COMMUNITY HOSPITAL
B. Barroso, C. Morisset, E. Bertandeau, H. Mangon, A. Dakar, J.M. Larrieu F. Mitterrand Hospital, France
Objective: A signicant advancement in the treatment of acute ischemic stroke management has been the use of recombinant tissue plasminogen activator (rtPA). In practice, French community hospitals experience difculty in treating their patients because stroke units (SU) are missing in Neurology wards. To improve quality of care and to provide modern stroke therapy, we decided to assess whether thrombolysis was feasible in the Emergency department of our community hospital located in Pau (south-west of France). Methods: Select patients were treated with rtPA and observed for 24 hours in the Emergency department. They were then transferred to the neurological department for follow-up. By reference to French legislation this use of rtPA therapy was dened as an "off-label use". NIHSS was obtained on admission, immediately after treatment and 24 hours post treatment. At that time we collected all major neurological improvements dened as an NIHSS score equal to 0 or 1 or an improvement of more than 8 points compared to baseline. Results: Results from the rst 40 patients are reported. They were treated between September 2004 and June 2006. A total of 1169 patients were admitted for stroke during this period. We collected 349 transitory ischemic attacks, 192 hemorrhagic strokes and 628 ischemic strokes. A total of 3.4% of strokes was treated by rtPA. A major neurological improvement was present in 14 patients (35%). Conclusions: According to the infrastructural local criteria and preparatory prerequisites described in this study, thrombolysis is a viable and feasible treatment option for stroke patients in Emergency departments of French community hospitals even in lack of SU. It has been shown elsewhere that good outcome in the rst 24 hours is an independent predictor of good functional outcome at 3 months. So, such an emergency organisation could be used as a compromise as long as SU are not available enough.
PREDICTORS OF INTRACEREBRAL HEMORRHAGE AFTER INTRAVENOUS RTPA THERAPY FOR ACUTE ISCHEMIC STROKE IN CLINICAL PRACTICE
D. Gasecki, G. Kozera, M. Swierkocka-Miastkowska, K. Chwojnicki, B. Karaszewski, S. Szczyrba, M. Wisniewska, W.M. Nyka Medical University of Gdansk, Gdansk, Poland
Background: Intravenous recombinant tissue plasminogen activator (rtPA) is an effective therapy for acute ischemic stroke, but it is associated with risk of intracerebral hemorrhage (ICH). Our aim was to identify baseline factors that are associated with thrombolysis-related ICH and to assess the clinical course of those patients compared to patients without ICH. Methods: we analyzed 52 patients (18 women) with acute stroke treated with IV rtPA within 3 hours of stroke symptom in Medical University of Gdansk, Poland, between 2000 and 2006. Results: 2 (3,8%) patients developed symptomatic ICH, and 4 additional patients (7,7%) had asymptomatic ICH identied on a routine follow-up CT (within 22-36 hours of stroke symptoms). In analyses based on clinical and radiological variables, the attributes associated with ICH were advancing age (p<0,05), early ischemic CT changes (p<0,05), a history of atrial brillation (p<0,05), and elevated pre-bolus diastolic blood pressure (p=0,06). No association between diabetes mellitus, serum cholesterol, the initial stroke severity, neurological outcome at 7 or 90 day and ICH was found. Clinical relevant was only parenchymal type of ICH, in 2of 3 cases associated with early neurologic deterioration. Conclusions: Advanced age, embolic stroke, elevated diastolic blood pressure and ischemic changes on CT could be predictive of ICH. Only PH-ICH seems to be of clinical signicance.
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THE "NO-REFLOW" PHENOMENON AFTER THROMBOLYSIS IN ACUTE STROKE - A MARKER OF POOR STROKE OUTCOME?
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A.Y. Jin, O. Islam, F.W. Saunders, A.M. Demchuk, D.G. Brunet University of Calgary, Calgary, Canada
Background: The no-reow phenomenon after thrombolysis-induced recanalization in acute stroke has not been well-described. We assessed the hypothesis that reperfusion failure despite thrombolysis-induced recanalization, i.e. no-reow, is common and is associated with a poor early stroke outcome. Methods: Patients treated with thrombolysis over a three year period (2001-2004) at Kingston General Hospital were considered in this retrospective study. Inclusion criteria were: admission noncontrast CT (NCCT) scan with either transcranial Doppler sonography (TCD), CT angiography (CTA), or CT perfusion (CTP) scan done before thrombolysis; follow-up NCCT and CTP scans done between Days 1 to 5 with either serial TCD examinations or CTA; and a modied Rankin Scale (mRS) score evaluated before hospital admission and at hospital discharge. Cerebral blood volume (CBV) and cerebral blood ow (CBF) maps were used to compare the affected and contralateral hemispheres before and after thrombolysis. Reperfusion failure was dened as any area with decreased CBV and CBF after thrombolytic therapy. Recanalization of the primary arterial occlusive lesion was evaluated by either serial TCD examinations or follow-up CTA. Reperfusion failure despite recanalization of the primary arterial occlusive lesion was classied as no-reow. Results: 20 patients were included in this study. 19 patients showed recanalization of the primary arterial occlusive lesion at follow-up. Of these patients, 7 (37%) showed reperfusion failure on follow-up CTP scan. Among patients with recanalization, those with no-reow had a median hospital discharge mRS of 4 (range 2 to 6), compared to a median mRS of 1 (range 0 to 4) in patients without no-reow (Mann Whitney U test: p (two-tailed) = 0.002). Discussion: The no-reow phenomenon is common despite thrombolysis-induced recanalization and is associated with a poor early stroke outcome. Possible causes of no-reow may include distal embolization, arterial reocclusion, and persistent branch vessel occlusion.
OUTCOME OF PATIENTS NOT TREATED WITH RT-PA DUE TO SPONTANEOUS IMPROVEMENT
J. Mart-Fbregas, E. Martnez, S. Martnez-Ramrez, D. Alcolea, D. Cocho, M. Martnez-Corral, M. Marqui, M. Surez, L.A. Querol, J.-L. Mart-Vilalta Hospital de la Santa Creu i Sant Pau, Spain
Background: Rapid and signicant spontaneous clinical improvement is an exclusion criteria for intravenous thrombolysis. However, there is controversy about the short- and long-term outcome of these patients. We report a prospective study of consecutive patients. Methods: We studied patients with a focal neurological decit admitted within 3 hours of onset of symptoms with the following characteristics: 1) Duration of symptoms >30 minutes, 2) NIHSS score of 5 or more points, obtained either by anamnesis (when it occurred outside the hospital) or by neurologic examination. 3) A spontaneous decrease in the NIHSS score to values <5 points that occurred before the 3 hours-limit. Improvement was assessed either by anamnesis (when it occurred outside the hospital) or by direct examination. We used the SITS-MOST criteria for intravenous thrombolysis. Favourable outcome at 24 hours was dened as a NIHSS below 5 points. Favourable outcome 1 and 3 months after stroke was dened as a score < 2 on the Rankin scale. The diagnosis of an acute infarction demonstrated by neuroimaging within the study period was recorded. Results: We evaluated 15 patients, with a mean age of 69 13.2 years, and 80% were men. Median NIHSS score at onset was 8, and median NIHSS score at inclusion was 3. Favourable outcome was observed in 13 (87%) patients at 24h, 11 (73%) at 1 month and 8/12 (67%) at 3 months. During the study period 11 (73%) patients developed a cerebral infarction. Mortality at 3 months was 13%. Discussion: The outcome of patients not given rt-PA due to spontaneous improvement is not uniformly favourable. One third of patients had an unfavourable outcome and 73% developed an acute infarct.
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Acute stroke: treatment concepts 1 Acute stroke: treatment concepts
OXIDATIVE STRESS, DOCUMENTED BY DETERMINATION OF MDA, IN ACUTE ISCHEMIC STROKE SUBTYPES, ACCORDING TO TOAST CRITERIA
A. Simion Faculty of Medicine and Pharmacy/Clinical Hospital of Neurology and Psychiatry, Oradea, Romania
Background: In ischemic stroke, oxidative stress has been shown to worsen the extent of cerebral injury. Our study tries to correlate oxidative stress with the subtype and outcome of ischemic stroke. Material and method: We studied a consecutive series of 104 ischemic strokes, evaluated with CT and/or MRI or MRA, Duplex sonography, transthoracic echocardiography, and electrocardiography. Strokes were divided into large-artery disease (LAD), small-artery disease (SAD) and cardioembolism (CE), according to the TOAST criteria. Cases with uncertain or unknown etiologies were excluded. Each patient was scored on the NIHS scale at admittance and had the Barthel index (BI) evaluated at discharge. Beside a complete laboratory evaluation, oxidative stress was assessed by measuring the seric malondialdehyde (MDA) levels with the tiobarbituric acid method at admittance (day 1), and on days 3 and 7. Results: We found different patterns for the course of oxidative stress in the stroke subtypes. By day 3 we obtained signicantly (p<0,001) higher level of MDA in all ischemic subtypes (view Table 1), but by day 7 MDA levels were increased only in CE (p<0,001) whilw in LAD they decreased (p<0,02) and showed non-signicant variations (p>0,05) in SAD (view Figure 1). MDA values do not correlate with NIHSS, or with BI. Complications, especially infectious ones, raise the MDA values on the second and third determination, but only bronchopneumonia signicantly inuenced the outcome.
Table 1. MDA values in stroke subtypes and overall LAD MDA2 MDA3 MDA3 2,430,31 4,180,43 3,130,43 SAD 1,830,34 3,860,46 4,060,64 CE 2,170,32 3,070,43 4,610,52 Ischemic stroke 2,20,4 3,70,6 3,90,5
of recanalisation rates after intravenous (IV) thrombolysis for stroke comparing studies where contrast was administered to those where it was not. Methods: Search results for MEDLINE and Embase from inception to October 2006 were screened and studies reporting recanalisation rates for IV thrombolysis for anterior circulation stroke were selected. Additional data were sought from two authors. We compared recanalisation rates for contrast (CS) and non-contrast (NCS) studies. Results: We identied 31 studies (7 CS, 24 NCS). Non-ionic contrast was administered for CT perfusion images (CTp) in 2 studies (40mls, n=1; 50mls, n=1), CTp +/- angiography (CTa) in 1 study (50mls +/- 50mls), and CTp and CTa in 1 study (weight adjusted; max 140mls). 3 studies involving catheter angiograms did not specify type or volume of contrast. The mean time limit for thrombolysis was 6.1h (SD 2.1) in CS and 4.9h (SD 1.6) in NCS. Recanalisation rates were assessed by CTa, magnetic resonance angiogram and transcranial doppler ultrasound. Recanalisation was assessed late (>24h) in 6 CS, and 15 NCS. Precise occlusion site was specically indicated in 4/7 CS and 19/24 NCS. Recanalisation was non-signicantly more frequent in CS (56/89, 63%) compared to NCS (841/1496, 56%) OR 1.32 (95% CI 0.85, 2.06). This remained true for late recanalisation (OR 1.34, 95% CI 0.79, 2.29). and for MCA M1 or M2 occlusions (OR 1.17, 95% CI 0.47, 2.91). Discussion: This was an indirect comparison and not a randomised study, and therefore limited. However, we found no evidence that contrast impaired recanalisation rates with IV brinolytic therapy.
Acute stroke: treatment concepts
PROGNOSTIC FACTORS OF THROMBOLYTIC THERAPY IN HYPERACUTE ISCHEMIC STROKE
J.H. Rha, B.N. Yoon, K.H. Ji, J. Lee Inha University Hospital, Seoul, South Korea
Background: To investigate the prognostic factors of intravenous thrombolysis, we evaluated 121 consecutive patients treated with IV tPA. Methods: Demographic and clinical proles, laboratory results, transcranial Doppler, and brain imaging were evaluated. Clinical assessment was done by National Institutes of Health Stroke Scale (NIHSS) for one week, and by modied Rankin Scale (mRS) at baseline and three months. Early improvement was dened as the complete resolution of the neurological decit or an improvement of 4 or more points by NIHSS within 24 hours of the stroke onset, and good outcome as mRS score of 2 or less at three months. We assessed the possible relationship of the factors with early improvement and good outcome, and also analyzed the correlation of TCD grade with NIHSS score. Comparisons of variables were performed using Fishers exact test, t-test and Mann-Whitney test. The predictors of early improvement and good outcome were analyzed by logistic regression, and the correlation of TCD grade and NIHSS score were analyzed by Spearman correlation. Results: On univariate analysis, younger age, absence of abnormal CT ndings (hyperdense middle cerebral artery sign [HMCAS], focal hypodensity in the total MCA territory > 33%) were signicantly associated with early improvement. Good outcome was associated with younger age, lower levels of baseline NIHSS score, mean blood pressure, fasting glucose, lipoprotein (a) [Lp(a)], and absence of abnormal CT ndings. Multivariate analysis revealed age < 63 years and no HMCAS as independent predictors of early improvement. Thrombolysis in brain ischemia grade by TCD monitoring signicantly correlated with NIHSS score for 24 hours. Conclusions: These results suggest that younger age, normal CT ndings are important prognostic factors of acute thrombolytic therapy, whereas age, CT ndings, baseline NIHSS, blood pressure, blood sugar and Lp (a) level might be associated factors of long term outcome. TCD can be a useful indicator of clinical improvement.
Fig. 1
Conclusions: We presume that the high levels of MDA on day 7 in CE could be tied to reperfusion. If so, antioxidant therapy would be most benecial if given to patients with embolic strokes or after thrombolysis.
STATES OF LEPTOMENINGEAL COLLATERALS AND RESPONSE TO THROMBOLYSIS IN PATIENTS WITH ACUTE MCA INFARCTS
K.H. Kang, H.C. Park, E.H. Kim, Y.S. Kim, C.K. Suh, Y.H. Hwang Kyungpook National University Hospital, South Korea
Background: MR-based thrombolysis using DWI/PWI mismatch is feasible method in selecting thrombolysis candidate. However, state of leptomeningeal collaterals in conventional angiography (CA) may also affect response to thrombolysis and clinical outcome. The purpose of this study is to correlate state of collaterals with response to thrombolysis. Methods: We retrospectively analyzed 16 patients from May to December 2006 who performed CA for Intra-arterial thrombolysis (IAT) in presumed MCA occlu-
SYSTEMATIC REVIEW OF THE EFFECT OF CONTRAST AGENTS ON RECANALISATION RATE AFTER INTRAVENOUS THROMBOLYSIS FOR ACUTE STROKE
K.A. Dani, K.W. Muir University of Glasgow, Glasgow, United Kingdom

Background: Recent assertions that contrast agents impair brinolysis are based on limited evidence from animal models. We undertook a systematic review
Poster Session Acute stroke: treatment concepts
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sion with DWI/PWI mismatch. Angiographic states of leptomeningeal collaterals were dened as minimal (retrograde ow to M4 segment), moderate (retrograde ow to M3 or M2 segment), and maximal (retrograde ow to distal to site of occlusion). IAT was done using urokinase or tPA infusion and/or mechanical thrombus crushing. Results: Mean values of onset to door and door to IAT were 231.953.3 min and 143.411.5 min. Among them, 11 patients regained angiographic recanalization (69%, TIMI Grade 2 or 3) and 6 patients had good clinical outcome (38%, mRS 0-1 at 1-3 months). There was no statistically signicant results in recanalization rate and clinical outcome among each collateral groups [response to thrombolysis - 3/3 in maximal, 4/5 in moderate, and 4/8 in minimal, (P=0.23); good clinical outcome - 2/3 in maximal, 3/5 in moderate, and 1/8 in minimal, (P=0.12)]. However, the rates of recanalization and good clinical outcome were much higher in maximal collateral group. Discussion: Unfortunately, we did not show statistically signicant results about effect of collateral circulation on response to thrombolysis and clinical outcome. However, we found trend that good collateral circulation is related to recanalization success and better clinical outcome. In future, standardized method of collateral grading system is needed for multi-center controlled study.
Results: Of the 100 subjects, 83 were felt to have suffered a cerebrovascular event. Twenty eight of the 83 subjects (34%) had symptoms lasting >24 hours. A decision had been made that such patients should be admitted. Of the 55 remaining subjects, 15 (27%) had suffered other events in the preceding month (1-5 events, median 1) necessitating admission. Of the 40 left, 19 (47%) had an ABCD score of 5 or 6. Two patients had subsequent events in the following month. One had an ABCD score of 3 and the other a score of 5. The patient with the score of 3 was young, normotensive but suffered a prolonged event (>1 hour). None of the patients underwent intervention other than the commencement of anti-platelet and antihypertensive therapy. None had suffered an intracerebral haemorrhage. Conclusion: Use of the ABCD score 1-4 as a means of selecting suitable subjects for outpatient management would have prevented the admission of 38% of the referrals (non-strokes and TIAs). It would have missed one subject who suffered a recurrent event, however admission of that subject did not alter his outcome. We decided to adopt the ABCD score but not use it in isolation and to admit subjects with events >30 minutes duration.
ANTICOAGULATION AND THE RISK OF ICH AFTER CARDIOEMBOLIC STROKE
PERSONAL EMAILS: A SIMPLE MEASURE TO IMPROVE THE QUALITY OF CARE IN THE STROKE PATIENTS
H. Hallevi, K.C. Albright, A.D. Barreto, S. Martin-Schilde, A. Khaja, E.A. Noser, N.R. Gonzales, K. Illoh, J.C. Grotta University of Texas-Houston, Fannin, TX, USA
Background: Heparin has not been shown to be effective in reducing mortality and morbidity after acute cardioembolic stroke, however anticoagulation (AC) eventually needs to be instituted for secondary stroke prevention. We aimed to study the timing and mode of starting AC in cardioembolic stroke patients. Methods: We conducted a retrospective analysis of all cardioembolic strokes cared for by our Stroke Team over 3 years. Patients were monitored in our Stroke Unit. Neuroimaging was done on admission, at 24 hours and with any neurological deterioration. Results: We included 204 patients with cardioembolic stroke in the analysis. Full dose AC with IV Heparin or Low Molecular Weight Heparin (LMWH) was given to 73 patients. Warfarin was started subsequently in 87% (63/73). Low dose AC (DVT prophylaxis dose) with or without aspirin was given to 131 patients. Warfarin was given subsequently to 26.7% (35/131). There were 22 (10.8%) cases of asymptomatic hemorrhagic transformation (HT). All but one occurred during the rst three days. Three patients experienced symptomatic HT 6 to 12 days from their stroke. In all three, warfarin was started while patients were bridged with full dose LMWH and aspirin (3/21, 14.3%, p=0.001). Two cases of serious systemic hemorrhage occurred among patients treated with IV heparin (2/48, 4.2%, p=0.054). Overall acute anticoagulation was associated with 6.8% (5/73) serious bleeding (p=0.05). Recurrent strokes occurred in two cases despite effective anticoagulation in one (0.1%, p=0.53). There were no cases of hemorrhage in patients treated with low dose AC and warfarin. Discussion: Symptomatic HT after cardioembolic stroke occurred late and was associated with aggressive anticoagulation and simultaneous ASA use in our series. Early asymptomatic hemorrhage seems unrelated to anticoagulation. Low dose AC appears safe, even in the setting of asymptomatic HT. Our data suggest that bridging patients with full dose LMWH until anticoagulated with warfarin may not prevent early stroke recurrence and is associated with an unacceptable risk of symptomatic HT.
M.F. Bellolio, R. Kashyap, L. Vaidyanathan, S. Enduri, A.M. Hoff, A.S. Yassa, S. Mishra, R.D. Brown, W.W. Decker, L.S. Stead Mayo Clinic College of Medicine, Rochester, USA
Background: Embolic or thrombotic arterial occlusion is a frequent cause of cerebral infarction, making antithrombotic therapy an important part of the care in stroke patients. Aspirin (ASA) reduces the risk of early recurrent ischemic stroke when given within 48 hours of initial symptom onset. We hypothesized that sending a friendly remainder by email to the consultant who saw a patient with Stroke or TIA in the Emergency Department (ED) and for any reason did not give ASA during the ED stay, could improve the rate of patients receiving aspirin. Methods: A consecutive cohort of patients presenting into the ED with a suspected diagnosis of TIA or Stroke were prospectively enrolled. We excluded patients with suspected diagnosis of intracerebral hemorrhage and those receiving thrombolytics. The intervention was to track ASA administration and send out timely follow up to those who did not provide the drug. This was done via individual (rather than group) email, specically stating the name and clinic number of the patient, and noting lack of aspirin administration as well as lack of documentation for not doing so. Results: Our study group was 64 patients in the pre-intervention period (Aug-Sept) and 59 post-intervention (Oct-Nov). During the pre-emails period 43.8% of the patients received ASA, and 66.1% after sending the emails (p=0.013) After the intervention, the patients with stroke or TIA were 2.51 times more likely to receive aspirin in the ED (95%CI 1.21-5.21) Discussion: This simple method of personal emails has been improving not only the rate of patients who receive aspirin, but also the quality of the documentation (reasons why the patient is not a candidate for ASA, such as suspected hemorrhage or ASA given by the pre-hospital services personnel) and has been maintained over the months.
CAN WE USE THE ABCD SCORE TO SCREEN PATIENTS FOR A WEEKLY TIA CLINIC? RETROSPECTIVE APPLICATION OF THE SCORE TO ASSESS ITS SUITABILITY
EFFECTIVENESS OF THROMBOLYSIS IN PATIENTS OVER 80 YEARS OF AGE
B. Brady, M. Sekiguchi, B. Silke, J. Harbison Stroke Service, St Jamess Hospital, Dublin, Ireland
Background: Prior to the establishment of a weekly TIA in St Jamess Hospital in 2006 suspected TIA patients were routinely admitted for investigation. In developing protocol for the clinic we considered the ABCD score (1) as a potential means of screening patients for the clinic rather than admission. The original paper reports a score of 5 or 6 being associated with a recurrence rate of >25% implying need for immediate admission. To assess the scores utility we applied the score retrospectively to a sample of patients admitted with suspected TIA. Method: 100 sets of notes on patients admitted with suspected TIA were reviewed by 2 doctors. Diagnosis was reviewed, ABCD score applied from available admission data and prior and subsequent admissions with TIA/stroke identied. Changes in management resulting from admission were noted.
C. Rueckert, T. Staudacher, D. Bengel St. Elisabeth Hospital, Ravensburg, Ravensburg, Germany

Background: Despite the fact that the clinical trials leading to the approval of thrombolysis excluded patients over 80 years, in many centers this therapy is offered to patients above this age. Methods: In our series of 324 patients treated with thrombolysis between 12/2000 and 01/2007 we analyzed the outcome of all 77 patients over the age of 80 (max: 92 years). Results: Overall median age was 71 years; 45,2% were women, 54,8% were men; in the subgroup of over 80 years 59,7% were women, 40,3% were men. 29,4% of all patients but 40,8% of the patients 80+ were admitted to the hospital within 1 hour of onset of symptoms. There was no difference in mean door-to-needle-time (55 minutes), mean time from onset of symptoms to therapy (131 minutes), and stroke severity at onset (mean National Institute of Health Stroke Scale=NIHSS 16).
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57,8% of all patients versus 77,5% of patients over 80 had a cardio-embolic origin, 17,7% (8,4%) an arteriosclerotic origin. At discharge mean NIHSS was 10 (overall) versus 11 (80+). While median Modied Rankin Stroke Scale (mRS) at discharge was 4 in both groups, there was a difference at three months: 2,7 (overall) versus 3,4 (80+). Accordingly, 25,6% of all (14,7% of 80+) have reached Rankin 0/1, 36,6% of all (35,3% of 80+) have reached Rankin 2/3. Overall in-hospital mortality was 18,5%, in the group of 80+ 29%, but the incidence of symptomatic intracerebral hemorrhage was only slightly different: 3,7% vs. 5,3%. Discussion: In good correlation with previous reports our data show a slightly but not signicantly higher incidence of symptomatic intracerebral hemorrhage in elderly patients. In-hospital mortality is higher and the proportion of favourable outcome lower than in younger patients. Nevertheless more than 20% of treated patients over 80 years reached Rankin 0-2 and about 50% Rankin 0-3. In our opinion these data show the practicability of thrombolysis and support the effectiveness of this therapy in selected patients over 80.
but it lacks the plasmin-sensitive cleavage site and the lysine-binding kringle 2 domain found in rt-PA. The lack of the kringle 2 domain may explain the fact that rDSPA1 has the highest brin selectivity among PAs, with a 100,000-fold increase in catalytic activity compared to a 550-fold increase for rt-PA and an absence of neurotoxicity in animal models of ischemic and hemorrhagic stroke. Discussion: The unique structural features of rDSPA1 suggest an advantageous risk:benet ratio and may explain the observed favorable clinical results including the potential for use in later time windows.
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BRIDGING WITH GPIIB/IIIA-RECEPTOR-ANTAGONISTS COMBINDED WITH INTRA-ARTERIAL PHARMACOMECHANICAL THROMBOLYSIS IN ISCHEMIC STROKE
R. Dabitz, U. Leppmeier, L. Fuhry, V. Collado-Seidel, R. Michailow, K. Schoeneboom, S. Triebe, H. Gunselmann, G. Ochs, D. Vorwerk Klinikum Ingolstadt, Ingolstadt, Germany
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 intravenous rt-PA usually very poor. Patients: We report in a retrospective analysis about 76 consecutive patients (39m, 37f; age 64 12.2 years), who were treated with GPIIb/IIIa-Rezeptor-Antagonists combined with pharmacomechanical intra-arterial thrombolysis. 25 pat. with tandem occlusion of the ICA and MCA, 26 pat. with occlusion of the MCA and 25 patients with basilar artery occlusion. The mean NIH-Stroke-Scale was 16.4, analogical to a mean modied Rankin Scale (mRS) of 4.7. Materials: After exclusion of ICH 39 patients were bridged with Abciximab (due to the Abestt trial) and in 37 cases with Tiroban followed by an intra-arterial thrombolysis with rt-PA. Results: At the time of discharge the mean mRS was 2.8. 23 pat. mRS: 0-2 (=31%); 2 pat. mRS: 3 (=3%); 21 pat. mRS: 4 (=28%); 6 pat. mRS: 5 (=8%). At the time of re-evaluation after rehabilitation the mean mRS was 1,8. 32 pat. mRS: 0-2 (=42%); 13 pat. mRS: 3 (=17%); 5 pat. mRS: 4 (=7%), 2 pat mRS: 5 (=3%). 24 of 76 (=32%) patients died nevertheless 23 pat. (=30%) showed ICH in the CT-scan, 10 (=13%) of them were symptomatic. 8 of these 10 patients showed already malignant infarction at the time of bleeding due to unsuccessful rekanalisation. One patient died due to perforation of the basilar artery. Conclusion: Bridging with GPIIb/IIIa-Rezeptor-Antagonists combined with intraarterial pharmakomechanical thrombolysis is feasible and may help to reduce the lethality and morbidity of ischemic stroke due to occlusions of the ICA, MCA and BA. The rate of complications and intracranial haemorrhage is in the range of those reported in other cohorts
PREVIOUS TREATMENT WITH ANGIOTENSIN II RECEPTOR BLOCKERS COULD PLAY A POSSIBLE PROTECTOR EFFECT IN ACUTE STROKE
M.A. Ortega-Casarrubios, B. Fuentes, B. San Jos, M.J. Aguilar-Amat, I. Ybot, P. Martnez, E. Dez-Tejedor Stroke Unit, Department of Neurology, La Paz University Hospital, UAM, Madrid, Spain
Background: Previous studies with angiotensin II receptor blockers (ARB) have demonstrated a protective effect in spontaneously hypertensive rats from cerebral ischemia. It is not known if all the hypotensor drugs share this property. Our goal is to analyse the impact of pre-stroke use of hypotensor drugs in stroke severity and outcome. Methods: Observational study from the Stroke Unit data bank of the Department of Neurology, with inclusion of consecutive stroke patients (January 2000-October 2005). Parameters analysed: Risk factors, previous hypotensor drug treatment, severity on admission(Canadian Stroke Scale, CSS),in-hospital complications, mortality and functional state at discharge (Modied Rankin Scale, mRS) Results: 1738 patients were included in the study, 55,9% were men. Average age: 69,61 12 years. 63,3% had high blood pressure and 27,9% DM. 39,4% received hypotensor drugs (90,2% of them for hypertension). Patients with ARB presented lower stroke severity on admission (EC 16 vs 29,4%, p=0,011) and better functional state at discharge (mRS 78 vs 63,6%, p=0,008) The multivariate logistic analysis showed that ARB pre-treatment was a predictive factor of lower stroke severity, independent of age, sex and stroke subtipe (OR 0,4; 95% IC 0,2-0,7) Patients treated with diuretic drugs had higher severity on admission (EC 34,5 vs 27,3, p=0,023) and worse outcome (mRS 58,9 vs 65,8%, p= 0,044). Other groups of hypotensor drugs did not show signicant benet on stroke severity. 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 conrm this posible protector role.
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WHY ARE EARLY ADMITTED STROKE PATIENTS EXCLUDED FROM TPA THERAPY?
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LACK OF KRINGLE 2 DOMAIN AND HIGH FIBRIN SPECIFICITY DIFFERENTIATE THE NOVEL PLASMINOGEN ACTIVATOR DESMOTEPLASE FROM RT-PA
S. Debiais, I. Bonnaud, B. Giraudeau, D. Saudeau, D. Perrotin, B. de Toffol, A. Autret CHRU Tours, Tours, France
Introduction: Our University hospital (300 000 inhabitants) receives patients who may benet from IV thrombolysis from the whole region. Since June 2003, an acute stroke network comprising 2 beds of admission and thrombolysis was created in the intensive care unit. Objective: To assess conditions of treatment with IV thrombolysis and to determine why stroke patients admitted within 3 hours of symptoms onset (SO) are not treated with IV TPA. Methods: During 18 months were prospectively recorded the following data for each patient: demographic data, delays of arrival and imaging, treatment and outcome. For the patient arrived in the rst 3 hours, the reason why IV TPA was not administered was noticed. Results: During 18 months, 364 patients were admitted, with a median delay of admission after SO of 2 h 50. Two hundred patients were admitted within three hours and among them, 17 (8,5%) patients received IV TPA. Among the patients admitted in the rst 150 minutes, the main reasons for exclusion were: mild stroke or clinical improvement (NIHSS < 6) for 48 patients, a non vascular diagnosis in 41 patients, aged older than 80 yo for 22, intracerebral hematoma for 17, NIHSS > 23 for 13. For 13 patients the only cause was network internal dysfunction.
D.B. Bharucha, M.K. Pugsley, K.-U. Petersen, M. Soehngen Forest Laboratories/PAION Deutschland GmbH, Jersey City, NJ, USA
Background: Thrombolytic therapy with recombinant tissue plasminogen activator (rt-PA) is effective in treating acute ischemic stroke (AIS) within the rst 3 hours after symptom onset. Desmoteplase, or rDSPA1 (recombinant Desmodus Salivary Plasminogen Activator 1), is a novel plasminogen activator (PA) shown to treat AIS up to 9 hours post-stroke onset with a positive risk:benet ratio (in a Phase IIa study in patients with penumbra) not shown in previous trials with rt-PA when treating patients beyond 3 hours. The observed clinical benet of rDSPA1 may relate to its unique structural features. Methods: Pharmacological and structural characteristics of desmoteplase are reported using in vitro studies. Fibrin specicity was determined for desmoteplase and rt-PA using an enzymatic assay for the kinetics of plasminogen activation. Neurotoxicity was determined using ischemic murine models. Results: rDSPA1 is a glycosylated serine protease structurally similar to rt-PA (with nger, epidermal growth factor-like, kringle 1, and serine protease domains),
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Discussion: In our institution, 18% of ischemic stroke patients are treated with IV TPA. For the early admitted patients, main reasons of therapy exclusion are non vascular diagnosis, mild stroke with NIHSS< 6, and age > 80 yo, as found in previous studies (Barber 2001; Huang 2006). Improvement of the pre-admission selection, decrease of the delays of arrival and correction of the network dysfunctions could increase dramatically the proportion of treated patients. Moreover, some patients with mild or improving decits could also benet from thrombolytic treatment.
associated with HMCAS, even though IAT was started later. Our results indicate that a randomized trial comparing both thrombolytic treatments in patients with middle cerebral artery occlusion is warranted.
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IS INTRAVENOUS TPA TREATMENT BENEFICIAL IN ACUTE ISCHEMIC STROKE RELATED TO INTERNAL CAROTID DISSECTION?
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NOVEL APPROACH IN ACUTE STROKE MANAGEMENT THROUGH L-LYSINE MONOHYDROCHLORIDE INDUCED ANGIOGENSIS AND REVASCULARIZATION
B. Fuentes, M. Alonso de Leciana, J. Masjun, J. Egido, P. Simal, F. Daz-Otero, A. Gil-Nuez, E. Dez Tejedor University Hospitals La Paz, Ramn y Cajal, Clnico San Carlos and Gregorio Maran, Madrid, Spain
Background: Small series reported the safety of intravenous tPA treatment in acute ischemic stroke (IS) related to extracranial internal carotid artery dissection (eICAD). However, no studies analysing specically the posible benets on outcome are available. Methods: Multicentre, prospective study conducted in 4 university hospitals. Consecutive IS patients were included. Stroke severity (NIHSS) and 3-months outcome (mRS) were compared: (1) tPA-treated patients with IS related to eICAD vs tPA-treated patients with other causes of stroke; (2) tPA-treated vs non tPA-treated eICAD patients. Results: 265 IS patients received intravenous tPA (7 of them with eICAD). There were no diferences in baseline NIHSS between patients with or without eICAD (14.3 vs 14.3; ns). However, NIHSS scores at 24 h and day 7 were signicantly worse in eICAD patients (17 vs 9.6 at 24h; 15.6 vs 7.3; p<0,05). No eICAD patients developed a signicant improvement at 24h (decrease in NIHSS 8 points) as compared to 67 (32%) of patients with other IS causes. When comparing tPA-treated eICAD (n=7) with non-treated eICAD patients (n=7), a trend to higher improvement in 24h and day 7 was found in the non tPA-treated eICAD group (NIHSS 7.6 vs 17 at 24h; 6.4 vs 15.6;p=0.205) with no differences in baseline NIHSS. At 3 months, 80% of tPA-treated eICAD and 20% of non-treated eICAD patients were dependent (mRS>2). Conclusions: Although intravenous tPA treatment in IS related to eICAD seems to be safe, the benet on outcome is signicantly minor than in other causes of IS, and possibly worse than in non tPA-treated eICAD.
S.C. Mukhopadhyay, G. Guha, M. Alam, A. Mukherjee, M. Hashini Green Cross Therapeutics Pvt. Ltd., India
Background: The efcacy and safety of L-Lysine Monohydrochloride (LMH) as angiogenic agent was studied in acute ischaemic stroke management. Material and methods: 120 patients (mean age 61.3 yrs) with CT/MRI evidence of ischaemic stroke was studied. 80 received LMH,1gm I.V. 6 hrly x 7 days, 40 did not receive LMH. Both LMH and non- LMH grs. did not receive thrombolytic therapy but had routine stroke management. Modied NIHSS,MRS and BI were used to assess clinical outcome, at baseline, 1 wk, 6wk, 3 mths and 6 mths. Basic haematological biochemical and urine analyses were done at baseline, 1 wk, 1 mth. MRI was done on a 1.5T whole body imager for T1 and T2 weighted, FLAIR, DWI, Angiography imaging sequences at baseline, 7th day and 6 wks. Adverse events noted. Result: Patient Inclusion time for therapy varied between 6-98 hrs. There was no mortality or signicant change in biochemical, hematological and urine analyses at any stage of therapy. Mean baseline Glasgow Coma Scale Score was 13.9. Imaging revealed acute infarct in anterior, middle and posterior cerebral artery territory, but most in MCA area (68.75%). Clinical outcome by NIHSS in LMH gr. revealed 15.05 3.52 at baseline, 7.95 2.31 at 1 wk, 4.14 1.16 at 6 wks., 1.81 0.88 at 6 months, vs. to 15.17 3.50 (baseline)12.17 2.92 (1wk), 8.61 1.85 (6wks), 4.33 0.84 (6months) in non LMH gr. with P Value 0.08(1wk), 0.02 (6 wk), 0.01 (6 months). Decrease in NIHSS become more pronounced as time progresses in LMH gr. Parallel improvements were seen in B.I at 90 days (95) and MRS (1). Infarct area in DWI/T2 imaging at 7th day showed remarkable improvement in LMH gr. compared to non- LMH gr. Discussion and conclusion: LMH signicantly increases both short term and long term clinical, functional and imaging recovery and was due to revascularization through angiogensis.Both anterior and posterior circulation improved equally. LMH can be given with much wider therapeutic window (upto 96 hrs) and has no adverse effect.
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AN EMERGENCY CLINICAL PATHWAY FOR THE MANAGEMENT OF CRITICAL STROKE PATIENTS: RESULTS OF A RANDOMISED CLINICAL TRIAL IN THE LAZIO REGION (ITALY)
A. De Luca, D. Toni, L. Lauria, M.L. Sacchetti, M. Barbolini, E. Puca, M. Ferri, M. Prencipe, G. Guasticchi Public Health Agency, Lazio Region, Rome, Italy
Background: Emergency Clinical Pathways (ECP) may play a crucial rule in the management of critical stroke patients. Objects To evaluate the effectiveness of introducing an ECP for the management of critical stroke patients in the emergency system of Lazio region (Italy). Methods: A cluster-randomized controlled trial (ISRCTN41456865) was designed to compare the practice of a test group of health professionals (HP) pertaining to Emergency Medical Services (EMS) and to Emergency Rooms (ERs), trained to use the ECP, with that of non trained EMS and ERs control groups. Groups were compared by chi2 or Fishers exact tests. Results: the two groups were similar at baseline as type and number of EMS ambulances and ERs. Over six months in 2005, 3298 suspected stroke patients were enrolled (1353 in the test groups: 573 by EMS and 780 by ERs; 1945 in the control groups: 485 by EMS and 1460 by ERs). Both the test groups referred to our hospital more suspected stroke patients than the control groups: EMS:219 (38.2%) vs 8 (1.6%) (p<0.05); ERs: 147 (18.8%) vs 116 (7.9%) (p<0.05). Conrmed ischemic stroke were (test groups: EMS =70, Ers=26; control groups: EMS=4, ERs=13). Among ischemic stroke patients eligible for i.v. thrombolysis (test groups: EMS=19, ERs=17; control groups: EMS=2, Ers=10), those referred by the test groups were treated more frequently than those of the control groups (EMS: 8 (42%) vs 0 (p>0.05); ERs:7 (41%) vs 2 (20%) (p>0.05). Discussion: Adherence to the ECP improved the appropriateness of stroke patient referral and treatment in the SU, particularly by the EMS. Hence, the educational program on early detection and timely transportation of stroke patients to the appropriate ward will be extended to all emergency health personnel.
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COMPARISON OF INTRA-ARTERIAL AND INTRAVENOUS THROMBOLYSIS FOR ISCHEMIC STROKE WITH HYPERDENSE MIDDLE CEREBRAL ARTERY SIGN
H.P. Mattle, M. Arnold, D. Georgiadis, C. Baumann, K. Nedeltchev, D. Benninger, L. Remonda, C. von Bdingen, G. Schroth, R.W. Baumgartner University Hospitals Bern and Zurich, Bern, Switzerland
Background: It is unclear whether intra-arterial (IAT) or intravenous (IVT) thrombolysis is more effective for ischemic stroke with hyperdense middle cerebral artery sign (HMCAS). The aim of this study was to compare IAT and IVT in such patients. Methods: Comparison of data from two stroke units with similar management of stroke associated with HMCAS, except that one unit performed IAT with urokinase and the other IVT with plasminogen activator. Time to treatment was up to 6 hours for IAT and up to 3 hours for IVT. Outcome was measured by mortality and the modied Rankin Scale (mRS), dichotomized at three months into favorable (mRS 0-2) and unfavorable (mRS 3-6). Results: 112 patients exhibited a HMCAS, 55 of 268 patients treated with IAT and 57 of 249 patients who underwent IVT. Stroke severity at baseline and patient age were similar in both groups. Mean time to treatment was longer in the IAT group (244 63 minutes) than in the IVT group (156 21 minutes; p=0.0001). However, favorable outcome was more frequent after IAT (n=29, 53%) than after IVT (n=13, 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 benecial than IVT in stroke
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REMOTE CEREBRAL HEMORRHAGE IN PATIENTS TREATED WITH INTRAVENOUS RT-PA
J. Mart-Fbregas, E. Martnez, M. Marqui, D. Alcolea, D. Cocho, M. Martnez-Corral, S. Martnez-Ramrez, M. De Juan, R. Marn, J.-L. Mart-Vilalta Hospital de la Santa Creu i Sant Pau, Spain
Background:The frequency, clinical presentation and prognosis of remote cerebral hemorrhage (rPH) after thrombolysis is poorly known. We report our experience in patients with ischemic stroke treated with intravenous rt-PA. Methods: A retrospective review of consecutive patients treated at our Hospital from 1999 to 2006, according to the ECASS II and the SITS-MOST (since 2004) criteria. A control Computed Tomography scan was routinely obtained in all patients within the rst 36 hours of treatment. Cerebral hemorrhagic complications were classied according to the ECASS study in hemorrhagic infarction (HI-1 and HI-2) and parenchymal hematoma (PH-1 and PH-2). rPH was dened as any extraischemic hemorrhagic lesion observed in the control CT. Neurologic worsening was dened as an increase in more than 3 points on the NIHSS score. A favourable outcome was dened as a score <2 on the Rankin scale. Results: We studied 163 patients (mean age 67.6 11.8 years, 57% of them were men). The frequency of hemorrhagic complications was: HI-1 (2.4%), HI-2 (4.9%), PH-1 (3.6%), PH-2 (2.4%), rPH (2.4%), rPH+PH-2 (0.6%). Patients with rPH (n=5) had a mean age of 70.4 8.1 and 40% were men. The median NIHSS score was 15 and mean time to treatment was 134 47.6 minutes. rPH were multifocal in 2, single in 2, and associated with a PH-2 in one patient. The location of rPH was lobar in 4 patients and in brainstem in one patient. rPH were symptomatic in 4 patients and asymptomatic in one. The neurologic worsening occurred 8, 14, 17 and 30 hours after rt-PA. The outcome was unfavourable in all patients, with 3 deaths. Discussion: Remote parenchymal hemorrhage is an uncommon complication after rt-PA (3%). It is usually lobar and symptomatic and has an unfavourable outcome.
rt-PA administered in distant hospitals using telemedicine tools imlemented in the RUN, compared to that of patients treated directly in the Besanon SU. Method: All patients admitted to the SU who were treated with rt-PA for ischemic stroke since 2005 were included. Patients were either treated in the SU after admission or were transferred to the SU after receiving rt-PA in a distant hospital. The decision to administer rt-PA in distant hospitals was made by the SU neurology team using tele rt-PA with telemedicine tools (video/imaging transfers). The thrombolysis decision respected contra-indication and followed the usual criteria for patients admitted within 3 hours or was guided by MRI ndings (after 3 hours). NIHSS scores were measured on admission, modied Rankin scores (mRS) were determined after treatment and at discharge as well as stroke causes and haemorrhagic transformations (HT). Results: Of 34 patients treated by rt-PA, 16 were in distant hospitals and 18 in the SU. Median treatment times were 3hrs in the SU (4hrs25 for those transferred there) and 2hrs30 in distant hospitals. Following rt-PA, 7/34 (20%) of patients developed HT, which was symptomatic in only 3 (8.8%), 1/3 of whom were treated in distant hospitals. mRS distribution was not statistically different between the 2 patient groups: mRS 0-1 in 6/34 (18%), of which 4/6 (66%) were in a distant hospital, mRS (2-3) in 9/34 (26%), of which 4/9 (44%) were in a distant hospital, mRS (4-5) in 16/34 (47%) of which 8/16 (50%) were in a distant hospital, and 3/34 (8%) of patients died, all of whom were treated in the SU. Discussion: No signicant difference was found concerning outcome or haemorrhagic complications between patients treated in the SU and distant hospitals. The study shows that tele rt-PA is safe and can improve patient outcome.
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DIURNAL FLUCTUATIONS IN THE EFFICACY OF RT-PA IN ACUTE ISCHEMIC STROKE
J. Gracia, S. Martinez-Ramirez, A. Ayo, D. Cocho, J. Mart-Fabregas, T. Segura Department of Neurology, University Hospital of Albacete, Albacete, Spain
Background: several studies have demonstrated that a circadian pattern of efcacy exists in myocardial acute infarction, with a greater efcacy in the evening. This fact has been explained for the presence of different levels of plasminogen-activator inhibitors and probably other haemostatic factors. There are not published data communicating this fact in intravenous thrombolytic therapy in stroke patients Objetives: to investigate possible diurnal uctuations in the efcacy of intravenous thrombolysis in ischemic stroke patients Methods: one hundred forty-eight patients with acute stroke treated with intravenous rt-PA were prospective enrolled in this study, conducted in two different hospitals between January 05 and May 06. Efcacy of thrombolysis was determined according to accepted clinical criteria: neurological response was assessed by NIHSS scale performed at 2 and 24 h after therapy, and long term functional outcome was evaluated by modied Rankin scale at three months. We compared the results dividing patients into 2 different groups, day (08-20 h.) and evening (20-08am) and again dividing into 4 intervals of 6 hours: 0-06am, 06-noon, noon-06 pm and 06-00. Results: The study population consists of 85 males and 63 females, age range 24-82 years (mean 68.47, SD 11.2). There were no demographic or clinical differences between the two cohorts from the different hospitals (74 patients every one) or among the pre-specied groups of time of thrombolysis. In the whole group, median NIHSS before treatment was 16 and median NIHSS at 2 h and 24 h were 11 and 9 respectively. There was no signicant relationship between the clinical or functional result of thrombolysis and the time of the treatment. Conclusions: Our results do not support the hypothesis that exist circadian variations in the response to thrombolytic therapy in ischemic stroke.
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A RETROSPECTIVE CLINICAL CASE-NOTE STUDY OF THE NUTRITIONAL MANAGEMENT PRACTICES OF STROKE PATIENTS IN A SCOTTISH POPULATION
S. Ray, B. Al Falasi, P. Rana, M.A. Haleem, M. Rajput, S. Atkinson University of Dundee, Dundee, United Kingdom
A Retrospective Clinical Case-note Study of the Nutritional Management Practices of Stroke Patients in a Scottish Population Background: Stroke is a leading cause of death and adult disability. Feeding in stroke remains important as a number of stroke patients are undernourished on admission and nutritional status declines during hospital stay, with increased morbidity and mortality. The Scottish Intercollegiate Guidelines Network, Quality Improvement Scotland and Council of Europe provide guidance for nutritional management of patients with dysphagia. This study aimed to assess the impact of guidelines on the nutritional management of stroke patients. Methods: Retrospective case note analysis was done for ischemic strokes admitted to Ninewells Hospital, Dundee. This audit-type study looked at a 3-month period prior to the establishment of guidelines and compared with 3 months post guideline. Results: There were 126 and 204 suspected cases of stroke in Periods 1 and 2 respectively. The corresponding number of CT diagnosed strokes was 78 and 107 respectively. Out of these, 33 records were retrieved for patients in Period 1 and 43 in Period 2. The weight recording rates were 27% in Period 1 vs. 35% in Period 2. One- fth of those weighed were monitored in Period 1 compared to one-third in Period 2. Discussion: There appear to be specic barriers to the implementation of guidelines in daily practice. A continuing clinical nutrition education programme as an adjunct to guidelines for stroke carers may help to overcome these limitations.
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NO PREVIOUS EXPERIENCE WITH INTRAVENOUS THROMBOLYSIS FOR ACUTE ISCHAEMIC STROKE DOES NOT INFLUENCE THE PROPORTION OF PATIENTS TREATED
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A. Kobayashi, M. Skowronska, T. Litwin, A. Czlonkowska Institute of Psychiatry and Neurology, Medical University of Warsaw, Warsaw, Poland
To determine the eligibility of ischaemic stroke patients admitted to the 2nd Department of Neurology for intravenous thrombolysis, identify the major exclusions and assess if changes of the in-hospital pathway and informative campaign in the local community and medical services can increase the number treated. To establish if lack of previous experience with thrombolytic treatment or trials is predictive of a low proportion of patients treated. A survey of the database of stroke patients admitted during the rst 30 months
IS REMOTE TELE RT-PA TREATMENT SAFE? THE EXPERIENCE OF THE EMERGENCY NEUROLOGY NETWORK IN FRANCHE-COMTE (RUN)
E. Vidry, E. Medeiros, E. Revenco, F. Vuillier, P. Decavel, T. Moulin University Hospital Besanon, Besanon, France
Background: The only validated treatment for acute ischemic stroke is thrombolysis with intravenous alteplase (rt-PA) performed in a stroke unit (SU). Its efciency is strongly time-dependent. Our aim was to evaluate the efciency and safety of
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following introduction of intravenous thrombolysis for acute ischaemic stroke in order to identify eligible patients. This included patients admitted within 2 hours of symptom onset (assuming a 1-hour door-to-needle time), age < 80 years, National Institute of Health Stroke Scale (NIHSS) score from 5 to 22, seizures at onset, platelet count >100,000 per ml, glycaemia from 50 to 400 mg per dl and international normalized ratio (INR) <1.6. We have compared the number of patients eligible with the number treated. 745 patients with acute ischaemic stroke were admitted. 18.4% were admitted within 2 hours of onset, 71.0% were aged under 80, 55.4% had an NIHSS score between 5 and 22. 96.1% had INR < 1.6, 98.9% had a platelet count higher than 100,000 per ml, 99.4 had blood glucose between 50 to 400 mg per dl and 97.4% had no seizures at onset. After adjusting for all inclusion criteria 7.1% of patients were found potentially eligible and 8.7% were actually treated (p=0.250). Out of the 65 treated patients 63.1% were independent after 3 months, 16.9% had died and none had a symptomatic intracranial haemorrhage. The proportion of ischaemic stroke patients treated with intravenous thrombolysis in a previously inexperienced centre is not lower than in other centres and countries were this treatment is provided for a longer period of time. The number of patients treated is higher than estimated mainly due to organizational changes introduced in our centre.
Results: After 5 days of using aspirin plus cilostazol, the extent of PAC-1 (58.5 19.2%, P<0.005) on activated platelet was signicantly reduced compared with the baseline (71.0 12.1%). But there was no any difference (34.1 13.3 vs 30.9 10.5%) in aspirin only. In case of P-selectin, both aspirin and cilostazol group showed any differences of their expressions after 5 days of initiating treatment. Compared clinical progression between two groups, there were no any signicant changes of NIHSS in the observation period. Conclusions: In this study, we showed that the combined regimen of aspirin and cilostazol had benecial effect to reduced PAC-1 activity on activated platelets in acute ischemic stroke. However, this regimen did not showed better clinical outcome than aspirin only. Therefore, we need the more detailed future study about the clinical benet of cilostazol in acute ischemic stroke.
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CARDIO-PROTECTION IN ACUTE STROKE: HYPOTHESIS FOR INTERVENTION FOR MORTALITY REDUCTION
J.C. Sharma, I.N. Ross, M. Vassallo Kings Mill Hospital, United Kingdom
Background: Measures of damage limitation for acute stroke have not produced substantial benet to reduce stroke mortality. Search continues for measures to reduce stroke mortality. Methods: Literature review for inuence of cardiovascular factors, specically the value of NT proBNP (a sensitive index of cardiac impairment) for stroke mortality, Results: Cardiovascular factors, in particular cardiac failure, adversely inuence acute stroke mortality. Recent studies reveal that Troponin and NT-proBNP are elevated in acute stroke patients, in response to the activated Renin-AngiotensinAldosterone-System and other neurohumoral changes, as a protective mechanism for sympatho-inhibitory activity. Elevated NT-proBNP has been reported to be associated with higher short and long term mortality. In one study all patients who died at 4 months had NT-proBNP levels above the median, no patient with NT-proBNP below the median value died. Two studies revealed that NT-proBNP is more signicant than clinical stroke severity for stroke mortality. Raised Troponin indicates myocardial injury, raised NT-proBNP indicates occult cardiac impairment in acute stroke patients. Protection of myocardium in stroke patients may be possible by the use of drugs such as beta-blockers and the drugs acting on RAAS. Reduction of mortality in studies of candesartan (ACCESS) and prior betablockers is one such example. Conclusion: Some stroke patients die due to occult cardiac impairment in acute phase due to common risk factors. This relationship between brain and heart needs evaluation. Protection of heart with currently available or new drugs in acute strokes is worth investigating since this intervention could be applied to a large proportion of acute stroke patients over a wide time window.
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NEUROPROTECTIVE EFFECT OF XG-102 ALONE OR IN COMBINATION WITH TISSUE PLASMINOGEN ACTIVATOR
K. Wiegler, C. Bonny, D. Coquoz, L. Hirt Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
Background: XG-102 (formerly D-JNKI1), a TAT-coupled dextrogyre peptide which inhibits the c-jun N-terminal kinase (JNK), is a powerful neuroprotective drug in rodent models of cerebral ischemia (Borsello et al., Nat Med, 2003; Hirt et al., Stroke, 2004) when administered by intra-cerebro-ventricular injection (i.c.v.). We studied the feasibility of systemic administration. We also evaluated in vitro the effect of combined administration of XG-102 and tissue plasminogen activator (TPA), known to exacerbate excitotoxicity. Methods: Young adult male ICR-CD1 mice were subjected to 30 min transient suture MCAo. XG-102 was administered intravenously (i.v.) 6 or 9 hours after ischemia. Neurological outcome was evaluated by neurological scores and rotarod tests. Rat organotypic hippocampal slice cultures subjected to oxygen (5%) and glucose deprivation (OGD) for 30 minutes. Results: XG-102 administered i.v. 6 hours after ischemia onset signicantly reduced the infarct volume at 48 hours. The lowest dose with maximal neuroprotection, was 0.3 g/kg, which reduced the infarct volume from 6219mm3 (n=18) for the vehicle-treated group to 189mm3 (P<0.001, n=5). Administration of XG-102 (1mg/kg) 9 hours after MCAo did not signicantly reduce the infarct volume. The behavioural outcome after transient MCAo was also considerably improved. In organotypic slices, TPA alone (0.9 g/ml) administered immediately after OGD, 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 (4919%, n=20 vs 1214%, n=24). Conclusion: XG-102 is a powerful neuroprotectant in our mouse stroke model, and can be administered i.v. up to 6 hours after MCAo. In vitro XG-102 can induce neuroprotection also in presence of TPA. Funding: CTI #7057.2
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A NEW DEVICE FOR THE TREATMENT OF THROMBO-EMBOLIC STROKES
G. Pearce, N.D. Perkinson, J.H. Patrick ORLAU, RJAH Hospital Oswestry, United Kingdom
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 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 (W0206120464). The unique interior surface of this device facilitates controlled removal of blood clots in arteries that block during thrombo-embolic strokes. Our device has an inner surface that generates a helical vortex which actually removes 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. In-vitro experimental results (Pearce et al 2006a, 2006b, 2006c, 2006d, 2007) show differences between uid ow patterns when uid is sucked through the device (mounted within the catheter) compared to uid sucking through a simple catheter. We have also established that the device removes clots quicker and with less volume of blood being removed, than with simple catheter being use. Methylene blue dye has been used to effectively demonstrate the mechanism of the device. Pearce and Perkinson, 2007 have also undertaken radial ow rates within the GP clot removal device. We have used both articial clots and actual blood clots (abattoir sourced) to show clot removal in plastic tubes and porcine abattoir arteries. At vacuum suction pressures of 66 KPa, when using the GP clot removal device (of internal diameter 2.5 mm) occlusive clots of about 1cm long are removed.
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EFFECTS OF ASPIRIN PLUS CILOSTAZOL TO REDUCE THE PLATELET ACTIVATION IN ACUTE ISCHEMIC STROKE
J.-K. Cha, S.S. Kim, H.W. Jeon, Jk Cha College of Medicine, Dong-A University Hospital, Busan, South Korea
Background: Aspirin has been still considered to be the most evidenced therapeutic regimen to prevent the recurrence of ischemic events in acute ischemic stroke. Recently, Cilostazol, a Phosphodiesterase III inhibitor, has been known as useful antiplatelet agents to curb the progression of atherosclerotic ischemic stroke. In this study, we investigated the usefulness of cilostazol on the top of aspirin to regulate the expression of P-selectin and PAC-1 on activated platelet in acute ischemic stroke. Methods: We analyzed seventy-seven patients with acute ischemic stroke (<72 hrs). Among them, 50 patients were prescribed aspirin 100 mg per day and another 27 aspirin 100 mg plus cilostazol 200 mg per day. All patients were serially valuated the expression P-selectin and PAC-1 on activated platelets at admission day and 5 days later. We also serially measured clinical progression by using NIH stroke scale at same time period.
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RAPID ALTERNATE DAY DOSE TITRATION OF DIPYRIDAMOLE IS WELL TOLERATED IN PATIENTS WITH ISCHEMIC STROKE
J.L. Pascual, H.M. Chang, M.C. Wong, C.P. Chen National Neuroscience Institute, Singapore General Hospital Campus, Singapore, Singapore
Background: The combination of aspirin (ASA) and dipyridamole (DIP) has been shown to be efcacious in the secondary prevention of acute ischemic stroke of arterial origin. However, DIP-induced headache is common and may affect compliance. We aimed to determine the feasibility and tolerability of rapid dose titration of DIP in Singaporean acute ischemic stroke patients. Method: Observational study of non-aphasic ischemic stroke patients requiring anti-thrombotic therapy and without hypersensitivity or contraindication to DIP. Patients were allocated to either open label DIP starting at 25mg tds followed by75mg tds and nally 150mg tds in either every other day(EOD) or week (EOW) titration regimes at the choice of the attending physician. Follow-up was at 1 month and occurrence of headache or other adverse effects, as well as any reason for stopping the drug were documented. Results: 188 acute ischemic stroke patients were started on ASA + DIP over a 6-month period. There were 113 patients on EOD and 75 on EOW titration schemes. No signicant differences in baseline characteristics between treatment groups were seen. The EOW regimen was associated with more adverse events (22% vs. 9%, p < 0.05), predominantly headaches (72%), leading to more drug discontinuations(12% vs 5%, p < 0.05). The majority of headaches in the EOD group (70%) occurred at 25 mg tds, while in the EOW group, patients had headache at 75mg tds or higher (88%). Discontinuation rates were similar for both groups(13% vs 9%, p = 0.19). Discussions: Rapid titration of DIP is well tolerated. These ndings need further conrmation with randomized trials but may form the basis of a treatment regime to be considered in acute stroke trials.
Methods: We prospectively included 14 patients treated with IV rt-PA within 3 hours after stroke onset (mean age 62.912.2 years, 10 (71%) male, mean NIHSS score at admission was 125.8). A blood sample were obtained before and immediately after thrombolysis, in 24 hours, in 3 and 7 days after IS onset to measure markers of brinolysis [Plasminogen Activator Inhibitor-1 PAI-1 (IU/ml), normal value 1-7] and endothelial function [Matrix Metalloproteinase-9 MMP-9 (ng/ml), normal value 169-705]. Results: Before thrombolysis increased plasma level of PAI-1 (14.117.9) and decreased level of MMP-9 (102.9106.8) was observed. After thrombolysis we revealed the tendency towards decreasing PAI-1 (6.811.2) and increasing MMP-9 (136166.1). In 24 hours, 3 and 7 days after IS onset level of PAI-1 insignicantly increased (7.25.1; 10.318.1 and 10.611.6 respectively) and MMP-9 level decreased (67.998.7; 35.17.5 and 54.326.6 respectively). Conclusion: IV rt-PA therapy in stroke patients may reduce the activity antibrinolytic system and cause short-term increase MMP-9 level.
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ANCROD IN A SIX HOUR TIME WINDOW? EVIDENCE FOR AND AGAINST EFFICACY
D.G. Sherman, D.E. Levy University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
The publication in Lancet (2006;368:1871-78) of the unsuccessful European ancrod trial (ESTAT), where the treatment began up to 6 hours after stroke onset, concluded that compared with the positive results of STAT (JAMA 2000;283:2395-2403) with its 3-hour window, ESTATs results suggested that ancrod was ineffective if started later 3 hours. Although not published, ancrods efcacy was marginally better than placebos at 3-6 hours (43.2% vs. 42.3%) but was substantially worse at 0-3 hours (33.3% vs. 43.3%), inconsistent with attributing ESTATs poor results to its later time window. Pooled analysis of the North American data from STAT and an earlier 6-hour study (Stroke 2004:25:291-97) shows that efcacy vs. placebo is virtually identical in 0-3 hour (43.0% ancrod vs. 36.1% placebo) and 3-6 hour patients (43.4% vs. 34.1%) with no signicant interaction of time-to-treat on ancrod response (p=0.69). Therefore, explanations other than enrollment beyond 3 hours must underlie the unfavorable ESTAT results. These include the fact that higher blood pressures were permitted in ESTAT (up to 220/120) than STAT (185/105). Symptomatic intracranial hemorrhages occurred in 10.1% of ESTAT patients with systolic BPs of 185-220 vs. 6.9% of those with lower pressures. The ESTAT publication states that deaths rarely occurred in patients with symptomatic ICH (4/44 ancrod vs. 2/9 placebo), but the actual data for 90-day mortality are 26/44 ancrod and 4/9 placebo. Other explanations for the unsuccessful ESTAT results include age imbalance (69.3 ancrod vs. 67.6 placebo, p<0.03) and a 23% higher mean patient ancrod dose in ESTAT than STAT. The nal answer on ancrods efcacy beyond 3 hours awaits conclusion of the two currently-enrolling trials with 6-hour windows.
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COMBINED IV ABCIXIMAB/IA TPA TREATMENT OF ACUTE BASILAR ARTERY OCCLUSION
U. Becker, G. Urban, R. von Kummer, G. Gahn University Hospital Dresden, Dresden, Germany
Background: Acute basilar artery occlusion (ABAO) is a disease with high mortality and morbidity. The optimal therapeutic approach remains still unclear. We intended to analyze the rate of recanalization, complications and outcome in patients with combined IV Abciximab/IA tPA treatment. Methods: Following a prospective protocol, patients, with ABAO received an IV bolus of Abciximab (0,25 mg/kg bodyweight), followed by a 12 hours infusion of Abciximab (0,125 mg/kg bodyweight). Immediately after the bolus, we performed DSA and administered tPA locally (up to 40 mg or until recanalization was achieved). We investigated the rate of recanalization, complications and the clinical course by standardized telephone interview after 6 months. Good outcome was dened as a mRS < 3. Results: Since 2003, we included 16 patients with ABAO, mean age was 60.9 years, 5 female, 11 male. Mean GCS ad admission was 9.4 (4-15), mean time window 8.2 hours (3-25). Recanalization was achieved in 13 patients (87%), symptomatic hemorrhage occurred in 2 patiens (12%). Survival after 6 months was achieved in 7 out of 16 patients (44%), 3 of them had a good outcome (19%). Discussion: Regarding survival and good outcome we observed similar results compared to other treatment regimes, however, the rate of recanalization was higher. We are encouraged to treat more patients with the combination of Abciximab and tPa to nd out whether morbidity can be reduced.
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PERFUSION-CT GUIDED INTRAVENOUS THROMBOLYSIS AT 3 TO 6 HOURS: FEASIBILITY AND SAFETY STUDY IN 15 PATIENTS
P. Michel, M. Wintermark, M.D. Reichhart, F. Vingerhoets, P. Maeder, R.M. Meuli, J. Bogousslavsky Centre Hospitalier Universitaire Vaudois, Switzerland
Objective: To show the feasibility, safety and possible effectiveness of applying perfusion-CT (PCT) for patient selection for intravenous thrombolysis with rtPA 3 to 6 hours after onset of acute ischemic stroke. Methods: Between 9/2002 and 1/2006, patients aged 18-80 with a NIHSS of 6-22 arriving too late in our stroke center for treatment within 3 hours were eligible for treatment. They had to have a minimal penumbra size for a given infarct (core) size in the MCA-territory on PCT, according to a linear progressive cut-off table. This model was designed for maximal potential benet: the smaller the core size is, the smaller the lower limit of the penumbra needs to be for inclusion. The maximal upper size for inclusion is a core of 30% of the MCA territory. The primary outcomes were symptomatic intracranial haemorrhage (ICH) and mortality at 90 days. Secondary outcomes were independence at 3 months (modied Rankin scale 0-2) and recanalisation rates at 24 hours measured by CT-angiography. The patients were compared to 75 consecutive patients thrombolyzed in our center within 3 hours based on NINDS-criteria (independently of their PCT results). Results (median standard deviation): 15 patients fullled the clinical and PCTcriteria. Age and NIHSS were similar in both groups. Median time to thrombolysis
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DYNAMICS OF MARKERS OF FIBRINOLYSIS AND ENDOTHELIAL FUNCTION IN PATIENTS WITH ISCHEMIC STROKE TREATED WITH INTRAVENOUS RT-PA
N.A. Shamalov, A.S. Kireev, N.A. Pryanikova, G.R. Ramazanov, A.G. Kobylyansky, I.A. Grivennikov, V.I. Skvortsova Federal Stroke Institute, Moscow, Russian Federation
Background: The aim of this study was to assess the dynamics of the markers of brinolysis and endothelial function in patients with ischemic stroke (IS) treated with intravenous (IV) rt-PA.
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was 255 ( 45) min. in the 3-6 hour group and 152 (34) min. in the comparison group. Symptomatic intracranial hemorrage was similar (6.7% vs. 6.7%) and 90-day mortality (6.7% vs. 10.7%) were similar. Good outcome was seen in 60% and 52% respectively (non-signicant), and 24 hour recanalisation rates were 60% and 50% (non-signicant). Conclusion: The time window for intravenous rtPA can safely be extended from 3 to 6 hours if perfusion-CT shows salvageable tissue and no extensive core volume. Clinical outcome and recanalisation rates are comparable to 0-3 hour thrombolysis based on plain CT.
Conclusion: Based on our initial experience, we conrm that intravenous thrombolysis carry a substantial benet for the patients with acute IS. However, we also uphold that one should strictly follow the thrombolysis protocol in order to avoid possible complications.
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INTRA-ARTERIAL THROMBOLYSIS IN ACUTE STROKE DUE TO MCA OCCLUSION
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I. Henriques, A. Calado, R. Roque, A. Bandeira, I. Fragta, C. Ribeiro, J. Candido, J. Reis Centro Hospitalar de Lisboa - Zona Central, Lisboa, Portugal
Background: Standard treatment for acute ischemic stroke in eligible patients is intravenous (ev) thrombolysis, but efcacy is limited by low rates of recanalization. Intra-arterial (IA) thrombolysis, combined transcranial ultrasound, or clot retrieval devices are being evaluated to improve thrombolysis efcacy. We prospectively studied consecutive patients with acute MCA occlusion submitted to IA rt-PA thrombolysis in the rst 6 hours after symptoms onset. Methods: We included patients not eligible for ev thrombolysis according to ECASS criteria. We excluded patients with vertebrobasilar stroke and with previous concomitant ev thrombolysis. Symptomatic cerebral hemorrhage was considered if associated with clinical deterioration. Major neurological improvement was dened as a reduction of more than 7 points in NIHSS after procedure. Excellent or good outcome was considered if modied Rankin scale was 2 or less. We studied 15 consecutive patients referred to our stroke unit (5 male) with median age of 72 (43 78) years. Results: Median NIHSS at admission was 19 (15-25), and 12 at discharge (2-25). MCA recanalization was total in 33% (TIMI grade 3) and partial (TIMI grade2) in 67%. In ve patients, recanalization was achieved together with a mechanical thrombectomy device. Hemorrhagic transformation was present in 7 patients (46%), and symptomatic in 5 (33%). Three patients died (20%) in the rst 72h and none after. At discharge, excellent or good outcome was observed in 27% of the patients. Discussion: In this group of large MCA infarcts not eligible for ev thrombolysis, total recanalization was achieved in 33% and partial in 67%. Mechanical thrombectomy device was used together with IA rt-PA thrombolysis in 33% of our patients. Independency was achieved in 27% at discharge. Since patients not eligible for ev thrombolysis with large MCA infarcts have a very high rate of disability and mortality, IA thrombolysis alone or together with mechanical device can be an alternative to current treatment. Randomized trials may conrm safety and efcacy in larger series.
SYSTEMIC THROMBOLYSIS WITH ABCIXIMAB IN ACUTE ISCHEMIC STROKE DUE TO ANTERIOR CIRCULATION INFARCTION BEYOND THE 3-HOUR TIME WINDOW
K. Barlinn, U. Becker, G. Gahn University of Dresden, Dresden, Germany

Background: Intra-arterial treatment of ischemic stroke using pro-urokinase is the only recommended therapy within 6 h of onset of symptoms in patients with occlusion of the middle cerebral artery (MCA). Results from other trials suggested that the glycoprotein IIb/IIIa antagonist Abciximab might also be useful in treatment of ischemic stroke in patients without MCA occlusion beyond the 3 h time window. We aim to evaluate the safety and efcacy of Abciximab at standard dose in patients with acute ischemic stroke without MCA occlusion beyond the 3 h time window. Methods: From May 2002 to January 2005, we retrospectively studied 7 patients with acute ischemic stroke attributed to the anterior circulation without MCA occlusion who were treated with Abciximab (0.25mg/kg bolus, followed by 0.125 g/kg/min x 12h) beyond 3 hours from onset of symptoms. All patients had whether a progression or a uctuation of focal neurological symptoms. MCA occlusion was excluded by computed tomography angiography (CTA). Intracranial bleeding complications were evaluated by CCT at day 1. National Institutes of Health Stroke Scale (NIHSS) was assessed at baseline and at discharge, modied Rankin Scale (mRS) was obtained at discharge. Results: Mean onset to treatment time was 9 (range 4,5-48) hrs. No symptomatic intracranial haemorrhage occurred. There were no cases of extracranial bleeding complications. One patient had myocardial ischemia diagnosed. All patients (100%) improved clinically from mean NIHSS 7 (range 2-15) to 2 (range 0-10). The rate of favorable outcome (mRS 0-2) at discharge was 57% (4 of 7 patients). Discussion: Regarding clinical outcome, the absence of symptomatic ICH and other bleeding complications, Abciximab seems promising in late thrombolysis of acute ischemic stroke in selected patients without MCA occlusion and progression or uctuation of symptoms. Nevertheless further prospective clinical trials are necessary to select patients who benet from treatment beyond the 3 h time window.
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ARE POLYAMINE LEVELS USEFUL IN PREDICTING OUTCOME FOLLOWING ACUTE STROKE?
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M.J. Macleod, P. Mahendra, M. Bruce, H.M. Wallace University of Aberdeen, Aberdeen, United Kingdom
Background: It is difcult to predict stroke outcome on infarct size and stroke severity alone. There is therefore interest in markers which might predict outcome following acute stroke. The endogenous polyamines, putrescine, spermidine, and spermine, are found in high concentrations in the brain and have a regulatory role in apoptosis. When neuronal cells are damaged polyamines are mopped up by erythrocytes. One small clinical study in acute stroke has suggested red cell polyamine levels may correlate with infarct size and severity. The aim of this study was to replicate and extend these ndings in a group of patients admitted with an acute cortical infarct of less than 48 hours duration. Patients with signicant comorbidity or unable to give consent were excluded. Methods: Bloods and clinical assessment including NIHSS were performed at admission, 12, 24 and 48 hours (depending on time of admission after onset of symptoms), 72 hours, 7 days, 14 days and 28 days. Samples were also available for 8 control subjects. Erythrocytes were separated and washed with isotonic NaCl, haemolysed with distilled water and extracted with HClO4. The extract was neutralised with KOH and frozen at -40 oC. Analysis of polyamines was performed using reverse phase HPLC and quantication by uorescence detection. Results: Data from 10 patients is presented (6M/4F). Average age was 71.6 years (8.9). Polyamine levels vary considerably between patients, but in all but one patient (who had a normal CT scan) were higher than normal control subjects at 7 days (p<0.008). Patients had a signicant rise in polyamine levels between baseline (mean 8.75.4) and 7 days (mean 22.38.3), p<0.032. There was a correlation between total polyamine levels and NIH SS at day 7 post stroke (r=0.654, p=0.04). Discussion: These ndings conrm that polyamine levels are elevated after an ischaemic cortical stroke, and peak at 7-14 days. If the correlation with NIHSS is
SETIS - SERBIAN EXPERIENCE WITH THROMBOLYSIS IN ISCHEMIC STROKE
D.R. Jovanovic, Lj. Beslac-Bumbairevic, G. Toncev, M. ivkovic, for SETIS Group Institute of Neurology, Clinical Center of Serbia, Belgrade, Yugoslavia
Background: First intravenous thrombolysis in IS in Serbia was carried out in February 2006. We present our preliminary one year experience with intravenous thrombolysis in treating IS patients. Methods: All patients with IS treated with intravenous thrombolysis in Serbia were included in the study. The time of stroke onset, rst neurological exam, CT exam and beginning of therapy were recorded. The early CT signs of ischemia were graded by the ASPECTS score. Neurological decit was assessed with NIHSS score and functional outcome with modied Rankin Scale (mRS). Results: During one-year period 24 patients with IS were treated with intravenous thrombolysis in three tertiary care centers. Average age of patients was 50.5 years, ranging 18 to 78, with 62% of them younger than 55. Median time from symptom onset to hospital door was 52.5 minutes, median time door-to-CT was 37.5 minutes, and time from symptom onset to treatment was 165 minutes. Early CT signs of ischemia were present in 62% of patients with median ASPECTS score 9. Median initial NIHSS score was 14 with its decline during rst 24 hours for at least 4 points in 50% of patients. Symptomatic intracerebral hemorrhage was present in two patients. After 30 days of follow-up, 33% of patients had favorable outcome (mRS < 1), 29% of patients had poor outcome (mRS 4-5) and two patients died, one with malignant MCA infarction with symptomatic parenchymal hemathoma, and the other patient with signs of heart insufciency.
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conrmed in larger studies, polyamines may be a useful prognostic indicator after an ischaemic stroke.
Long-term outcome of stroke 1 Long-term outcome of stroke
and 0.831 (95%CI 0.812-0.850), and in the end of follow up at 10 years 0.464 (95%CI 0.410 to 0.518) and 0.290 (95%CI 0.259 to 0.321) respectively, (log rank test=24.23, p=0.0001). No differences were seen in recurrence rates (log rank test=0.17, p=0.68). Conclusion: Obesity in patients with acute stroke is associated with better short and long-term survival. The mechanisms involved in obesity-related neuroprotection in acute stroke demand further investigation.
Long-term outcome of stroke
TIME SPENT AT HOME POST STROKE: HOME-TIME A MEANINGFUL AND ROBUST OUTCOME MEASURE FOR STROKE TRIALS
J. Dawson, T.J. Quinn, J.S. Lees, T.-P. Chang, M.R. Walters, K.R. Lees Gardiner Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
Background: Assessment of stroke outcome requires a measure of functional recovery eg. modied Rankin scale. Such instruments are prone to bias and variation in clinical application. Approaches to improve rigour often increase complexity without similar increases in clinical utility. Length of stay in hospital and nursing homes is strongly related to incremental increases in mRs score but is weakened as an outcome measure because fatal outcomes tend to shorten stay. We examined duration of stay in the patients own home or chosen environment Home-time - as an alternative outcome more likely to show a graded response with less confounding by survival issues. Methods: We examined prospectively collected resource use data from the GAIN International trial. We assumed Home-time if patients returned to their own or relatives home after stroke, restricting analysis to the rst 90 days and using ANOVA with Bonferroni contrasts of adjacent mRS categories. Results: We had full outcome data from 1717 of 1788 intent to treat patients. Mean age SD was 70 12 years; 737 were female. Mean initial NIHSS was 136 and 321 had primary intracerebral haemorrhage. Increasing Home time was associated with signicantly improved mRs scores (p<0.0001; table).
mRs 0 N Home-time duration (mean) 95% CI 197 mRs 1 268 mRs 2 205 mRs 3 214 mRs 4 366 mRs 5 143 mRs 6 (death) 324 1.0 p=0.0003 0.31.6
BIOCHEMISTRY VERSUS CLINICAL SEVERITY OF ACUTE STROKE: SIGNIFICANCE OF NT PROBNP TO PREDICT ONE YEAR MORTALITY
J.C. Sharma, I.N. Ross Kings Mill Hospital, United Kingdom

Background: We have investigated the value of biochemical measurements to predict stroke mortality. Methods: Logistic regression was used to investigate signicant variables of the biochemical and clinical parameters in 125 previously independent (mRS <4) acute stroke patients for mortality at one year. Results: Age range 40 to 95, mean 7312, Female:Male 63:62. 20 patients had died at one year. Results are given for means SD between dead and alive patients using Students t test. There was no signicant difference in mean creatinine 11132 vs 10141, p=0.32, eGFR 54 vs 62, p=0.08; oxygen saturation97.0 vs 97.0, p=0.60; HbA1C 6.010.7 vs 6.31.3, p=0.38; glucose 6.61.4 vs 7.02.8, p=0.53; serum osmolality 30611 vs 30318, p=0.52; cholesterol 4.51.1 vs 4.91.2, p=0.16 and HDL 1.40.7 vs 1.50.7, p=0.42. There was a signicant difference in urea 10.14.6 vs 7.54.4, p=0.01; ALT 133.3459 vs 3033, p=0.02; alk phosphatase 140116 vs 91.645, p=0.002; NT proBNP 9801249 vs 125244, p<0.001; Barthel Index 2.22.5 vs 7.14.9, p<0.001; Scandinavian stroke scale (SSS) 2214 vs 3512, p<0.001 and NT proBNP log 61.7 vs 3.51.7, p<0.001. Logistic regression analysis using the signicant variables from univariate analysis revealed that NT proBNP was the most signicant variable to predict mortality Wald 17.9, p<0.001 followed by SSS wald 5.7, p=0.02. Other biochemical variables and Barthel Index were not signicant to predict mortality. Conclusion: NT proBNP, a measure of cardiac impairment, is the only signicant biochemical variable to predict one year mortality, more signicant than the measures of clinical stroke severity. This provides an opportunity for intervention to reduce stroke mortality.
72.6 64.1 45.9 31.5 11.2 9.1 * * * * p=0.37 69.975.5 61.367.0 41.849.9 27.535.6 8.913.4 5.512.8
Home time = days spent living electively in existing setting, within the rst 90d. *p<0.0001 compared to preceding column
4
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
THE IMPACT OF OBESITY ON SHORT AND LONG-TERM OUTCOME AFTER FIRST EVER ACUTE STROKE. THE STROKE OBESITY PARADOX?
J. Vivancos, J. Alvarez-Sabn, A. Lpez-Farr, E. Martnez-Vila, J. Montaner, T. Sobrino, J. Castillo, on behalf of The MITICO Study investigators Hospital Universitario de La Princesa, Stroke Unit, Neurology Service, Madrid, Spain
Background: The MITICO study primary objective is to determine the prognostic value of inammation molecular markers (IMM) in vascular recurrence risk. As a secondary objective, we studied the inuence of antiplatelet, statins and antihypertensive drugs on IMM prole. Methods: Multicenter prospective observational study, including non-anticoagulated ischemic stroke patients (within 1 to 3 months of stroke onset), with no inammatory processes. Four visits were performed during the one-year of follow-up to identify vascular death (VD) or vascular event (VE). Blood samples were obtained at baseline visit for further determination of brinogen, high-sensitive C-reactive protein, IL-6, IL-10, ICAM-1, VCAM-1, MMP-9 and cellular bronectin. Results: From 965 included patients (recruited in 59 hospitals), 780 subjects (67.511.2 years, 33.6% female) were valid for the main analysis. One-hundred and three patients (13.2%) showed a new VE and 116 patients (14.9%) either a VE or VD (66.4% stroke, 21.5% coronary and 12.1% peripheral). Only 21 patients were not taken antiplatelet drugs. Statins treatment was associated with reduction of VE and VD (47.4% vs 28.2%. p=0.001). None of them modied the one-year functional outcome. There were signicant changes between baseline and nal plasma levels of IL6, MMP-9 and cellular bronectin in statins-treated patients in comparison with non-treated patients (IL6: 0.9 [-1.5, 6.5] vs 0.3 [-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; cFn: 4.4 [-4.8, 14.7] vs -6.1 [-10.8, 3.6] p<0.0001). Discussion: Statins treatment is associated with a signicant reduction of VE and VD. Statins treatment inuences IMM by lowering IL6, MMP-9 and cFn plasma levels along follow-up period.
S. Scalidi, K. Xynos, T. Pappa, J. Zafeiriou, N. Mentis, N. Kokolakis, K. Vemmos Acute Stroke Unit, Dept. of Therapeutics, Univ. of Athens Med. School, Alexandra Hosp., Halandri, Greece
Background: Obesity has long been implicated as a higher morbidity and mortality risk factor for cardiovascular disease. However, its potential role and pathophysiological signicance on the outcome of patients after an acute stroke has not been yet established. Our aim was to assess short and long term survival as well as recurrence rate of obese patients suffering an acute stroke, compared to that of the non-obese population. Methods: We prospectively studied 1998 patients with rst-ever acute stroke. Apart from the stroke risk factors and body mass index (BMI), we scored consciousness level and neurological decit on admission by means of the Glasgow Coma Scale (GCS) and the Scandinavian Stroke Scale (SSS). Cox regression and Kaplan-Meier method was used in order to estimate the impact of obesity on survival and recurrence. Results: In our study population, 473 patients (23.7%) were classied as obese (BMI>30) and 1525 (76.3%) as non-obese (BMI<30). Obese patients had higher proportion of hypertension, diabetes and cholesterol. No signicant difference in age, GCS and SSS was observed between groups. After adjustment for age, sex, risk factors and stroke severity, obesity was an independent prognostic factor for survival Hazard Ratio=0.637 (95%CI 0.527-0.770), p=0.0001. Cumulative survival for obese and non-obese patients was: after 1 month 0.895 (95%CI 0,864-0.921)
Poster Session Long-term outcome of stroke
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MORTALITY AND VASCULAR MORBIDITY AFTER ISCHEMIC STROKE AT A YOUNG AGE. A CROSS-SECTIONAL STUDY IN WESTERN NORWAY
U. Waje-Andreassen, H. Naess, L. Thomassen, G.E. Eide, C.A. Vedeler Haukeland University Hospital, Bergen, Norway
Background: The aims of this population-based long-term follow-up study were to obtain data on cardiovascular mortality and recurrent stroke, coronary disease (CD) and peripheral artery disease (PAD) for long-term survivors of ischemic stroke and controls. Methods: After a median observation time of 11.1 years we evaluated all 232 patients aged 15-49 years with rst-ever cerebral infarction in 1988-1997 and 453 birthday- and sex-matched controls for causes of death. We used information from the Norwegian national death register, from hospital records and autopsy reports when available. Among long-term survivors we evaluated 144 patients and 167 controls for cardiovascular events by questionnaires, hospital records and clinical examination including an electrocardiogram (ECG) for patients. Results: 45/232 (19%) patients and 9/453 (2%) controls died during follow-up (p < 0.0005). Causes of death among patients were: stroke (9), acute myocardial infarction (9), other heart disease (4), sudden death (5), unknown (5), cancer (7) and others (7). One patient had 2 causes of death by autopsy. Controls died from acute myocardial infarction (1), cancer (6) and others (2). Among long-term survivors recurrent stroke was registered for 38 (26.4%) patients versus stroke in 5 (3%) controls (p < 0.0005), CD occurred in 19 (13.2%) patients versus 9 (5.4%) controls (p = 0.018) and PAD occurred in 17 (11.8%) patients versus 2 (1.2%) controls (p < 0.0005). Discussion: Mortality is increased after ischemic stroke at a young age and cardiovascular death is dominating among patients. Cardiovascular morbidity is higher on cerebral, coronary and peripheral level in long-term surviving patients compared with controls. Key-words: stroke, mortality, cardiovascular morbidity.
LONG-TERM PROGNOSIS OF STROKE IN YOUNG ADULTS: RESULTS FROM THE FIRST 227 CONSECUTIVE CASES ENROLLED DURING 5-YEARS IN THE ATHENIAN REGISTRY OF STROKE IN YOUNG ADULTSARSYA
K. Spengos, S. Vassilopoulou, M. Papadopoulou, A. Papapostolou, G. Papadimas, E. Manios, G. Tsivgoulis Eginition Hospital, University of Athens, Athens, Greece
Background: California- and ABCD-scores reliably predict short-term risk of stroke after TIA. Both scores contain similar components. However, diabetes mellitus (DM) is only included in the California Score. Aim of the present study was to evaluate the potential relationship of DM with the early risk of stroke in a cohort of hospitalised TIA patients. Methods: All patients hospitalised in our Department with denite TIA during a 5-year period were identied and their medical charts as well as their Emergency Room records were retrospectively reviewed by two investigators blinded to follow-up. Patients with previous history of stroke and those who missed their follow-up evaluations at the outpatient clinic of our Department at 1 month after admission were excluded. DM was specied as fasting serum glucose 7.0 mmol/L, nonfasting serum glucose 11.1 mmol/L, or use of oral blood sugar-lowering drugs or insulin. The outcome events of interest in all TIA patients were subsequent strokes during the 1-month follow-up period. Statistical analyses were performed using the Kaplan-Meier product-limit method and stepwise Coxs proportional hazards model. Results: The 30-day risk of stroke in the present case series (n=226) was 9.7% (95%CI:5.8-13.6%; 22 events). The 30-day risk of stroke was higher in patients with DM (17.3%; 95%CI:7.6-27.0%) than in non-diabetic patients [(7.1%; 95%CI:3.211.0%); log-rank test=5.20; df=1; p=0.0225]. After adjustment for demographic characteristics, stroke risk factors, history and number of prior TIAs, duration and symptoms of TIAs, as well as secondary prevention treatment strategies during hospitalisation, DM was independently (p=0.015) associated with a three-fold greater 30-day risk of stroke (HR:2.98; 95%CI:1.28-6.94). Discussion: DM is an independent predictor of subsequent stroke in patients presenting with TIA. It should be taken into account by prognostic scores that stratify the risk of early stroke in TIA patients.
EFFECTIVENESS OF THROMBOLYTIC THERAPY ON OUTCOME WITHIN 3 MONTHS AFTER ISCHEMIC STROKE: THE TELEMEDICAL PILOT PROJECT FOR INTEGRATIVE STROKE CARE (TEMPIS)
A.M. Toschke, P.U. Heuschmann, J. Schenkel, H. Audebert Kings College London, London, United Kingdom
Background: Randomized trials showed a benet of intravenous application of tissue-type plasminogen activator (tPA) for ischemic stroke patients after three months. Observational studies reported inconsistent results regarding effectiveness of this treatment in terms of early mortality. Data on mortality after tPA administration after 3m outcome from unselected community hospitals are scarce. Methods: Data were collected from the Telemedical Pilot Project for Integrative Stroke Care (TEMPiS) in Southern Germany including comprehensive stroke centres and community hospitals. Patients were followed three months after stroke onset. Propensity score analysis was used for adjusting differences in sociodemographics, clinical characteristic, stroke severity, and comorbidities by tPA treatment. Results: Between July 2003 and March 2005 1710 patients after ischemic stroke were observed with a mean age of 74y (SE 0.3y); 48% were male. 76 (4.4%) patients were treated with tPA. Patients receiving tPA were younger, more often male, had less often recurrent strokes; prevalence of diabetes, atrial brillation, dyslipidemia and hypertension did not differ compared to non-tPA patients. The proportion of tPA patients who died in-hospital or after 3 month was similar (7.9% or 14.5%) compared to patients not receiving tPA (6.4% or 15.4%; p=0.61 and p=0.83). After adjusting for baseline differences by propensity score, patients receiving tPA tended to have a lower probability of death in hospital (odds ratio (OR) 0.58, 95%CI 0.21-1.63) and at 3 months (OR 0.69; 95%CI 0.32 to 1.50). Conclusions: The tPA treatment within the TEMPiS community hospitals had no adverse effect on in-hospital and 3months mortality after stroke.
LONG-TERM SURVIVAL AFTER FIRST-EVER STROKE IN THE BESANON STROKE REGISTRY: IMPACT OF STROKE UNIT ORGANISATION
P. Decavel, E. Medeiros, E. Vidry, F. Vuillier, E. Revenco, M. Pellicier, T. Moulin University Hospital Besanon, Besanon, France
Background: Development of stroke management over a number of years has changed the vital and functional prognosis of patients. The aim was to test the inuence of stroke management on the long-term survival of patients admitted with rst-ever stroke in the Besanon stroke registry. Method: To test long-term outcome of patients with rst-ever stroke over 3 different periods (period 1: 1987-1994; period 2: 1998-2002; period 3: 2003-2006) corresponding respectively to basic stroke unit period, stroke unit organisation period and network organisation period in 3 cohorts of unselected stroke patients. Results were statistically adjusted according to age, gender and stroke characteristics. During the different periods, all patients with a rst-ever stroke (infarction, haematoma and TIA) admitted to the Besanon university hospital were registered prospectively and assessed according to standardised diagnostic criteria. Patients were followed up over several years and the outcome was analysed during the rst year. Results: There were 6103 patients (55% male) which included 4250 (70%) infarctions, 678 (11%) haematoma and 1175 (19%) TIA. The median age of the cohorts was 71 years. The cohorts were different for each period in terms of recruitment (gender - p = 0.035 - and age - p < 0.000) and stroke subtypes (p < 0.000). In the rst year after stroke, the overall survival rate was 75% (period 1), 80% (period 2) and 82% (period 3). Although there was no difference in survival rates for patients with TIA in any period, there was continuous improvement in survival rates for patients with haematoma (p = 0,041) or infarction (p = 0,022). Adjustments to age and gender amplied these results. Conclusion: This study shows the strong impact of stroke management organisation on long-term patient outcome in the Besanon area.
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DOES ADMISSION C-REACTIVE PROTEIN PREDICT OUTCOME IN STROKE PATIENTS UNDERGOING THROMBOLYSIS?
CHANGES IN QUALITY OF LIFE FROM ONE TO SIX MONTHS FOLLOWING ACUTE STROKE AND ITS DETERMINANTS
R. Topakian, A.M. Strasak, H.-P. Haring, K. Nussbaumer, F.T. Aichner Academic Teaching Hospital Wagner-Jauregg, Linz, Austria
Objective: After acute stroke, increased levels of C-reactive protein (CRP) measured at discharge are associated with unfavourable outcome. We tested the hypothesis that admission CRP may predict outcome in stroke patients undergoing intravenous thrombolysis treatment (IVT). Methods: From January 2003 to June 2006, 129 patients underwent IVT for acute ischemic stroke in our centre. 111 patients were valid for analyses after exclusion of those with stroke involving a territory other than the middle cerebral arterys and those probably infected (admission CRP >6 mg/dl). Patient data were collected in a prospective local registry. CRP was measured by turbidimetry (Cobas Integra 700, Roche). Results: 52 (46.8%) patients were independent after 3 months, dened by a modied Rankin Scale (mRS) score <3. Admission CRP levels were non-signicantly higher in 1) patients independent after 3 months compared to patients with mRS >2 [median (range): 0.4 (0-5.7) mg/dl vs. 0.3 (0-5.9) mg/dl, p=0.131], 2) patients who survived (87.4%) vs. patients who died within 3 months [median (range): 0.4 (0-5.9) mg/dl vs. 0.2 (0.1-1.5) mg/dl, p=0.275], and 3) patients who did not deteriorate neurologically within 24 hours (91.9%) vs. those who developed deterioration dened by an increase of the National Institute of Health Stroke Scale (NIHSS) score of at least 4 points compared to baseline [median (range): 0.4 (0-5.9) mg/dl vs. 0.2 (0.1-0.7) mg/dl, p=0.091]. In multivariate logistic regression analyses, baseline NIHSS was the only variable signicantly associated with independency after 3 months (OR 1.235, 95%CI 1.118-1.363, p<0.001). Conclusion: Our ndings suggest that admission C-reactive protein is not useful in predicting outcome in stroke patients with thrombolysis treatment.
O.M. Ronning, K. Stavem Stroke Unit, Akershus University Hospital., Lrenskog, Norway
Background: There is little information available about change in health-related quality of life (HRQoL) during the rst few months following acute stroke, and whether baseline variables can predict who will have the largest improvement in HRQoL. This study assessed the change in HRQoL from one to six months following acute stroke and the determinants of these changes. Methods: Patients > 60 years of age, who experienced an acute stroke and were admitted to hospital within 24 hours of onset, were followed prospectively. HRQoL was measured with the SF-36 health status questionnaire. Results: Of the 550 eligible patients, 315 fullled the inclusion criteria and were alive after 30 days. At one month 174 responded to the questionnaire of whom 140 also completed the second questionnaire. The changes in HRQoL were statistically signicant on all the SF-36 scales (Physical functioning: p<0.001, Role physical: p<0.001, Vitality: p<0.001, Social functioning: p<0.001, Role emotional: p<0.001, Bodily pain: p=0.016, General health: p=0.002, mental health p=0.02). Mean scores for the two summary scales, physical component summary (PCS) and mental component summary (MCS), increased from one to six months from 36 to 42 (p < 0.001) and 43 to 53 (p < 0.001). Higher baseline scores at one month were associated with lower changes in PCS and MCS in multivariate analysis. Less severe stroke related to large improvement in PCS. Treatment in stroke unit was associated with a larger improvement in MCS. Discussion: In the present study we show a marked improvement in HRQoL from one to six months. There was a favourable change in all domains assessed.
12 10 Long-term outcome of stroke
LONG TERM SURVIVAL OF STROKE PATIENTS FOLLOWING AN INPATIENT REHABILITATION ADMISSSION
INITIAL EXPERIENCE WITH VIDEO BASED MODIFIED RANKIN ASSESSMENT
C.E. Connolly, J. Estell, F. Kohler, R. Renton Braeside Hospital, Prairiewood, NSW, Australia
Objective: Patients admitted for stroke rehabilitation generally have numerous comorbidities and a signicantly increased mortality rate compared to the rest of the population. The pioneers of Rehabilitation medicine demonstrated that rehabilitation improved quality of life and minimised dependency. Limited research has however been done to determine the survival period of patients after inpatient rehabilitation for stroke. The aim of this study is to determine the survival period of stroke patients following an episode of rehabilitation in our unit. Method: All patients admitted to the Braeside Rehabilitation Unit (NSW Australia) for stroke rehabilitation in the two years from 1st January 1997 to 31st December 1998 were identied. The hospital databases were checked to determine; the last date of patient contact with a health service, or any indication that the patient had died, and if so, the date of death. If there was no recent contact or conrmed date of death a search was performed on the National Death Register kept by the Australian Institute of Health and Welfare to establish if death had occurred Results: 253 patients were admitted for stroke rehabilitation during the reference period. Of these 7 patients died within 28 days of discharge, 20 patients died within 1 year and 30 within 2 years of discharge. By the end of eight years 72 patients had died. Discussion: The study shows that 71.5% of patients who were discharged following 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 patient group. Further investigation with regards the survival periods in different stroke subtypes is warranted.
T.J. Quinn, J. Dawson, M.R. Walters, K.R. Lees Gardiner Institute of Cardiovascular and Medical Sciences, Glasgow, United Kingdom
Introduction: Modied Rankin Scale (mRs) is the preferred outcome measure in stroke trials. Despite availability of training and structured interview interobserver variability remains apparent - kappa=0.75 among UK SAINT trial investigators. We hypothesised that off-line assessment of video recorded interviews would offer the means to improve reliability. Methods: 102 consenting patients were graded independently by two assessors. Patients were randomised to undergo of structured interview or standard assessment. One assessment from each pair was further randomised to video recording. Videos were assessed by four experienced researchers, blind to interviewers and other panellists gradings. Results: 100 videos were of technical quality to allow assessment. A range of ages (median:70 range:30-96) and stroke subtypes (Cortical 44; Lacunar 41; Posterior 9) representative of a trial population were included. Initial mRs scores agreed in 66.7% of cases. Use of the structured interview did not signicantly improve reliability. At video assessment there was consensus amongst scorers for 55% of cases (kappa 0.70). Greatest variability was seen for mRs grades 2 and 4 (kappa=0.60, 0.65).
Paired mRs Assessment Agreement Disagree = 1 mRs grade Disagree > 1 mRs grade Video Assessment (4 reviewers) Consensus 3/4 Agree 2/4 Agree Total 68 29 5 Total 54 32 13 Structured (n=49) 30 14 5 Structured (n=48) 24 17 7 Standard (n=53) 38 15 0 Standard (n=51) 30 15 6
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ASSESSMENT OF QUALITY OF LIFE IN STROKE PATIENTS CAREGIVERS. HOW TO PREDICT CAREGIVERS AT RISK
Discussion: We have shown that off-line assessment of mRs is possible in a mock clinical trial setting. Video assessment did not alter interobserver variability but offers potential for central endpoint committee review with resultant improvements in precision: pilot work to assess effect on reproducibility is now underway.
E. Marco, E. Duarte, M. Tejero, J.M. Muniesa, R. Belmonte, A. Aguirrezabal, M. Pou, C.B. Samitier, F. Escalada Physical Medicine and Rehabilitation Department, Hospital de lEsperana, Barcelona, Spain
Background: The increased proportion of stroke survivors has led to more impaired and disabled subjects. The patient disability condition and the provision of care have negative consequences for caregivers. Objectives: To detect the most affected
Poster Session Long-term outcome of stroke
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dimensions in quality of life of stroke patients caregivers, and predict caregivers at risk of presenting a worse health-related quality of life. Methods: Cross-sectional study of 215 family caregivers of stroke patients. Main variables were assessed with: the Short Form 36 (SF-36), the Geriatric Depression Scale and the FIM-instrument. Statistical tests: Chi-squared and Fisher test, Student t test, ANOVA, Mann-Whitney U test and Spearman correlation. Results: The SF-36 subscales of vitality, social function, emotional role and mental health are the most affected. There is a positive correlation between caregivers health perception and patients health perception in these subscales. Motor disability and assistence time required are the patient characteristic with a major inuence in caregiver health perception. The presence of depression and osteoarthritis in caregivers have a signicant effect on their perception of health. A model to be used to detect the caregiver at risk of presenting a bad perception of health status is constructed. This predictive model contemplates 8 different probability groups ranging from 8.1 to 88.4%. Discussion: Health-related quality of life of caregivers is affected in different dimensions. To detect which caregivers are at most risk of presenting a bad perception might be useful to provide resources and services to help caregivers in charge of stroke patients.
pneumonia during hospitalization. Data from a sample of 100 patients examined 2 years before showed similar rates (dysphagia 27.0%, pneumonia 6.0%). Predictors of increased risk of pneumonia were stroke severity, hemorrhagic (rather than ischemic) stroke, and the presence of a total anterior circulation syndrome. Discussion: The low incidence of aspiration pneumonia in our Institution supports the effectiveness of a standardized swallowing assessment and feeding procedure, and continuous training of the nursing staff. The incidence of pneumonia remains in fact persistently low over time. However, there is a small group of patients at higher risk of developing pneumonia. These patients, who are likely to have an hemorrhagic stroke, severe symptoms and larger lesions, could benet of more selected strategies, to be eventually tested in this particular stroke subgroup.
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QUALITY OF LIFE AND LONG-TERM FUNCTIONAL OUTCOME IN YOUNG PATIENTS AFTER AN ISCHEMIC STROKE
A.A. Gongora, C. Mader, J.P. Arroyo, R. Garcia, A. Leyva Institute National of Neurology and Neurosurgery, Mexico City, Mexico
Background and purpose: The purpose was to evaluate quality of life and longterm functional outcome in patients under 45 years, after ischemic stroke to identify variables that will accurately predict quality of life and long-term functional outcome. Methods: This was a cross-sectional, descriptive correlational design. The modied Rankin scale, Barthel index and Short From -36 (SF 36) were administered to 192 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 stroke. Multiple regression analysis was used to predict quality of life. Results: 192 patients with a previous history of ischemic stroke <45 years of age were included. The cause of the stroke was cardioembolism 20%, major blood vessel atherosclerosis 9%, arterial dissection 28%, hypercoagulable state 15%, and not determined 28%. The most important risk factors associated with the cause of the stroke were hypertension and major blood vessel atherosclerosis with 82% (p < 0.0005), diabetes mellitus and major blood vessel atherosclerosis 47% (p < 0.0005). The mean Barthel index was 95 with Barthel > 85 in 98% of cases. Rankin score was < 2 in 48%. (Rankin 3 4 = 52%). There was no signicant difference between the cause of the stroke and the SF 36 prole category results. The SF 36 category which was affected the most, was emotional role with over 30% of patients with an average value of less than 33. Conclusions: There seems to be no difference between the long term functional outcome and quality of life and the cause of the ischemic stroke. The identication of alterations in the emotional role of patients furthers the need for support programs.
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POSTSTROKE EPILEPSY IN PATIENTS TREATED WITH SYSTEMIC THROMBOLYSIS
B. Dimitrijeski, A. Villringer, A. Hartmann Charit-Campus Benjamin Franklin, Berlin, Germany

Objectives: Poststroke Epilepsy (PSE) is an important complication after ischemic stroke. We aimed to asses the occurrence of poststroke epilepsy, and to identify possible predictors in patients with ischemic stroke treated systemically with thrombolysis. Methods: Patients with supratentorial stroke treated between 1998 and 2003 systemically with rt-PA according to the NINDS trial-protocol were followed prospectively. Neurological status was measured at admission, discharge, 3months-follow-up and long-term follow-up. Occurrence of poststroke epilepsy was noted. Predictors for PSE were identied using univariate analysis. Results: A total of 134 Patients were treated. Long-term follow-up (mean followuptime for the survivors was 39 months, range 14-66 months) was completed for 132 patients, 2 patients were lost to follow-up. Good clinical outcome (Rankin<2) and mortality at 3 months was 50% and 13%, and at long-term follow-up 45% and 28% respectively. Poststroke epilepsy occurred in 14 patients (11%). Factors univariately associated with poststroke epilepsy were NIH at discharge (p= 0.001), cardio-embolic stroke (p=0.018) and increasing infarct size (p=0.003). Conclusions: The prevalence of poststroke epilepsy in patients treated with systemic 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 higher risk for developing PSE.
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PROGNOSIS IN FIRST-EVER ISCHEMIC STROKE/TRANSIENT ISCHEMIC ATTACK PATIENTS WITH SIGNIFICANT EXTRACRANIAL CAROTID ARTERY DISEASE
INCIDENCE OF ASPIRATION PNEUMONIA AFTER SYSTEMATIC APPLICATION OF AN EXPERT BEDSIDE SWALLOWING EVALUATION AND FEEDING PROCEDURE IN A STROKE UNIT
H.J. Lin, P.S. Yeh Chi-Mei Medical Center, Yong Kang, Tainan, Taiwan
Background: The impact of signicant extracranial carotid artery disease on the prognosis in patients with ischemic stroke or transient ischemic attack (TIA) is unclear in Taiwanese people, who have lower prevalence of such artery disease than Western people. Methods: From a prospective hospital-based registry of patients with rst-ever ischemic stroke or TIA, we investigated the outcomes among those with newly found extracranial carotid artery disease > 50% stenosis. Data were collected according to predetermined evaluation systems and diagnostic criteria, and the subjects received regular follow-up. The composite outcome endpoint was subsequent stroke, myocardial infarction, or vascular death after the index event. The Kaplan-Meier product-limit method was used to estimate the cumulative risk of the endpoint, and the Cox regression model for evaluating prognostic factors. Results: We enrolled 109 patients with a mean age of 69 years and 72% of men. The mechanisms of the ischemic events included 64% of large artery atherosclerosis, 13% of small vessel disease, 9% of cardioembolism, and 12% of undetermined etiology. All patients received medical treatments only. After a median follow-up duration of 21.1 months, 33 events developed, including 14 strokes, 2 acute myocardial infarcts, and 17 vascular deaths. The cumulative risks of the endpoint were 7% in 1 month, 24% in 1 year, and 31% in 2 years. The Cox model analyses revealed prior ischemic heart disease as a signicant prognostic factor (hazard ratio, 2.6; 95% condence interval, 1.0-6.8)
V. Palumbo, S. Centorrino, P. Nencini, G. Pracucci, D. Inzitari University of Florence, Florence, Italy

Background: Aspiration pneumonia is one of the most common and severe complications of stroke-related dysphagia. We aimed to evaluate the variation over time of the incidence of pneumonia in acute stroke patients admitted to a Stroke Unit, who underwent an expert swallowing assessment and standardized feeding procedures. Methods: We evaluated after 2 years a second sample of 102 patients with acute stroke (83% ischemic, 17% hemorrhagic) admitted consecutively in a Stroke Unit over 6 months. All patients were systematically screened for dysphagia on admission using the Standardized Bedside Swallowing Assessment, which involves three stages: general evaluation (level of consciousness, postural control, voluntary cough, voice quality and ability to swallow saliva), sipping water from a spoon, and, if safe, proceeding to drink water from a glass. If difculty on swallowing was present, non-oral nutrition was considered, and the patient was referred to a speech therapist for expert assessment. Results: Median NIHSS of the cohort was 9, mean age 66.2 years, 63% of patients were male. Dysphagia was diagnosed in 18 (17.6%) patients; 6 (5.8%) patients developed
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Conclusions: Patients with rst-ever ischemic stroke/TIA and newly found signicant extracranial artery disease are predisposed to grave vascular outcomes, in particular those with concomitant ischemic heart disease.
Conclusions: More likely, [11C]-(R)-PK11195 uptake relates to macrophage (late inammatory response) rather than microglial activity. Because the uptake was higher in the normally perfused rather than chronically hyposperfused areas it may be that reperfusion promotes the inammatory response.
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Long-term outcome of stroke 2 Brain imaging new developments

TC PERFUSION PREDICTS EARLY CLINICAL RESPONSE TO INTRAVENOUS THROMBOLYTIC THERAPY OF ISCHEMIC STROKE IN THE FIRST 3 HOURS
PLASMA GLUTAMATE LEVELS PREDICT FATIGUE AFTER TIA AND MINOR STROKE
A.B. Syed, L.M. Castell, A. Ng, C. Winward, P.M. Rothwell Stroke Prevention Research Unit, Department of Clinical Neurology, University of Oxford, Oxford, United Kingdom
Background: Post-stroke fatigue (PSF) is common and can be severe, even after minor cerebral ischaemic events, but the mechanism(s) are poorly understood. High levels of plasma glutamate are associated with fatigue in multiple sclerosis and in chronic fatigue syndrome. We aimed to determine whether plasma glutamate and glutamine levels predicted PSF after transient ischaemic attack (TIA) and minor stroke. Methods: We studied consecutive patients with TIA and minor stroke from the Oxford Vascular Study (OXVASC). Participants were excluded if they had a Barthel Score less than 18/20, a Rivermead Mobility Index (RMI) of less than 10/15, or Mini Mental State Examination (MMSE) less than 23/30. Blood samples were taken within one week of the presenting event and fatigue was assessed at home by a research nurse (blind to all biochemical analyses) 6 months after the event with the Chalder Fatigue Scale. Enzymatic spectrophotometric techniques were used to assay plasma glutamine and glutamate levels. Results: Among 38 patients (28 stroke, 10 TIA, 15 male, mean age 74 yrs), 64% of stroke patients and 25% of TIA patients reported PSF. PSF was independent of age, sex, depression, smoking, medication and (among stroke patients) residual neurological decit. However, there was a negative correlation between plasma glutamine/glutamate ratio and PSF (r=-0.38. p=0.02). Plasma glutamate correlated positively with PSF (r=0.35, p=0.02). Discussion: Plasma glutamate and the glutamine/glutamate ratio appear to predict PSF 6 months after TIA or minor stroke. Further research is warranted to conrm the predictive value of these tests and to determine whether the relationship is causal.
M. Revilla, E. Palacio, F. Gonzlez, C. Ramn, P. Snchez-Juan, A. Gonzlez-Mandly, E. Marco de Lucas, A. Gutirrez, M. Rebollo, J. Berciano Hospital Universitario Marqus de Valdecilla, Santander, Spain
Background and purpose: CT perfusion (CTP) and CT angiography (CTA) imaging techniques identify tissue in penumbra and intravascular thrombus in acute ischemic stroke, but their utility in the stroke therapy in the rst three hours has not been dened. We evaluated if CTP and CTA ndings conditioned early clinical response to intravenous (iv) thrombolytic therapy in the rst three hours. Methods: Forty-seven consecutive patients were treated with iv tPA according to SITS criteria. Additionally, 33 of them were studied with CTP+/-CTA before tPA administration. We evaluated cerebral blood ow (CBF), mean transit time (MTT) and cerebral blood volume (CBV) images, CBF/CBV mismatch and arterial occlusion. Early recanalization was detected with control CTA+/-transcranial doppler examination. Early clinical response was measured by NIHSS at 0, 1, 24 and 72 hours post-treatment. Results: Clinical evolution of patients by mean NIHSS was 13.5 (0 h), 10.8 (1 h), 9.4 (24h) and 7.6 (72 h). Between 0 and 72 hours NIHSS differences, measured by mean rank, were as follows: 16.4 vs 19.4 if there was CBF abnormality (n=26); 14.2 vs 19.3 if there was CBV abnormality (n=15); 15.2 vs 6.2 if there was CBF/CBV mismatching (n=21) (p=0.01, Mann-Whitney U); 12.9 vs 8.5 if there was arterial occlusion (n=15); and 13.2 vs 4.5 if there was early recanalization (n=12) (p=0.001, Mann-Whitney U). Conclusion: Findings of mismatch and early recanalization of arterial occlusion in CTP/CTA images predict a better early clinical response and may help in the selection of patients for iv thrombolysis of stroke in the rst three hours.
Brain imaging -- new developments 1 Brain imaging new developments
Brain imaging new developments
INTRAPLAQUE HAEMORRHAGE IS ASSOCIATED WITH MULTIPLE DIFFUSION WEIGHTED IMAGING LESIONS IN SYMPTOMATIC PATIENTS WITH HIGH GRADE CAROTID STENOSIS
THE USE OF [11C]-(R)-PK11195 LIGAND AND POSITRON EMISSION TOMOGRAPHY IN ACUTE ISCHAEMIC STROKE: INSIGHTS INTO THE INFLAMMATORY PROCESS
N. Altaf, S. Goode, P.S. Goode, J.R. Gladman, S.T. MacSweeney, D.P. Auer University of Nottingham, Nottingham, United Kingdom
Introduction: Magnetic Resonance Imaging sensitively detects carotid intraplaque haemorrhage (IPH) that is increasingly accepted as surrogate marker of plaque instability. The aim of this study was to investigate an association between IPH and the presence, pattern and extent of cerebral acute and sub-acute ischaemic lesions identied by diffusion weighted imaging (DWI). Methods: 46 patients (18 females, mean age 71.5 years 10.7) with high grade carotid stenosis (>70% stenosis) presenting with stroke, TIA or amaurosis fugax were prospectively recruited. All patients underwent MRI assessment of IPH in the carotid artery and DWI of the brain. The presence, extent and pattern of DWI hyperintense lesions were compared with the IPH status of the presenting carotid artery. Results: 32 (69.6%) patients had evidence of IPH in the presenting carotid artery and 26 (56.5%) had DWI lesions. The mean delay from the presenting symptom to MRI was 21.8 18.5 days. Patients with carotid IPH were more likely to have ipsilateral DWI lesions than those without IPH (22/32 [69%] vs. 4/14 [29%], P<0.05); had more lesions (mean 2.8 3.3 vs. 0.7 1.2, P<0.05); multiple lesions were strongly associated with IPH (17/32 vs. 1/14), whereas the DWI hyperintense lesion volume was similar (mean 2.1 3.4 ml vs. 1.7 4.0 ml, P=0.6). 18/32 (56.3%) of patients with IPH had multiple DWI lesions and 3/14 (21.4%) patients without IPH had multiple lesions (P<0.05). The association between carotid IPH and the presence of DWI lesions was marginally signicant (Odds ratio = 3.8; 95% C.I. 0.8 18.2, P=0.09) after controlling for stroke and time between symptom and MRI. Conclusion: Intraplaque haemorrhage in the presenting carotid artery is moderately associated with DWI ischaemic lesions and strongly with multiple lesions supporting a thromboembolic pattern.
J.A. Zavala, M.N. Perera, H.H. Ma, G. OKeefe, H. Tochon-Danguy, U. Akermann, J. Ly, D. Reutens, C. Rowe, G.A. Donnan National Stroke Research Institute, Australia; Centre for PET Austin Health, Australia
Inammation after an ischaemic insult to brain tissue may have a key role in the survival of viable hypoperfused tissue. Microglial and other inammatory cells are rapidly activated (within hours) after pathological insults to the CNS. Macrophages accumulate after a period of days. Peripheral benzodiazepine binding sites (PBBS) are mitochondrial membrane receptors in microglia and macrophages. (R)-PK11195 is a ligand that binds to PBBS. [11C] PET scan can be used as a non-invasive method of inammatory response imaging. In this study we aimed to understand the spatial and temporal changes of inammatory response after ischaemic stroke. We hypothesized that [11C]-(R)-PK11195 uptake levels increase not only within the core of the ischaemic lesion but also in hypoperfused regions. Methods: We studied ischaemic stroke patients within 1 month of onset. Imaging was performed including CT, CT perfusion or MRI/A. [11C]-(R)-PK11195 was given intravenously followed by 3-dimendional dynamic acquisition (PET) over 60 minutes. Distribution volume ratio maps were created using ipsilateral cerebellum as reference tissue. The PET images were then coregistered to DWI and perfusion maps. Results: Fourteen patients were studied (median age 72 years, range 52 to 89 years). PET scans were performed from 48 hours to 20 days after stroke onset. Nine patients had corresponding perfusion scans. There was no [11C]-(R)-PK11195 uptake within the rst 5 days (5 patients) but increased uptake in 7 of 9 scans performed from day 6 to day 20 after stroke onset. Increased uptake was found at least as frequently beyond the infarct as within its core. For patients submitted to perfusion scans, there was little uptake in chronically hypoperfused areas compared to elsewhere outside the infarct core.
Poster Session Brain imaging new developments
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TISSUE SWELLING WITHOUT HYPOATTENUATION ON NON-CONTRAST CT IS RARE BUT POTENTIALLY REVERSIBLE IN ACUTE ISCHEMIC STROKE
MRI ON DAY 1 IDENTIFIES PATIENTS AT RISK FOR DELAYED STROKE PROGRESSION AFTER I.V. THROMBOLYSIS
I. Dzialowski, S. Subramaniam, V. Puetz, A. Krol, J.M. Boulanger, P.A. Barber, M.D. Hill, S.B. Coutts, T. Watson, A.M. Demchuk, for the Calgary CTA Study Group University of Dresden, Dresden, Germany
Background: Early ischemic changes (EIC) on non-contrast CT (NCCT) can represent tissue hypoattenuation or cortical swelling and are both scored traditionally in the Alberta Stroke Program Early CT Score (ASPECTS). However, only hypoattenuated brain tissue seems to be specic for ischemic core whereas isolated cortical swelling (ICS) might be reversible. We sought to assess ASPECTS ignoring isolated cortical swelling (ASPECTS - ISC) and compare the incidence of deviation from classic ASPECTS. Methods: We studied ischemic stroke patients from 04/2002-07/2005 presenting within 24 hrs of onset in whom a NCCT was performed. We prospectively applied ASPECTS to all baseline NCCT scans by 3-reader consensus scoring any EIC. A normal scan scores 10, a complete middle cerebral artery infarction 0. In the same session, we interpreted ASPECTS - ISC. We independently assessed followup ASPECTS at day 1-7. We determined the incidence of differences between ASPECTS-ICS and ASPECTS and proportion of reversibility at follow-up. Results: We identied 335 patients with a mean age of 67 years, mean onset-toNCCT-time of 286 min, median baseline NIHSS score of 7 and median ASPECTS of 10. We found ASPECTS - ICS > ASPECT scores in 7/335 (2.1%) of patients. In this group, mean onsetto-NCCT-time was 399 min and median ASPECTSdifference was 2 (range 1-4). In 5/7 patients follow-up imaging was available and 2/5 (40%) showed higher nal ASPECTS (> 1-point increase) than baseline classic ASPECTS consistent with reversibility. In the population without baseline ASPECTS difference, 16/247 (6%) of available follow-up images showed higher nal ASPECTS than baseline classic ASPECTS. Conclusion: In our study, isolated tissue swelling was rare but likely to reverse. ASPECTS interpretation should ignore isolated cortical swelling to better represent irreversible ischemic core.
R. Kern, K. Szabo, S. Bukow, M. Griebe, A. Frster, M.G. Hennerici, A. Gass Universittsklinikum Mannheim, University of Heidelberg, Mannheim, Germany
Objective: Deterioration of clinical status after treatment with tPA for acute stroke is a possible outcome but difcult to predict on an individual basis. Besides an early malignant course a delayed symptom progression can occur. In an approach to characterize the stability in the post-tPA phase we performed systematic follow-up MRI in this patient group. Methods: MRI (T2w, T1w, T2*w, DWI, TOF-MRA, PWI) was performed in 45 acute stroke patients on the rst day after CT-based tPA therapy (3h time-window). 8/45 patients had an early malignant course and in 12/45 there was marked clinical improvement with MRI demonstrating successful therapy on day 1 and no further MRI was performed. In 25/45 patients MRI on the 1st and 7th day were compared. MRI ndings on day 7 were either considered improved (= vessel recanalisation; resolution of hypoperfusion), stable (= no progress of infarct size, of hemorrhagic transformation [HT], or of vessel pathology) or progressive (= progression of infarcted or hypoperfused tissue size, HT or vessel pathology). Results: In 19/25 (76%) MRI was stable or improved on day 7, whereas 6/25 (24%) were progressive: 6 patients showed new DWI lesions - 4 in the same, 2 in a different vascular territory. One patient developed HT between day 1 and 7. 67% of patients with persistent vascular obstruction and persistent hypoperfusion on day 1 had progressive MRI ndings on day 7 and did not improve clinically.
LACTATE DOES NOT PREDICT INFARCT GROWTH
V. Cvoro, J.M. Wardlaw, S. Muoz Maniega, I. Marshall, P.A. Armitage, C.S. Rivers, M.S. Dennis Division of Clinical Neurosciences, University of Edinburgh, Edinburgh, United Kingdom
Background: In patients with acute ischaemic stroke, the mismatch between magnetic resonance (MR) diffusion- and perfusion weighted imaging (DWI and PWI) was initially thought to predict infarct growth, but recent studies have questioned the strength of this association. Lactate is a marker of early ischaemia and is elevated in acute stroke lesions. N acetyl aspartate (NAA) which represents neuronal loss falls more gradually. We examined whether elevated lactate or decreased NAA in mismatch tissue predicted infarct expansion. Methods: Patients with acute ischaemic stroke underwent diffusion tensor imaging (DTI), dynamic susceptibility contrast PWI, T2W and MR spectroscopic imaging (SI) at admission, days 5 and 14, and 1 and 3 months. A 0.5 cm diam. voxel grid 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. 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 was 77 years (range 37-95), NIHSS 16 (range 7-29); 30% were rst imaged <6 hrs, 40% from 6-12 hrs and 30% from 12-24 hrs. Lactate (34.421.2 vs 18.99.7 p<0.01) but not NAA (122.123.9 vs 11530.6 p=NS) was elevated in mismatch 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 did not (lactate 39.320.5 vs. 23.927.3, p=NS; NAA 118.723.4 vs. 13718, p=NS respectively). Furthermore there was no difference in mismatch tissue over the rst ve days in lactate or NAA between lesions that grew and not. Summary: Lactate may be a marker of ischaemia, but its presence in mismatch tissue does not predict infarct growth. Infarct growth must be related to other individual factors.
Fig. 1. MRI performed on day 1 and day 7 of a 68-year-old patient who underwent intravenous thrombolysis 2.5 hours after symptom onset DWI on day 7 showed multiple new acute lesions in the right PCA territory with a persistent perfusion decit on TTP maps. On MRA, vascular obstruction of the left PCA even became more prominent. MRI characteristics were considered progressive.
Discussion: MRI on day 1 can identify those patients with a persisting unstable situation at risk for stroke progression as indicated by hypoperfusion due to incomplete vessel recanalisation after thrombolysis. Identifying these patients is important for clinical management with close monitoring and blood pressure management.
TRANSCRANIAL SONOGRAPHIC DELINEATION OF INTRACEREBRAL HEMORRHAGE A PROSPECTIVE MULTICENTER STUDY
K. Meyer-Wiethe, R. Kern, S. Meairs, G. Seidel University Hospital Schleswig-Holstein, Campus Lbeck, Lbeck, Germany
Background: A prospective study was performed in patients suffering from acute intracerebral hemorrhage (ICH) in two German stroke centers to determine sensitivity, extent of midline shift (MLS) and lesion volume determined by transcranial ultrasound (US). Materials and methods: US was performed with two systems (Philips SONOS 5500 and HDI 5000) via the temporal acoustic bone window. We used sector transducers 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.
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There was no difference in baseline characteristics between the patients from the different centres. The localisations of the lesions were as follows: 23 basal ganglia, 2 frontal, 5 parietal, 2 temporal, 1 occipital lobe. In 30 of 33 patients (91%), US identied the lesion correctly. In three patients ICH could not be detected due to inadequate insonation conditions. Both US and CT showed no case of signicant midline shift of > 2 mm. CT depicted ventricular hemorrhage in 12 patients (US: 7 patients sensitivity 0.58, specicity 1.0). There was a close correlation between blood clot volume measured in CT and US (r = 0.85, P < 0.001, n = 30). Conclusions: In this prospective multicenter study US correctly diagnosed, localized and measured intracerebral hemorrhage in patients with adequate bone windows. In contrast, US depiction of ventricular hemorrhage showed high specicity, but low sensitivity. This study is part of the UMEDS project (Ultrasonographic Monitoring and Early Diagnosis of Stroke) funded by the European Commission (QLG1-CT-2002-01518).
Results: We analyzed 340 DWI and 177 MT scans and both modalities in 124 subjects. ADC and MTR values showed a signicant inter-site variation which was stronger for the MTR. After z-score transformation multiple regression analysis showed WMH severity and age as signicant predictors for all ADC and MTR histogram metrics of NABT. Only lesional ADC was increasing with WMH severity while such correlation was not seen with MTR. Conclusions: Despite some variation from a multi-centric collection of ADC and MTR data both modalities appear sensitive for changes in NABT which appear to occur with ageing and increase with the severity of WMH. However, the ADC was more sensitive for discerning tissue changes within WMH and their relation to lesion size.
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CHANGES IN BRAIN VOLUME 2 YEARS AFTER EC-IC BYPASS SURGERY: A PRELIMINARY SUBANALYSIS OF THE JAPANESE EC-IC BYPASS TRIAL
DIAGNOSTIC VALUE OF COMBINED ANALYSIS OF T2-WEIGHTED GRADIENT ECHO IMAGING AND POSTCONTRAST TIME-OF-FLIGHT MR ANGIOGRAPHY IN HYPERACUTE ISCHEMIC STROKE
J. Jinnouchi, K. Toyoda, T. Inoue, S. Fujimoto, S. Gotoh, K. Yasumori, S. Ibayashi, M. Iida, Y. Okada National Hospital Organization Kyushu Medical Center, Nippon Steel Yawata Memorial Hospital, Kitakyushu, Japan
Background: Changes in cerebral blood ow (CBF) may be associated with brain atrophy, especially in patients with cerebral artery occlusive disease. However, previous studies have failed to nd a signicant relationship between CBF and brain atrophy. Recently, Japanese extracranial-intracranial (EC-IC) bypass trial (JET) revealed that EC-IC bypass was effective for stroke prevention. JET is a multicenter, randomized, prospective study of patients with hemodynamic brain ischemia due to cerebral artery occlusive disease. Here, we compared the changes in brain volume and cerebral hemodynamics in patients with and without EC-IC bypass surgery. Methods: We registered 10 Japanese patients with mild ischemic stroke for the JET. Six patients successfully underwent EC-IC bypass surgery and 4 were treated medically. We studied changes in brain volume on magnetic resonance imaging. We also examined the association of cerebral hemodynamics on single photon emission computed tomography with the changes in brain volume. The differences between patients with and without EC-IC bypass were investigated. Results: The affected/unaffected ratio of the % brain volume declined in patients without EC-IC bypass surgery (p<0.02, n=4), and the affected/unaffected % rCBF ratio increased in patients with the surgery (p<0.03, n=6). Acetazolamide reactivity increased in the affected hemisphere of patients with surgery (p<0.01). Two-year increase (decrease) in acetazolamide reactivity of the affected hemisphere showed a signicant positive correlation with 2-year changes in the affected/unaffected % brain volume ratio (R2 = 0.737, p=0.0007). Conclusions: Change in acetazolamide reactivity might be a good predictor for brain atrophy in cerebral artery occlusive disease.
S.I. Sohn, C.H. Sohn, H.W. Chang, S.H. Choi, S.R. Kim, H.C. Park Keimyung University, DongKang Hospital, Andong General Hospital, Daegu, South Korea
Background: Identifying the composition and the length of clot may be important in choosing the optimal treatment on acute thrombolysis. We assessed the diagnostic value of combined analysis of T2-weighted gradient echo imaging (GRE) and postcontrast MR angiography (PC-MRA) in patients with acute middle cerebral artery (MCA) occlusion. Methods: From May 2004 and December 2006, consecutive 49 patients with occlusion of the MCA M1 segment within the rst 6 hours from the onset of symptoms admitted to our emergency department were enrolled. Then all patients were imaged using acute stroke MR protocol included GRE for susceptibility vessel sign (SVS) and pc-MRA for the length of occlusion and had conventional angiography. We classied into 4 groups as the visibility and length of GRE SVS and the signal gap of PC-MRA: longer clot length of GRE SVS than the signal gap of PC-MRA (group A), longer signal gap of PC-MRA then the length of GRE SVS (group B), the signal gap of PC-MRA without GRE SVS (group C), non-visible of the signal gap of PC-MRA and negative GRE SVS (group D). MR ndings were compared with ndings of conventional angiography. Results: Among 49 patients, 42 (85.7%) patients with good MR imaging were selected (23 men, mean age: 66.5). Group A was the most common type. The difference of the length and the gap in group A and B may be associated with the shape of thrombus. Long difference assumed oval shape clot and short difference tended to be barrel shape clot. Group C showed focal occlusion of the MCA M1 segment by atherosclerosis. Group D had poor collateral circulation on conventional angiography. Conclusions: Compared to independent analysis of GRE SVS or PC-MRA in patients with acute arterial occlusion, combined analysis was showed more accurate information for the clot property and occlusion status.
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PERFUSION PATTERNS IN PATIENTS WITH SEVERE INTERNAL CAROTID ARTERY DISEASE USING PERFUSION-CT
M.G. Delgado, V. Mateos, S. Calleja, R.L. Roger, P. Vega, C.H. Lahoz Hospital Universitario Central de Asturias, Oviedo, Spain
Introduction: Cerebral perfusion prole of patients with chronic internal carotid artery disease has not been well studied. Material/Methods: Between January 2006 and January 2007, we studied consecutive patients with severe internal carotid artery (ICA) disease by CT-Angiography and Perfusion-CT. Hypoperfusion was dened as increased MTT, decreased CBF and CBV. Five perfusion patterns are described: cerebral hemisphere hypoperfusion (type 1), middle and anterior cerebral arteries territory (MCA and ACA) hypoperfusion (type 2), MCA territory hypoperfusion (type 3), watershed territory hypoperfusion (type 4) and normal pattern (type 5). Results: We identied 26 patients, 24 males and 2 females. 73% of patients had critical ICA stenosis and 27% of patients had ICA occlusion. Perfusion patterns were: 38% type 1, 31% type 2, 15% type 3, 8% type 4, 11% type 5. In ICA occlusion we only found 3 patterns: 43% type 1, 43% type 2 and 14% type 3. In critical ICA stenosis we found: 37% type 1, 21% type 2, 16% type 3, 10% type 4 and 3 patients (16%) had a normal perfusion study (type 5) with anterior collateral circulation preserved and ipsilateral posterior communicating cerebral artery absence. Six patients (26%) with abnormal perfusion study had a complete circle of Willis. Conclusions: The majority of patients with critical ICA stenosis or occlusion had cerebral perfusion decit. There were more patients with critical ICA stenosis than
GLOBAL CHANGES ON DIFFUSION WEIGHTED IMAGING (DWI) AND MAGNETIZATION TRANSFER (MT) IN RELATION TO WHITE MATTER HYPERINTENSITIES: THE LADIS STUDY
S. Ropele, A. Seewann, W. van der Flier, L. Pantoni, E. Rostrup, T. Erkinjuntti, L.-O. Wahlund, R. Schmidt, F. Barkhof, F. Fazekas Medical University Graz, Graz, Austria
Objective: DWI and MT imaging should improve the detection and quantication of cerebral tissue changes associated with white matter hyperintensities (WMH). Supportive data come mostly from single centres which studied only one modality in small and selective groups of individuals. We therefore aimed to investigate and compare the sensitivity of these techniques for describing changes in normal appearing brain tissue (NABT) and WMH in a multi-centre setting. Subjects and methods: Within the LADIS study investigating the impact of WMH on 65 to 85 year olds without prior disability we obtained DWI and MT in 9 centres with 1.5T whole body systems from different manufacturers. Lesions were delineated on the FLAIR images; apparent diffusion coefcient (ADC) and MT ratio (MTR) maps were calculated, co-registered and the respective values assessed globally for WMH and NABT by means of histogram analysis. The mean value, the peak position (PP), and the relative peak height (rPH) were related to subjects age and WHM severity.
Poster Session Brain imaging new developments
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occlusion with cerebral hemisphere perfusion decit (type 1). A normal perfusion study can be found in symptomatic patients.
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CT PERFUSION IN ASSESSMENT OF BRAIN CIRCULATION IN PATIENTS WITH STENOSIS OR OCCLUSION OF INTERNAL CAROTID ARTERY
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INTER-OBSERVER AGREEMENT ABOUT THE PRESENCE AND DISTRIBUTION OF BRAIN MICROBLEEDS IN ADULTS WITH STROKE
G. Witkowski, P. Richter, A. Rozenfeld, R. Poniatowska, A. Dowzenko, H. Jarosz, D. Ryglewicz Institute of Psychiatry and Neurology, Warsaw, Poland
Background and purpose: The risk of stroke due to severe stenosis or occlusion of internal carotid artery (ICA) is higher in patients with insufcient collateral brain circulation. Transcranial Doppler Ultrasonography (TCD) is routinely applied for assessment of collateral circulation. Computer tomography perfusion (CTP) imaging is used in the clinical practice especially in the evaluation of brain blood ow during acute stroke, transient ischemic attacks (TIA), in epileptogenic foci and differential diagnosis of brain tumors. CTP also can be applied in assessment of brain circulation in patients with unilateral stenosis of ICA. The aim of the present study was to correlate the signs of collateral circulation in TCD with the results of CTP in patient with symptomatic carotid arterial occlusion or stenosis. Methods: 17 patients hospitalized in First Department of Neurology, Institute of Psychiatry and Neurology with TIA due to stenosis or occlusion of ICA were introduced to the study. 4 patients were previously treated with the intravascular occlusion (Gold Baloon) because of carotid cavernous stula and brain aneurysm. In Doppler examination blood ow through ophthalmic artery and anterior communicant artery was estimated. CTP was routinely applied in all cases. Results: Unilateral cerebral hypoperfusion was more pronounced in case of insufcient cerebral collateral circulation. In these patients Mean Transit Time parameter (MTT) was prolonged for about 30-40%. Conclusion: CT perfusion can be considered as a complementary method to TCD. This examination helps to estimate the inuence of arterial stenosis or occlusion on cerebral blood ow. It can also predict the increased risk of ischemic stroke in patients with carotid stenosis.
C. Cordonnier, G. Potter, C. Jackson, C.L.M. Sudlow, J.M. Wardlaw, R. Al-Shahi Salman Division of Clinical Neurosciences, University of Edinburgh, Edinburgh, United Kingdom
Background: The increasing use of haem-sensitive gradient echo (GRE, T2*) sequences in magnetic resonance (MR) imaging of stroke has lead to frequent detection of brain microbleeds (BMBs). If BMBs are found to be of diagnostic or prognostic signicance, and are used for these purposes in clinical practice, observer variation in their assessment must be known. Methods: Two doctors assessed the MR imaging of 264 adults with stroke. BMBs were dened as small, homogeneous, round foci of low signal intensity on T2*-weighted images of less than 10 mm in diameter. Reviewers were blinded, and quantied BMBs on each side of the brain in the following locations: lobar (cortex, grey-white junction, deep white matter), deep (basal ganglia grey matter, internal capsule, external capsule, and thalamus), and posterior fossa (brainstem and cerebellum). Results: Thirty percent (95% condence interval [CI] 26-34) of patients had 1 BMB or more. Agreement about the presence/absence of BMBs at any location was moderate (75%, 95% CI 70 to 80; kappa 0.44, 95% CI 0.32 to 0.56). Agreement was worse in lobar locations (81%, 95% CI 76 to 85; kappa 0.44, 95% CI 0.30 to 0.58) than in deep locations (90%, 95% CI 86 to 93; kappa 0.62, 95% CI 0.48 to 0.76) or the posterior fossa (95%, 95% CI 92 to 97; kappa 0.66, 95% CI 0.47 to 0.84). Discussion: This study provides insight into one of the reasons why inter-observer agreement about the presence of BMBs is only moderate. Agreement was moderate in lobar locations, but substantial in deep areas and the posterior fossa. This may be due to the existence of BMB mimics in lobar locations, especially vessel ow voids. We will explore agreement about BMB size and number, and ways of increasing agreement about lobar BMBs, in an effort to develop a BMB grading scale.
Interesting cases 1 Interesting cases
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MULTIPLE LOCALISED CERVICOCRANIAL ARTERY DISSECTIONS DEVELOPING AFTER AORTIC ARCH DISSECTION
STUDIED ON BROCAS APHASIA BY DIFFUSION TENSOR IMAGING
Y. Zhang, S. Wang, C. Wang, X. Zhao, Y. Wang Beijing Tiantan Hospital, afliated with Capital University of Medical Sciences, Beijing, China
Background and purposes: Diffusion tensor imaging (DTI) is sensitive to the rate and direction of water diffusion, The bers distributing of language functional areas exhibit that extensive and complicated relationship between language areas and other areas. We studied Brocas aphasia cases by the technique in order to comprehend clinic symptom of the aphasia type. Methods: DTI in axial covering the entire brain volume were obtained in thirty volunteers and thirty Brocas aphasia patients who suffered from left hemisphere damaged after stroke. Used SIEMENS DTI software to post process and to measure fractional anisotropy (FA) value and display the course of Brocas area and the mirror side. Results: The results showed that the left Brocas area FA of volunteers was 0.3081 0.0325, the mirror side was 0.3069 0.0630, and there were no signicant between them (p>0.05). On the other hand, the left Brocas area FA of Brocas aphasia patients was 0.2578 0.05260, right corresponding area was 0.3063 0.0562, there were signicant between them (p<0.05). Conclusions: The Brocas area bers of Brocas aphsia were damaged. and using DTI can analyse the bers distributing of language functional areas, offer anatomy information for clinic and explain the bafing of neurology of widen activating signal language areas on cortex. Key words: DTI, Brocas Aphasia, Brocas area
A. Lovrencic-Huzjan, V. Vukovic, S. Antic, I. Galinovic, V. Demarin University Hospital, Zagreb, Croatia

A 56-year old male without vascular risk factors, presented with syncope, shock and encephalopathy afterwards. The diagnosis of aortic arch dissection was set. Aortic arch was operated, aortic valve was replaced and warfarin was introduced. During the rst year of follow up, he was symptom-free. However carotid color Doppler (CCD) showed a newly developed localized distal right common carotid and proximal internal carotid artery dissection. During the second year of follow up, he was ten months symptom-free. Afterwards, he had two attacks of vertigo and nausea, without vomiting. No other neurological symptoms or signs developed. He started complaining on the pain in the right shoulder. CCD conrmed persistent right carotid dissection, and a new right subclavian artery dissection was displayed. This is the rst report of a previously healthy patient who developed consecutive localized carotid and subclavian dissections during two-year follow-up of aortic arch dissection.
Interesting cases
BILATERAL ISCHAEMIC STROKES IN A 33 YEAR OLD WOMAN WITHIN A FEW MONTHS OF PITUITARY IRRADIATION
G. Beamond, K. Murray, P. Keston, C. Sudlow University of Edinburgh, Edinburgh, United Kingdom

Cranial irradiation is associated with increased stroke risk, usually years after exposure. We describe a 33 year old female with recurrent ischaemic strokes, starting only 4 months after cranial irradiation. She presented initially with acromegaly and a pituitary macroadenoma on MR brain scan. After transphenoidal hypophysectomy, she received octreotide and 45Gy of radiotherapy to the pituitary bed in 25 fractions over 5 weeks. Subsequent hypopituitarism was treated with DDAVP, hydrocortisone, thyroxine and the oral contraceptive. 4 months later she developed sudden onset apraxia, agnosia, acalculia and agraphia,
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transient episodes of right arm jerking, right-sided weakness and dysphasia. MR brain scan, MR angiography and CT angiography showed bilateral hemispheric watershed infarction, complete occlusion of the cavernous sinus portion of the right internal carotid artery (ICA) and severe stenosis of the intracavernous left ICA. She had no vascular risk factors, and investigations for causes other than radiotherapy were negative. She received aspirin and then warfarin. Her neurological decit almost completely resolved over the next few weeks, and subsequent CT perfusion scan showed good perfusion bilaterally. 11 months after her initial strokes, warfarin was discontinued and aspirin re-started. She re-presented 2 weeks later with further left hemisphere ischaemic strokes and radiological evidence of complete occlusion of both intracavernous ICAs. Warfarin was re-started. Several months later she had residual language difculties and mild right upper limb dysfunction. We assume that her recurrent strokes are due to large artery radiation-induced arteritis with associated thromboembolism. Such early development of this complication has not been described previously.
cyclophosphamide. However his aphasia and weakness persisted. Retrospective analysis of his initial CT neck scan showed signs of inammation within the left carotid sheath. Wegeners Granulomatosis is a rare cause of central nervous system infarction, usually due to small vessel vasculitis. We present a case of carotid artery thrombosis related to extravascular granulomatous involvement of a large vessel. There is no reported association between ankylosing spondylitis and Wegeners granulomatosis.
Interesting cases
CLINICAL PRESENTATION OF INTERNAL CAROTID ARTERY DISSECTION: REPORT OF 10 CASES
I. Divjak, M. Jovicevic, A. Jovanovic Institute of Neurology, Clinical Centre Novi Sad, University of Novi Sad, Novi Sad, Yugoslavia
Background: Internal carotid artery dissection (ICAD) is a recognized cause of stroke, particularly in young adults. It may occur spontaneously or result from local trauma. Clinical diagnosis may be difcult and the classical triad of symptoms is uncommon. Imaging plays a pivotal role in the diagnosis of ICAD. The aim was to analyze the spectrum of clinical presentation in 10 ICAD patients, with a special emphasis put on a patient presenting with Horners syndrome and facial and neck pain as the only symptoms of ICAD. Methods: Ten patients with ICAD aged 35-45 (mean age 42.1 years) were evaluated in the period January 2001 December 2006. The ICAD diagnosis was established using MRI, MRA and duplex sonography in all cases. In one case CT angiography was additionally performed. Results: Four patients presented with facial pain, Horners syndrome and contralateral sensorimotor decit. One patient presented with facial and neck pain and Horners syndrome only. Five patients presented with contralateral sensorimotor decit, with or without speech impairment. Two patients had traumatic ICAD (one while unloading sacks of corn and the other after sudden head turning) and other eight patients had spontaneous ICAD. MRI revealed infarction in 9 patients, while in the patient presenting with facial and neck pain and Horners syndrome diffusion MRI did not show evidence of infarction. Good outcome (dened as modied Rankin score of 0-2) was seen in all patients. Complete recanalization of ICAD was associated with favorable prognosis. Discussion: The spectrum of clinical presentation of ICAD is variable. ICAD is not necessarily accompanied by infarction on diffusion MRI.
Interesting cases
HEAD POSITION DEPENDENT VERTEBROBASILAR TIAS
A.A. Weck, H. Hungerbhler, A. Mironov, G. Schwegler Cantonal Hospital of Aarau, Aarau, Switzerland
Based on studies using duplex ultrasonography mechanical compression of the extracranial vertebral artery (VA) during rotation of the head is not very rare, but hardly ever symptomatic with signs of vertebrobasilar ischemia. As a general rule, to become symptomatic prearranged anatomical conditions in the vertebrobasilar circulation must be present: ow restriction in the contralateral VA (occlusion/severe stenosis/hypoplasia) and lack of functioning posterior communicating arteries. We report a 62 years old man who suffered from blurred vision after head rotation to the right side. Back in the neutral position his visual symptoms resolved rapidly. Driving car was a major problem for him due to impaired sight by turning his head to watch the trafc on the right side. Ultrasonography showed a normal right VA and a severe hypoplasia of the left VA (1.2 mm diameter). Both posterior communicating arteries were absent. Transcranial colour coded sonography documented a massive decrease of ow velocities in the posterior cerebral artery during head turning to the right reproducing his typical symptoms (video demonstration) and a transient reactive hyperemia of BFV above baseline values by return to the neutral position. Angiography of the right VA was normal in neutral position. By turning the head to the right, the VA became stenotic at level C6-C7 (V2 entrance zone). After maximal head rotation the bloodow 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. We suggest a rotational obstruction due to extraluminal cervical fascial bands of the longus coli muscle. Surgical evaluation is planned. The TCCD monitoring of the posterior cerebral artery is a reliable and reproducible method to detect cases of vertebrobasilar insufciency dependent on head rotation and mechanical compression.
Interesting cases
BILATERAL SPONTANEOUS CAROTID ARTERY DISSECTION
H. Weitenberg, M. Uyttenboogaart, J. De Keyser, G.J. Luijckx University Medical Centre Groningen, Groningen, The Netherlands
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 artery dissection. Case: A previous healthy 40 year old man presented with an isolated Horner syndrome on the right side. Several weeks before patient had an upper airway infection. This was followed by a period of right sided headache. Besides the Horner syndrome neurological examination was normal. MR angiography (MRA) 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. To prevent tromboembolic complications patient was treated with antiplatelet therapy for a year. Control MRA showed normalisation of the right and a slight pseudo-aneurysm of the left carotid artery. Discussion: The pathogenesis of spontaneous carotid dissection is at present uncertain. If multiple vessels are involved bromuscular dysplasia, Ehlers-Danlos, Marfan syndrome, osteogenesis imperfecta and alpha-1-antitrypsin deciency should be considered. These conditions were ruled out in this patient. Recently an association between spontaneous carotid artery dissection and upper airway infection has been reported. Suggested pathophysiological mechanisms are local infection of the arteries, or mechanical by sneezing. The higher incidence of carotid artery dissections in autumn is an argument for the possible relationship with upper airway infection. This case demonstrates that after excluding an underlying connective-tissue disorder upper airway infection should be considered as a cause of spontaneous bilateral carotid artery dissection.
Interesting cases
INTERNAL CAROTID ARTERY OCCLUSION DUE TO WEGENERS GRANULOMATOSIS
T. Das, W. Sunman, R.H. Harwood, J. Beavan, S. Munshi Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
A 44 year-old male presented to the Emergency Department (ED) with profuse epistaxis. Three months previously he was seen by otorhinolanrygologists for left sided otalgia, tinnitus and hearing loss. They noted left middle ear effusion and a polyp in the post-nasal space. Computed Tomography (CT) of the neck demonstrated an ulcerated pharyngeal mass. A nasopharyngeal biopsy showed a granulomatous lesion with central necrosis. A diagnosis of tuberculosis was considered as he had severe ankylosing spondylitis and was being assessed for anti-TNF therapy. He had no vascular risk factors. In the ED, he developed sudden-onset aphasia and right hemiplegia, with a left Horners syndrome. CT head scan showed a hyperdense left middle cerebral artery and early signs of cerebral infarction. He had greatly raised inammatory markers, a mild anaemia and normal renal function. Electrocardiography, urinalysis and chest X-ray were normal. His cANCA (PR3) level was high and indicative of Wegeners granulomatosis. Magnetic Resonance Imaging showed a nasopharyngeal mass involving the horizontal 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
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Interesting cases
TRANSIENT ISCHEMIC ATTACK AND LIVEDO RACEMOSA ANTIPHOSPHOLIPID SYNDROME
L. Valdemar, A. Marinho, G. Lopes Dept. Neurology, Hospital Geral de Santo Antnio, Porto, Portugal
Background: The Antiphospholipid Syndrome (APS) is an autoimmune disorder characterized by persistently elevated titters of antiphospholipid antibodies, associated to thrombotic events, without vasculitis, typically affecting females (82%). Ischemic stroke is reported in 30% of the patients with APS, with transient ischemic attacks (TIA) representing one third of them, but only 7% at disease onset. Livedo Racemosa (LR) is a rare pathologic skin condition occurring in some immunologic disorders. When associated to cerebrovascular disease it is called Sneddons Syndrome (SS). Case presentation: A fty three years old male patient, with hypertension, suddenly became nauseated, vomited, and had vertigo and disequilibrium. The neurological examination showed dysarthria, right dysmetria and ataxic gait. He also had an exuberant LR. He completely recovered from all symptoms and signs in less than 24 hours. The cerebral MRI showed bihemispheric ischemic leukoencephalopathy and no signs of acute ischemia with diffusion technique. High and persistent titters of autoantibodies were found (anticardiolipin, antiB2GPI and lupus anticoagulant). AngioMRI, transcranial Doppler, ultrasonography of cervical and renal arteries, ECG, transesophagic echocardiogram and serologic studies were normal. Anticoagulation was started. Discussion: This patient, with a cerebellar TIA, presented as a SS and fulls clinical, imagiological and laboratorial criteria for APS with LR. Ischemic cerebrovascular disease can be a manifestation of APS, but its association with LR is rare. This clinical presentation, in a male patient, is even less frequent. Relationship between SS and APS with LR is not clear, as these two entities are clinically indistinguishable and classied as a continuous spectrum of a disease.
Wernickes aphasia is usually associated with a lesion of the posterior part of the lateral temporal areas, namely Wernickes area, conduction aphasia is associated with lesion of the left arcuate fasciculus or of the left supramarginal gyrus, and so on. However, we found that not all aphasia types met with the pattern. A fty-six man suffered from aphasia after stroke, he understanded what words mean, but had trouble performing the motor or output aspects of speech, and he couldnt communicate through writing. The results of Western Aphasia Battery showed he was Brocas aphasia, but we found the damaged lesion was Wernickes area instead of Brocas area. On the other hand, we studied regional blood volume (rCBV) and regional cerebral blood ow (rCBF), mean transit time (MTT), and time to peak (TTP) of Brocas area of the patient by perfusion-weighted imaging, and compared with that of the contralateral hemisphere, we also measured the metabolic rate of N-acetylaspartate (NAA), choline (Cho), and creatine (Cr) by magnetic resonance spectroscopy, and compared the results with that of the contralateral hemisphere. We found the Brocas area were in a hypoperfusion and hypometabolism state compared with the contralateral hemisphere, maybe this can explain why the type of this case was Brocas aphasia while damaged lesion was Wernickes area. The aphasia case challenged the anatomy of aphasia theory.
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RECURRENT TRANSIENT ATAXIC HEMIPARESIS REVEALING A HYPOGLYCAEMIC PARANEOPLASIC SYNDROME
P. Olivier, J. Zapf, P. Michel Centre Hospitalier Universitaire Vaudois, Switzerland

Aim: We describe a patient presenting with recurrent ataxic hemiparesis as a consequence of hypoglycaemia due to a benign pleural brous tumour. Case description: A 80 year old hypertensive women with a history of a pleural tumor resected 11 years earlier presented four episodes of mild transient right hemiparesis and mild confusion upon awakening on four consecutive mornings. On admission, mild right ataxic hemiparesis was present. At the end of her rst night in the stroke unit, worsening of the right ataxic hemiparesis and decreased vigilance occurred. Investigations: Head CT and CT-angiography were performed. Blood sugar, insuline, cortisol, C-peptide, insuline-like growth factor-I (IGF-I) and IGF-II were measured. Thoraco-abdominal CT and PET were done. Results: Cerebral CT with angiographic sequences didnt reveal any abnormality. Hypoglycemia of 1.2 mmol/l was detected during worsening and neurological status normalized promptly with treatment. Recurrent hypoinsulinemic hypoglycaemia (glycemia 1.0-2.2 mmol/L; insulin <2mUl/l (5.0-18.0); C-peptide < 0.30 ugL (0.7-3.0)) was documented and required continuous glucose perfusion. Cortisol and IGF-I were normal. IGF-II (740ng/ml) and "big IGF-II fraction (212 ng/ml; 28.7% of total IGF-II, N<15%) were elevated. An extrapulmonary tumor occupying most of the right hemithorax was found, consistent with a benign pleural tumor on PET. Thoracotomy revealed a benign pleural brous tumor of the fuso-cillary type, identical to the one resected 11 years earlier. After complete resection, no more symptoms occurred, and IGF-II and its fractions normalized. Conclusion: This elderly lady presented with recurrent ataxic hemiparesis suggestive of a lacunar warning syndrome. Demonstration of severe hypoglycaemia during these episodes led to the detection of a fuso-cillary pleural tumor. This stroke-imitating paraneoplastic syndrome was related to hypersecretion of a fraction of IGF-II, and was completely cured by resection of the tumor.
Interesting cases
AN UNRECOGNIZED CAUSE OF THUNDERCLAP HEADACHE: REVERSIBLE CEREBRAL VASOCONTRICTION SYNDROME
K. Koopman, M. Uyttenboogaart, G.J. Luijckx, J. De Keyser, P.C. Vroomen University Medical Centre Groningen, Groningen, The Netherlands
Background: An unrecognized cause of thunderclap headache (TCH) is Reversible Cerebral Vasoconstriction Syndrome (RCVS). We describe 3 patients with RCVS. Cases: Three women, aged between 40-55 yrs, presented with TCH. One patient had a history of migraine with sumatriptan abuse and one had an exacerbation of Crohns disease. SAH was ruled out by CT scan and CSF examination. MR venography was normal. Brain MRI in 2 patients showed infarction in the posterior regions. Cerebral angiography (DSA) showed diffuse beading in one patient. She was suspected of having primary angiitis of CNS (PACNS) but did not respond to treatment with immunosuppressants. All had increased velocities on TCD. RCVS was diagnosed and they were treated with calcium channel inhibitors. This led to clinical improvement and normalisation of TCD within weeks. Discussion: RCVS is characterised by a reversible segmental vasoconstriction of the cerebral vessels, most commonly occurring in women aged 20-50 yrs. It is associated with conditions such as migraine, certain drugs and pregnancy. The striking presenting feature is TCH, with or without focal signs. CSF is (near) normal, in contrast to PACNS and SAH. Brain imaging ndings vary between normal and infarction, particularly in the posterior circulation. Segmental vasoconstriction on DSA does not differentiate between vasculitis and RCVS. One of the hallmarks of RCVS is the complete reversibility of vasoconstriction on TCD. Treatment is with calcium channel blockers, in severe cases combined with prednisone. These patient cases underline that (1) TCH, normal CSF, and MRI or angiographic abnormalities may point to RCVS, (2) TCD is helpful in diagnosing RCVS and (3) proper diagnosis of RCVS has important therapeutic consequences.
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THREE CASES OF CEREBRAL PEDUNCULAR INFARCTION WITH PURE DYSARTHRIA
G.S. Kim, J.H. Lee, S.A. Choi, J.H. Cho NHIC Ilsan Hospital, Goyang Shi, Kyungki Do, South Korea
Background: Pure dysarthria can be seen in patients with stroke involving the corticobulbar tract, usually at the lenticulocapsular, pontine base, or cortical areas. Infarction of cerebral peduncle is rare. Its manifestation is dysarthria-clumbsy hand or dysarthria-one arm weakness. Pure dysarthria due to cerebral peduncular infarction is extremely rare. We experienced three cases of cerebral peduncular infarction with pure dysarthria. Cases: All cases showed inaccurate articulation in the labial sound than palatal or lingual sound. One with left cerebral peduncular infarction showed slight impair of right sided hopping in neurologic examination. The others with right cerebral peduncular infarction showed dysarthria only. There is no severe stenosis of relevant arterial system in magnetic resonance angiography. In short follow-up period, they showed full recovery of symptoms. Discussion: Dysarthria of infratentorial origin has been described in infarctions of
Interesting cases
BROCAS APHASIA ELICITED BY WERNICKES AREA DAMAGED
Y. Zhang, N. Wie, H. Chen, N. Zhang, Y. Wang Beijing Tiantan Hospital, afliated with Capital University of Medical Sciences, Beijing, China
Aphasia is one of the common symptoms in acute and chronic stroke patients, many postmortem and radiologic studies have documented the pattern of associations between brain lesions and aphasic syndromes, such as Brocas aphasia is mainly due to a lesion damaged of the left inferior frontal area, namely Brocas area,
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the basis pontis and cerebellum. We also observed pure dysarthria in patients with an infarction of the cerebral peduncle. Focal injury to corticobulbar tract within cerebral peduncle seemed to be a possible cause of pure dysarthria.
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PRIMARY ANGITIS OF CENTRAL NERVOUS SYSTEM IN A PATIENT OF ACQUIRED DEFICIENCY SYNDROME (AIDS), A CASE REPORT
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A. Al Memar, N. Akhtar, A. Trip Atkinson Morley Wing at St Georges Hospital London, London, United Kingdom
Background: Cerebral vasculitis in patients infected with human immunodeciency virus (HIV) is usually secondary to infectious agents rather then HIV itself. It is extremely rare to have cerebral vasculitis where no other cause can be found and role of HIV is postulated in genesis of cerebral vasculitis. This is a case report of 44-year-old, was diagnosed to have HIV in January 2005, when he presented with features of fever headaches, night sweating and hairy leukoplakia. He presented to us in December 2005 with the features of, personality change was hemi paresis and cortical blindness. He had mild leukopenia of 3.7 ANA, ANCA and other antibodies of vasculitic screen were negative. MRI- was suggestive of gross abnormality involving left occipital lobe. Occipital lobe biopsy was consistent with clear-cut vasculitis. Methods: We compared the clinical and biopsy results between our case and previously published cases. Result: PCR and histological ndings looking into the possibilities of HSV 1+2, CMV, Adeno virus, VZV, JC virus and HIV were negative there was no evidence of cerebral lymphoma. In the view of negative specic viral staining, and absences of antibodies of vasculitic screen suggest the diagnosis of primary angitis of the central nervous system in a patient infected with HIV. Discussion: To our knowledge only eight cases are reported in literature in which primary angitis of central nervous system was suspected to be associated with HIV. This case Illustrates a rarity of condition but does raise the strong hypothetical link between HIV and primary vasculitis. In our case histological studies were compatible with a diagnosis of primary angitis of the central nervous system, but the pathogenic role of HIV in the genesis of the vasculitic process cannot be elucidated.
CEREBRAL INFARCTION IN ACUTE (MYELOMONOCYTIC) LEUCEMIA AT INITIAL PRESENTATION
S. Koskina, A. Tavernarakis, I. Xydakis, E. Mamouzelos, E. Koutra, N. Matikas Evangelismos Hospita, Athens, Greece
Acute leukemia (A.L) is a rare cause of stroke in young adults. We present the case of a patient in whom stroke was the rst manifestation of the disease. The patient, a 48 years old woman,was admitted to the hospital to investigate unremitting fever. Few days later, she suffered a stroke (left hemiplegia),and then a second one (right hemiparesis and aphasia), and developped thrombosis of the left supercial femoral vein. The patient didnt have any known risk factors other than a mild hypertension. Successive computerized tomography scans showed mainly a hypodense area in the right temporo-parietal region. Blood tests were performed, that revealed evidence of disseminated intravascular coagulation (D.I.C.) and positive lupus anticoagulant,while other ancillary investigations, including lumbar puncture, thoracic and oesophageal cardiac ultrasound and carotid artery triplex were normal. Finally,the patient was diagnosed from a bone marrow biopsy,as having acute myelomonocytic leukemia. Treatment was initiated, but the patient died two months later from multiorgan failure and sepsis. There are several mechanisms causing thrombotic episodes in acute leukemias. D.I.C.,positive lupus anticoagulant or antiphospholipid antibody in serum, leucostasis syndrome in leukemias with leukocytosis, or direct viral damage to endothelial cells in virus induced leukemias are mechanisms encountered in the literature. The particularity of the present case is the fact that stroke, probably caused by D.I.C., was the rst manifestation of A.L. Thus, it is of the utmost importance that young adults presenting with stroke, be investigated thoroughly to diagnose any underlying hematologic malignancy and initiate, as soon as possible,the apropriate treatment.
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FAMILIAL SNEDDONS SYNDROME
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S. Llufriu, A. Cervera, S. Amaro, A. Chamorro Stroke Unit, Hospital Clinic, Barcelona, Spain
Background: Sneddons syndrome is a non inammatory arteriopathy characterized by livedo reticularis and cerebrovascular disease. It is an uncommon cause of stroke in young people and it has been associated to the Antiphospholipid syndrome. It mainly occurs sporadically, although few familial cases have been reported. In familial cases the most common pattern of inheritance is autosomal dominant, although the gene responsible is not known. Case report: A 34 year-old woman with right hemiparesis, progressive ataxia since early childhood and frequent migraine attacks. In the last year, she had experienced episodes of dizziness, and dysphagia. The neurological exam disclosed mild cognitive impairment, right hemiparesis, horizontal nystagmus and left cerebellar signs. On clinical exam, prominent skin lesions -mainly in the thighswere consistent with livedo reticularis. Global atrophy, multiple and conuent subcortical ischemic strokes and abundant microbleeds were found on brain MRI, whereas angio-MRI, carotid ultrasonography and transesophageal echocardiogram were normal. Prothrombotic states and antiphospholipid antibodies were ruled out as appropriate. A skin biopsy was non specic. Two sisters and one brother had livedo reticularis and a history of early-onset stroke (neuroimaging available). The remainder sister had 2 abortions and livedo reticularis but not neurological decits. Her father died from a myocardial infarction at the age of 54. Discussion: Sneddons syndrome is a devastating cause of stroke in the young with few cases reported in the literature. We add a new family of this entity which its main clinical ndings, imaging and immunological traits are reviewed.
ARTERIAL OCCLUSION AND STROKE AFTER CISPLATIN CHEMOTHERAPY
K.A. Pasco, P. Hart St Georges Hospital, London, United Kingdom

Background: Malignancy as a risk factor for cerebrovascular disorders and as a thromboembolic risk is well described. Cisplatin, used alone or in combination, has become standard treatment for various solid tumours. Side effects of cisplatin include neurotoxicity and Goldhirsch et al rst described the association of acute stroke with cisplatin use in 1983, suggesting this agent increases ones risk of stroke above that of the tumour alone. Case reports: We describe three cases of acute ischaemic stroke post cisplatin chemotherapy, all supported by clinical and radiological evidence. The cases are aged 17, 36 and 44 years, two female; one male and each with different tumour subtypes (neuroendocrine, cervical adenocarcinoma and medulloblastoma). All received cisplatin based chemotherapy in conjunction with other treatment. All had Middle Cerebral Artery (MCA) territory infarction 2-10 days post cisplatin therapy. All had received more than two treatment cycles. In two cases arterial occlusion was conrmed, in the third it was found to be highly likely. Discussion: Cisplatin regimes are implicated in acute stroke and the mechanisms may be multi-factorial. Our cases could be explained by direct cisplatin endothelial toxicity and enhanced platelet aggregation thus leading to arterial thrombus formation. Work also suggests that cisplatin predisposes to a hypercoagulable state through an acquired protein C deciency or increased von willebrand factor. Other reports suggest cisplatin induced vasospasm through hypomagnesaemia. Additionally, our cases demonstrate the close temporal relationship between cisplatin administration and acute stroke onset in the absence of other cardiovascular risk factors and support the suggestion that stroke tends to occur after several treatment cycles. A review in 2006 identifying cisplatin use as a stroke risk factor, more so than other chemotherapeutic agents, also found the MCA territory most often affected, which lends further weight to our own case ndings.
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INTRACRANIAL PRESSURE AND CEREBRAL BLOOD FLOW CORRELATION
I. Voznjuk, M. Odinak, S. Golokhvastov, N. Tsygan Military Medical Academy, Russian Federation

Background: Current imaging methods are unable to differentiate neuroinammatory processes such as endothelial activation. We imaged activated endothelium in a mouse model of acute stroke using a novel iron oxide nanoparticle MRI contrast agent - MNP-Psel - targeted to the adhesion molecule P-selectin.
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Methods: MNP-Psel was compared to the non-targeted iron oxide MRI contrast agent Feridex. In ten C57 Black 6 mice the left middle cerebral artery was transiently occluded for 30 minutes while a body temperature of 36.5 0.5 C was maintained throughout and after the procedure. 24 hours after reperfusion, six mice were injected with MNP-Psel and four with Feridex at a dose of 2.8 mg Fe/kg. MRI scans (T1, T2, and T2*) were obtained at 9.4 T, and infarct was identied from T2 maps. Subtraction images (pre-contrast post-contrast) from T1 maps, T2 maps and T2* were obtained at 1, 36, 72 and 108 minutes after contrast injection. Changes in T1 and T2 values in the contralateral hemisphere were subtracted from the stroke hemisphere to reveal the infarct tissue-specic contrast accumulation effect. After imaging, the mice were euthanized and brain sections through the cortex and striatum were taken for iron histochemical staining by the Prussian blue method. Results: MNP-Psel and Feridex had similar T1 effects. T2* images demonstrated a peri-infarct prolonged contrast effect with MNP-Psel but not Feridex. T2 subtraction maps revealed a prolonged MNP-Psel infarct-specic contrast effect not seen with Feridex. Iron staining on vessel walls in the infarct hemisphere indicated endothelial localization of the MNP-Psel contrast agent. Discussion: Injection of MNP-Psel, but not Feridex, resulted in a prolonged infarctspecic iron oxide contrast effect associated with endothelial iron accumulation. This suggests that MNP-Psel accumulated in infarct and peri-infarct areas via P-selectin-binding on activated endothelium. This demonstrates the feasibility of using MRI to image specic neuroinammatory processes that contribute to the evolution of stroke injury.
(CRP) less than 3 and tests for vasculitis and thrombophilia were negative. Electrocardiogram (ECG) showed sinus rhythm with right bundle branch block and echocardiogram a hyperechoic myocardium with restricted lling. Cardiac MRI showed global wall thickening, oedema suggesting an inammatory process, global subendocardial late enhancement characteristic of amyloid [1], and impaired diastolic function. There was an IgG lambda paraproteinaemia with partial immune paresis and 20% plasma cells in bone marrow. Serum amyloid protein scan showed no visceral deposition and rectal biopsy was inconclusive. Discussion: Systemic symptoms preceding amaurosis and a contralateral TIA and an abnormal echocardiogram gave a clue to a rare cause of cardio-embolic stroke, primary amyloidosis. This was conrmed by cardiac MRI, bone marrow and serum electrophoresis. Anticoagulation is indicated despite sinus rhythm in view of a 33% risk of cerebral embolism [2] due to impaired cardiac function References: [1] Maceira AM et al. Circulation. 2005;111:186-93. [2] Hausfater P et al. Scand J Rheumatol. 2005;34:315-9.
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POSTERIOR INFERIOR CEREBELLAR ARTERY DISSECTION CAUSING ANEURYSM AND TRANSIENT ISCHEMIC ATTACK: ANEURYSM DISAPPEARANCE AND PREVENTION OF RECURRENT BRAIN ISCHEMIA WITH CONSERVATIVE TREATMENT. A CASE REPORT
D. Muentener, A. Mironov, A. Valavanis, R.W. Baumgartner, H. Hungerbuehler University Hospital of Zurich, Zurich, Switzerland
Isolated spontaneous dissection of the posterior inferior cerebellar artery (PICA) causing aneurysm formation is rare. Up to 70% present with subarachnoid hemorrhage and remaining cases with ischemic events. We present a 49 year old man with vertebro-basilar transient ischemic attack (TIA). Magnetic resonance imaging showed two cerebellar DWI lesions in the territory of left PICA with a normal MR angiography (MRA). Transforaminal duplex sonography revealed a stenotic signal, but identication of the affected artery was not possible. Digital subtraction angiography (DSA) performed 2 days after MRA showed a stenosis and a fusiform aneurysm of the proximal left PICA likely due to dissection. The patient was treated with oral aspirin. One month later another vertebro-basilar TIA occurred. Aspirin was replaced by oral anticoagulation. No further ischemic event was observed in the next 12 months. DSA performed 6 months after symptoms onset showed complete resolution of the aneurysm, which retrospectively conrmed the diagnosis of PICA dissection. Anticoagulation was discontinued. We conclude that dissecting aneurysms of the PICA can resolve spontaneously. Anticoagulation may be an efcient and safe treatment in patients with PICA dissection causing TIA and aneurysm.
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PERIPHERAL VERTIGO OF CARDIAC ORIGIN. TWO CASES OF CARDIOEMBOLIC PICA INFARCTS, ASSOCIATED WITH PFO, PRESENTING AS A MISLEADING ISOLATED VERTIGO
S. Beretta, P. Santoro, C. Ferrarese University of Milano-Bicocca, Monza, Monza (MI), Italy

Background: Isolated vertigo as a manifestation of acute cerebellar infarct in the posterior inferior cerebellar artery (PICA) territory was rst reported by about 25 years ago. Nonetheless, this presentation of cerebellar strokes still represents a clinical challenge, especially in young patients. Results: We report two cases (man, age 48; woman, age 59) presenting with stereotyped-rotatory dizziness, nausea, vomiting, inability to stand unaided and nystagmus, which were evaluated in the ER by a ENT and a neurologist and were admitted to the ENT department with the diagnosis of peripheral vertigo. Such initial manifestation was followed by delayed neurologic signs within 2 days after the onset. An acute, large inferior cerebellar ischemic stroke due to occlusion of 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 cerebral arteries, normal heart rhythm and morphology, except from a signicant patent foramen ovale (PFO). Both patients recovered completely within 3 months and underwent a successful percutaneous closure of PFO. Discussion: Early diagnosis of cerebellar infarction simulating vestibular neuritis is difcult and these patients are likely to be excluded from rtPA therapy. Carefully looking for subtle neurological signs and the eventual use of diffusion weighted MRI may overcome this problem in selected patients. Finally, PFO needs to be investigated as a potential cause of this disorder in young patients.
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ISCHEMIC STROKE AFTER CHEMOTHERAPY WITH CISPLATIN, ETOPOSIDE AND BLEOMYCIN FOR A TESTICULAR NON-SEMINOMA CARCINOMA: A CASE REPORT
M. Vikelis, M. Xifaras, A. Basta, G. Gekas General Hospital of Nikea, Nikea, Greece

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 infarction and pulmonary embolism seem to occur infrequently. Case report: We present the case of a 37-year-old man that was treated with a combination of cisplatin, bleomycin and etoposide (BEP) for a testicular nonseminoma carcinoma. Two days after the rst course of BEP he experienced sudden-onset right hemiplegia with involvement of the lower facial muscles and right homonymous hemianopia. A MRI-scan of the brain revealed an extended infarction in the vascular territory of the right middle cerebral artery. Angiography of the head and neck arteries revealed a completely thrombotic right internal carotid artery. There was no evidence of coagulopathy, vascular, or endocardial disease that may have led to a cerebrovascular accident and the patient had no known vascular risk factor except for smoking. The time sequence between the chemotherapy and the stroke clearly suggest a causal relationship between them in our patient. Particularly, a cisplatin-related cause is probable, since such adverse effects are unknown with bleomycin or etoposide. Conclusion: Whereas a cause and effect relationship is probable for some vascular events following chemotherapy, some cases may represent coincidence or may be disease related. Several factors appear to be responsible for cisplatin vascular toxicity, such as an increased thrombogenicity and vascular spasm due to hypomagnesaemia. Potential late vascular toxicity has also to be taken into account.
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CARDIAC AMYLOIDOSIS - A RARE CAUSE OF TRANSIENT ISCHAEMIC ATTACK (TIA)
D.M. Collas Watford General Hospital, Watford, Hertfordshire, United Kingdom

Introduction: A 41-year old male with a TIA is presented. Method: After an initial 30 minute episode of motor and sensory loss in the right arm and leg the patient re-presented within 24 hours with a stroke involving face, arm and leg. Limb weakness resolved within 1 hour and facial weakness within 1 day, mild dysarthria persisting. There had been right amaurosis 6 weeks before, and 1 week of mild confusion, 1 month of lethargy, knee pain, and weight loss and urticarial rash over a 5 month period. He had a cholesterol of 6 but no other common risk factors for stroke, being a normotensive non-smoker. Results: Computed tomography (CT) revealed a left striato-capsular infarct with mild mass effect conrmed on magnetic resonance imaging (MRI), with signal increase on diffusion weighting, and normal carotids on duplex scan and MR angiography. Erythrocyte sedimentation rate (ESR) was 40 but C-reactive protein
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CEREBRAL LIPIODOL EMBOLISM WITHOUT PULMONARY INVOLVEMENT DURING TRANSCATHETER ARTERIAL CHEMOEMBOLIZATION
B.G. Yoo, J.K. Kim, J.H. Ko, E.G. Kim Kosin University College of Medicine, Busan, South Korea
Background: Use of lipiodol in transcatheter arterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) treatment has been found to be associated with a number of complications. However, cerebral lipiodol embolism has been rarely reported. All of the reported cases of cerebral lipiodol embolism have pulmonary involvement. Case report: A 68- year-old woman with advanced HCC underwent a second course of TACE at the hepatic artery using a mixture of 30 mL lipiodol. During the procedure he had dysarthria and deteriorated consciousness, followed by status epilepticus and semicoma. There was no breathing difculty, and skin examination was normal. Two hours later, MRI showed restricted diffusion in the cortex and cortical-subcortical junction, both cerebral and cerebellar hemispheres. Two days later, a follow-up MRI showed multiple cerebellar and cerebral infarcts with hemorrhagic transformation. A transcranial doppler with a bubble study demonstrated a right-to-left shunt. Conclusion: We report a patient with cerebral lipiodol embolism without pulmonary involvement during TACE of HCC. TACE is not an innocent procedure and clinicians must be alert to complications such as right-to-left shunt. To reduce the risk of lipiodol embolism, a smaller lipiodol dose and survey for detection of intracardiac shunt before the procedure can be considered.
the second stage of labour. Three hours post delivery she developed left sided weakness, left homonymous hemianopia and a GCS of 11/15. CT Brain showed a large intracranial haemorrhage in the right basal ganglia. Case 3: A 39 year old woman with a severe headache and systolic blood pressure of 200mmHg eight days post-partum, developed left sided weakness. CT Brain showed infarction in the right middle cerebral artery territory. CT angiogram showed bilateral carotid dissection. Intravenous heparin was started and subsequently warfarin. Five weeks later she had a new headache in her right temple. MR angiogram showed further occlusion of the right vertebral artery. Intravenous methylprednisolone was started followed by oral prednisolone in view of possible recurrent inammatory process. All 3 women improved. Each patient could walk independently with residual weakness to varying degrees. None had speech or swallow difculties. One patient had mild cognitive impairment not evident in everyday function. The challenges in rehabilitation include strategies to cope with infant care, depression in not participating fully in nursing and a fear of not being able to bond with the newborn if hospitalised for a long period. It is vital that patients receive rehabilitation as soon as possible.
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IRON DEFICIENCY ANAEMIA AND STROKE
J.C. Whrle, M. Silomon, M. Kaspers, R. Werner Katholisches Klinikum Koblenz, Koblenz, Germany
Background: Stroke is a rare complication of iron deciency anaemia that may be related to reactive thrombocytosis with thrombophilia or to impaired oxygen delivery. Case report: A 45 year-old woman had a severe right-sided hemiparesis upon awakening resolving within 30 minutes. Subsequently, symptoms recurred and progressed to hemiplegia and global aphasia on arrival in our stroke unit. She was a cigarette smoker and had felt weak for the last 3 months; she had hypermenorrhagia. Immediate cranial computed tomography showed early signs of infarction in the territory of the left middle cerebral artery (MCA). In the presence of ubiquitous high blood ow velocities, transcranial ultrasound revealed a signicant reduction in the left MCA (systolic/diastolic velocities 89/34 cm/s left vs. 193/77 cm/s right). There were small hypoechogenic plaques in both proximal internal carotid arteries. Thrombolysis was withheld because of severe microcytic anaemia with haemoglobin 5.9 mg/dl and thrombocytosis (698.000/l). We found iron deciency (iron 22 ug/ml, ferritin 4 ng/ml). Screening for thrombophilic factors and cardiac embolism was negative. The patient received blood transfusions, low dose heparin, and aspirin. Within days, sonography and MR angiography revealed normalized ow patterns in both MCAs. Hypermenorrhagia remained the only cause of anaemia. She became ambulatory, but had persistent Brocas aphasia and a severe spastic brachial paresis. Discussion: While extracranial artery thrombosis is recognized as sequelae of severe iron deciency anaemia (e.g. Caplan et al. Neurology 1984), isolated intracranial artery occlusion is exceedingly rare. Intracranial artery obstruction may have been caused by embolism from proximal sites with complete resolution of the original thrombus or by local MCA thrombosis.
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CROSSED CONDUCTION APHASIA: A CASE REPORT
Y. Zhang, Y. Liu, X. Zhao, C. Wang, Y. Wang Beijing Tiantan Hospital, afliated with Capital University of Medical Sciences, Beijing, China
Conduction aphasia is known as a disconnection syndrome, and characterized by a comparatively reduced ability to repeat spoken language and well comprehension. According to Geschwind, conduction aphasia results from damage to the arcuate fasciculus, one major pathways connects Brocas and Wernickes areas. Both Brocas and Wernickes areas are left intact. We found that not all conduction aphasia cases met with these standards. A 50 year-old highly educated, right-handed man suffered from aphasia after stroke. And he had uent paraphasic expression, severe impairment of repetition and poor comprehension without motor impairment. Western Aphasia Battery showed that he was conduction aphasia, and the damaged lesion was right hemisphere, thereby, he was crossed conduction aphasia case. We found that he had severe decits in repeating no-words and short memory capacity, although he failed to show cognitive limitation in phonological output tasks. By diffusion tensor imaging, we found that the fractional anisotropy (FA) values of right arcuate fasciculus were smaller than that of the mirror side, that were to say the right major pathways connects Brocas and Wernickes areas were damaged. On the other hand, we also found that the FA values of right Wernickes area were smaller than that of mirror area, that means the Wernickes area was also damaged, maybe this damaged can explain why the case had uent output and poor comprehension and his language disorders liked Wernickes aphasia, that were to say he was Wernicke-like crossed conduction aphasia. The case proved that three supposes of conduction aphasia:Wernicke-Geschwinds theory of disconnection, the defect pattern of auditory-speech shorten memory and the Bidirectional pattern.
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ISCHEMIC STROKE OR MULTIPLE SCLEROSIS RELAPSE AFTER 44 YEARS OF REMISSION?
Y.-M. Huang, O. Nordmark, M. Lee, H. Naver Uppsala University Hospital, Uppsala, Sweden
Background: MS and stroke differ in many ways but share a nal common path with neuronal and axonal loss. It is not known how these diseases inuence each other, nor their coincidence or best strategy concerning therapy and stroke prevention. Here we report a patient with 60 years history of MS, complete neurological remission for >40 years and progressive gait and balance problems with spasticity for the last 5 years. Case presentation: Woman born 1923, had at age 24, 27 and 29 right-sided optic neuritis, at age 31, 32 and 33 episodes of vertigo and diplopia, and at age 33 an episode of slight left leg weakness and spasticity with minor sequelae. CSF at age 31 and 33 showed slight mononuclear pleocytosis, normal protein and glucose. ACTH courses given at age 31 and 33 had benecial effect. After 1956, she remained healthy till 2001 when gait and balance problems and left-sided spasticity developed insidiously, making unaided walk difcult but she did not consult physician.
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STROKE IN THE PUERPERIUM AND PERI-PARTUM PERIOD
K.M. Tan, A. Carroll National Rehabilitation Hospital, Rochestown Avenue, Dun Laoghaire, Co. Dublin, County Dublin, Ireland
Stroke in the puerperium and peri-partum period, although rare, causes devastating consequences. The following are 3 cases. Case 1: A 28 year old woman with an acute right frontal headache developed left sided weakness 10 days post caesarean section. CT brain showed right basal ganglia, internal capsule and parietal infarcts. CT angiogram showed right carotid dissection. Intravenous heparin was commenced followed by warfarin. Case 2: A 32 year old woman had a severe headache, nausea and vomiting in
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DWI was performed in three patients. The two asymptomatic patients with DWI did not show any acute lesion. The other one showed acute lesion in AChA territory. Conclusion: We suggest that brinolysis is a therapy to take into account in CWS. DWI was normal in treated patients who recovered.
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MIGRAINE WITH AURA AS AN ISOLATED PRESENTING SYMPTOM OF CEREBRAL VENOUS THROMBOSIS
R.E. Petrea, J.R. Romero, S. Seshadri, J. Viereck, V. Babikian, C.S. Kase Boston University School of Medicine, Boston, MA, USA
Background: Headache is the most common presenting symptom of cerebral venous thrombosis. In the majority of cases headache is a non-specic symptom accompanied by other neurological signs. Methods: Case report. A 27 year old right handed man presented to the emergency department (ED) with a 30 minute headache with visual aura and sensory symptoms. He reported a generalized, excruciating throbbing headache followed by bright lights in front of both eyes lasting about 15 minutes. A tingling march from the right side of his face down to his right upper and lower limbs progressed over another 15 minutes. All decits resolved completely in 30 minutes. He had a total of four episodes only with visual aura and headache, the rst one 2 months prior to the ED presentation. Two of these episodes were evaluated by head CT (computer tomography) and lumbar puncture both of which were normal. His neurological examination was entirely normal. Results: MRI (magnetic resonance imaging) of the brain revealed a hyperintense signal on T1 and FLAIR sequences in the superior sagittal sinus suggesting thrombosis. Tiny venous infarcts were seen in the parietal cortex bilaterally. MRV (magnetic resonance venography) conrmed lack of ow in the superior sagittal, left transverse and sigmoid sinuses, extending to the jugular bulb. Laboratory work-up revealed a nephritic syndrome and an abnormal activated protein C resistance. He was treated with anticoagulation with no recurrence of his headache. Conclusions: New onset recurrent migraines with aura can be an isolated presenting symptom of cerebral venous thrombosis. Any headache that progresses in an unusual fashion should also prompt the consideration of cerebral venous thrombosis and the appropriate imaging for diagnosis.
Fig. 1. Brain CT: slight bilateral signal changes in capsula externa.
In May 2005, she was seen in emergency room because of sudden expressive dysphasia and confusion. Symptoms disappeared after 45 min. BP 170/80. When 83 and having UTI, she had head trauma after fall in Febr, 2006, followed by increase left-sided hemiparesis. Brain CT: unchanged. CSF: >2 oligoclonal IgG bands in CSF absent in serum. MRI showed on T2 multiple pericallosal lesions (Fig. 1, A), on T1 no gadolinium enhancement (B) and no fresh ischemic lesions at apparent diffusion coefcient image (C) but leucoaraoisis. After UTI treatment, she was mentally intact but had severe gait and balance problems and spasticity persistent at 10 m follow-up. Questions: 1. Did the patient have stroke in 2001? TIA in May 2005? 2. Cause of left-sided hemiparesis in February 2006, stroke or MS relapse? 3. Best available management both from medical and social aspects? 4. How can imaging help in diagnosis?
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EOSINOPHILIC VASCULITIS: A RARE CAUSE OF DOLICHOECTASIA OF THE CAROTID AND INTRACRANIAL ARTERIES
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M. Labuda, S. Lanthier Universit de Montral, Faculty of Medicine; CHUM-Hpital Notre-Dame, Montreal, Canada
Background: Present in 12% of strokes, intracranial arterial dolichoectasia (IADE) is associated with atherosclerosis and elastic tissue diseases, and attributed to internal elastic lamina disruption. Goals: To clarify pathogenesis of IADE and to stress the diagnostic challenge of eosinophilic vasculitis (EV). Methods: Case report. Results: A 46-year-old man presented in 2005 with <2-minute episodes of aphasia and right limb tremor and weakness without altered vigilance. In 1999, similar episodes were attributed to carotid and IADE and treated with warfarin for 6 months followed by aspirin. He denied allergies and other neurological, constitutional or systemic symptoms, except pruritus since 2003; investigation had shown skin inltration by lymphocytes and idiopathic blood eosinophilia. Physical exam was normal, as well as brain MRI and 24-hour EEG witnessing episodes. Selective brain angiography revealed progression of carotid and IADE and no arterial stenosis. Temporal artery biopsy revealed trans-mural non-necrotic inltration by lymphocytes and eosinophils, multinucleated cells, and histiocytes forming a single granuloma. Blood tests showed increased white cell count (14.8 x 109/l; 37% eosinophils) and IgE level, negative HIV, aspergillus and hepatitis serologies, and normal inammatory, prothrombotic and vitamin B12 workups. Echocardiography, thoraco-abdominal CT, abdominal CT-angiography, and stool exam were normal. Skin tests indicated pollen and cat hypersensitivity. On bone marrow biopsy, cells (50% eosinophils) had no chromosomal abnormalities. His neurologic symptoms, pruritus and eosinophilia resolved with prednisone (1mg/kg/d for 4 months, tapered over 3 more months). We did not nd previous reports of EV with IADE. Discussion: EV can cause IADE by disrupting the internal elastic lamina. In this case, idiopathic blood and tissue eosinophilia is consistent with hypereosinophilic syndrome, but vasculitis as the sole organ inltrated by eosinophils is unexpected. Differential diagnosis includes atypical Churg-Strauss syndrome.
THROMBOLYSIS IN CAPSULAR WARNING SYNDROME (CWS): FOUR CASE-REPORTED
R.M. Vivanco, A. Rodriguez-Campello, A. Ois, M. Gomis, C. Pont, E. Cuadrado, J. Roquer Stroke Unit, Hospital del Mar, Barcelona, Spain
Background: CWS, rst described by Donnan in 1993, is characterized by stereotyped episodes of motor or sensory decit (usually more than 3 episodes in 24 hours). It is associated with a high risk of imminent lacunar infarction with permanent decits resembling those of CWS in more than 40% of patients. Pathophysiology of CWS has not been well characterized. Ischemia mechanism is probably due to small vessel penetrating disease and hemodynamic factors associated as well as molecular mechanisms. Diffusion-weighted imaging (DWI) shows acute lesions in majority of cases. There are no proven therapies for preventing completed stroke in this unstable situation. The use of thrombolytic treatment was not described previously in these cases. We report four cases of CWS treated with brinolysis Patients and methods: Four patients were evaluated between February 2005 and December 2006 (0.5% of ischemic stroke). 3 of them were male (75%). Mean age was 67.5 years. Hypertension was the main vascular risk factor. Stroke symptoms were compatible with lacunar syndrome (motor pure or sensitive-motor), with mean NIHSS 10. Number of episodes varied between 3 and 6 (mean 4). All patients were treated with rtPA in the rst three hours since last episode. Results: 3 patients remained asymptomatic after treatment (mRS 0) and did not present any other episode. One patient presented a new episode after the rtPA with left hemiplegia (mRS 4). Blood pressure was monitored in all patients during episodes and no decrease coinciding with the clinical worsening was observed. In all patients laboratory tests, CT scan, non-invasive studies for carotid and intracranial artery disease were normal. Atrial brillation was found in one patient.
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MYOCARDIAL INFARCTION DURING STROKE THROMBOLYSIS: A CASE REPORT
POST-PARTUM CEREBRAL ANGIOPATHY: REPORT OF THREE CASES
M. Herrera, M.E. Erro, J. Gllego, R. Muoz, B. Zandio, J.A. Villanueva Hospital de Navarra. Pamplona, Pamplona, Spain
Background: One potential harm of thrombolytic therapy for brain infarction is thrombolytic-induced breakup of thrombi (mostly in the heart or aorta) leading to new strokes, myocardial damage or limb ischemia. Methods: We report a patient who presented a myocardial infarction during stroke thrombolysis. Case report: A 78-year-old man was admitted to the neurology stroke care unit for sudden aphasia and right hemiparesis. The NIH Stroke Scale (NIHSS) score was 15. Brain CT scan was normal. A transcranial doppler revealed left proximal ACM oclussion.The ECG showed an atrial brilation with normal repolarization pattern. The patient was started on tPA therapy 150 minutes after stroke onset. During drug infusion, he developed hypotension, oxygen desaturation and bradycardia. He also suffered neurological deterioration with somnolence, complete right hemiplegia and left forced gaze deviation. An anaphylactic adverse reaction was suspected and tPA infusion was stopped. A new CT scan ruled out brain hemorrhage. An ECG was perfomed with signs of anterior acute miocardial damage. A thoracic CT scan ruled out an arterial ascending aortic dissection. A coronary angiography conrmed occlusion in distal territories of left anterior descending and circumex arteries and mechanical recanalization was unsuccessfully tried. Two days later a transesophageal echocardiogram revealed an anterolateral myocardial infarction,dense left atrial spontaneous echo contrast, non complicated atheromatosis in the aortic arch, and no intracardiac thrombus. Discussion: This patient had an ischemic stroke of a likely embolic origin from an intraauricular thrombi; tPA therapy could have favoured the fragmentation of this thrombi and thus facilitated a second-step coronary embolism. A shock during brinolytic therapy should raise the possibility of this rare complication, conrmed by a simple electrocardiographic recording.
J. Willeit, M. Furtner, M. Knoach, T. Gotwald, S. Kiechl Dept. of Neurology, Innsbruck, Austria

Background: The post-partum angiopathy (PPA) is a rare disease of unknown etiology characterized by segmental vasoconstriction of medium-sized and large cerebral arteries. No standard management has been established. Methods: We report 3 cases with PPA, in whom serial magnetic resonance tomography (MRT) and MR angiography were performed. Results: All three women delivered a healthy child after an unremarkable pregnancy. They received dopamin agonists to suppress lactation. After hospital discharge the patients complained of severe headache. Two developed seizures, hemianopsia and hemiparesis. Blood pressure monitoring showed intermittent and severe hypertension. The cerebral MRT demonstrated high signal intensity lesions in the occipito-parietal/frontal region on T2-weighted and diffusion-weighted imaging. Most of the lesions showed high signal intensity on ADC maps compatible with vasogenic edema, and MRA showed narrowing of large and medium-sized cerebral arteries. The results of extensive tests for cerebral vasculitis were negative. In two of the patients, lowering of blood pressure was accompanied by complete recovery of the neurological decits and normalization of imaging ndings. In the last patient, blood pressure lowering was without any clinical effect. Aggressive medical therapy including high-dose methylprednisolon and nimodipin resulted in a gradual improvement. Conclusion: These cases provide evidence that apart from hypertension, ergot derivates might act as a trigger of PPA. PPA can be complicated by both vasogenic edema and ischemic stroke. The clinical course is highly heterogenous, ranging from self-limited and fully reversible to vasculitis-like progressive forms. Apart from blood pressure-lowering therapy some patients may require high dose corticosteroids.
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Interesting cases
DISSECTING FUSIFORM VERTEBRAL ANEURYSM IN AN ADOLESCENT: ENDOVASCULAR TREATMENT
LEFT VENTRICLE NONCOMPACTION, MYOPATHY, DYSMORPHIC FEATURES AND STROKE IN A YOUNG WOMAN
C. Semedo, M. Manita, J. Reis, P. Raimundo, P. Esperana, J.M. Cndido Centro Hospitalar de Lisboa - Zona Central, Lisboa, Portugal
Introduction: Intracranial aneurysms are rare below 18 years old, corresponding to less than 1% of all the treated aneurysms. Most centres handle no more than 1 case a year. Moreover, dissecting fusiform aneurysms of posterior circulation have a difcult approach and have been traditionally treated by parent vessel occlusion. Nowadays aneurysmatic stent placement, with or without coiling, has become a valuable treatment option. Case report: 15 years-old female patient with a right sided cervical and occipital severe headache, thunderclapping, with nausea and dizziness, holding on for a month in spite of oral analgesiae. The patient had no history of previous trauma and had been otherwise healthy. Neurological examination was normal. The CT revealed an isodense, calcied lesion in the right lateral-cistern and the MRI showed to be probably a displasic aneurysm partially thrombosed with 13mm of diameter, with light mass effect over the adjacent medullary side, continuous with the RVA (right vertebral artery). The cerebral angiogram revealed a displasic/dissecting fusiform aneurismatic formation of the distal RVA (V4), with PICA (posterior inferior cerebellar artery) originating directly from the aneurismatic sac. A Leo stent (4,5mmx20mm) was placed in VA between the two extremities, through all the aneurism length, and after that partial occlusion of the remaining aneurismatic sac was excluded with coils, with the purpose to induce the progressive thrombotic occlusion of the residual sac, in order to protect PICA and allow collateral circulation. The control angiogram, 2 days after, conrmed the complete exclusion of the aneurysm, with the main vessel patency. The patient was discharged asymptomatic. Clinical and transcranial doppler revaluation was normal 3 months after. Conclusions: This is an interesting case combining an aneurysm in an early age with an fusiform aneurysm difcult approach, turning it into a therapeutic challenge. In these situations endovascular stent placement and embolization can be an effective and safe method.
A. Mendes, F. Silveira, M. Garcia, E. Azevedo Hospital S. Joo, University of Porto, Porto, Portugal
Background: Left ventricle noncompaction is a rare congenital cardiomyopathy characterized by numerous prominent trabeculations and intratrabecular recesses in the ventricles. Heart failure is the most common presenting condition. Other manifestations include arrhythmia and thromboembolic events. We present a case of stroke associated to noncompaction of left ventricle, unspecic myopathy and some dysmorphic features. Case report: A 20 years old woman was referred to our department for investigation after having a left middle cerebral artery ischemic stroke with aphasia and right hemiparesis. At 5 months of age she was diagnosed with a hypertrophic cardiomyopathy. Since her 15 years she complained with limbs fatigue and muscle spasms, and an unspecic myopathy was diagnosed after investigation including electromyography and skeletal muscle biopsy. There was no relevant familial history. She presented some dysmorphic features such as short stature, webbed neck, low hairline at the nape of the neck and bilateral cubitus valgus. The patient had a good mental state and recovered from the aphasia and most of the right hemiparesis. There was evidence of a distal muscular atrophy in lower limbs. Stroke investigation disclosed a left internal carotid artery (ICA) occlusion. Ecocardiography and cardiac catheterism identied left ventricle noncompaction. Blood investigations were negative, including for serologic, immunologic and prothrombotic changes, as well as for muscle enzymes. Cariotype was 46, XX. She started anticoagulation. Six months later she remained clinically stable, and there was no recanalization of left ICA. Discussion: Cardioembolism was the probable cause of stroke. Although left ventricle noncompaction may be associated with neuromuscular involvement, like in Barth syndrome, it doesnt usually affect women. Her dysmorphic features resemble Turner or Noonan syndromes, which could not be conrmed in this case. To our knowledge, there is no description in the literature of the congenital associations found in this patient.
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LEFT VENTRICULAR PAPILLARY FIBROELASTOMA, A RARE CAUSE OF POSTERIOR CIRCULATION INFARCTION
J. Damsio, R. Almeida, A. Furtado, L. Caiado, A. Tuna Hospital Geral de Santo Antnio, Oporto, Portugal
Background: Papillary broelastoma compromise approximately 7.9% of benign cardiac tumours. They are most commonly detected on the cardiac valves, being the intra-ventricular localization very rare. Although mostly asymptomatic, their clinical manifestations may be sudden death, myocardial infarction or cerebral infarction of cardiogenic embolic source. The embolic mechanism may be explained by one of two mechanisms: dislodgment of tumoral fragments or embolization of brin thrombi that arise on the papillary surface. Case report: A 68-year-old male, hypertensive, presented with sudden dysphagia, dysarthria, gait disequilibrium, vertigo, nausea and vomiting. On neurologic examination he had rotatory nystagmus on lateral gaze; decreased right palatal excursion; broad based stance and gait with right side deviation. Cranial computed tomography (CT) revealed recent infarct on the right cerebellar hemisphere. The diagnostic studies were normal except the transthoracic echocardiogram that disclosed an ectopic, mobile mass with the stalk attached deeply in the left ventricular wall. The patient started anticoagulation. A month later he was submitted to surgical resection of the tumour. The histology revealed a papillary broelastoma. One year later he was symptoms free, had a normal neurologic examination. There was no evidence of recurrence of the tumour on control echocardiography. Discussion: We report a case of posterior circulation stroke of cardiogenic embolic origin as a rst manifestation of very rare and treatable intra-ventricular papillary broelastoma.
day. Investigations revealed anaemia (Hb-9.7) and deranged liver function tests (Bilirubin-29, AST-99, Alkaline phosphatase-388). Initial chest radiograph, abdominal ultrasound and CT brain were normal. The epigastrc pain persisted and he developed headache, sweating and nausea, whilst his liver function tests gradually deteriorated. On the tenth day as an inpatient, he suffered a brief episode of syncope. A repeat ultrasound showed mild intrahepatic duct dilatation. A magnetic resonance cholangiopancreatogram was performed which suggested a dissection of the abdominal aorta. Subsequent CT angiogram conrmed type A dissection of aorta extending from the aortic root to both common carotid arteries and down to the right common iliac artery. He was commenced on beta blockers and surgical repair was undertaken. Aortic dissection can present deceptively and delay in diagnosis can be catastrophic especially if thrombolytic treatment is given for treatment of the associated stroke. Such an incident has been previously reported. Our case illustrates the need for a high degree of suspicion in all stroke patients.
Recovery and rehabilitation 1 Recovery and rehabilitation
OPTIMISING REHABILITATION OUTCOMES FOR APHASIA FOLLOWING STROKE THROUGH NEW LEARNING
H. McGrane Queen Margaret University College, Speech and Language Sciences, Edinburgh, United Kingdom
Many people with aphasia retain residual language impairments to varying degrees of severity following rehabilitation. Currently there is no theory of rehabilitation that explains the therapeutic process involved in the restoration of a damaged language system. Therefore it is not possible to discern what approaches/tasks would be most successful at restoring particular language functions. Does rehabilitation facilitate the accessing of the damaged language system or could it involve new learning resulting in the creation of new language representations? The main objective of this study was to investigate whether adults with aphasia could learn new vocabulary. The methodology incorporated procedures based on evidence from the literature in order to facilitate and promote optimum learning. The novel stimuli (20 new words) were taught to 12 adults (<65 years) who presented with varying degrees of severity of aphasia. The training procedure incorporated learning theory and a cognitive neuropsychological model of language. The immediate and delayed recall of this vocabulary was investigated using a range of assessments to facilitate the capture of new learning which was measured not only in terms of the accurate production of the stimuli but also the recognition and knowledge of the word forms and meanings. Overall ndings of this investigation with the presentation of select case studies demonstrate the ability of people to learn new language representations despite severe language impairment. The ndings, which strongly suggest that language rehabilitation could incorporate the process of new learning, have signicant clinical relevance in terms of developing a theory of rehabilitation and to the procedures employed in speech and language therapy.
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ISOLATED INFERIOR SAGITTAL SINUS THROMBOSIS (ISST)
N. Tran, J. Silva Hamilton General Hospital, McMaster University, Hamilton, ON, Canada
Background and purpose: The inferior sagittal sinus (ISS) is the rarest affected area of cerebral vein thrombosis. Only one previous case of isolated inferior sagittal sinus thrombosis (ISST) has been reported. We describe a new case of isolated ISST. Methods: A 70 year-old man presents with a four day history of decreased appetite, global weakness followed by decreased level of consciousness. He had a witnessed right sided focal motor seizure with secondary generalization. He was found with right sided weakness, right facial droop, right sided hyperreexia, drowsiness, disorientation to time and was febrile (39.9 C). He also had features of frontal lobe dysfunction including apathy, decreased insight and volitional activity. His condition did not change despite empiric treatment with acyclovir, cefotaxime, ciprooxacin and levooxacin. Results: Initial CT-head showed frontal paramedian hypodensities. CSF demonstrated elevated protein and pleocytosis, primarily lymphocytes. Auto-immune and coagulation work-up were negative. Peripheral blood cell count showed leukocytosis, 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. MR-Venogram showed attenuation of the ISS only. After anticoagulation treatment the patient improved and managed to go home with some residual frontal lobes dysfunction. Follow-up MRI showed improved ischemic area and incomplete recanalization of the ISS. Conclusion: Primary isolated ISST can present as a febrile non-infectious encephalopathy. In our case, we were unable to demonstrate any particular etiology.
Recovery and rehabilitation
EFFECT OF RHYTHMIC AUDITORY CUES ON GAIT OF STROKE PATIENTS
S.I. Lin National Cheng Kung University, Tainan, Taiwan

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 rhythmic auditory cue (RAC) for locomotion control was affected by the residual proprioceptive function in patients with chronic stroke. Methods: Fourteen chronic stroke patients went through a joint repositioning test of the knee and ankle, and were classied into intact and impaired joint position sense (JPS) groups. EMG activity and peak joint angular acceleration of the affected leg during two walking conditions, normal and with RAC, were recorded and compared. In RC, subjects were asked to match their foot-oor-contact with a beeping tone delivered by a metronome. Results: Walking speeds did not differ signicantly between the two conditions or the two patient groups. Compared to normal condition, RAC had shorter EMG activation time in patients with impaired JPS, but not in patients with intact JPS. Stride characteristics did not differ signicantly between walking conditions or the two patient groups. Discussion: Chronic stroke patients were found to use RAC to regulate locomotion.
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STROKE AND EPIGASTRIC PAIN: CONSIDER AORTIC DISSECTION
S. Mavinamane, H.G. M Shetty, M. Robinson, K.R. Davis University Hospital Wales, Cardiff, United Kingdom
Aortic dissection may rarely present with stroke and the diagnosis can be difcult with atypical symptoms. Thrombolysing such stroke patients can be disastrous. We report a patient with Aortic dissection who presented initially with an epigastric pain and stroke. A 73 year old hypertensive man, presented with a left hemiparesis and dysarthria for 3 hours. He had epigastric pain for 2 weeks, which worsened signicantly on the day of admission. Examination revealed epigastric tenderness, dysarthria, and left hemiparesis. The hemiparesis and dysarthria resolved completely by the following
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However, the effect of RAC was not equal between patients with intact and impaired lower extremity JPS: walking with cues lead to shorter EMG activation time in patients with impaired JPS, but not in patients with intact JPS, compared to walking without cues. These ndings imply that after chronic sensory loss, changes in sensorimotor processing for locomotion might have occurred and affected the use of augmented sensory cues. Thus clinically, instead of using augmented sensory inputs routinely, their use should be planned and effects carefully monitored.
FACTORS PREDICTING EARLY HOSPITAL DISCHARGE FOLLOWING ADMISSION FOR ACUTE STROKE
J. White, L. Dacey, R. Navaratnasingam, M. Wani Morriston Hospital, Swansea, Cardiff, United Kingdom
Background: Reducing hospital length of stay following admission for acute stroke has economic benets for the healthcare provider. However, identifying patients suitable for a reduced length of stay with early supported discharge is difcult at the time of admission. This study explored the relationship between clinical and social characteristics at the time of admission, with length of hospital stay for acute stroke inpatients to predict a safe early discharge. Methods: A retrospective case control study of all patients admitted with acute stroke to a UK hospital, over a 3 year period. Patients were categorised into two groups, those requiring a 10 day or less hospital admission and those requiring longer. 23 separate clinical and social characteristics were assessed to evaluate their impact on length of hospital admission. Results: 359 patients, mean age 76.2 years, mean length of stay 54 days (median 24 days), mean Barthel Score on admission 10.8. Ten factors, on admission, were independently associated with a reduced length of stay: CT brain scan showing no sign of haemorrhage, (odds ratio (OR) 11.07 (95% condence interval (CI) 1.87 to 65.11)); no receptive dysphasia (OR 7.59 (CI 1.98 to 29.03)); no sensory decit on admission (OR innite (CI 5.49 to innite)); no hemi neglect (OR innite (CI 5.72 to innite)); sinus rhythm (OR 2.72 (CI 1.35 to 5.49)); living with support prior to admission (OR 2.52 (CI 1.49 to 4.26)); Functional Ambulation Categories (FAC) score 4 (OR 10.68 (CI 6.23 to 18.31)); Barthel Score 19 (OR 12.32 (CI 6.63 to 22.88)); and urinary continence (OR 11.98 (CI 5.66 to 25.29)). Discussion: This study has identied 10 clinical and social factors present at admission that may help identify patients who could be potentially discharged early from hospital, allowing prompt referral to early supported discharge teams and other intermediate care services.
THE EFFECTS OF TYPE AND INTENSITY OF PHYSIOTHERAPY ON LOWER LIMB STRENGTH AND FUNCTION AFTER STROKE
E.V. Cooke, R.C. Tallis, S. Miller, V.M. Pomeroy St. Georges University of London, London, United Kingdom
Background: Stroke survivors often have permanent residual motor impairment. This may be due to a sub-optimal dose of conventional physical therapy (CPT) and the discouragement of strength training. However, experimental evidence suggests that strength training might be benecial. Hypothesis: adding functional strength training (FST) to CPT improves muscle function, gait and functional mobility more than either CPT alone or CPT plus neuro-facilitation (NF). Methods: Multi-centred randomised controlled observer-blind trial. Subjects were within 3 months of stroke with the ability to voluntarily move their paretic lower limb. A power calculation estimated sample size as 102. Subjects underwent baseline measurements before being allocated randomly to; CPT; or CPT + NF; or CPT+FST for 6-weeks. All additional therapy was provided up to1-hour/day, 4 times/week. Outcome measures were made at 6 weeks after baseline. Measurement battery included: muscle strength; walking speed; and functional mobility (Rivermead). Analysis followed the intention to treat principle. Data, outcome minus baseline, was tested for differences between groups using the Kruskal-Wallis test. Results: 109 subjects were recruited. Mean age was 68.3 (SD12.03) years. The attrition rate was 8.3%. Only Rivermead data is reported here. Median (IQR) change in Rivermead score following intervention was 5.0 (9.7) for control, 6.5 (14.3) for NF and 7.0 (13.7) for FST. The Kruskal-Wallis statistic was 1.06 (p = 0.59). Discussion: Immediately after intervention no statistically signicant differences were found between groups for functional mobility, however there was a trend towards CPT + FST. Muscle strength (for which the trial was powered) and gait data are currently undergoing analysis.
DIFFERENCES IN VISUAL ATTENTION BETWEEN HEMIPLEGIC SIDES IN POSTSTROKE PATIENTS
S. Shimizu, M. Maeda, Y. Ikeda, H. Nagasawa Faculty of Rehabilitation, School of Allied Health Sciences, Kitasato University, Kanagawa, Japan
Background and purpose: We previously reported that visual attention in the circumferential eld in healthy persons was greater in the left lower eld than in the right upper eld. The present study investigated differences in visual attention between left and right hemiplegic sides based on simple reaction times (RTs) to visual stimuli. Methods: Participants were 10 stroke patients with right hemiplegia (RH group), 10 stroke patients with left hemiplegia (LH group), and 20 normal control subjects. RTs were recorded using RT estimation software on a personal computer. Fixation point and reaction stimuli were presented on a screen. Stimuli were presented at one of 16 sites located on circles with radii of 1 cm or 11 cm; visual angles (VA) were 2 degrees (VA2) or 20 degrees (VA20). Stimuli were randomly presented ve times at each site for a total of 80 trials, and the delay from presentation to the subject pressing a key was recorded as RT. Stroke patients used their unaffected hand to press the key, while half of the control subjects used their right hand (CR group) and the other half used their left hand (CL group). Results and discussion: In the comparison of the LH and CR groups, RTs for the LH group were slower; however, no signicant differences were observed between stimuli positions. In contrast, the comparison of the RH and CL groups showed no signicant difference in RTs. For the RH and CL groups, RTs to left lower eld stimuli were signicantly shorter than RTs to upper eld stimuli. These results indicate that patients with left hemiplegia may have decreased attention in all visual elds compared to patients with right hemiplegia.
MOTOR NETWORK CHANGES AND FUNCTIONAL RECOVERY IN STROKE PATIENTS TREATED WITH VERY EARLY MOBILISATION IN AN ACUTE STROKE UNIT. A LONGITUDINAL FUNCTIONAL MRI STUDY
T. Askim, B. Indredavik, S. Mrkved, O. Haraldseth, A. Hberg Norwegian University of Science and Technology, Trondheim University Hospital, Trondheim, Norway
Background: Functional MRI (fMRI) might elucidate mechanisms of brain plasticity. The aim of this study was to investigate the relationship between functional recovery and brain activation patterns after an acute stroke. Methods: 14 patients (62-75 years) with rst ever ischemic stroke and unilateral hand paresis, but intact language were included. 16 age and gender matched controls were also investigated. All patients were treated in an acute stroke unit with very early mobilisation and early supported discharge. They underwent MRI, fMRI and functional tests 4-8 days from onset and after three months. fMRI paradigms were 1 Hz and self-paced (SP) index nger tapping. Results: No patients had infarction involving primary motor cortex (M1). There was signicantly improved hand function as measured by all functional tests. 1 Hz task: Patients in the acute phase activated more prefrontal regions than the controls. There was increased activation in contralateral thalamus, anterior cingulate cortex and ipsilateral prefrontal cortex for patients in the chronic compared to the acute phase. SP task: Controls had signicantly larger activation in contralateral M1 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 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, but encompassed other cortical regions. This was at great variance to the results from the SP task. These ndings indicate that the injured brain adapts to different motor task demands using different networks.
DEPRESSION IN CAREGIVERS OF LONG-TERM STROKE SURVIVORS
D. Varga, E. Boros, J. Kenez, Z. Nagy National Institute for Neurology and Psychiatry, Budapest, Hungary
Objective: Caregivers of stroke patients may experience high levels of burden, that can result in deterioration of the caregivers mental and/or physical health. Our aim was to examine the prevalance of depression among caregivers.
Poster Session Recovery and rehabilitation
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Methods: A sample of 87 stroke survivors and their informal caregivers was studied. Caregiver burden was evaluated with Beck Depression Inventory and Caregiver Strain Index. Patients functional, cognitive and behavioural status was also assessed with a questionnaire yielding information pertinent to these items. Results: 69% of caregivers of long-term stroke survivors suffered some kind of depression. In 50% the patients serious residual functional status, in 77% mental-behaviourial symptoms were mentioned as cause of depression. Presence of both caused depression in 87% of caregivers. Patients generate high caregiver burden are signicantly older and had signicantly higher volume of cerebral infarction. Conclusion: High percentage of caregivers suffer from depression. The level of self-percepted burden was stronger associated to the patients mental-behaviourial symptoms, than to the degree of their disability.
rate was calculated and differences between groups were analysed with descriptive statistics. ARAT data was used to calculate the sample size for a Phase III trial. Results: 30 subjects were recruited with an attrition rate=0%. No statistically signicant differences were found between groups, however there was a trend for CPT+FST to produce greater improvement at a clinically relevant level: mean ARAT change of +13 (CPT) and +22 (CPT+FST). The power calculation estimated a sample size of 246 for a Phase III trial. Discussion: Results of this pilot study suggest that increased intensity of CPT may not further enhance motor recovery after stroke but adding FST to CPT might. A Phase III trial is feasible using the methods of this study although a large multicentre trial will be required.
10 8 Recovery and rehabilitation
MODIFIED OBSERVATIONAL PERSPECTIVE AND STROKE REHABILITATION
A PILOT STUDY INVESTIGATING THE COMPARISON BETWEEN FAMILIAR AND UNFAMILIAR ENVIRONMENT ON PATIENTS ABILITIES TO COMPLETE AND PROCESS ACTIVITIES OF DAILY LIVING, POST BRAIN INJURY
L.M. Ewan, T. Haire, K. Kinmond, H. Chatterton, N. Smith, P. Holmes Manchester Metropolitan University, Alsager, United Kingdom
Background and purpose: Motor imagery has been questioned as a neuropsychological rehabilitation technique for stroke patients with structured observation being proposed as a more valid approach (Holmes, 2006). Similar to imagery however, observation conditions provide two spatial visual perspectives: rst and third person. Since there is evidence that the different perspectives are linked to different brain activity, the use of each perspective may be moderated post-stroke. The practical considerations of this change have not been examined experimentally. This research explored observational visual perspective in individuals who had experienced stroke to aid the development of observation-based rehabilitation programmes. Method: 21 individuals who had experienced stroke were matched against 19 individuals who had not had a stroke. Following ethical approval and full written informed consent, a stroke and observation specic questionnaire was employed to explore viewing experiences; specically kinesthisis. Participants viewed DVDs of activities of daily living from both visual perspectives. Results: Non-parametric analysis indicated that individuals who had not had a stroke showed a statistically greater preference for a rst person visual perspective and reported stronger kinesthisis with this perspective. In contrast, individuals who had experienced stroke showed no preference for either perspective and were generally unable to report kinesthisis with either the rst or third person perspective. Discussion: Stroke may lead to a change in preferred visual perspective and experience of observational kinesthisis as a consequence the lesion damage and functional motor inactivity. Observation-based rehabilitation interventions may support neural change. However, further research is required to investigate these changes linked to individual differences in stroke aetiology. This study provides evidence that visual perspective should be considered in all imagery and observation-based stroke rehabilitation interventions.
J. Scott Hammersmith Hospitals NHS Trust, London, United Kingdom

Background: Cognitive impairment is common post-brain injury and is associated with poor long-term outcomes. Environmental context is thought to impact on cognitive processing, and it is possible that the venue where cognitive abilities are assessed will inuence the patients performance. The Assessment of Motor and Process Skills (AMPS) is an observational tool used to measure the quality of a persons ability to perform activities of daily living, based on normative data for age and injury. Hypothesis: Patients will perform better in terms of cognitive ability, at home compared to in hospital. Objective: To compare the process abilities of patients with brain injury in hospital and at home using the AMPS, with a same subject design. Methods: Patients admitted with brain injury, who had cognitive impairment but were orientated, were assessed in the hospital and at home within 48 hours using AMPS. The scores for process skill (the skills needed to organize and adapt actions to complete tasks) were compared at the end of the study. Results: 7 out of the 8 patients assessed performed better within the hospital context.
Median AMPS process score Home Hospital 0.16 0.94 Interquartile range 0.2-0.54 0.47-1.29 P 0.05
Discussion/Conclusion: The structure and lack of external stimuli may account for the improved performance within the hospital context. Patients with cognitive processing decits performed better within the hospital setting. This implies that the level of challenge therapists use to assess patients cognition through function may need to be higher in hospital to ensure sufcient process ability at home.
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FUNCTIONAL RECOVERY IN ISCHAEMIC STROKE PATIENTS YOUNGER OR OLDER THAN 65 YEARS
J. Jansa, Z. Sicherl, K. Angleitner, A. Grad University Medical centre Ljubljana,Ljubljana, Slovenia

Background: To compare duration of occupational therapy (OT), functional outcome and quality of life in group of ischaemic stroke (IS) patients younger or older than 65 years. Methods: IS patients who were consecutively included into OT within early hospital stay and contacted three months after stroke; 24R-hemiplegia, 26L-hemiplegia; 31 males, 19 females. Assessment tools: Extended Barthel index (EBI), Canadian Occupational Performance Measure (COPM) and EuroQol (EQ). They were done during OT and at follow up. Results: There were 25 patients younger than 65 years (mean 55 yrs, range 39-65) and 25 were older than 65 yrs (mean 73 yrs, range 67-81). Mean duration of OT in younger group was 15 days (range 4-54); mean duration of OT in older group was 8 days (range 2-28). This difference was statistically important (p<0,007). The EBI and EQ were assessed in the whole sample; we were able to follow clients priorities with COPM in 32 patients; 15 in younger group and 17 in older group. Difference in EBI was statistically important from the rst assessment to follow-up in both groups (p<0,0001;p<0,0001);there were no statistically important differences among groups in initial or follow-up assessment (p=0.28; p=0.67). Difference in EQ was statistically important in both groups (p<0,01;0,002);there were no statistically important difference among groups (p=0,63;p=0,45). Regarding the use of COPM; 32 patients (64%) of our sample expressed in total 87 activities. There
THE EFFECTS OF CURRENT PHYSICAL THERAPY AND FUNCTIONAL STRENGTH TRAINING ON UPPER LIMB FUNCTION AND NEUROMUSCULAR WEAKNESS AFTER STROKE: A PILOT STUDY
C. Donaldson, R. Tallis, V. Pomeroy St Georges, University of London, London, United Kingdom

Background: Scientic evidence suggests that functional strength training (FST) might have a better effect than current physical therapy (CPT) on upper limb motor recovery after stroke. Aim: to assess the feasibility and sample size for a clinical trial to compare CPT and FST. Methods: A randomized, single-blinded, clinical trial. Subjects were within 3 months of infarction (anterior circulation) with upper limb weakness. Subjects were randomised into 3 groups. All received routine CPT. Control Group 1 received no extra physical therapy (CPT), Group 2 received increased intensity (CPT+CPT), Group 3 received CPT and FST. Intervention lasted 6 weeks. A treatment recording form, developed by our team and validated in clinical practice, was used to standardise and record CPT. Measurements included: muscle strength, Action Research Arm Test (ARAT) and 9-Hole Peg Test. Measurements were taken before treatment began, after six weeks of intervention, and 12 weeks thereafter. Analysis: Attrition
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were 15 patients from younger group and 17 patients from older group. 14 patients from each group named 58 activities (68%) of basic activities of daily living; 6 younger, 4 older expressed in total 14 (18%) issues of productivity and 5 from each group named in total 14 (14%) leisure activities. Discussion: Results showed that both groups need less help as measured by EBI. Equally, the quality of life, as measured with EQ has improved. We were able to follow client functional priorities in both groups, although the younger group received more OT. Further work is needed to clarify this issue.
Management and economics 1 Management and economics
COMPARISON OF BLOOD PRESSURE MANAGEMENT AFTER STROKE AND CORONARY EVENT. THE REDUCTION OF ATHEROTHROMBOSIS FOR CONTINUED HEALTH (REACH) REGISTRY
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E. Touz, J. Rther, D. Batt, F. Aichner, M. Alberts, M. Ohman, P. Durieux, J. Coste, S. Goto, G. Steg Hpital Sainte-Anne, Paris, France
Background: Management of blood pressure (BP) is not optimal in patients with atherothrombotic diseases. We looked for differences in BP control and the use of antihypertensive drugs in patients with cerebrovascular disease (CVD, including stroke or TIA) and coronary artery disease (CAD). Methods: 68,236 patients were enrolled in the REACH Registry, an international (44 countries worldwide) prospective, observational study of patients with or 3 risk factors for atherothrombotic disease. Of these patients 12,153 had isolated CVD and 33,611 had isolated CAD. At inclusion BP was measured and treatment data were collected. Results: There were no major differences in age, previous hypertension and other risk factors between the CVD and CAD patient groups. However, CAD patients experienced lower mean BP values, were more likely to have a BP<140/90 mmHg, and to receive 3 or more antihypertensive drugs (34.2% vs. 22.7%, p<0.0001). The use of 3 or more antihypertensive drugs was also more common in CAD patients with elevated BP (140/90 mmHg) (39.4% vs. 26.2%, p<0.0001). After adjustment for age, sex, other risk factors, and world regions, the CAD group maintained signicantly better control of BP (OR=1.4; 95%CI: 1.3-1.5, p<0.0001) and the use of 3 drugs (OR=1.4; 95%CI: 1.3-1.5, p<0.0001). Similar trend was observed across world regions.
CVD only (12,153) Mean age (SD) Male, % Previous hypertension, % Mean systolic BP (SD) All P values < 0.0001. 68.9 (10.2) 56.4 80.7 140.2 (19.6) CAD only (33,611) 67.8 (10.2) 70.8 78.7 134.5 (18.7)
A SERIES OF INVESTIGATIONS INTO SENSORY REHABILITATION POST STROKE
S.L Hillier University of South Australia, Adelaide, Australia

Background: Sensory loss post-stroke is well documented, however the role sensation plays in the recovery of motor function is less understood. We have conducted a series of clinical trials investigating different applications of sensory input as part of rehabilitation post-stroke. Methods: Firstly we have applied combinations of peripheral and central stimulation to either the foot or hand in chronic and acute stroke rehabilitation participants. The rationale is that such stimulation will excite the cortex and facilitate positive neuroplastic responses to subsequent task specic training. The second series of trials involved training awareness and appreciation of sensory input to the lower limb post stroke. The rationale for these experiments was based more on a learning or attention-training paradigm. Results: Results from these trials offer some functional evidence that afferent input is effective in driving recovery, however data from TMS investigations have been less convincing. We found sensory appreciation could be improved via specic training in chronic stroke participants but not as convincingly in acute. There was also some preliminary indications that the increased sensory awareness led to improved postural control in some participants. Discussion: Our ndings warrant further investigation and current studies are exploring the relationship between sensory input in the lower limbs and functional activity.
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Conclusion: Blood pressure management is better after a coronary event than after a cerebrovascular event. This result could be explained by the under use of combination therapies in stroke patients compared to CAD patients.
IS THE BIO-PSYCHOSOCIAL MODEL SUITABLE TO EXPLAIN THE DEVELOPMENT OF DEPRESSION AFTER STROKE?
T.A. Barskova, G. Wilz Technical University Berlin, Department of Clinical and Health Psychology, Berlin, Germany
Background: Depression after stroke is common and increases morbidity and mortality in the rst years after stroke onset. Nevertheless little is known about the role of psychosocial factors on the etiology of depression in early as well as in the late poststroke stages. With reference to the bio-psychosocial model, the aim of our study was to investigate the inuence of stroke survivors mental impairment as well as the quality of their social relationships on the development of poststroke depression. Method: The study used a longitudinal design. Eighty-one German stroke patients were investigated twice, directly after discharge (on the average three month after stroke onset) and one year later. Hierarchical regression analyses and cross-lagged partial correlation analyses tested direct and indirect mediating effects of potential predictors on poststroke depressive symptoms. Results: Time 1 patients perceived cognitive and emotional functioning predicted psychological depressive symptoms at time two. Quality of patients social relationships mediated the effect of the stroke-related emotional decits on depression. Discussion: In contrast to the previous research the study provided more evidence for causal inuence of different risk factors on PSD. Results support the biopsychosocial model of poststroke depression. Early and late poststroke depression seem are based on partially different etiological mechanisms.
Management and economics
US SURVEY OF STROKE NEUROLOGISTS AND NEUROINTERVENTIONALISTS ON TREATMENT CHOICES FOR INTRACRANIAL STENOSIS
T. Turan, M. Lynn, M. Chimowitz Emory University School of Medicine, Atlanta, GA, USA
Background: We sought to determine the effect of an NIH-sponsored clinical trial on treatment choices of physicians managing patients with intracranial stenosis. Methods: Surveys of treatment choices were sent pre- and 1 year post-publication of the Warfarin vs. Aspirin for Symptomatic Intracranial Disease (WASID) Trial results. The pre-WASID survey was sent to neurologists and the post-WASID survey was sent to neurologists and neurointerventionalists. The post-WASID survey included questions about the minimum benet that physicians would require to make stenting their treatment of choice. Data was analyzed using the chi-square test. Results: There was a signicant difference in the choice of antithrombotic agents for the treatment of both anterior circulation (p<0.001) and posterior circulation (p<0.001) stenoses after publication of WASID (see Table). There was no signicant difference in risk reductions required by neurologists vs. neurointerventionalists for stenting to become their treatment of choice. For
Table 1. Antithrombotic choices before and after WASID MCA or IC siphon % of MD pre-WASID n=181 41 44 11 4 % of MD post-WASID n=199 7 85 4 4 Basilar or vertebral % of MD pre-WASID n=181 49 36 10 4 % of MD post-WASID n=199 15 74 7 4
Warfarin Antiplatelet Combination Other
Warfarin Antiplatelet Combination Other
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a primary endpoint rate of 20%/2 yrs in the medical arm (the rate in WASID for high-risk patients with 70-99% stenosis), 33% of physicians required a 25% reduction from stenting, 15% required a 33% reduction, 14% required a 40% reduction, 21% required a 50% reduction, 13% required a 60% reduction, and 4% would continue to use medical therapy regardless of the stenting rate. Discussion: The results of WASID had a signicant impact on physician treatment practices. For high-risk patients with intracranial stenosis, 40% is the minimum relative risk reduction required from intracranial stenting to make it the treatment of choice for a clear majority (at least 60%) of physicians.
PRIMARY CARE MEDICINE AND STROKE: THE IRISH NATIONAL AUDIT OF STROKE CARE
D. ONeill, D. Whitford, F. Horgan, M. Wiley, R. Conroy, S. Murphy, H. McGee, D. ONeill, on behalf of the Irish National Audit of Stroke Care Trinity College Dublin, Dublin, Ireland
Primary care services have a key role in the prevention and management of stroke. As part of the Irish National Audit of Stroke Care, a survey of general practitioners (GPs) was performed to document the availability of evidence-based structures for supporting stroke care and prevention in general practice and to prole the views, experiences, and needs of Irish GPs in this context. In a cross-sectional study of randomly selected GPs practising in the Republic of Ireland was surveyed by postal survey. Of the target sample of 484 GPs, 36 were ineligible and 204 responded (response rate = 46%). Regarding the acute management of stroke, nearly a fth of GPs (17%) reported initially managing at least a substantial minority (20%) of their patients at home. The majority of GPs viewed existing rehabilitation services for their stroke population as inadequate. Overall, general practice showed little structured organisation for long-term follow-up of stroke patients. There was little or no organised system of care for the primary prevention of stroke within primary care in Ireland. Three quarters of GPs believed there were barriers to implementing secondary prevention strategies in their practiceJust over 60% reported time as a barrier, 57% of reported stafng issues and almost a third (33%) funding as barriers. Other barriers listed included lack of protocols/guidelines (17%) and lack of space (almost 10%). The main barriers listed for secondary prevention were very similar to those recorded for primary prevention. There was little or no organised system of care for the prevention and management of stroke within primary care in Ireland. However, there were encouraging signs of development. GPs in practices involved in a national cardiac prevention programme and those with good or excellent access to practice nurses were more likely to engage in evidence-based activities to manage stroke.
HOSPITAL DISCHARGE CODING UNDERESTIMATES BURDEN OF STROKE
M. Taylor, C. McAlpine, M. Walters Stobhill Hospital, Glasgow and Western Inrmary, Glasgow, United Kingdom
Background: Hospital discharge coding is an important process which informs health resource planning. During an audit project we noted a discrepancy between the information services division (ISD) of the Scottish Executive numbers for stroke disease workload and the numbers recorded by the local stroke consultants. Methods: 280 stroke service discharges were reviewed from 2 different stroke units during different time periods within the health board division. One doctor coded them according to ICD10. The actual coding was then reviewed and compared to this. Results: 219 out of the 280 (78%) stroke service discharges had a nal diagnosis of stroke when coded by the doctor. Of those 219 only 166 (76%) of patients were recorded as stroke by hospital coding. In particular, of those diagnosed as a lacunar stroke (43 patients) only 23 (53%) were coded as stroke on discharge. Of the 61 diagnosed as not stroke by the doctor 19 had a false positive coding of stroke by coders on discharge. Discussion: There are several potential sources of error in the coding process. This has major implications for both national stroke statistics and local stroke service planning and resources. Urgent further work is required to identify the extent to which false positive stroke codes are generated and whether this pattern of false negative stroke coding is reproduced elsewhere.
EDUCATIONAL MULTIMEDIA CAMPAIGNS HAVE DIFFERENTIAL EFFECTS ON PUBLIC STROKE KNOWLEDGE AND AWARENESS OF INDIVIDUAL STROKE RISK
FIRST IRISH NATIONAL AUDIT OF STROKE CARE
F. Horgan, A. Hickey, S. Murphy, M. Wiley, R. Conroy, H. McGee, D. ONeill, on behalf of the Irish National Audit of Stroke Care Trinity College Dublin, Dublin, Ireland
Improving services for people with stroke represents a global challenge, especially in the light of the proven efcacy of many treatment modalities. The UK National Sentinel Stroke Audit was a pioneer in developing a national prole of hospital services for stroke. We report on the design of a project which builds on this methodology, but which also proles nation-wide preventive, community rehabilitation and long-term care services for people with stroke. The Irish Heart Foundation, in association with the Irish Department of Health and Children, commissioned a national audit of stroke services in March 2006. The project involves hospital audits, and community-based surveys of general practitioners (GP), allied healthcare practitioners (AHPs), patients and carers, and nursing homes. All 37 public hospitals (100%) providing acute services to stroke patients are participating in the.Organisational and Clinical Audit Proformas of the UK National Sentinel Stroke Audit 2004. A random sample of 484 GPs were surveyed by post and 46% responded. The AHP survey, involved interviews with regional, disciplinary and nursing managers, and frontline staff, with 85% response. 200 people with stroke and a family member will be interviewed one year after discharge using a questionnaire on health status and service needs and utilization, as well as 200 people with stroke who have been discharged to nursing homes, and a family member. Final results are due in September 2007. This audit is of interest for two main reasons: it provides evidence of the feasibility of using the UK National Sentinel Audit in another jurisdiction, but also provides a methodology which allows for the measurement of availability of the full range of services for people with stroke across the modalities of primary and secondary prevention, acute treatment, rehabilitation and long term care. This global overview is vital to the delivery of services across the full spectrum of stroke prevention and care.
J.J, Marx, M. Nedelmann, B. Haertle, M. Dieterich, B.M. Eicke Johannes Gutenberg-University Mainz, Mainz, Germany
Background: Aim of the study was to evaluate the educational effects of different media in a multimodal educational program on public knowledge of risk factors and warning signs of stroke. Methods: Computer-assisted telephone surveys were conducted among an average sample of 500 members of the general public, before and immediately after an intense three months educational campaign in a German area of 400.000 inhabitants. The multimodal educational program comprised of 400 poster advertisements on billboards, busses, local emergency transport cars etc. Print media included yers dispensed in pharmacies and at the doctors ofce and mail circular to all households. Slogans, stroke interest stories and interviews appeared regularly in local newspapers, on television and radio, and several public events focussed on the subject. Results: Before the educational intervention stroke knowledge was generally low, especially in men and elderly individuals. General knowledge of the nature of stroke (65.7% correct answers before versus 84.9% after the campaign, p<0.01) and the awareness of being at risk of stroke (32.7% vs. 41.9%, p<0.01) signicantly increased due to the campaign, especially in respondents of lower educational Background: In contrast, there was hardly any effect on detailed knowledge of specic stroke warning signs or different risk factors. Mass media were most frequently reported as the main information source (66.5%). Information yers were also remembered by a high proportion of respondents (59.0%), while widespread poster advertisements received far less attention (26.7%). Discussion: Our data indicate that educational programs are effective in increasing general knowledge of stroke in the public. They improve awareness of individual stroke risk and this may inuence behavior in acute stroke. Especially in individuals of lower educational background repeated information using short-tailored messages presented in mass media proved to be effective. It is difcult, however, to transfer detailed information by means of a large educational campaign.
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THROMBOLYTIC THERAPY IN ACUTE ISCHEMIC STROKE IN TAIWAN
M. Tseng, K. Chang, J. Liu National Sun Yat-Sen University, Kaohsiung, Kaohsiung, Taiwan
Background and purpose: Starting Jan 1, 2004, the use of intravenous recombinant tissue plasminogen activator (rtPA) in patients with acute stroke becomes available for reimbursement from the National Health Insurance (NHI) Program in Taiwan. The purpose of this study was to study the frequency of intravenous rtPA for stroke treatment in Taiwan the rst year after the reimbursement, and to examine the characteristics regarding the usages in the health care system. Methods: We studied the administrative claims data of NHI beneciaries of 2004. The compulsory and universal NHI covers more than 96% of the total population of Taiwan since the implementation in March 1995. We identied patients treated with rtPA by searching the database of Details of Inpatient Orders with the rtPA-specic order code. The associated data of Inpatient Expenditures by Admissions were examined. Results: Among 90,550 admissions with cerebrovascular diseases in 2004, there were 93 patients treated with rtPA. The mean age was 64.0 11.0 years (range 35.5 to 82.4). Fifty-nine or 63% of patients were men, 69% had a Charlson comorbidity index of 0, 27% 1, and 4% 2. Neurologists were admitting physicians for 66.7% of patients. About one-forth of patients were treated in medical centers, 57% regional hospitals, and 17% district hospitals. Median length-of-stay (LOS) was 10 days (range 1 -136), and in-hospital death were found in one case (1.1%). Patients cared for by neurologists as compared to non-neurologists had signicantly lower median LOS (8.5 versus 19 days, P = 0.016). Patients admitted into medical centers had longer median LOS (16 days), as compared to regional hospitals (12) or district hospitals (6) (Kruskal-Wallis test, P = 0.002). Discussion: Intravenous rtPA was not widely applied within the rst year following reimbursement from NHI in Taiwan. Because the analysis was based on NHI claims data, some important patient-level data, particularly initial stroke severity and functional outcomes, were not available.
quality of organization of stroke care and research activity in stroke services in England. Methods: The 2006 National Sentinel Audit of Stroke assessed by questionnaire the quality of stroke service infrastructure and included two questions on research activity: (A) How many stroke research studies are you involved in?, and (B) How many Whole Time Equivalent staff are employed in stroke research?. Data were collected by local staff from 235 sites in England in April/May 2006. Data analysis was performed using SPSS. As research activity formed part of the total score for Organisation of Care, we did not compare with the total score. We examined the association between responses to the 2 questions on research activity with each of the other 9 domains of Organisation of Care. Results: Correlation was shown at the 0.01 level (2-tailed) between responses to the 2 questions research and the following 6 domains: acute care organisation, organisation of care, interdisciplinary services (overall service), TIA/neurovascular services, team working agreed assessment measures and communication with patients and carers. The strongest correlation was with acute care organisation (Spearmans rho 0.381 for research question (A) and 0.387 for question (B)). No signicant correlation was found with the domains interdisciplinary services (stroke unit), team working (records) and team working team meetings. Discussion: The signicant correlation between quality of organization of stroke care and research activity suggests that well organized stroke care facilitates stroke patient participation in research and/or that participation of stroke services in research facilitates improved services.
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COST EFFECTIVENESS OF STROKE UNIT (SU) CARE FOLLOWED BY EARLY SUPPORTED DISCHARGE (ESD)
. Saka, V. Serra, Y. Samyshkin, S. Merkur, A.J. Mcguire, C. Wolfe Kings College, London, Division of Health and Social Care Research, London, United Kingdom
Introduction: Stroke is the second leading cause of death in England and Wales 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 patients with respect to non-stroke specialised hospital units. In addition to that another trend has been ESD of some stroke patients. This allows inpatient beds to be available for the care of stroke patients faster, decreases the necessary number 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 followed up by ESD (SUESD). Methods: Data from the South London Stroke Register, and local ESD were utilised for clinical and resource use data. The cost effectiveness of SUESD was compared with with SU without ESD (SUNESD) and general medical ward care without ESD (GWNESD). We used a Markov model to simulate the care process for 10 years. Societal perspective was used for costing and included direct care costs as well as informal care costs and productivity losses due to mortality and morbidity. Results: SUESD option leads to better outcomes, although it increases total care costs. We found that it costs 9,200 per additional quality adjusted life years (QALY) when SUESD was compared with GWNESD and 8,600 when compared with SUNESD. The incremental cost effectiveness ratio (ICER stayed within accepted limits of 30,000 per QALY gained. The multi-way (+10%) and probabilistic sensitivity analyses did not have a signicant impact on the results. Discussion: This is the only study to date looking at the CE of SU followed by ESD, comparing it with other treatment options. The results of the study suggests that treatment in stroke unit followed by early discharge of patients with an enhanced outpatient care policy (SUESD) offers the best results in terms of effectiveness, with an additional cost within accepted reasonable CE levels. GWNESD, although cheaper than the other two, appeared the least effective strategy.
COST OF STROKE FOR SOCIETY IN YOUNGER PERSONS RECEIVING REHABILITATION
A.K.S. Sunnerhagen, A.A. Bjrkdahl Gteborg University, Gteborg, Sweden

Background and purpose: In recent years a number of costs of stroke studies have been conducted based on incidence or prevalence estimating costs a given time. As there still is a need for a deeper understanding of factors inuencing the cost the aim of this study was to calculate the direct and indirect costs for society in a younger (<65) sample of stroke patients and to explore factors affecting the costs. Methods: 58 patients, included in a study home rehabilitation, were followed 1 year and interviewed about use of health care services, assistance, medicine and assistive devices. Costs were calculated. A linear regression of cost and variables of functioning, ability, community integration and health-related quality of life was undertaken. Result: Inpatient care contributed substantially to the direct cost with a mean length of stay of 92 days. Rehabilitation during the rst year constituted of in average 28 days in day clinic, 38 physiotherapy sessions and 20 occupational therapy sessions. Total direct mean cost was 33 604 Euro and indirect cost 32 129 Euro. The direct costs were inuenced by the process skill (the ability to plan and perform a given task and to adapt when needed) and presence of aphasia. Indirect cost for informal caregiving increased for patients less health-related quality of life scoring low on home integration. Conclusion: Costs are high in this group compared to other studies partly due to length of stay as well as loss of productivity.
11 9 Management and economics

DOES ORGANISATION OF STROKE CARE CORRELATE WITH RESEARCH ACTIVITY IN STROKE?
STROKE OCCURRENCE AND DISEASE CLASSIFICATION IN GERMANY- A NATIONWIDE ANALYSIS BASED ON THE GERMAN DRG REPORT 2004
D.F. Jenkinson, G.A. Ford, A.R. Rudd, A. Hoffman, G.D. Lowe UK Stroke Research Network, Leazes Building, Royal Victoria Inrmary, Newcastle upon Tyne, London, United Kingdom
Background: It is unclear whether participation of stroke services in research leads to improved patient care, or conversely whether better organized stroke services facilitate greater participation in research. We determined the association between
P.L. Kolominsky-Rabas, B. Griewing, J. Rthemann Dep. of Health Economics, Institute for Quality and Efciency in Health Care (IQWiG), Cologne, Germany
Background: Data are limited regarding the number of stroke patients and their fraction in each ICD-10 (International classication of diseases) and DRG (Diagnosis Related Groups) category in German hospitals since so far data are only available from cohort studies and stroke registers with a limited number of patients.
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Methods: Based on the analysis of more than 1.780 German hospitals transferring their DRG (B70 A- D) and ICD-10 data to InEK (Institut fr Entgeltsystem im Krankenhaus) we compiled a detailed overview of stroke occurrence and disease classication of all German inpatient strokes in 2004. Results: 235.097 stroke patients were reported for 2004. 5.658 (2%) thereof died within 3 days after admission (B70 C), 189.403 (81%) had a non-hemorrhagic stroke (DRG B70 B), 20.929 (9%) had a hemorrhagic stroke (B70 A), and 19.107 (8%) stayed in hospital for one day only (B70 D). As categorised with the ICD-10 coding system there were 11.500 (4%) patients with subarachnoid haemorrhage (SAH, I60), 33.075 (12%) with intracerebral haemorrhage (ICH, I61), 6.482 (2%) with other non-traumatic intracranial bleeding (I62), 180.863 (66%) with ischaemic stroke (I63), and 40.882 (15%) with stroke neither dened as haemorrhagic nor ischaemic (I64). This implied an overall ratio of 19% haemorrhagic (I60,61,62) and 81% non-haemorrhagic (I63,64) strokes for Germany in 2004. Conclusions: This nationwide analysis based on the German DRG report 2004 gives a detailed overview of stroke occurrence and disease classication in Germany. Numbers revealed are higher than previous assumptions made by assessing data available from cohort studies and stroke registers containing a limited sample of patients.
factors was performed 6 and 12 months after the initial event by an investigator not involved in the usual follow-up of patients. Results: At 6 months, 41% of patients with diagnosed hypertension at inclusion had BP<140/90 mmHg and 55% of those with diagnosed hypercholesterolemia had LDL<1g/L. Compliance to treatment was excellent in 81% of patients. In univariate and multivariate analyses, initiation or reinforcement of appropriate treatments was the main factor associated with BP<140/90 mmHg (OR=2.2; 95%CI: 1.0-4.5) and LDL<1g/L (OR=3.3; 1.3-8.7) or with decrease in BP (p<0.0001) and LDL (p<0.0001). Patients characteristics including sociodemographic characteristics, education, income, and knowledge of disease and risk factors were not associated with control of BP or LDL. Among patients with BP140/90 mmHg, about 40% received either no treatment or only one drug, and treatment was reinforced in only 20% of them. Results were similar at 12 months with no improvement in the rate of control of risk factors. Conclusion: In-hospital initiation of secondary stroke prevention could inuence the long term quality of secondary prevention. Therapeutic inertia is an important impediment to achieve the BP and LDL control goals after stroke, even in relatively motivated/compliant patients.
14 12 Management and economics

A NEW METHOD OF ESTIMATING THE TIME USED BY HEALTH CARE PROFESSIONALS (HCP) FOR ACUTE STROKE CARE IN EUROPE, EUROPEAN REGISTERS OF STROKE (EROS) COLLABORATION
LONGER TERM STROKE CARE: HOW SHOULD SERVICES BE DEVELOPED IN THE POST-ACUTE PHASE?
. Saka, A.J. Mcguire, P. Heuschmann, A. Rudd, C. Wolfe Kings College London, Division of Health and Social Care Research, London, United Kingdom
Intro: The EROS project is assessing the provision of stroke care in 8 European centres. As stroke is a labour intensive disease, time spent by the HCP make up a major part in the resources used. The purpose of our study was to analyse the time spent by HCP. Methods: A questionnaire was developed, piloted and used in 7 of the participating centres to the EROS project. The forms included the description of 5 case scenarios with different severities (case 1 the least, case 5 the most severe according to NIH scores). In the forms HCP were asked to dene the activities they would carry out daily, weekly, on admission and on discharge for each case scenario. The answers were recorded in minutes (mins). We analysed the mean and the median time spent by HCP groups (classied as nurses, doctors and therapists which included speech and language therapists, physiotherapists, occupational therapists) for different case scenarios. We used Kruskall Wallis test to test the correlation between the times spent by HCP in different countries. Results: 145 interviews with HCP were included. The nurses spent more time with patients than the other HCP (mean total daily time; for nurses 25-305 mins, for doctors 5-55 mins, for therapists 0-66 mins). For all of the specialists groups there was a tendency to spend more time with mid range severity cases (cases 2 & 3), total time spent increasing steadily from mild to moderate and declining from moderate to severe. There was statistically signicant correlation between the time spent by the nurses and the doctors (p values between 0.0001 and 0.05) but not for the therapists. Conclusion: The HCP time use questionnaire helped gather data when the forms were lled through an interview with the HCP. Although this tool mainly will be used in costing the stroke service provision we found strong correlation between the time spent by doctors and nurses in different countries. The lack of such a correlation in the case of therapists can be explained by the differences in the way the function of therapists are dened in EROS centres.
A.M. Cox, L. Kalra, A.G. Rudd, C.D.A. Wolfe, C. McKevitt Kings College London, Division of Health and Social Care Research, London, United Kingdom
Background: Organised stroke care, such as inpatient stroke units and early supported discharge, improves outcomes for patients. There is less evidence for the optimal organisation and delivery of stroke care in the longer term. Following the MRC Framework for developing complex interventions, we undertook Phase 1 work to identify the potential components of an intervention to improve longer term stroke care. Methods: In-depth interviews with a purposive sample of health professionals (n=25) working in stroke. Participants were asked to describe existing services for patients in the post-acute phase, identify successes and shortcomings and propose ways to improve service provision. Interviews were recorded, transcribed and analysed using framework analysis. Results: Participants highlighted gaps in the available evidence base regarding the optimal setting, timing, intensity and focus of therapy delivery. There are theoretical questions that need to be resolved to improve post-acute services. These include whether specialist care is necessary and what specialism means in this context, the nature of multi-disciplinary working, and how to overcome the structural and professional divisions that currently inuence service provision. Problems relating to the delivery of services include transfer of care between services, lack of psychology support, capacity to provide intensive therapy, inadequate service provision for the cognitively and perceptually impaired. Conclusion: This interview study identied gaps in the evidence base, theoretical questions that underpin the organisation of services as well as practical problems in care delivery. These will need to be addressed in formulating an improved model of post-acute stroke care.
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IMPACT OF CHANGES TO THE DRG CLASSIFICATION ON ACUTE ISCHAEMIC STROKE CARE IN GERMANY
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P.L. Kolominsky-Rabas, V. Ziegler, J. Rthemann Dep. of Health Economics, Institute for Quality and Efciency in Health Care (IQWIG), Cologne, Germany
Background: In 2005, the German Diagnosis Related Groups (DRG) classication was modied to allow, for the rst time, differentiation between different forms of acute ischaemic stroke (AIS) care. Prior to this, the German DRG system consisted of only one classication for AIS: B70B. The new classication distinguishes between complex (B70B) and non-complex (B70E) neurological treatments for AIS. The advanced category of complex neurological treatment (OPS 8-981) comprises specic diagnostic and treatment features including potential thrombolysis commonly provided in stroke units (SU). Methods: To assess the inuence of the changes made to the DRG system in 2005 on patient disease management, we analyzed the data, from more than 250 of the 1.750 German hospitals, sent to the InEK (Institut fr Entgeltsystem im Krankenhaus) for the years 2004-2006.
IMPORTANCE OF THERAPEUTIC INERTIA IN SECONDARY STROKE PREVENTION: IMPLEMENTATION OF PREVENTION AFTER A CEREBROVASCULAR EVENT (IMPACT) STUDY
E. Touz, M. Voicu, J. Kansao, R. Masmoudi, B. Doumenc, A. Ferreira, P. Durieux, J. Coste, J.-L. Mas Hpital Sainte-Anne, Paris, France
Background: Many patients do not receive prevention according to recommendations after stroke, but the relative importance of patient- and physicians-related factors is uncertain. Methods: We prospectively assessed individual factors associated with blood pressure (BP)<140/90 mmHg and LDL-cholesterol<1g/L in a cohort of 240 consecutive stroke/TIA patients (Rankin<4; 80 years; no major comorbidity) from a stroke unit and 3 emergency departments. A standardized assessment of risk
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Results: Prior to the changes in the DRG classication (2004), 6.480 (34%) patients received either plain or contrast MRI (Magnetic Resonance Imaging) as part of their stroke care. After changes made to the DRG system, 1.112 (59%) AIS patients in the B70B group and 5.971 (34%) patients in the B70E group underwent MRI in 2005. The corresponding gures for 2006 were 1.180 (71%) patients in the B70B group and 4.613 (27%) patients in the B70E group. Concurrently, the percentage of thrombolytic treatment given to patients increased in the complex treatment group from 15% in 2005 to 33% in 2006. Conclusions: Distinguishing between complex and non-complex AIS care is relevant and more accurately reects patient disease management. Thus, the changes to the DRG system improve the frequency of appropriate MRI imaging and thrombolytic treatment in hospitals providing complex neurological treatment.
Conclusion: The PFG identied an under-researched area that they regard as important to understanding the consequences of stroke. Their participation led to the development of a cost measure relevant to the population under study. The measure is currently being piloted with people recruited to the South London Stroke Register.
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MARKET SHARE OF INPATIENT CARE STROKE UNITS FROM THE TOTAL HOSPITAL CARE MEASURED BY THE DIAGNOSIS RELATED GROUPS (DRG) SYSTEM
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I. Boncz, A. Sebestyn, J. Betlehem, L. Gulcsi Department of Health Economics, Policy and Management, University of Pcs, Pcs, Hungary
Aim: In the early 1990s, a Diagnosis Related Groups-like nancing system was introduced in Hungary including all the Hungarian acute care hospitals. The aim of the study is to analyse the market share of acute stroke units according to DRG system. Data and methods: Data were derived from the nancial database of the National Health Insurance Fund Administration, the only health care nancing agency in Hungary (1996-2005). All the acute care stroke units were involved into the study. The following indicators were used for the analysis: number of cases, the number of DRG cost-weights, hospital days. Regression lines and Pearson coefcients (R2) were calculated. Results: Although it was no signicant changes in the number of stroke cases (18.000-20.000 patients/year), the market share of stroke care within in-patients care measured by the number of cases decreased continuously from 1,07% (1996) to 0,77% (2005). The market share of stroke care within in-patients care measured by the number of DRG cost-weights has been also decreased from 1,06% (1996) to 0,84% (2005). The market share of stroke care from the total in-patients care hospital days has been also decreased from 1,41% (1996) to 1,01% (2005). The market share of acute stroke care in 2005 compared to 1996 felt to 72,3% in the number of cases, 79,3% in DRG cost-weights and 71,6% in hospitals days. The Pearson coefcients (R2) for number of cases, DRG cost-weights and hospitals days are 0,74, 0,72 and 0,55 respectively. Conclusion: The market share and health insurance nancial conditions of acute stroke care units varied signicantly between 1996-2005. The overall nancial effect of DRG system on the Hungarian stroke care seems to be relatively good or neutral, but not disadvantageous.
THE APPLICATION OF TELEMEDICINE FOR STROKE IN THE BALEARIC ISLANDS
S. Tur, I. Legarda, M.J. Torres, C. Jimenez Son Dureta Hospital, Palma de Mallorca, Spain
Background and purpose: Systemic thrombolysis for acute ischemic stroke is administered only in Son Dureta University Hospital (SDUH) in the island of Mallorca. It is impossible to move a patient from Ibiza or Menorca to Mallorca in time to treat. Our main aim is to extend the use of this treatment to the other Balearic Islands (Menorca, Ibiza) through telemedic support. Methods: The Department of Neurology of SDUH has Stroke Unit, neurologist on duty 24 hours per day and experience in thrombolytic treatment. Our hospitals are connected by a video conference system (red ATM). All hospitals have specic equipment (Tandberg MXP) to allow us to explore a patient at a distance and a CT image transferer. After a rst phone contact, emergency physicians consult stroke neurologists via a two-way video conference system. Medical history, neurologic examination according to National Institute of Health Stroke Scale (NIHSS) and head CT scan are reviewed to select a candidate patient for t PA treatment. Can Misses Hospital in the island of Ibiza has organized a stroke team. There is a specic stroke bed in the Intensive Medical Care Unit and we share the same stroke protocol. Both doctors and nurses have been trained. This activity began in the island of Ibiza in July 2006. Verge del Toro Hospital in the island of Menorca is developing its own assistance process. Results: We are registering clinical data, number of contacts, number of thrombolyses, onset to contact and to treatment time, complications, mortality, neurological decits and disability at admission, discharge and after 3 months (NIHSS and modied Rankin Scale) and no treatment reasons. Conclusions: Telemedicine allows us to extend specialized assistance and thrombolytic treatment to underserved areas.
Experimental studies 1 Experimental studies
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AN EXTENDED WINDOW OF OPPORTUNITY FOR GRANULOCYTE-COLONY STIMULATING FACTOR TREATMENT IN RAT FOCAL CEREBRAL ISCHEMIA
COSTS OF STROKE BORNE BY INDIVIDUALS AND FAMILIES: USER-LED DEVELOPMENT OF A PATIENT BASED COST MEASURE
C. McKevitt, N. Fudge, A. Sriskantharajah, C. Coshall, C. Wolfe, KCL Stroke Research Patients & Family Group Kings College London, London, United Kingdom
Background: The high costs to the state/health service associated with stroke care are documented in several economic analyses. These provide little information about the costs borne by families/individuals. Our Stroke Research Patients and Family Group (PFG) identied personal costs resulting from stroke as a research priority but methods to assess these costs are not well developed. We report a user-led study to adapt an existing generic, but untested, cost questionnaire for completion by stroke patients. Method: PFG discussions and 5 individual qualitative interviews were held to identify preferred research methods and specic cost items. These were used to develop a topic guide for a novel qualitative method, guided conversations, between 10 stroke survivors/carers. These were recorded, transcribed and analysed to nalise items for the cost measure. The existing generic questionnaire was adapted to incorporate stroke specic items, and reviewed by the PFG to ensure all topics were covered and approve wording. Results: User-led qualitative methods led to identication of items to include in a questionnaire. These include: payment for adaptations, medications, alternative therapies, diabetic/organic food, nutritional supplements, clothing suitable for disability, transport; direct and indirect loss of family income. The cost measure was incorporated into a structured interview questionnaire with content validity, for use in a pilot study.
J. Minnerup, R. Wysocki, R. Laage, A. Schneider, W.R. Schbitz University of Mnster, Mnster, United Kingdom
Background: Granulocyte-Colony Stimulating Factor (G-CSF) is known as a regulator of white blood cell proliferation and differentiation. We and others have shown that G-CSF is effective in treating cerebral ischemia in rodents, both relating to infarct size as well as functional recovery. We assessed the hypothesis that G-CSF has acute neuroprotective effects and long-term recovery effects in rat focal cerebral ischemia after delayed treatment onset. Methods: Wistar rats (n=24/group) underwent middle cerebral artery occlusion (MCAO) for 90 min. Four hours after onset of occlusion animals received 60 g/kg G-CSF i.v. over 20 min or vehicle. Infarct volumes were determined by TTC staining. For evaluation of long-term functional outcome photothrombotic ischemia was induced in the parietal cortex. For treatment, animals (n=10/group) were given vehicle or 10 g G-CSF/kg i.v. starting 24 or 72 hours after induction of ischemia and daily repeated for 10 days. Rotarod testing was performed at 1, 2, 3, 4, 5 and 6 weeks after ischemia. Brain sections were immunostained for anti-BrdU and NeuN. Results: After MCAO we observed a infarct volume reduction by 33% in the total infarct volume as compared to vehicle-treated rats (334.0 31.5 mm3 vs. 223.3 27.3 mm3 , p < 0.05). G-CSF treated rats in both the 24 h and 72 h time-window performed signicantly better in the rotarod test than vehicle-treated animals. The number of newly generated neurons (BrdU+/NeuN+) in the dentate gyrus was increased (p < 0.01) by G-CSF treatment.
Poster Session Experimental studies
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Discussion: In Conclusion we demonstrate an infarct reducing effect of a 4 h treatment delay with G-CSF in a severe hemispheric stroke model (MCAO). In the photothrombotic model we have shown that the time window for initiation of poststroke functional recovery by G-CSF is at least 72 h. This effect correlated with a profound induction of neurogenesis. G-CSF is therefore thought to activate dual mechanisms within the brain such as the previously shown neuroprotective effect plus a substantial recovery/neurogenesis inducing function.
oxygen therapy. These effects were observed 6 hours after the ischemic stroke. Hence further studies are needed to investigate the long term effects of the combination therapy.
Experimental studies
BLOOD-BRAIN BARRIER (BBB) OPENING AFTER TRANSIENT FOCAL CEREBRAL ISCHEMIA IN RATS
EFFECTS OF THE TP RECEPTOR ANTAGONIST S 18886 IN A RAT MODEL OF MIDDLE CEREBRAL ARTERY PHOTOTHROMBOTIC OCCLUSION
I. Marinkovic, A. Durukan, U.A. Ramadan, D. Strbian, M. Pitkonen, E. Pedrono, L. Soinne, T. Tatlisumak Biomedicum Helsinki, Helsinki, Finland
Background: It is widely believed that BBB breakdown after transient focal cerebral ischemia occurs in a biphasic pattern. The aim of this study was to evaluate quantitatively the pattern of BBB damage after transient focal cerebral ischemia and its correlation with the size of the ischemic lesion by the use of contrast-enhanced magnetic resonance imaging (MRI). Methods: Adult male Wistar rats (n=10) were underwent 90 minutes of transient focal cerebral ischemia with the suture occlusion method and imaged with MRI at 4.7 Tesla at 2, 24, 48, 72 hr and 1 week after reperfusion. Diffusion weighted imaging, FLAIR (uid attenuated inversion recovery), and T1-weighted (with and without contrast agent gadolinium) sequences were acquired. After calculating lesion area and contrast-enhanced areas, their ratio was obtained. The gadolinium permeability (by calculating Ki values via the Patlak plot approach) was estimated for all imaging time points. Results: In all post contrast images, gadolinium enhancement occurred in a similar spatial pattern with ischemic lesion and there was no statistically signicant difference between ratios (mean ratio was 0.94 for T1-weighted sequence, p=0.06 and 0.91 for FLAIR, p=0.6). The Ki values of ischemia regions (cortex and subcortex) for all groups were statistically signicant (p<0.01) compared with the identical regions in the contralateral brain hemisphere. The difference in Ki between different time points was not statistically signicant (p=0.38). Discussion: Our results showed that BBB leakage to gadolinium (molecular weight 590 Da) occurs in a monophasic pattern during the period of 2 hr to 1 week after transient focal cerebral ischemia in rats and BBB damaged brain area is highly similar to the ischemic area depicted on DWI.
T. Hirvonen, V. Blanc-Guillemaud, L. Lerond, J. Jolkkonen CNServices, Kuopio, Finland

Background: Platelet activation represents the major source of increase in TXA2 biosynthesis after a cerebro-vascular event and plays an essential role in the pathogenesis of thrombotic stroke. S 18886, a TXA2 and prostaglandin endoperoxide (TP) receptor antagonist is being developed as an anti-atherothrombotic agent and is expected to be effective in cerebral artery thrombosis. The aim of this study was to investigate the effects of S 18886 in comparison to aspirin and clopidogrel, in a rat middle cerebral artery (MCA) model of focal thrombosis induced by photochemical reaction. Methods: S 18886 (10 mg/kg), aspirin (100 mg/kg) and clopidogrel (30 mg/kg) were orally administered to male Wistar rats (n=10-16/group) 2 hours before thrombosis induction. A group receiving the vehicle served as control. Blood ow in the distal MCA was monitored by a laser Doppler owmeter for a 70-min period. Time to occlusion (TO) and total patency time (TPT), expressed as a percentage of observation period, were measured. Results: There were no statistical differences in time to occlusion between treatment groups. However S 18886 and clopidogrel prevented MCA occlusion in 2/10 and 2/11 animals, respectively. S 18886 signicantly increased the incidence of reopening (87.5% versus 25% in control group; p<0.05) and the TPT measured when MCA blood ow was above 70% of baseline (67.9 8.3% versus 20.9 4.2% in control group, p<0.001). The increases in the incidence of reopening (55.5%) and the TPT (41.1 12.4%), observed with Clopidogrel were not statistically signicant. Aspirin had no effect on these parameters. Conclusion: The present study demonstrates that single oral administration of S 18886 increases incidence of MCA reperfusion and improves MCA blood ow during reperfusion. The ndings suggest that anti-platelet therapy with the TP receptor antagonist S 18886 can be potentially benecial in cerebro-vascular diseases
EFFECT OF HIGH-DOSE OESTROGEN THERAPY ON CEREBRAL PLASTICITYAFTER TRANSIENT FOREBRAIN ISCHAEMIA IN GERBIL
HYPERBARIC OXYGEN TREATMENT COMBINED WITH THROMBOLYTIC THERAPY REDUCES INFARCTION SIZE IN EXPERIMENTAL ISCHEMIC STROKE
E.A. Wappler, A. Gal, G. Szilagyi, J. Vajda, J. Skopal, K. Felszeghy, C. Nyakas, Z. Nagy National Institute of Psychiatry and Neurology, National Stroke Center, Budapest, Hungary
Background: After ischaemic injury repair mechanisms in the brain tissue reduce the functional decit. Neuroprotective effect of oestrogen is well documented, however its effect on repair mechanisms are still not elucidated. In our work we focused on the expression of plasticity genes and functional recovery after oestrogen treatment in transient ischaemic model. Methods: 3 month-old ovariectomized femail gerbils (n=40) were subjected to 10 min transient forebrain ischaemia or sham procedure. Half of the ischemic animals were pre-treated i.p. with 4 mg/kg body weight oestrogen 20 min previous to surgery. From one series of animals brain samples were collected on postoperative day 4 for histological and molecular biological examinations. Parafn-embedded brain slices were stained with TUNNEL-caspase double labelling uorescent antisera. Marker mRNA levels were determined with real-time PCR. Gene expression levels were assessed by ddCT method using TaqMan gene expression assays. On other series of animals attention and learning behaviour were tested in spontaneous alternation, novel object recognition and spatial learning paradigms beginning from postoperative day 7. Results: Oestrogen signicantly decreased the number of apoptotic and necrotic cells in CA1 region. Oestrogen treatment resulted in a signicant increase in Bcl-XL, nestin and GAP-43 mRNA expression. In ischaemic insult inpaired attention and working memory in all behavioural tests, while oestrogen pre-treatment improved attention and prevent or decreased memory decit. Discussion: Our novel nding is that oestrogen is not just neuroprotective in our model, but augmented the expression of plasticity genes and these correlate well to better outcome in behaviour tests. This work was supported by OTKA T037887, GVOP-3.1.1.-2004-05-0389/3.0.
L. Kppers-Tiedt, A. Manaenko, A. Gnther, D. Michalski, A. Wagner, D. Schneider Klinik und Poliklinik fr Neurologie; Universitt Leipzig, Leipzig, Germany
Background: In acute ischemic stroke effective treatment is still limited. The only approved therapy is thrombolysis with rtPA within the rst three hours, but this therapy is only an option for a small number of patients due to the time window and the risk of hemorrhage. This study investigated the effects of thrombolysis in combination with hyperbaric oxygen therapy (HBOT) in acute ischemic stroke in rats. Methods: In 22 male Wistar-Rats an ischemic stroke was induced by embolic occlusion of the middle cerebral artery using clots of 20 mm length. After stroke induction the animals were randomized to one of three groups: 1) Control (room air and placebo), 2) Thrombolysis (room air and rtPA), 3) HBOT (hyperbaric oxygenation (2.5 ATA) and rtPA). rtPA was given intravenously two hours after the embolic stroke. The animals were exposed to room air/HBOT before or during thrombolysis for one hour. 6 hours after the stroke the animals were sacriced and brain slices stained with Triphenyltetrazoliumchloride to calculate the infarct volume. Results: The ischemic infarctions calculated 6 hours after the embolic stroke extended to 50% of the hemisphere. Thrombolysis alone did not reduce the infarction size (about 43% of the hemisphere), but the combination of thrombolysis and HBOT lead to a signicant decrease of infarction size to about 20% of the hemisphere (HBOT before rtPA p=0.01; HBOT during rtPA p=0.02, Student-Newman-Keul-Test). Discussion: In this study we could demonstrate a signicant reduction of infarction size in an embolic stroke model in rats by combining thrombolytic and hyperbaric
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S 18886, A THROMBOXANE A2 RECEPTOR ANTAGONIST, PREVENTS OCCURRENCE OF SPONTANEOUS BRAIN DAMAGE IN STROKE-PRONE RATS VIA ANTI-INFLAMMATORY ACTIVITIES
ULTRASOULD-THROMBOLYSIS WITH 488KHZ - SAFETY-STUDIES WITH AN MRI-BASED RAT STROKE MODEL
P. Gelosa, E. Nobili, A. Gianella, V. Blanc-Guillemaud, L. Lerond, U. Guerrini, E. Tremoli, L. Sironi Dept. Pharmacol. Science, Univ. Milan; Italy; Inst. Recherches Internationales Servier, Courbevoie, Milan, Italy
Background and aim: Spontaneously Hypertensive Stroke-prone rats (SHR-SP) are an established model of human cerebrovascular disease. In this rat strain, the development of hypertension and inammation precedes the appearance of brain abnormalities. The aim of the present investigation was to assess the efcacy of S 18886, an orally active antagonist of TP-receptors (the receptors for thromboxane A2), in protecting the brain of SHRSP and whether this effect was related to its anti-inammatory properties. Methods and results: Male SHR-SP (n=10 per group), fed with a high-salt diet, received by gavage vehicle or S 18886 (3 or 30 mg/kg/day). In vehicle-treated animals, brain lesions, as detected by magnetic resonance imaging, developed spontaneously after 40 2 days (mean SEM). Treatment with S 18886 had no effect on arterial blood pressure, signicantly delayed the appearance of brain damage, at the dose of 30 mg/kg/d (p<0.001), and increased survival, in a dose dependent manner (p<0.001 and p<0.0001 at the dose of 3 and 30 mg/kg/d respectively). In comparison with vehicle-treated SHRSP, treatment with S 18886 (30 mg/kg/d; n=5), preserved brain tissue by preventing macrophage inltration (ED1 positive cells) (p<0.05), and reduced the accumulation of perivascular macrophages (ED2 positive cells) and lymphocytes T helper (CD4+ positive cells) as assessed by immunohistochemistry. Furthermore, S 18886 attenuated the transcription of the pro-inammatory cytokines IL-1beta, TNF-alpha, IL-6, and MCP-1, as assessed by RT-PCR. Conclusion: These data indicate that S 18886 prevents the occurrence of spontaneous brain damage in SHRSP by reducing inammation, suggesting that S 18886 may exert a benecial anti-inammatory effect in cerebrovascular disease.
M. Walberer, M. Nedelmann, D. Schiel, K. Volk, P. Reuter, M. Kaps, T. Saguchi, G. Bachmann, H. Furuhata, T. Gerriets University Giessen, Germany; Kerckhoff-Clinic Bad Nauheim; Jikei University Tokyo, Giessen, Germany
Objective: Ultrasound can enhance the effect of i.v.-thrombolysis in acute stroke. First clinical trials with 2MHz-ultrasound revealed an improved recanalisation rate but yet no convincing clinical benet. Lower ultrasound frequencies might be more effective. However, clinical trials as well as animal experiments have shown severe side-effects. Safety of new therapeutic ultrasound devices thus needs to be determined. Methods: Male Wistar rats were subjected to middle cerebral artery-occlusion for 90 minutes followed by reperfusion (suture technique). Rt-PA (Actilyse ) was injected intravenously thereafter. Then transcranial ultrasound treatment (488kHz; sweep: 10%; 0.7W/cm2 ; continuous wave) was started and continued for 60 minutes. Sham treated animals were used as controls. Intracerebral temperature was recorded during ultrasound application in a sub-study. MRI (Bruker PharmaScan, 7.0 Tesla) was performed after 24h. Ischemic lesion volume (T2-WI and DWI) and vasogenic brain edema (T2-relaxation time) were quantied. T2*-WI was used to determine hemorrhagic complications. Results: 488kHz-ultrasound treatment did not noteworthy affect brain temperature. Ultrasound did not increase lesion volume or edema formation. No hemorrhagic complications could be detected on T2*-weighted imaging. Conclusion: The 488kHz-device did not exert any side-effects in our MRI-based rat stroke model. Further safety- and efciency-studies are required prior rst clinical applications.
GW3965, AN AGONIST OF THE LXR NUCLEAR RECEPTORS, IS NEUROPROTECTIVE IN EXPERIMENTAL STROKE
CDP-CHOLINE INCREASES EAAT2 ASSOCIATION TO LIPID RAFTS AND AFFORDS NEUROPROTECTION IN EXPERIMENTAL STROKE
M.A Moro, J.R Morales, M.P. Pereira, J.R. Caso, O. Moldes, J. Vivancos, C. Gubern, J. Serena, A. Davalos, I. Lizasoain Facultad de Medicina, Universidad Complutense Madrid, Madrid, Spain
Background and purpose: Liver X receptors alpha (LXR-alpha) and beta (LXRbeta), also known as NR1H3 and NR1H2, respectively, are ligand-activated transcription factors that belong to the superfamily of nuclear receptors. Apart from their role in the regulation of cholesterol homeostasis and fatty acid metabolism, LXR receptors have been described to inhibit the expression of inammatory mediators such as inducible nitric oxide synthase (iNOS), cyclooxygenase-2 (COX-2) or matrix metaloproteinase-9 (MMP9). Since these anti-inammatory actions might be useful in stroke, we have investigated the effects of the LXR agonist GW3965 on stroke outcome in a rodent model of cerebral ischaemia by permanent occlusion of the middle cerebral artery (MCAO). Methods: Male Fischer rats were used. Infarct size: 48 after MCAO, animals were sacriced with an overdose of pentobarbitone and a serial of 2 mm thick coronal slices were made and stained with 2,3,5-triphenyltetrazolium chloride 1% in 0.2 phosphate buffer. Infarct size was determined using a computer image analysis system. Experimental groups were control, permanent middle cerebral artery occlusion (MCAO), and MCAO+GW3965 (20mg/kg). GW3965 or vehicle (DMSO) were administered i.p. 10 min after MCAO. Stroke outcome was assessed by measurement of infarct size. Protein expression of iNOS, COX-2 and MMP9 in cerebral cortex were studied by Western blot and data were expressed as % of densitometry of bands in the MCAO group. Results: The administration of the LXR agonist GW3965 reduced infarct volume (180.4 7.7 mm3 vs. 150.2 5.5 mm3 in MCAO and MCAO+GW3965, respectively, n=6-10, p<0.05). Furthermore, GW3965 reduced MCAO-induced expression of iNOS (41 1% of MCAO, n=4, p<0.05), COX-2 (43 3% of MCAO, n=4, p<0.05) and MMP-9 (43 1% of MCAO, n=4, p<0.05) was reduced in animals treated with GW3965. Conclusions: Activation of LXR receptors induce neuroprotection in experimental stroke, very likely due to anti-inammatory mechanisms.
I. Lizasoain, O. Hurtado, J.M. Pradillo, D. Fernndez-Lpez, T. Sobrino, T. Gasull, M. Castellanos, F. Nombela, J. Castillo, M.A. Moro Facultad de Medicina, Universidad Complutense Madrid, Madrid, Spain
Background: EAAT2 is responsible for up to 90% of all glutamate transport and has been reported to be associated to lipid rafts. In this context, we have recently shown that CDP-choline induces membrane translocation of EAAT2. Since CDP-choline preserves membrane stability by recovering sphingomyelin levels a glycosphingolipid present in lipid rafts, we have decided to investigate whether CDP-choline increases association of EAAT2 transporter to lipid rafts. Methods and results: For lipid rafts isolation, brain homogenates from each group were subjected to a discontinous sucrose gradient in the presence of Brij-58 and 8 fractions were collected. Flotillin-1 was used as a marker of lipid rafts due to its known association to these microdomains. We have found that otillin-1 was found mainly in fractions 2 and 3 and their levels were similar in all the groups studied. EAAT2 protein was predominantly found colocalised with otillin-1 in the fraction 2, and CDP-choline increased EAAT2 levels in fraction 2 at both times examined (3 and 6 hours after 1g/Kg CDP-choline administration). Furthermore, exposure to middle cerebral artery occlusion also increased EAAT2 levels, an effect which was further enhanced in those animals receiving 2 g/Kg CDP-choline 4 hours after the occlusion. Infarct volume measured at 48 h after ischemia showed a reduction in the group treated with CDP-choline 4 h after the ischemic occlusion. Conclusions: We have demonstrated that CDP-choline induces a re-localisation of EAAT2 into lipid raft microdomains in rat brain. This effect is also found after experimental stroke, when CDP-choline is administered 4h after the ischemic occlusion. We have also shown that this delayed post-ischaemic administration of CDP-choline induces a potent neuroprotection.
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ENHANCEMENT OF SENSORIMOTOR RECOVERY UNDER CEREBROLYSIN TREATMENT IN A RAT MODEL OF FOCAL CEREBRAL INFARCTION
M. Hitzl, J.M. Ren, D. Sietsma, S.M. Qiu, H. Moessler, S.P. Finklestein EBEWE Pharma GmbH Nfg.KG, R&D Neuro Products, Unterach, Austria
Background: Many efforts have been made to nd drug products having the potential to reduce infarct volume and/or promote neurological recovery after stroke. Cerebrolysin a unique drug product composed of neurotrophic and neuroprotective peptides from biological origin seems to t perfectly into this specication. It has therefore been tested in an rodent model of stroke. Methods: Focal cerebral infarction was produced in mature male Sprague-Dawley rats by occlusion of the proximal right middle cerebral artery. Animals have subsequently been treated with Cerebrolysin at a daily dose of 1.0, 2.5, or 5.0 ml/kg body weight starting 24, 48 or 72 hours after stroke onset for 21 days. Behavioral assays were performed before and during Cerebrolysin treatment (forelimb and hindlimb placing and body swing tests). At the end of Cerebrolysin treatment the infarct volume has been determined using a computer-interfaced imaging system. Results: Cerebrolysin treatment of rats after focal cerebral infarction resulted in enhanced recovery of sensorimotor function compared to vehicle-treated animals. Enhancement of sensorimotor recovery has been found when Cerebrolysin treatment at a dose of 2.5 ml/kg was started 24 or 48 hours after stroke onset. Discussion: These ndings clearly demonstrate that administration of Cerebrolysin after stroke can enhance neurological recovery.
risk can only be estimated by invasive diagnostics, which themselves bare the risk of cerebrovascular accidents. Therefore we searched for a reliable non-invasive diagnostic tool for preoperative risk estimation. Methods: A computer model of the brain supplying arteries was designed, whose parameters can be determined by non-invasive measurements and picture-giving procedures to t the model to the individual physiological state of the patient. Comparing time series generated by the model with those measured at the patient the model can be evaluated and in the case of insufcient results its parameters can be changed by an optimization process based on evolutionary algorithms. Results: The patient adapted models behaved physiologically and showed good agreement between the modelled data and those recorded from the subjects. The reaction of individual cerebrovascular systems in critical situations similar to the occlusion of the internal carotid artery was investigated by special scenarios. Even though in this rst step of examination the optimization process was only related to a few parameters, it became obvious that evolutionary algorithms are suitable provided that some physiological laws are considered. Discussion: Although some difculties remain concerning the parameter estimation and optimization we hope, that this exible, time saving, cheap and non-invasive method makes a valuable contribution to avoid complications of induced vessel occlusion during medical treatment by an improved operation planning.
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NATURAL REGULATORY CD4+CD25+FOXP3+ T-LYMPHOCYTES (TREG) PREVENT DELAYED INFARCT GROWTH BY AN INTERLEUKIN-10 DEPENDENT MECHANISM
11
R. Veltkamp, E. Suri-Payer, C. Sommer, C. Veltkamp, H. Doerr, T. Giese, A. Liesz University Heidelberg, Heidelberg, Germany
Background and aims: Inammatory cascades contribute to secondary ischemic brain damage. Tregs are important anti-inammatory modulators in various inammatory diseases. We studied the role of Tregs in ischemic stroke. Methods: Focal ischemia was induced by transtemporal MCAO. Tregs were eliminated either by preischemic depletion with mAb (clone PC61) in C57Bl/6 mice or by adoptive transfer of CD4+CD25- into rag2-/- mice. Infarct volume and cerebral cytokine expression (RT-PCR) were measured at various time points after MCAO. Effect of IL-10 was tested by intraventricular injection or by transfer of Tregs from IL -10 -/- mice. Results: Treg depletion had no effect 24h after MCAO, but Treg-depleted mice had signicantly larger infarct volumes 7d after MCAO (control: 7.4mm3 ; antibody-treated: 12.1mm3 ). Correspondingly, transfer of CD4+25- T cells into lymphocyte-decient rag2-/- mice resulted in larger infarcts (12.9mm3 ) than transfer of CD4+ cells (6.8mm3 ; p<0.05). Intraventricular IL-10 reversed this effect. Treg derived IL-10 was particularly important as adoptive transfer of CD4+CD25+ cells derived from IL-10 -/- failed to prevent infarct growth. In mice lacking Tregs, RNA levels of proinammatory cytokines were signicantly more elevated in ischemic hemisphere compared to control (6h after MCAO: TNFa 4x; IL-1b 2x; 72h after MCAO: IFNg: 5x). Cerebral invasion of Tregs became rst detectable 72h after MCAO by FACS and immunohistochemistry. Conclusions: Tregs are master anti-inammatory modulators in ischemic stroke which reduce secondary infarct progression by downregulating proinammatory cytokine induced cell death. Based on our ndings, this effect is probably mediated by early humoral IL-10 signalling and by delayed Treg invasion.
RHEOENCEPHALOGRAPHY: A NON-INVASIVE METHOD TO ASSESS THE ELECTRICAL IMPEDANCE CHANGES RELATED TO THE PULSATILITY OF THE CEREBRAL BLOOD FLOW
J.M. Pons, J.J. Prez, P. Ortiz, E. Guijarro, A. Navarr, J. Sancho 1 Consorcio Hospital General Universitario Valencia; 2 Centro de investigacin e innovacin en bioingeniera Universidad Politcnica de Valencia, Valencia, Spain
Objective: Rheoencephalography (REG) measures the electrical impedance changes of the head caused by the pulsatility of the cerebral blood ow (CBF). However, the use of REG in the clinical practice is limited because signal is buried by the extracranial component. Our research group has formulated a mathematical algorithm that allows the extraction of the intracranial component from the REG signal. The main goal of this work is to validate the separation method. For this purpose, an experimental model that arrests mechanically the extracranial blood ow is used. Material and methods: REG signal was acquired in healthy volunteers in two conditions: (i) normal and (ii) during the arrest of the scalp blood ow by means the scalp compression with a pneumatic cuff. Subsequently, the intracranial component extracted with our algorithm was statistically compared with the REG traces recorded in scalp compression condition. Results: Intracranial component extracted by our algorithm matches well with the REG trace recorded in scalp compression condition. Additionally, the morphology of the extracted intracranial component agrees with the intraparenchymal impedance traces previously described in the literature. Conclusions: Our results suggest that the intracranial REG component can be reliably extracted from the raw REG signal by cancelling the scalp blood artifact. This method could provide a new non-invasive technique to assess the cerebral blood ow. Nevertheless, additional works would be necessary to check and to assess the diagnostic capability of our REG technique. This work was supported by grant PI04/0303 from the Instituto de Salud Carlos III (Fondo de Investigacin Sanitaria) in the framework of the Plan Nacional de Investigacin Cientca, Desarrollo e Innovacin Tecnolgica (I+D+I).
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NONLINEAR ANALYSIS OF BRAIN SPIROGRAPHY SIGNALS - THE WAY TO A NEW NON-INVASIVE DIAGNOSTIC TOOL (A PILOT STUDY)
M. Swierkocka-Miastkowska, G. Osinski Department of Neurology for Adults, Medical University of Gdansk, Gdansk, Poland
Background: Ischaemic stroke is associated with disturbances of respiration rhythm. The purpose of this study was to analyze breathing patterns of acute phase stroke patients in comparison to healthy subjects. Methods: Brain spirography (BSG) as a new method of experimental clinical breath research was deviced and tested in Medical University of Gdansk. It has a detecting system coupled with pressure sensors. Signals from the sensors through the analog-digital converter are transferred to the computer for making visual representation of respiration activity on a screen. Data from 55 patients with rst-ever supratentorial ischaemic stroke and a control study of 25 volunteers were obtained. In patients the respiration curves were measured 3 times during rst 5 days of hospitalization. All patients were assessed with the National Health
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FIRST EXAMINATIONS WITH AN AUTOMATICALLY OPTIMIZED COMPUTER MODEL FOR INDIVIDUAL SIMULATIONS OF CEREBRAL HEMODYNAMICS
F.C. Roessler, V. Metzler, R. Grebe, G. Siegel Clinic for Neurology, UK-SH, Campus Lbeck, Lbeck, Germany
Background: During the medical treatment of some cerebrovascular diseases it is necessary to occlude brain supplying arteries. Sometimes these interventions cause a cerebral ischemia and the patient will suffer from strokes. Until now this
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Institues Stroke Scale and (if needed)Glasgow Coma Scale. The curves were analyzed with 3 nonlinear methods: Return Map Plot (RMP), calculation of Fractal Dimension (FD) with Higutchi algorithm and graphical representatiom of Visual Map Plot (VMP). Results: We analyzed 25 physiological and 165 pathological data sets. As a result we obtained average values of FD for both groups: in the group of volunteers FD=1.599 0.072, in stroke patients FD=1.8730.076. The values analyzed with ANOVA test are signicantly different (p<0.003). Discussion: As a number of stroke patients is instantly high, it is very important to develop quick, easy-to-use and non-invasive methods to monitor acute phase of stroke. A set of graphical interpretation of RMP and VRP together with value of FD and estimation of trends in groups of signals could give us clinically important information by visual representation of the analysis of dynamic status of respiratory pattern.
anti-apoptotic factors and IL-1, while the expression pro-apoptotic bax remained unchanged. Discussion: These data suggest that deprenyl is neuroprotective in an in vitro model of ischemia. Although deprenyl upregulates the expression of Bcl-2 under basal conditions, its effect on anti-apoptotic factors is not signicantly manifested during OGD.
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BCL-2 AND BCL-XL GENES THERAPY INCREASES PLASTICITY AND CELL CYCLE GENES EXPRESSION AFTER HYPOXIA IN PC12 CELLS
A. Gal, G. Szilagyi, E. Wappler, Z. Bori, J. Vajda, J. Skopal, Z. Nagy National Institute of Psychiatry and Neurology, National Stroke Center, Budapest, Hungary
Introduction: Hypoxia induces cell necrosis and/or apoptosis. Antiapoptotic gene therapy could be an option to prevent the cell death and activate the repair mechanisms. In this study we measured the expression of plasticity and pro/antiapoptosis genes (Bcl-2, Bcl-XL, Bax, synapsin-1, nestin and c-fos) in PC12 cell culture system after adenovirus containing Bcl-2 or Bcl-XL gene delivery. We found previously that the gene transfer has a cytoprotective effect, protects the mitochondrial function and augmented repair protein GAP-43 expression after hypoxic insults. Materials and methods: The cells were treated by Argon gas (1 hr) for induction 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 after hypoxia. We examined the selected mRNA levels with real-time PCR. The gene expression levels were determinated by ddCT method using TaqMan gene expression assays. Results: Hypoxia and reoxygenization increased the pro-apoptotic Bax gene expression while the c-fos mRNA level was decreased. Gene transfers of Bcl-2 or Bcl-XL resulted in a signicant increase of Bcl-2, Bcl-XL, synapsin-1, nestin and c-fos mRNA expression levels after hypoxic insults. Conclusions: In our in vitro model, Bcl-2 or Bcl-XL anti-apoptotic gene delivery was not only cytoprotective but it augments repair genes expressions after hypoxic insults. The double actions of these genes appear to be benecial in preventing hypoxic cell injury. However, the link between the augmented anti-apoptotic and repair mRNA expression is not clear at the moment. Keywords: PC12, hypoxia, Bcl-2, Bcl-XL gene transfer, plasticity genes
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MRI AND BEHAVIOR EFFECTS OF EARLY INTRAVENOUS DELIVERY OF MESENCHYMAL STEM CELLS AT EXPERIMENTAL CEREBRAL INFARCT IN RATS
L. Gubskiy, K. Yarygin, O. Povarova, Yu. Pirogov, R. Tairova, A. Dubina, I. Cheblakov, D. Kupriyanov, V. Skvortsova Fundamental and Clinical Neurology Department, Russian State Medical University, Moscow, Russian Federation
Background: To measure the effect of early intravenous delivery of mesenchymal stem cells (MSCs) on neurological and neurobehavioral functional decits and MRT volume of experimental cerebral infarct in rats. Methods: 3-month-old 19 male Wistar rats (weight 180 to 250 g) were subjected to focal ischemia in the region of MCA by electrocoagulation before bifurcation into frontal and parietal branches under intraperitoneal anesthesia by chloral hydrate (300 mg/kg). The rats were randomized into three groups: sham (3), control (8) and experimental (8 animals with intravenous delivery of 6 million of MSCs on the 1 - 2nd days after operation). MRT was performed on 1-2 and 7 days at BioSpec 70/30, neurological and behavior functional tests (elevated cross - maze, open-eld tests) also where performed. Results: Neurological severity scores in experimental and control groups on 1, 7 and 14 days after operation were equal but lower than those in the sham-operated group. At open-eld test the horizontal activity of control rats was higher than experimental animals. There were no signicant differences between control and MSC groups on the cross-maze on 10 but not 20 day. Before delivery of MSCs volumes of cerebral infarct (at T2-weighted imaging) were without signicant difference between control and experimental groups. There was signicant decrease of the volumes in both groups on 7 day. Discussion: Early intravenous delivery of MSCs did not change the rate of decrease of the volume of cerebral infarct at the rst 7 days of experimental cerebral infarct in rats. There were no difference between groups at neurological and behavior functional tests except for more high activity of control rats at open eld test.
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(-) DEPRENYL-N-OXID IS NEUROPROTECTIVE AFTER TRANSIENT HIPPOCAMPUS ISCHEMIA IN GERBILS
G. Szilgyi, K. Magyar, Z. Nagy National Stroke Centre, Budapest, Hungary

Introduction: As we reported previously, (-)deprenyl-N-oxid (DNO) has signicant cytoprotective effects in PC12 cell culture. Decreased cell death and reactive species production and increased mitochondria trans-membrane potential were 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 occlusion in Gerbils. Methods: We performed transient, bilateral carotid artery occlusions for 10 minutes. The treated group was injected 0.4 mg/kg/day of N-oxid-deprenyl intra peritoneal for 4 days. The control rats were injected with the vehicle only. The gerbils were killed after 4 days. On the formaldehyde xed sections TUNEL and caspase-3 immuno-histochemistry were performed and NIKON/BIORAD confocal microscope was used for analysis. Consecutive images were taken from the hippocampus. The TUNEL and caspase-3 positive cells were counted automatically with Image J 1.37 software (NIH, USA). Results: All the caspase-3 positive cells were TUNEL positive too. In the CA2 regions we found signicantly less caspase positive neurons az there were found in the controls. Similarly in the same region signicant decrease in number of TUNEL positive cells were counted. Discussion: In our previous study we demonstrated the neuroprotective effect of deprenyl. This drug decreased signicantly the TUNEL labelled and TUNELcaspase-3 double labelled neurons in the penumbra region after permanent MCA occlusion in rat. In the present experiment one of the deprenyl metabolite DNO decreased similarly the number of TUNEL positive cells in the CA2 hippocampus region. DNO cytoprotective effect was previously documented in PC12 cell culture. The neuroprotective effect of the highly polar molecule in the in vivo model could be related the transient opening of BBB in this model. Grant: OTKA T037887.
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OXYGEN-GLUCOSE DEPRIVATION-INDUCED CELLULAR CHANGES IN ORGANOTYPIC SLICE CULTURES OF THE HIPPOCAMPUS: PROTECTIVE EFFECT OF (-)DEPRENYL
B. Bali, Z. Nagy, K.J. Kovcs Semmelweis University, Budapest, Hungary

Background: (-)Deprenyl is an irreversible inhibitor of type B monoamine oxidase (MAO-B), which is now used as a neruoprotective compound for treatment of Parkinsons or Alzheimers diseases. Evidence suggests that the therapeutic efcacy of deprenyl may not be related exclusively to the inhibition of the enzyme MAO-B, however the cellular mechanisms underlying its neuroprotective effect remained unknown. Methods: To test the impact of deprenyl on ischemia-induced changes in vitro, we followed the time course of propidium iodide (PI) uptake as an indicator of neuronal cell death in organotypic hippocampal slice cultures exposed to oxygen-glucose deprivation (OGD) for 45 min. The expression of apoptotic factors (Bcl-2, Bcl-xl and Bax) as well as of the proinammatory citokine interleukin-1 (IL-1) was measured by polymerase chain reaction (PCR) Results: The rst signs of neuronal death were detected 2 hours after OGD and were extended to all subelds of the hippocampus by 24 hours post-injury. Presence of deprenyl (10-9 M) signicantly delayed the cell death induced by the insult. Exposure of control cultures to deprenyl signicantly increased the abundance of Bcl-2 and Bcl-xl mRNAs as revealed by RT-PCR. OGD resulted in an elevation of
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Vascular surgery and neurosurgery/Interventinal neuroradiology 1 Vascular surgery and neurosurgery/Interventinal neuroradiology
Vascular surgery and neurosurgery/Interventinal neuroradiology
CAROTID ENDARTERECTOMY: COMPLICATIONS AND CLINICAL OUTCOME
INTRA-ARTERIAL AND INTRAVENOUS THROMBOLYSIS IN ACUTE ISCHEMIC STROKE FROM CAROTID T OCCLUSION
R. Martinez, Y. Silva, J.A. Amado, O. Andres, J. Puig, S. Pedraza, M. Castellanos, J. Serena Hospital Universitari Dr. Josep Trueta, Girona, Spain
Background: To investigate the rate of perioperative complications and the clinical outcome of endarterectomy in patients with symptomatic carotid-artery stenosis of at least 70% in daily clinical practice. High risk patients were included. Method: Ninety-ve patients consecutively diagnosed as having symptomatic carotid stenosis >70% were included over a 4 year period up to 2006. The therapeutic decision was taken collectively by a multidisciplinary team from the neurology, neurosurgery and neuroradiology departments. Vascular risk factors, neurological examination, neuroimaging ndings, carotid and transcranial colour duplex study, intra- and post-operative complications (local and systemic), stroke recurrence and mortality at 3 months were recorded. Patients were admitted to the neurology department both on the occurrence of stroke and for immediate postoperative attention. Results: Seventy-six percent of patients were men, mean age 708.5 years. Hypertension had a frequency of 72.6%; hypercholesterolemia, 51.6%; diabetes, 31.6%; smoking, 29.5%; and ischaemic cardiac heart disease, 23.2%. Sixty percent had suffered a stroke and 40% a TIA. Forty percent of patients had a symptomatic stenosis >90% and 24% had a contralateral asymptomatic stenosis >70% or occlusion. The occurrence of stroke or death within 3 months of carotid endarterectomy was 4.2%. Two patients died perioperatively (2.1%), one as a result of a hyperperfusion syndrome and the other due to a brain infarction. Two patients (2.1%) suffered stroke recurrence. Minor haemodynamic alterations were detected in 42.1% of patients during the rst days after endarterectomy (hyper or hypotension) and 43.2% had local complications (XII or VII minor pareses). Conclusions: Among patients with severe carotid-artery stenosis and coexisting conditions, carotid endarterectomy in clinical practice, including high risk patients, has a low perioperative risk although minor complications are frequent, which may be attributable to the close neurological control.
P. Nencini, S. Mangiaco, M. Nesi, I. Romani, G. Cagliarelli, M. Pratesi, V. Palumbo, M. Cellerini, A. Rosselli, D. Inzitari Careggi Hospital, Florence, Italy
Background: Outcome in acute ischemic stroke from internal carotid artery occlusion is poor with high mortality or severe long-term disability. We evaluated if intra-arterial (IAT) or intravenous thrombolysis (IVT) may inuence outcome. Methods: From February 2004 to August 2006, twenty-nine patients with acute internal carotid artery T occlusion were admitted to two Hospitals in Florence, Italy. All patients underwent screening for IVT (SITS-MOST protocol), colour duplex sonography or cerebral angiograph, and had a 3-month follow-up with mRankin scale (mRS). Results: Eleven patients (male 64%, mean age 66 years, mean NIHSS 20) were treated with IATwithin 6 hours from symptom onset; 11 patients (male 27%, mean age 72 years, mean NIHSS 18) with IVT within 3 hours from symptom onset; and 7 patients (male 86%, mean age 64 years, mean NIHSS 18) had standard treatment. Recanalization was achieved in 8/29 (27.6%) patients (6 TIMI 3 and 2 TIMI 2), all treated with IAT. Four out of 11 (27.3%) IAT patients had a 3-month good (mRS 0-2) outcome compared with no patients in both the IVT and standard treatment group. The 3-month mortality rate was 36% in IAT, 27% in IVT, and 43% in the standard group, respectively. Symptomatic haemorrhage occurred only in IAT group (27% of patients). Conclusions: The prognosis of ischemic stroke due to internal carotid artery T occlusion remains severe. Our data may suggest a favourable effect on the intra-arterial approach. More data are needed to conrm this hypothesis.
RETROSPECTIVE VALIDATION OF THE ABCD SCORE IN PATIENTS PRESENTING WITH TRANSIENT ISCHAEMIC ATTACKS UNDERGOING CAROTID ENDARTERECTOMY
S. Shaikh, J. Brittenden, E. MacAulay, M.J. Macleod University of Aberdeen, Aberdeen, United Kingdom
Introduction: Patients who have experienced a transient ischaemic attack are at risk of developing a stroke especially within the rst two weeks after a TIA. The ABCD score aims to predict an individual patients risk, thus facilitating the ability to fast-track investigation and treatment of the high-risk group who have a score of 5 or 6. We aimed to assess the ABCD score of patients who had undergone carotid endarterectomy. Method: 194 of patients who underwent CEA between January 2001 and December 2005 were identied from a prospectively collected database. Results: 90 (46.4%) patients undergoing CEA presented with a TIA. The remaining operations were performed for cerebrovascular accident (n=59), amaurosis fugax (n=36) and asymptomatic carotid disease (n=9). All patients had an ipsilateral high-grade internal carotid artery stenosis (>70%). Of the 89 patients with TIAs (case-notes of 1 patient were destroyed), the median age was 71years (range 45-83) with a male to female ratio of 1.6:1. Post-operative complications included 2/89 (2.22%) TIAs, 2/89 (2.24%) lingual nerve paraesthesia, and 4/89 (4.5%) haematomas none of which required drainage. The ABCD scores were as follows: 1, n=4 (4.49%); 2, n=15 (16.85%); 3, n=19 (21.34%); 4 n=22 (24.71%); 5 n=17 (19.10%); 6 n =12 (13.48%). Conclusions: All patients undergoing CEA for TIAs were treated as per the recommendations of the European carotid trial, yet according to the ABCD score two thirds of these patients would be considered to be at low risk of a subsequent neurological event. These patients would not have been fast-tracked for treatment and thus further validation of this score is urgently required.
CAROTID ENDARTERECTOMY AUDIT OF GREAT BRITAIN & IRELAND
A. Rudd, T. Lees, A. Halliday, P. Rothwell, A. Hoffman, D. Kamugasha Royal College of Physicians, London, United Kingdom
Background: A prospective two-year audit involving all hospitals that offer Carotid Endarterectomy (CEA), aiming to capture data on all CEA cases performed between Dec 05 & Dec 07, to assess quality of process of care & outcomes against the available evidence base. Main reporting spring 2008. A rm evidence base supports the role of CEA & its urgency in the prevention of stroke. In the UK 110,000 patients per annum suffer rst stroke & 30,000 suffer TIAs. 10%-15% of the stroke patients should have CEA. The Healthcare Commission commissioned the audit following a pilot funded by the Stroke Association. Methods: All surgeons who undertake CEA are eligible to participate and undertake to contribute to: Organisational Survey (2 rounds) describing individual surgeon routine practice: investigations, case selection criteria, surgical technique & post-operative assessment and Clinical Audit to collect patient level data (indications, investigation, surgical technique & 30-day morbidity/mortality). Results: Organisational Survey (Round 1): Median number of CEAs performed per annum overall is 17 (IQR 10-25) - 90% of these done for symptomatic disease Over 70% of surgeons say they are able to see patients referred by letter within 2 weeks 99% of surgeons would not operate on symptomatic carotid stenoses <50% and 53% would not operate <70%. 62% of surgeons would be prepared to undertake CEA within 2 weeks following a non-disabling stroke if the CT scan showed no infarct and 39% if the CT scan showed a small infarct Vascular surgeons perform nearly all CEA but about one quarter of surgeons perform fewer than 10 cases per year. There are signicant variations across the country in access to CEA services. Discussion: Recruitment is still open. 86% of eligible surgeons have registered and so far contributed 1300 cases for the Clinical Audit for which data collection will continue until end of December 2007. The rst round of the Organisational Survey completed May 2006 and the second is currently Round 2 is underway will report April 2006
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Venous diseases 1 Venous diseases
Venous diseases
INCIDENCE OF INHERITED THROMBOPHILIA IN GREEK PATIENTS WITH CEREBRAL VENOUS THROMBOSIS
DEVELOPMENT OF A RISK SCORE TO PREDICT THE PROGNOSIS OF CEREBRAL VEIN AND DURAL SINUS THROMBOSIS (CVT)
K. Lysitsas, I. Gravas, G. Papaioannou, P. Kyriakidis, E. Dermitzakis, J. Rudolf Papageorgiou General Hospital, Thessaloniki, Greece
Background: Hereditary thrombophilia has been reported to be present in approximately 30% of all patients with cerebral venous thrombosis (CVT). However, data on the incidence of inherited thrombophilia in Greek CVT patients are scarce. Methods: We report the results of the diagnostic work-up including a full thrombophilia screening in a consecutive case series of 27 patients (8 males, 19 females, age range 17 59 years) with CVT from a Greek tertiary healthcare facility. Results: Cephalalgia was the leading symptom in 85% of the patients (n=23), focal neurological signs were present in 48% (n=13), and epileptic seizures in 22% (n=6). Multiple thrombosis of cerebral sinus was a common nding in MRI and MRV: Thrombosis of the superior sagittal sinus was found in 78% (n=21), of the transverse sinus in 41% (n=11), the sigmoid sinus in 7% (n=2), of the sinus rectus in 18% (n=5) and of the cavernous sinus in one patient only. Elevated D-dimers were found in 48% (n=13, hyperhomocysteinaemia in 30% (n=8), heterozygous mutation of the MTHFR gene in 44% (n=12) and homozygous MTHFR mutation in 18% (n=5). Other hereditary thrombophilias (e.g. FV-Leiden mutation, n=1, or the prothrombine G20210A mutation, n=2) were found in single cases only. Conclusion: In this consecutive open case series of Greek patients with CVT, the incidence of inherited thrombophilia was considerably higher than reported from other comparable study populations.
J.M. Ferro, T. Rodrigues, L. Bacelar-Nicolau, H. Bacelar-Nicolau, P. Canho, I. Crassard, A. Dutra, A. Massaro, M.A. Mackowiak-Cordiolani, D. Leys, J. Fontes Department of Neurosciences, Hospital de Santa Maria, Lisboa, Portugal
Background: Although cerebral vein and dural sinus thrombosis (CVT) has an overall favourable prognosis, a variable proportion of patients die or became dependent after CVT. It is relevant to identify such high-risk patients. Method: We used the ISCVT sample (624 patients) with a median follow-up time of 478 days to develop a Cox proportional hazards regression model. Because of non proportional hazards, the used model was stratied by the median age of 37 years. A treatment of inuential observations (dfbeta analysis) led us to not include 9 outlier subjects. The model was tested in the whole ISCVT sample and in two validation samples 1) the VENOPORT (91 patients), 2) of 169 consecutive CVT patients admitted to 5 ISCVT participating centres after the end of the ISCVT recruitment period. Results: In the ISCVT sample the model (HR - CNS infection 5.11; malignancy 3.96; deep system 3.32; coma 3.17; mental 2.25; haemorrhage 1.57; male 1.76) accurately predicted 89% of good and 47% of bad outcomes (accuracy: 85%) at 6 months, for a cut-off of 83% in the estimated survival probability. Area under the ROC curve was 0.79 (p=0.000). In the VENOPORT validation sample the model accurately predicted 91% of good and 25% of bad outcomes (accuracy: 84%). Area under the ROC curve was 0.69 (p=0.077). In the 5 ISCVT centres validation sample the model accurately predicted 93% of good and 24% of bad outcomes (accuracy: 86%). Area under the ROC curve was 0.79 (p=0.000). Conclusion: The prognostic model presents a good external validity. The model accurately predicts the majority of favourable outcomes and 1/4 to 1/2 of unfavourable outcomes. It can be used to avoid dangerous interventions in low-risk patients and to select patients for intensive monitoring and aggressive interventions. From hazard ratios a prognostic score and estimated survivor probability at 6 months can be computed.
Heart & brain 1 Heart & brain
DIAGNOSING PATENT FORAMEN OVALE(PFO) IN CRYPTOGENIC STROKE:TRANSCRANIAL DOPPLER VS TRANS OESOPHAGEAL ECHO
S. Kumar, M.S. Randall, L.O. Toole, J.N. West, G.S. Venables Shefeld Teaching Hospitals NHS Trust, Shefeld, United Kingdom
Background: PFO is associated with cryptogenic stroke in young patients (<55 years). Trans Oesophageal Echo (TOE) has been the standard for diagnosing PFO. Contrast enhanced Trans Cranial Doppler (TCD) is a simpler, easier & less invasive technique that detects a right to left shunt (RLS).The aim of this study was to compare the utility of the two techniques in the management of young patients with stroke. Methods: TCD & TOE were performed in 100 consecutive patients with ischaemic stroke or TIA (< 55 years; mean age 40years). Statistical analysis was performed using SPSS software. Results: 51% of patients had RLS on TCD and only 41% on TOE. After a positive result on ce TCD 2 patients who had a negative TOE on the rst occasion were shown to have a shunt on repeat TOE. Other structural abnormalities detected by TOE were inter atrial septal aneurysm (19), aortic atheroma (7), atrial thrombus (2), left ventricular hypertrophy (2) & mitral valve abnormalities (3). Using TOE as the standard, TCD sensitivity was 90% and specicity was 76%.With the combination of the two tests as the standard, the sensitivity of TCD & TOE was 93% & 75% respectively. The negative predictive value of TCD was 92%,while that of TOE was only 76%.McNemars test showed a signicant difference between TCD & TOE(P=0.03). Discussion: This study reveals the added value of TCD in combination with TOE. The higher sensitivity and negative predictive value of ceTCD may be due to an extracardiac shunt or inadequate valsalva during TOE. The size of the shunt on TCD may assist in the risk assessment for stroke recurrence in young people with stroke. TOE is useful to exclude other sources of cardiac emboli. TCD has been shown to be reliable, more sensitive, less invasive and easy to use in a clinical setting making it the ideal screening tool. All young cryptogenic stroke patients should have both TCD & TOE; undergo risk stratication based on degree of shunt on TCD, the presence of intra cardiac abnormalities and other concomitant risk factors to facilitate appropriate management.
Venous diseases
DURAL ARTERIOVENOUS FISTULAS AND PREMATURE ANTICOAGULATION CESSATION AFTER CEREBRAL VENOUS THROMBOSIS
P. Cardona, H. Quesada, P. Sanchez, M.A. Fong, A. Escrig Bellvitge Hospital, Hospitalet de Llobregat, Barcelona, Spain
Dural arteriovenous stulas (DAVF) rarely are associated with cerebral venous thrombosis (CVT). We report ve cases of symptomatic intracranial dural arteriovenous stulas during follow-up of CVT. Methods: We retrospectively review forty patients with intracranial venous thrombosis between 1996-2006. In ve cases DAVFs were developed during follow-up period 1 year after anticoagulation stopping (after 6 -9 months of period treatment); leptomeningeal drainage were present in all the cases. Results: Symptoms as pulsatile tinnitus or headache appeared 3-12 months interval after anticoagulation cessation. All ve patients where the initial angiogram studies had showed abnormalities of the venous transverse or sigmoid sinuses, persistent abnormalities were seen on the later angio-MR previous to stopping oral anticoagulant (6-12 months period) as occluded or liforme sinus. Two of ve patients had factor V Leiden previously unknowned. Embolization of DAVF was performed in three cases with good outcome. Discusion: DAVF appeared over previous ocluded or liforme transverse sinus demonstrated in angio-MR. All stulaes were on the transverse or sigmoid sinuses.It was hypothesized that factor V Leiden and other inhereted deciencies of coagulation factors, might be involved in the pathogenesis of DAVFS secondary to venous thrombosis predisposition over damaged venous wall. Also the anticoagulation cessation may predispose to DAVF formation. Conclusion: The longterm anticoagulant therapy in occluded or partial thrombosed sinus might be important for prevention of thrombosis and DAVF formation although patients were asymptomatic. Due to a potential risk of intracranial hemorrages, embolisation previous to prompt anticoagulation may be developed in these cases.
Poster Session Heart & brain
141
Heart & brain
Heart & brain
MODERATE HYPOTHERMIA FOR ANOXIC ENCEPHALOPATHY AFTER IN-HOSPITAL AND OUT-OF-HOSPITAL CARDIAC ARREST: RESULTS IN ROUTINE CLINICAL PRACTICE
THE ROLE OF THE MORPHOLOGICAL CHARACTERISTICS OF PATENT FORAMEN OVALE IN CRYPTOGENIC STROKE: AN MRI STUDY
R.A. Bernstein, K. Dewan, A.M. Naidech, M.J. Alberts, D. Fintel, D. Bergman, R. Oakley Northwestern University, Chicago, IL, USA
Background and purpose: Randomized trials have shown that induced moderate hypothermia (MH) improves neurological outcomes after out-of-hospital cardiac arrests due to ventricular brillation/tachycardia (VF/VT). However, the effectiveness and safety of this treatment for other arrhythmias or for in-hospital arrests is less clear. In addition, the prognostic signicance of early brainstem dysfunction after hypothermia is unknown. We devised a standard protocol for MH in patients with anoxic encephalopathy after cardiac arrest of any type, including both in hospital and out-of hospital arrests. Methods: For this retrospective case series, we collected demographic, clinical, and outcome data on our rst 21 consecutive patients treated with MH for anoxic encephalopathy after cardiac arrest. Target temperature was 33o C for 24 hours from start of cooling, with controlled re-warming over 8 hours. Neurological outcomes were dichotomized based on discharge disposition as good (discharge to home or rehabilitation) or poor (discharge to nursing home or death). Brainstem dysfunction was dened as any of the following: pupillary non-reactivity, absent caloric or oculocephalic reexes, absent corneal reexes, or absent gag reex. Results: Of the 21 patients who underwent MH after cardiac arrest, 62% were male, and the mean age was 60 [range 35-88]. In hospital arrests (n=16, 76%) outnumbered out-of-hospital arrests (n=5, 24%). Arrest arrhythmias included pulseless electrical activity (44%), asystole (24%), VF/VT (19%), primary respiratory arrest followed by cardiac arrest (10%) and unknown (5%). The mean time to return of spontaneous circulation was 16 minutes [95% CI 9.7-22.7 min]. Discharge dispositions were to home (10%), rehabilitation (19%), nursing home (14%) and dead (57%). Good outcome (discharge to home or rehabilitation) occurred in 3 of 5 (60%) of out-of-hospital arrests, and 3 out of 16 (18%) of in hospital arrests. Among patients surviving 3 or more days, all of those with brainstem dysfunction had poor outcomes (n=8); of those without brainstem dysfunction on day 3, 6 out of 7 (86%) had good outcomes. Conclusions: Moderate hypothermia after cardiac arrest is feasible in routine clinical practice. Good neurological outcome may be more common in out-of-hospital arrests; only a randomized trial can determine if this therapy is effective for in-hospital arrests. Consistent with experience in the pre-hypothermia era, patients with brainstem dysfunction on or beyond day 3 have poor outcomes.
C. Bonvin, K.O. Lovblad, H. Mller, R. Sztajzel University Hospitals of Geneva, Genve, Switzerland
Background and purpose: Patent foramen ovale (PFO) is an established cause of cryptogenic stroke in young patients. The aim of our study was to evaluate, in patients admitted for a cryptogenic stroke or transient ischemic attack (TIA), whether the number and distribution of ischemic lesions on MRI differed according to the morphological characteristics of the PFO including size and degree of interatrial right-to-left shunting (RLS) and presence of atrial septal aneurysm (ASA). Patients and methods: We included 220 consecutive patients less than 60 years old admitted from 2000 to 2006 for a cryptogenic stroke or TIA (absence of any other determined stroke etiology following TOAST criteria after complete diagnostic workup). Hypercoagulable state was not an exclusion criterion, since it may play a role in the paradoxical embolism. Demographic data have been analyzed from the patients personal records. MRI scans and echocardiographies were evaluated by independent experienced investigators, blinded to the patients history. Two different methods were systematically assessed to diagnose PFO and ASA: contrast transcranial Doppler (c TCD) and transesophageal echocardiography (TEE) as well as transthoracic echocardiography (TTE) in most patients. Results: Recruitment of patients is completed and neurologists, cardiologists and neuroradiologists are currently working intensively on the data. We will especially determine (i) the prevalence of PFO and ASA in cryptogenic strokes, (ii) compare c-TCD, TEE and TTE methods in their ability to detect and quantify the PFO, (iii) correlate the number and size of MRI lesions with size of PFO, ASA and degree of RLS in univariate and multivariate analysis (logistic-regression model and ANCOVA). To our knowledge, this study is the rst to compare simultaneously c-TCD, TEE and TTE ndings with MRI lesions in patients with cryptogenic stroke. This study may help to better assess the risk of stroke in these patients and thus have critical impact on treatment options.
Large clinical trials (RCTs) 1 Large clinical trials (RCTs)
DELAYS IN TREATMENT FOR SYMPTOMATIC CAROTID STENOSIS AT RESEARCH ACTIVE CENTRES
Heart & brain
R.L Featherstone, J. Ederle, M.M. Brown UCL Institute of Neurology, London, United Kingdom
Background: Treatment of symptomatic carotid artery stenosis is an effective secondary prevention measure for stroke. The earlier endarterectomy is performed after symptoms, the better the long-term outcome. We have used baseline data from the International Carotid Stenting Study (ICSS), an ongoing multicentre study of symptomatic patients randomized between carotid endarterectomy and stenting, to assess delays in treatment. Methods: The interval between the most recent TIA or non-disabling stroke, recorded at randomization, and the date of procedure (carotid endarterectomy or stenting) was calculated for all ICSS patients where data on the procedure was returned by December 2006. Data came from 36 centres in the UK, Europe, North America and Australia. Results: The median delay between event and treatment was 55 days (n=854). Most of the delay occurred before randomization, median delay between randomization and treatment was 14 days. The three centres with the shortest average delay between event and treatment were compared with the three that had the longest. The median delay at the fastest centres was 14 days (N=42 patients) compared to 123 days in the three slowest centres (N=72 patients), a signicant difference (p<0.001). Discussion: Signicant differences exist in treatment delays between centres. Even the most efcient research active centres are failing to treat many patients with symptomatic carotid stenosis within 2 weeks of the presenting symptoms, when the benet is greatest. Such treatment delays result in a substantial proportion of patients being left at high risk of a recurrent event while awaiting investigation and treatment. The results emphasise the need to reorganize stroke services to investigate and treat carotid stenosis urgently.
IS HEART DISEASE A PROGNOSTIC FACTOR FOR ACUTE STROKE OUTCOME? A PROSPECTIVE STUDY
I. Ybot, M.J. Abenza, B. Fuentes, B. San Jos, M.A. Ortega-Casarrubios, P. Martnez, E. Dez-Tejedor University Hospital La Paz, UAM, Madrid, Spain
Background: Heart disease in ischemic stroke (IS) may be the cause of stroke, a coexistent illness, or even a consequence of stroke, but its presence means a higher risk for vascular death. Objective: To analyse the presence of cardiopathy in patients with acute IS and its impact on stroke outcome. Methods: Prospective study with inclusion of consecutive IS patients in a 4-month recruitment period. Previous or current cardiopathy, vascular risk factors, stroke severity on admission, in-hospital complications and modied Rankin Scale (mRS) at discharge were analysed. Results: 91 patients included, 33% with known heart disease. Most frequent entities were arrhythmia, including atrial brillation (AF) (53.3%) and ischemic cardiopathy (36.7%). They were older (72 vs 63 years old; p<0.05), had greater frequency of hypertension (80% vs 42%; p<0.05), hypercholesterolemia (60% vs 19%; p<0.05) and peripheral artery disease (20% vs 4,9%; p<0.05), had more severe strokes on admission (p<0.05) and worse outcome at discharge (mRS>2: 48.1% vs 18.2%;p<0.05) than patients without previous history of heart disease. It was diagnosed cardiopathy in 11 among 61 patients without known heart disease (18%), being AF the most frecuently diagnosis (6 patients). In the logistic regression analysis, the only independent factor of poor outcome was the stroke severity on admission, without signicant inuence of heart disease. 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.
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Large clinical trials (RCTs)
Behavior and mood 1 Behavior and mood
THE SAFETY AND EFFICACY OF CLOPIDOGREL VERSUS TICLOPIDINE IN JAPANESE STROKE PATIENTS COMBINED RESULTS OF TWO PHASE III MULTICENTRE RANDOMISED CLINICAL TRIALS
S. Uchiyama, T. Yamaguchi, Y. Fukuuchi Tokyo Womens University, Tokyo, Japan

Background: Compared with aspirin, both ticlopidine and clopidogrel have demonstrated superior efcacy in preventing recurrent vascular events, but adverse drug reactions (ADRs) are more common with ticlopidine. For the rst time, the safety and efcacy of these agents have been compared directly among Japanese stroke patients in a combined analysis of 2 phase III randomised, controlled studies. Methods: Patients aged 2080 years with a history of noncardioembolic stroke were randomised to receive clopidogrel 75 mg once daily (n=941) or ticlopidine 200 mg once daily (n=928) for 26 or 52 weeks. The primary endpoint was safety (incidence of ADRs; n=1869). The major secondary endpoint was efcacy (combined incidence of cerebral infarction, myocardial infarction, and vascular death; n=1862). Results: Baseline characteristics of each group were similar (mean age, 64.7 years; 71.3% males). The clopidogrel group had signicantly fewer ADRs than the ticlopidine group (35.0% vs 48.7%; p<0.0001) and a signicantly lower incidence of hepatic dysfunction (13.4% vs 25.6%; p<0.001). The frequency of hemorrhagic ADRs was similar in the two treatment groups (clopidogrel group, 11.9%; ticlopidine group 10.1%; p=0.612). Both drugs were equally effective in preventing vascular events (clopidogrel group, 3.6%; ticlopidine group, 3.8%; p=0.510). Conclusions: In Japanese patients with a history of noncardioembolic stroke, both clopidogrel and ticlopidine are equally effective in the prevention of recurrent vascular events. However, clopidogrel is safer than ticlopidine. Now that clopidogrel is available in Japan, it should be considered as the preferred treatment choice, as occurs for Western patients.
SYMPTOMS AND DIAGNOSIS OF DEPRESSION IN APHASIC STROKE PATIENTS
A.C. Laska, B. Mrtensson, T. Kahan, M. von Arbin, V. Murray Karolinska Institutet, Department of Clinical Sciences, Stockholm, Sweden
Background: We investigated the feasibility of assessing depression, and symptom occurrence, in patients with aphasia. Methods: 89 acute stroke patients with aphasia of all types were followed for six months. The diagnosis of depression was made in accordance with DSM-IV criteria at baseline, 1, 3, and 6 months. A standard aphasia test was performed. A battery of yes and no capability questions from the comprehension part of the aphasia test were selected for depression diagnostic purposes. Results: In 60 patients (67%) at baseline, and successively increasing to 100% at six months, comprehension allowed reliable DSM-IV diagnosis. The possibility to undertake a DSM-IV interview was related to the degree of aphasia (p<0.01), and was least in patients with global and mixed non-uent types of aphasia. A comparison at one month between patients reliably fullling the criteria for a depression (D) and those who did not (Non-D) revealed: none of the two cardinal symptoms occurred among the Non-D. Of the other symptoms, weight loss (36% in D, 16% in Non-D); insomnia (50% in D, 33% in Non-D); loss of energy (25% in D, 20% in Non-D); and impaired concentration (27% in D, 19% in Non-D) occurred (all n.s.). At six months weight loss, insomnia, and loss of energy still occurred in above 10% in Non-D. In all, criteria for depression were fullled in 24%. Discussion: It is possible to verify the presence or absence of a depression according to DSM-IV criteria in two thirds of aphasic stroke patients in the acute setting. Some depression symptoms occur irrespective of depression diagnosis. Hence, if a cardinal symptom is fullled depression may possibly be over-diagnosed in the individual stroke patient with aphasia.
Large clinical trials (RCTs) 2 Behavior and mood

SYMPTOM PROFILES IN MAJOR AND MINOR POSTSTROKE DEPRESSION
ETHNICITY DOES NOT AFFECT THE HOMOCYSTEINE-LOWERING EFFECT OF VITAMIN THERAPY IN SINGAPOREAN STROKE PATIENTS
K. Kasiman, J.W. Eikelboom, G.J. Hankey, H.M. Chang, M.C. Wong, C.P. Chen National Neuroscience Insititute, Singapore General Hospital Campus, Singapore
Background: Increased plasma total homocysteine (tHcy) levels are a risk factor for stroke and can be reduced with vitamin therapy. However, data on the tHcylowering effects of vitamins are limited largely to white populations. Thus, we aimed to determine in Singaporean patients with recent stroke: (1) the efcacy of vitamin therapy (folic acid, vitamin B12, and B6) on lowering tHcy, and (2) whether efcacy is modied by ethnicity (Chinese, Malay & Indian). Methods: A total of 506 eligible patients (420 Chinese, 41 Malays and 45 Indians) were recruited after presenting with ischemic stroke within the past 7 months. Patients were randomized to receive either placebo or vitamins as part of a large multi-centre double-blinded clinical trial. Fasting blood samples collected at baseline and at 1 year were assayed for levels of plasma tHcy. Results: Mean baseline tHcy was similar in the 2 groups, At 1 year, mean tHcy was signicantly higher in the placebo group compared with the vitamin group. 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 efcacy in lowering tHcy across Asian populations.
V. Murray, P. Gustavsson, B. Mrtensson Karolinska Institutet Danderyd Hospital, Dept. Clin. Sciences, Stockholm, Sweden
Background: Findings on clinical proles in poststroke depression are conicting. Meta-analysis is difcult due to different methodologies. Hence, new data are needed. Symptom proles in major and minor poststroke depression were compared. For clarity, or basis for hypotheses, the symptom proles of the major depressed stroke patients were compared with those of major depressed psychiatric patients. Methods: Stroke patients fullling DSM-IV diagnostic criteria for major or minor depression (n=127), and psychiatric in-patients with a major depression (n=40) were assessed by the Montgomery-sberg Depression Rating Scale (MADRS). Results: The MADRS proles of major and minor depressed stroke patients were similar, with lower scores in minor depression but for inner tension; pessimistic thoughts; and suicidal thoughts where scoring was equally high. No basic clinical or neuroradiology differences were identied. Stroke patients with lesions
Poster Session Behavior and mood
143
involving the cortex rated higher for sadness, while in those with a central lesion only, inner tension (anxiety) was more pronounced. In the comparison of proles between major depressed stroke patients and psychiatric patients, the items on sadness and reduced sleep were similarly pronounced. Discussion: Given the similarity in sadness i.e. depressed mood, equivalent to cardinal criterion 1 in the DSM classication of a depression, it is striking that inability to feel, the equivalent of the DSM cardinal criterion 2, was much less pronounced in stroke than among the psychiatric patients. Conclusions: The difference between major and minor poststroke depression may be more quantitative than qualitative, while the difference between poststroke and psychiatric major depression could be more qualitative.
impairment, delirium, catastrophic reaction and self-referred apathy in elderly. The identication of those neuropsychiatric disturbances is clinically relevant for their functional state recovery.
Stroke and movements disorders 1 Stroke and movements disorders
MYOCLONUS AFTER ACUTE STROKE
Behavior and mood
L. Idrovo Freire, F. Vivancos Matellanos, M. Lara Lara, E. Diez-Tejedor Hospital Universitario La Paz, Madrid-Spain
Introduction: Hyperkinetic abnormal movements during acute stroke are uncommon, with an estimated prevalence of 1%. Myoclonus is a clinical manifestation dened as a sudden, brief, involuntary and shock-like movements caused by muscular contraction (positive) or inhibitions (negative). Methods: We report 3 patients that on examination during the acute phase of stroke showed hemi-asterixis (two of them) and a positive myoclonus in the other (videos). Results: The patients with asterixis had similar clinical features and both suffered cardioembolic ischaemic infarcts of the posterior cerebral artery territory. The patient showing a positive myoclonus had a thalamo-mesencephalic haemorrhage. On all cases, neuroimaging studies revealed that the postero-lateral thalamus was involved. The patients who showed asterixis, in addition to the thalamic compromise, also had temporo-occipital lesions (one of them the cerebellar hemisphere was also affected). On the other hand, in the patient with the haemorrhagic stroke the rostral mesencephalus was also affected. In all cases, these abnormal movements had a good outcome. Discussion: Hyperkinetic abnormal movements during stroke are unusual neurological manifestations and acute-onset hemi-asterixis is even less frequently reported. Asterixis is usually associated with thalamic lesions (ventral and posterolateral) though any lesion of the cerebellar-rubrothalamic-cortical pathway can enhance myoclonic activity.
ENDOREACTIVE POST-STROKE DEPRESSIONS ARE ASSOCIATED WITH POORER MOTOR RECOVERY
V. Kontzevoj, V. Skvortsova, M. Savina, E. Petrova Russian Medical State University, Russian Federation
Background: The majority of recent studies showed that poststroke depression (PSD) inuence the recovery of neurological decit and daily activities. However, some studies didnt take into account the clinical heterogeneity of PSD. Some of PSD are known to have endogenic structure. Objective: We hypothesized that PSD with different psychopathological structure would inuence differently on motor recovery. Methods: 115 subjects with rst stroke (57 males, 58 females, the mean age 65 years) were observed in xed terms. Depression was diagnosed using criteria of ICD-10. The elaborate psychopathological analysis of their clinical features was made. The degree of neurological impairment was assessed by the Orgogoso Scale. The recovery was assessed by criterion of Wilxoson. Results: During rst year after stoke depressions were observed in 38 patients (33%). 6 cases with manifestation of depression before stroke were not included in further analysis. In 21 patient were diagnosed reactive PSD. In 12 patients were diagnosed endoreactive PSD that had both reactive and endogenic features (vitalized affects, circadian rhythmus with worsening of depressive symptoms at the morning etc.). In patients without PSD (n = 77) Orgogozo scale total score changed signicantly from 13 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 insignicant. In patients with reactive PSD changes of Orgogozo scale total score were signicant 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 insignicantly in all dened time intervals. Conclusions: Endoreactive PSD compared with reactive ones are associated with poorer motor recovery.
Intracranial aneurysms and vasospasm 1 Intracranial aneurysms and vasospasm
LOCAL LEVELS OF ENDOTHELIN-1 AND NITRIC OXIDE METABOLITES IN BASILAR ARTERY AND CEREBROSPINAL FLUID AFTER EXPERIMENTAL SUBARACHNOID HEMORRHAGE IN RABBITS
Behavior and mood
V. Neuschmelting, S. Marbacher, A.R. Fathi, R.W. Seiler, S. Jakob, J. Fandino University Hospital Berne, Berne, Switzerland
Objective: The genesis of Endothelin-1 (ET-1) and Nitric Oxide (NO) as two important mediators in the development of cerebral vasospasm (CVS) after subarachnoid hemorrhage (SAH) is controversially discussed. The objective of this study was to determine whether local levels of ET-1 and NO in cerebral arterial plasma and/or in cerebrospinal uid (CSF) are associated with the occurrence of CVS after SAH. Methods: CVS was induced using the one-hemorrhage-rabbit-model and conrmed by digital subtraction angiography of the rabbits basilar artery (BA) on day 5. Prior to sacrice local samples of CSF and basilar arterial plasma (BAP) samples were assessed by transclival approach to the BA in addition to systemic arterial plasma (SAP). ET-1 levels were determined by an immunometric technique (in pg/ml SEM) and total nitrate/nitrite level spectrophotometricly (in mol/L SEM). Results: Angiographically detectable CVS could be documented in animals with induced SAH (n=12, p<0.05). The ET-1 level in CSF was signicantly elevated by 27.3% to 0.84 0.08 pg/ml in SAH animals (n=7) in comparison to control (0.66 0.04 pg/ml, n=7, p<0.05). There was no signicant difference of ET-1 levels in SAP and BAP samples of SAH animals compared to controls. Highly signicant lack of local NO metabolites could be documented in BAP of SAH animals (36.8 3.1 mol/L, n=6) compared to controls (61.8 6.2 mol/L, n=6, p<0.01). Decreasing tendency of local NO level remained insignicant in CSF and SAP (n=6, p>0.05). Conclusions: This study demonstrates elevated ET-1 level in CSF and local lack of NO in BAP samples to be associated with CVS after experimental SAH. Possible genesis of local changes of ET-1 and NO level after SAH are discussed in respect to controversial data reported to date.
NEUROPSYCHIATRIC PROFILE OF ELDERLY ACUTE STROKE PATIENTS
C.O. Santos, L. Caeiro, J.M. Ferro, M.L. Figueira Servio de Neurologia e Servio de Psiquiatria, Department of Neurosciences, Hospital de Santa Maria, Lisboa, Portugal
Background: Neuropsychiatric disturbances after acute stroke are relatively frequent. Elderly stroke patients have a high proportion of concomitant diseases, a worse recovery and an aging brain. We aim to describe the neuropsychiatric prole of a sample of elderly acute stroke patients. Methods: Consecutive acute stroke patients (4 days after stroke onset) hospitalised in a Stroke Unit were assessed with a standardized protocol including: MMSE, Delirium Rating Scale, Montgomery Asberg Depression Rating Scale, Denial of Illness Scale, Catastrophic Reaction Scale, Mania Rating Scale, Apathy Scale and Apathy Evaluation Scale. Neuropsychiatric prole of patients aged </65 years old (younger vs elderly) was compared. Bivariate analysis was performed to nd associations between neuropsychiatric disturbances and demographic, clinical and imaging data in the elderly patients. Results: We studied 55 elderly patients (mean age of 72.5 years old), 13 (24%) of them presenting an acute cognitive impairment, 7 (13%) delirium, 27 (49%) acute depression, 27 (49%) denial, 8 (15%) catastrophic reaction, 1 (2%) mania, 9 (39%) were identied as clinically apathic and 8 (35%) considered themselves as apathic. Elderly patients presented a higher frequency and severity of acute cognitive impairment (p=.01), a higher severity of delirium (p=.04) and catastrophic reaction (p=.02) and they considered themselves as more apathic (p=.02). Discussion: Although the frequency of neuropsychiatric disturbances was similar to that presented by younger patients, we found a higher severity of cognitive
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Intracranial aneurysms and vasospasm
SHARED EXPERIENCE IN THE ACUTE TREATMENT OF PATIENTS WITH CEREBRAL ANEURYSM
M. Carvi y Nievas, J. Hattingen, H. Hllerhage, M. Mller-Schimpe Neurosurgery, Frankfurt am Main/Hchst, Germany

Objective: evaluation of our shared endovascular-microsurgical experience treating cerebral aneurysms. Method: An interventional neuroradiologist and a neurosurgeon administered the emergent treatment of 97 consecutive SAH-patients harboring 108 cerebral aneurysms. Decisions were based on the patient-clinical-condition, aneurysm morphology and location, degree of ICP and on CBF distribution patterns. The benets of joined case-assessment were retrospectively analyzed evaluating the rate of aneurysm occlusion, the employment of complementary treatments, the patient clinical evolution and number of observed complications. Results: Initially, 39 aneurysms in 34 patients were endovascular (EV) and 65 aneurysms in 63 patients were surgical (S) treated. Four non-ruptured aneurysms remain under control. Three patients in the surgical group died without angiocontrol. Complete radiological aneurysm occlusion was achieved in 35 (89.5%) EV- and 60 (95.2%) S treated aneurysms. Complementary treatments included 24 CSF-drainages and 7 decompressive surgeries in the EV-group as well as 5 EV-procedures to treat severe vasospasm in the S-group. Four aneurysms-remnants (2 EV and 2 S-treated) remain unchanged. One EV-treated-aneurysm grew and was surgically occluded. Favorable evolution was observed in 27 (79.4%) EV and 52 (82.5%) S treated patients. CT-documented rebleedings (7 - 1), angiographic vasospasm (3 - 5), occlusion of main vessels (1 - 2) were the method related complications in EV and S-groups respectively. Conclusion: After comparing literature data, shared decisions in the emergent aneurysm-treatment increases the rate of aneurysm-occlusion, improves patients evolution and allows appropriated complementary treatments reducing the number of complications.
INTEREST OF PERFUSION AND DIFFUSION MR IMAGING TO FOLLOW PATIENTS WITH CEREBRAL VASOSPASM AFTER ANEURYSMAL SUBARACHNOID HEMORRHAGE
E. Le Bars, H. Brunel, M. Moynier, G. Boubotte, A. Bonaf CHU Hpital Gui de Chauliac, Montpellier, France
Objective: study the potentiality of Diffusion and Perfusion MRI to improve the vasospasm diagnosis sensitivity in case of aneurysmal subarachnoid bleeding. Methods: Thirty cases of aneurysmal SAH were evaluated with TCD, DWI and PWI within the rst three days and the following sixth and tenth day after the bleeding. The fourth MRI examination is done at 6 months to evaluate brain damages. For each patient, the apparent diffusion coefcient, the cerebral blood volume, the cerebral blood ow, the tissue mean transit time, the Time to Peak (TTP), the time inow of contrast agent were evaluated for each exam. Two methods for the evaluation of DWI and PWI analysis were carried out: a qualitative analysis for the thirty cases; a longitudinal quantitative analysis of PWI based on two groups of patients. The control group showed no modication of PWI during the study. In the other group variations of PWI time data outside the ischemic area were found. Results: We found in two patients a complete reversibility in DWI anomalies. Three patients showed PWI anomalies without DWI modication. The amplitude of relative perfusion time data at the acute stage of vasospasm is statistically signicant between the two groups. The evolution of relative perfusion time data for the group with altered perfusion is statistically signicant compared to the control group. The relative TTP evolution is correlated with the clinical symptoms during the acute stage of vasospasm, MRI lesion and with the neurological decits at 6 months. The longitudinal analysis of the rTTP value was the most sensitive parameters witch was correlated with the decit and with a risk of a lesion at six month. Conclusion: The DWI and PWI appear to be sensitive imaging techniques for cerebral vasospasm evaluation. According to these preliminary results, perfusion appears to be an important tool for the evaluation of symptomatic or asymptomatic vasospasm and for the follow up of those patients.
NOREPINEPHRINE INDUCES DILATION IN THE RABBIT BASILAR ARTERY DUE TO ALPHA ADRENOCEPTOR DEPENDENT MECHANISM AFTER EXPERIMENTAL SUBARACHNOID HEMORRHAGE IN VIVO
V. Neuschmelting, A.R. Fathi, S. Marbacher, R.W. Seiler, S. Jakob, J. Fandino University Hospital Berne, Berne, Switzerland
Objective: Norepinephrine (NE) is routinely administrated for prevention and treatment of cerebral vasospasm (CVS) after subarachnoid hemorrhage (SAH). The aim of this study was to determine mechanisms responsible for angiographic dilation and hypertension observed during continuous NE infusion in the rabbit basilar artery (BA) after SAH. Methods: CVS was induced using the one-hemorrhage-model. On day 5 the animals underwent control angiography prior to continuous intravenous administration of NE. Alpha-1 adrenoceptor antagonist (prazosine) and alpha-2 antagonist (rauwolscine) were added for partial inhibition. Changes in diameter of the BA were digitally calculated in m and expressed in percentages SEM. Prior to sacrice, local samples of cerebrospinal uid (CSF) and BA blood were obtained by transclival approach. Endothelin-1 (ET-1) and nitric oxide (NO) levels were determined in random samples of both groups. Results: SAH induced CVS in the BA (-13.9% 2.0, n=36, p<0.0001). NE caused hypertension from 83.2 0.8 mmHg to 170.3 0.9 mmHg (p<0.001). A dilation of 12.4% 2.6 (p<0.0001) of the BA during NE administration could be documented. Alpha-2 adrenoceptor inhibition partially reversed NE-dependent blood pressure plateau and signicantly narrowed BA diameter by 11.3% 1.7 (n=12, p<0.05). Additional alpha-1 inhibition instead showed similar antihypertensive effect while its narrowing effect on the dilated BA was less (-4.8% 0.9, n=12) and remained insignicant (p>0.05). ET-1 and NO levels in CSF, BA and systemic plasma remained unchanged after NE administration and were not affected by additional alpha antagonism (n=7 each, p>0.05). Conclusion: This study demonstrates the novel nding that NE causes dilation of the BA in the SAH rabbit model due to alpha adrenergic dependent mechanism, independently, however, from ET-1 and NO system.
PILOT STUDY OF NON-INVASIVE MEASURES OF ENDOTHELIAL DYSFUNCTION IN ACUTE ISCHAEMIC STROKE
S.L. Soiza, I. Ford, H. Clark, M. Bruce, K.K. Kalal, D.J.P. Williams University of Aberdeen, Aberdeen, United Kingdom
Introduction: Endothelial dysfunction (ED) is believed to be important in the pathogenesis of ischaemic stroke. Studies show serum markers of endothelial activation are acutely raised after stroke. A direct, non-invasive measure of global ED has recently been developed.1 The method relies on pulse wave analysis (PWA) before and after administration of endothelium-dependent (salbutamol) and independent (glyceryl trinitrate (GTN)) vasodilators. We believe this is the rst study employing this technique in stroke patients. Methods: 29 patients with recent ischaemic stroke, 21 controls matched for risk factors, and 9 healthy controls underwent PWA at the right radial artery using SphygmoCor. ED was assessed by the ratio of the change in augmentation index after 400mcg inhaled salbutamol via spacer over the change after 400mcg of sublingual GTN.1 Serum markers of ED (vonWillebrand factor, E-selectin and sVCAM-1) were obtained simultaneously. One-way ANOVA was used to look for signicant differences between the groups. Results: See Table 1. Correlation between the various measures of ED was poor.
Table 1. Mean values of measures of endothelial function Healthy Controls Augmentation Index (AIx), % AIx drop after Salb/GTN vonWillebrand Factor, U/ml E-selectin, ng/ml sVCAM-1, ng/ml 9.7 0.57 0.91 36.2 274.2 Matched Controls 32.7 0.23 1.01 50.9 361.7 Acute Stroke 32.6 0.30 1.30 49.9 353.4 P <0.001 0.02 0.05 0.43 0.40
Conclusions: Patients who have suffered an acute ischaemic stroke have evidence of endothelial dysfunction, but this was not signicantly different from that found in a population matched for risk factors for stroke. Reference: [1] Hayward et al. J Am Coll Cardiol 2002;40:521-528.
Poster Session Intracranial aneurysms and vasospasm
145
Vascular biology 1 Vascular biology
Vascular biology
IMPAIRED FLOW MEDIATED DILATATION IS ASSOCIATED WITH POOR OUTCOME IN ISCHEMIC STROKE
POTENTIAL OF ERYTHROPOIETIN IN TREATMENT OF SPINAL CORD INJURY AND VASCULAR FAILURE
I. Voznjuk, M. Odinak, N. Tsygan Military Medical Academy, Russian Federation

Nowadays the use of cytokines that promote neuron survival and growth is a promising trend in the treatment of spinal cord injury and vascular failure. One of the few nerve growth factors which are used in clinical practice is erythropoietin. The purpose of the study was to evaluate the potential of erythropoietin in the treatment of spinal cord injury and vascular failure. The experiment involved 48 male adult rats. The rats were subject to spine compression at 20 N for 30 sec at level L3-L4. The animals were divided into three groups: intact rats (8 animals); the rats that received sodium chloride (0.9%, 0.5 ml) intraperitoneally 10 min after the trauma (20 animals); the rats that received erythropoietin (5,000 units/kg) intraperitoneally 10 min after the trauma (20 animals). All the rats underwent daily neurological examination (the assessment of hind limb and tail muscle strength, the pain sensitivity of the hind part of the body, and pain reexes of hind limb exion and tail withdrawal). The results of the examination were assigned numerical scores. Histological spinal cord examination was carried out on the 1st and 21st day after the trauma. The lifetime of the rats that received erythropoietin (4.631.69 days) was reliably (p<0.05) higher than in rats that received sodium chloride (2.751.28 days). On the 11-16th day after the injury, the muscle strength in rats that received erythropoietin was reliably (p<0.05) higher than in rats that received sodium chloride. The speed of the recovery of the muscle strength was reliably (p<0.025) higher in rats that received erythropoietin. Histological examination showed a smaller number of damaged neurons and a smaller area of spinal hemorrhage in rats that received erythropoietin. The data proves that erythropoietin increases the lifetime, extent and rate of neurologic recovery after spinal cord injury in rats. This may be due to the neurotrophic and vascular-protective effect of erythropoietin. Thus, erythropoietin may have high potential in the treatment of spinal cord injury and vascular failure.
D. Santos, M. Blanco, N. Perez de la Ossa, S. Arias, J. Serena, X. Rodriguez-Osorio, F. Nombela, M. Rodriguez-Yaez, R. Leira, A. Davalos Hospital Clinico, University of Santiago de Compostela, Santiago de Compostela, Spain
Background: Brachial arterial ow-mediated dilatation (FMD) reects endotheliumdependent vasodilator function. FMD is diminished in patients with atherosclerosis, is a marker of low nitric oxide bioavailability, and is associated with an increased risk of vascular or cardiac events. Our aim was to investigate the relationship between FMD and outcome in patients with acute ischemic stroke. Methods: In 120 consecutive patients (58.3% male, median age 73 years) with acute ischemic stroke within the rst 24 hours of evolution we measured FMD by high-resolution ultrasonography. FMD was calculated as the relationship between basal diameter of the brachial artery before (d1) and after (d2) transient vascular occlusion (300 mmHg for 4 minutes) with a sphygmomanometer (FMD= d2 d1/d1). The intima-media thickness (IMT) >0.9 mm, extracranial carotid atherosclerosis, stroke severity (NIHSS score) at baseline and discharge, and modied Rankin Scale (mRS) at 3 months were also evaluated. Poor outcome was dened as mRS >2. FMD was categorized according to ROC analysis. Results: Median [quartiles] FMD was 8.9 [4.3, 13.9]. Median FMD values were signicantly lower in patients with IMT >0.9 mm (p<0.0001), and extracranial carotid atherosclerosis (p<0.0001). FMD negatively correlated to stroke severity, both at baseline (p=0.038) and discharge (p=0.034). Median FMD was signicantly lower (4.5 [2.3, 10.3] vs 9.4 [5.6, 15.1], p=0.003) in patients with poor outcome (n=38). The adjusted odds ratio of poor outcome for FMD >4.5% was 9.69 (1.97, 47.68; p=0.005). Conclusions: Impaired FMD in patients with acute ischemic stroke is associated with poor outcome.
Vascular biology
A SYSTEMATIC ASSESSMENT OF THE GENETIC INFLUENCES ON CAROTID INTIMA MEDIA THICKNESS (CIMT)
Vascular biology
REDUCED ADAMTS-13 (VON WILLEBRAND FACTOR-CLEAVING PROTEASE) ACTIVITY IN THE EARLY PHASE AFTER TIA OR ISCHAEMIC STROKE
L. Paternoster, N. Martnez-Gonzlez, M. Chung, R. Charleton, S. Lewis, C. Sudlow University of Edinburgh, Division of Clinical Neuroscience, Edinburgh, United Kingdom
Background: CIMT is a measure of subclinical atherosclerosis, associated with increased risk of stroke and myocardial infarction, and a heritability of around 50%. It should be informative in studying the genetics of vascular disease, particularly large artery ischaemic stroke. Studies of the association between various genes and CIMT have produced conicting results. We aimed to identify genes whose association with CIMT has been studied in >5000 subjects, and to perform meta-analyses to evaluate reliably the evidence for an association. Methods: For each relevant study, we extracted information on subjects, methods and mean (&SD) CIMT per genotype. We calculated study-specic and pooled mean difference in CIMT between genotypes. Results: 8 genes were studied in >5000 subjects: angiotensin converting enzyme (ACE); apolipoprotein E (APOE); beta 2 adrenergic receptor; methylenetetrahydrofolate reductase; endothelial nitric oxide synthase; factor V; interleukin 6; paraoxonase 1. Several relevant studies (accounting for 19% of subjects studied across all genes) had insufcient published data for inclusion. 2 genes (ACE and APOE) showed a signicant association with CIMT. The DD genotype of ACE had a mean CIMT 0.02mm greater than the II genotype. e4 allele-containing genotypes of APOE had a mean CIMT 0.07mm greater than e2 allele-containing genotypes. For both genes, we found larger associations among smaller studies, Asian subjects and subjects at high vascular risk. Discussion: We have identied 2 genes likely to inuence CIMT, but methodological issues such as small study bias and missing data make it difcult to estimate the true size of the associations. To increase the reliability of our results, we are seeking additional data from studies with insufcient published data.
D.J.H. McCabe, R. Starke, P. Harrison, P.S. Sidhu, M.M. Brown, S.J. Machin, I.J. Mackie The Adelaide and Meath Hospital, Trinity College Dublin, Dublin, Ireland
Background: Reduced ADAMTS-13 (von Willebrand factor-cleaving protease) enzyme activity is well described in patients with thrombotic thrombocytopenic purpura (TTP), and may lead to the accumulation of very large von Willebrand factor (VWF) multimers. Large VWF multimers may promote platelet activation and thrombus formation in vivo and could exacerbate ischaemia or infarction in patients with TIA or ischaemic stroke who do not have TTP. Methods: Using a collagen binding assay, we performed a pilot study to measure ADAMTS-13 activity in platelet poor plasma in 56 patients in the early phase (4 weeks) and 46 patients in the late phase (3 months) after a TIA or ischaemic stroke while they were on treatment with aspirin (75-300 mg daily). We compared these data with those obtained from 22 controls subjects who were not on aspirin. The results were expressed in percentages relative to pooled normal plasma. Results: Mean ADAMTS-13 activity was signicantly lower in the early phase (70.3%, P = 0.002) but not in the late phase (80.1%, P = 0.07) after TIA or stroke compared with controls (94.5%). Discussion: We have shown that ADAMTS-13 activity is signicantly reduced in the early phase after TIA or ischaemic stroke. Studies in larger cohorts of patients are required to assess the importance of this nding, and further work is ongoing to assess the impact of reduced ADAMTS-13 activity on platelet function ex vivo under high shear stress conditions.
146
Vascular biology
Vascular biology
THE EFFECT OF ACUTE HYPERHOMOCYSTEINAEMIA ON CEREBRAL BLOOD FLOW OF HEALTHY ELDERLY VOLUNTEERS
S.R. Hart, A.A. Mangoni, C. Swift, C. Deane, R. Sherwood, A. Wierzbicki, S.H. Jackson Div. of Clinical Neuroscience, University of Edinburgh, United Kingdom
Background: Mildly increased plasma homocysteine is an independent risk factor for ischaemic stroke. However, the underlying fundamental causal arterial mechanisms in vivo linking hyperhomocysteinaemia with cerebrovascular disease remain unclear. Objective: To test the hypothesis that acute increases in plasma homocysteine produced by methionine are associated with an acute decrease in cerebral arterial blood ow velocity (CABFV) measured by transcranial Doppler (TCD) ultrasound. By contrast, the simultaneous response of peripheral arterial distensibility was measured by pulse wave velocity (PWV) and digital volume pulse (DVP). DESIGN: A double-blind, cross-over, placebo controlled design was used and cerebral blood ow velocity and peripheral arterial distensibility and plasma homocysteine concentrations were measured between 12 and 20 hours after methionine loading or placebo. Results: Between 13 and 16 hours after initial exposure to a methionine loading test, mean CABFV showed a signicant 5.1% decrease in mean blood ow velocity (34.10.3 m/s vs 36.00.3 m/s, p <0.01) compared to placebo (Sample size = 8). However, between 17 and 20 hours after methionine exposure, CABFV showed no signicant sustained change, compared to placebo (36.11.0 m/s vs 35.30.3 m/s, p < 0.1). There was no signicant change in peripheral arterial distensibility measured by PWV during hyperhomocysteinaemia compared to placebo (9.90.2m/s vs 10.10.2m/s, p<0.5) and no difference in DVP, stiffness index (83.71.8% vs 83.71.6%, p<0.1). Conclusion: In healthy elderly volunteers, acute hyperhomocysteinaemia resulted in a signicant initial decrease in CABFV but no sustained reduction in cerebral blood ow velocity. There was no signicant simultaneous change in peripheral arterial distensibility suggesting that elderly cerebral arterial response to hyperhomocysteinaemia is different to that of peripheral arteries.
ASSOCIATION BETWEEN STROKE SUB-TYPES AND INTERLEUKIN-1 GENE POLYMORPHISM WITHOUT SALIVA INTERLEUKIN-1 BETA IMPLICATION
M. Caillier, Y. Bejot, G.V. Osseby, F. Contegal, D. Minier, R.M. Gueant-Rodriguez, M. Giroud Stroke registry of Dijon, Dijon, France
Background: Ischemia-induced inammation is characterised by early inltration of leucocytes in the ischaemic region and development of brain oedema. Interleukin-1 (IL-1) is one of the key modulators of the inammatory response. The IL-1 gene cluster on chromosome 2q14 contains three related genes (IL-1 alpha, IL-1 beta and IL-1 receptor antagonist, IL-1 ra). Clinical studies suggest an early intrathecal IL-1 beta production and IL-1 beta mRNA expression in blood mononuclear cells during stroke. We aimed to investigate the association between ischemic stroke sub-types and IL-1 gene polymorphism as well as production of saliva IL-1 beta. Methods: The -889C/T IL-1A, -511C/T IL-1B and IL-1RN (VNTR) polymorphism was genotyped in patients with stroke due to large vessel disease (n=22), cardioembolism (n=33), lacunar stroke (n=24), other determined mechanism (n=17), undetermined cause (n=21), transient ischemic attack (n=19) and in control group (n=19) by PCR. IL-1 beta concentration was determined in saliva using ELISA. Results: There was no signicant rise in the concentration of salivary IL-1 beta in acute stroke compared to the control groups results. Studied polymorphisms did not inuence concentration levels. Genotypes frequency of IL-1A CT and TT were signicantly higher in lacunar stroke with respect to the control group (62,5% and 31,6%, respectively; p=0,04), but not T allele. For IL-1RN (VNTR), IL-1RN 4-4 genotype frequency was higher in cardioembolic stroke than in control group (85,7% and 46,2%, respectively; p=0,04). This result was also conrmed for the allele 4 (35,4% and 21,1% respectively, p=0,02). Discussion: This study suggests than IL-1A and IL-1RN gene polymorphism is related with respectively lacunar and cardioembolic stroke onset.
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 earlyonset (< 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 degenerative changes and deposition of amorphous and electron-dense materials as well as proliferation of collagen bers. Smooth muscular cells exhibited hypertrophy. Pericytes showed phagocytoced material and residual bodies. In adventitia was thickened with abundant collagen bers, 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 correspond to the microvascular pathology in the brain. Added patients with chronic kidney disease and early-onset cognitive impairment are needed to establish a complete characterization of small vessel disease.
Poster Session Vascular biology
147

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Poster Session II

Cerebrovasc Dis 2007;23(suppl 2):1147

Thursday 31 May 2007

Risk factors of stroke 1 Risk factors of stroke

Risk factors of stroke

Risk factors of stroke

CLOPIDOGREL RESISTANCE: ROLE OF BODY MASS AND CONCOMITANT MEDICATIONS

Risk factors of stroke

Poster Session Risk factors of stroke

Cerebrovasc Dis 2007;23(suppl 2):1147

7 5 Risk factors of stroke

Risk factors of stroke

AGE PREDICTS DELAYED TRANSIENT ISCHAEMIC ATTACK INVESTIGATION AND MANAGEMENT

Risk factors of stroke

Risk factors of stroke

Cerebrovasc Dis 2007;23(suppl 2):1147

16th European Stroke Conference

Risk factors of stroke

DEPRESSIVE SYMPTOMS AND RISK OF STROKE: THE ROTTERDAM STUDY

Risk factors of stroke

NO INCREASED RISK OF RECURRENT STROKE IN PFO CARRIERS

Risk factors of stroke

Risk factors of stroke

Poster Session Risk factors of stroke

Cerebrovasc Dis 2007;23(suppl 2):1147

Risk factors of stroke

PSYCHO-SOCIAL FACTORS INFLUENECE STROKE OUTCOME

G. Szab, L. Molnr, C. vry, Z. Nagy National Stroke Centre/Budapest, Balassagyarmat, Hungary

Risk factors of stroke

Risk factors of stroke

Risk factors of stroke

Cerebrovasc Dis 2007;23(suppl 2):1147

16th European Stroke Conference

Risk factors of stroke

Risk factors of stroke

Risk factors of stroke

Risk factors of stroke

L. Csiba, Z. Bajk, K. Csap, P. Soltsz Debrecen University, Debrecen, Hungary

Risk factors of stroke

RISK FACTOR ANALYSIS IN PATIENTS ADMITTED WITH RECURRENT ISCHEMIC STROKES

Poster Session Risk factors of stroke

Cerebrovasc Dis 2007;23(suppl 2):1147

24 22 Risk factors of stroke

Risk factors of stroke

Risk factors of stroke

Risk factors of stroke

Cerebrovasc Dis 2007;23(suppl 2):1147

16th European Stroke Conference

Risk factors of stroke

Risk factors of stroke

HEREDITARY TROMBOPHILIAS AND NEUROLOGICAL COMPLICATIONS

Risk factors of stroke

Risk factors of stroke

Poster Session Risk factors of stroke

Cerebrovasc Dis 2007;23(suppl 2):1147

Risk factors of stroke

Stroke and diabetes

ISCHEMIC STROKE IN PATIENTS UNDERGOING DIALYSIS

THE TEMPORAL PATTERN OF POST-STROKE HYPERGLYCAEMIA IS A PREDICTOR OF LONG-TERM SURVIVAL

3 Stroke and diabetes 1 Stroke and diabetes