Abstract
BASP Breakfast Session
MRI carotid plaque imaging predicts future stroke in patients with mild to moderate stenosis – ICAD study
Simpson R1,2,3*, Hosseini A1*, Bath P1,4, MacSweeney S2, Auer D1,3
1 Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
2 Department of Vascular Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK
3 Sir Peter Mansfield Imaging Centre, University of Nottingham, Nottingham, UK
4 Stroke Trials Unit, University of Nottingham, Nottingham, UK
*Both authors contributed equally.
Introduction: Carotid endarterectomy for symptomatic moderate carotid stenosis is still debated with variation in surgical practice. We demonstrated that MRI-detected plaque haemorrhage (PH) is associated with an increased risk of stroke in severe carotid stenosis and with all recurrent events in moderate stenosis. The aim of this study was to determine whether MRI-PH can predict future stroke in patients with mild/moderate symptomatic carotid stenosis.
Method: As part of the ICAD study, 135 patients with recent TIA/stroke, 30–69% carotid stenosis and no planned carotid intervention were recruited. Participants had a carotid MRI to determine PH status based on signal hyperintensity >150% of adjacent muscle. All patients were followed-up prospectively with stroke and diffusion positive TIA as the primary, and stroke as the secondary endpoints.
Results: 132 patients completed the study (77 males, 55 females). 46 (34.8%) showed ipsilateral MRI-PH (35 males). We observed 12 strokes (8 MRI-PH and 4 without) and 13 infarctions during follow-up (median = 654 days, IQR = 643). Cox regression showed a HR of 4.51 (95% CI 1.38–14.68, P = 0.012) for infarction and 4.08 (95% CI 1.23–13.58, P = 0.02) for stroke. Controlling for stenosis (>/<50%), HR for stroke was 4.69 (95% CI 1.40–15.74, P = 0.012). Strokes in patients without MRI-PH occurred late (after 3 years) in 3 out of 4.
Conclusion: We show that MRI-PH is a significant predictor of future cerebral infarctions and stroke in recently symptomatic patients with mild/moderate carotid stenosis. MRI-PH status can thus offer decision support when there is clinical uncertainty regarding the benefit of carotid intervention.
Use of genomic instruments to reclassify cryptogenic stroke and their potential to guide therapy
McCaig K, Bonney W, Appleby P, Donney A
The Farr Institute, University of Dundee, Dundee, UK
Introduction: A significant proportion of ischaemic stroke sub-types are cryptogenic. We hypothesised that stroke sub-type specific genomic instruments would facilitate reclassification of certain cases of cryptogenic stroke and potentially guide therapeutic decisions.
Method: Populations of patients with specific stroke sub-types, cardioembolic (CE) and large artery (LA) were defined within the GoDARTs bio-resource using electronic record linkage. Patients who could not be sub-classified were considered as having a cryptogenic (CY) stroke. This pilot study did not consider small vessel disease. We constructed a beta weighted genetic risk score for CE, and grouped the score into low, medium and high risk categories. We then compared frequencies of CE genomic risk score categories in our cryptogenic cases and a control population.
Results: We identified 249 patients with CE stroke, 464 patients with LA stroke and 527 stroke patients with CY stroke. We found that our CE stroke genetic risk score was significantly associated with our CE stroke population (OR = 1.93, 95% CI = 1.40–2.66, P = 0.0001). This association was especially apparent when we compared those in the high risk category to those in the low risk (OR = 1.99, 95% CI = 1.31–3.03, P = 0.001). We also observed a significant association between those in the highest CE stroke genetic risk category and our CY stroke population (OR = 3.09, 95% CI = 2.34–4.11, P = 4.30e-15).
Discussion: A genetic risk score for CE stroke also associates significantly with individuals classified as CY. Such patients scoring highly on a CE genetic risk score may benefit from the re-classification of their stroke to CE stroke and receive appropriate anti-coagulation therapy.
Parallel 1B: Late Breaking Trials and Studies
Missed opportunities to prevent ischaemic stroke? Frequency of non-anticoagulation in a prospective multicentre cohort study of AF-associated ischaemic stroke and TIA
Wilson D1,4, Shakeshaft C4, Charidimou A1,4, Ambler G2, White M3,4, Cohen H5, Yousry T3,4, Al-Shahi Salman R6, Lip G7, Brown M1, Jager H 3,4, Werring D1,4, on behalf of the CROMIS-2 collaborators
1 Stroke Research Group, UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
2 Department of Statistical Science, UCL, London, UK
3 Lysholm Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, London, UK
4 Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square London, UK
5 University College London Hospitals NHS Foundation Trust, London, UK
6 Division of Clinical Neurosciences, Centre for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh, Edinburgh, UK
7 University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK
Introduction: Oral anticoagulation reduces ischaemic stroke risk in patients with atrial fibrillation (AF) and is recommended in current guidelines; by contrast, aspirin is neither effective nor recommended. There are few data on the prevalence, characteristics and antithrombotic treatment of patients with AF-related ischaemic strokes associated with previously-known, but non-anticoagulated AF.
Method: In the CROMIS-2 multicentre prospective cohort study at 79 UK hospitals, we compared baseline demographics and risk factors between acute ischaemic stroke or TIA patients with previously-known but non-anticoagulated AF to those with newly-diagnosed AF. All patients were subsequently anticoagulated. We used t-tests and Chi squared tests for univariate analysis.
Results: Of 952 patients analysed, 32% had previously-known AF before their stroke, yet were not anticoagulated. Compared to those with newly diagnosed AF, patients with previously known AF seemed more likely to have a history of dementia or cognitive impairment (4.35% vs. 2.15%; p = 0.058) and had a higher pre-qualifying stroke event CHA2DS2-VASc score (mean 3.92 vs. 3.60; p = 0.02). Of the 301 patients with known AF prior to their qualifying stroke event, 225 (75%) were prescribed antiplatelets. CHA2DS2-VASc was known in 245 of these patients, of whom only 23 (9.4%) had a score ≤1.
Discussion: Just under one third of our cohort had known AF prior to their qualifying stroke or TIA, yet were not prescribed anticoagulation despite >90% having a pre-stroke CHA2DS2-VASc ≥2. A higher CHA2DS2-VASc score and a history of cognitive impairment or dementia were associated with non-use of anticoagulation. Antiplatelet agents were commonly used instead.
Swallowing Treatment using Electrical Pharyngeal Stimulation (STEPS) after stroke: A randomised controlled phase III trial
Bath P1, Scutt P1, Love J2, Clavé P3, Cohen D4, Dziewas R5, Iversen H6, Soda H7, Woisard V8, Hamdy S9, for the STEPS Investigators
1 University of Nottingham, Nottingham, UK
2 Phagenesis Ltd, Manchester, UK
3 Universitat Autònoma de Barcelona, Barcelona, Spain
4 Northwick Park Hospital, London, UK
5 University Hospital Münster, Münster, Germany
6 University of Copenhagen, Copenhagen, Denmark
7 Bad Neustadt Hospital, Bad Neustadt, Germany
8 Université Toulouse, Toulouse, France
9 University of Manchester, Manchester, UK
Introduction: Dysphagia is common after stroke, is associated with a poor outcome and has limited treatment options. Pharyngeal Electrical Stimulation (PES) is a novel treatment for post-stroke dysphagia that has shown promise in previous small trials.
Method: STEPS was an international multicentre phase III single-blind endpoint-masked randomised trial assessing the safety and efficacy of PES versus sham treatment in patients with recent stroke and dysphagia. Treatment was delivered via the Phagenyx® system on 3 consecutive days with PES given at 5 Hz and 75% of tolerated intensity for 10 minutes/day. The sham arm received assessment of threshold and tolerated intensities but no formal PES. The primary endpoint was penetration aspiration scale (PAS) at 2 weeks. Secondary endpoints included clinical measures of swallowing (dysphagia severity rating scale, DSRS), feeding status, dependency (modified Rankin Scale), pneumonia, dependency and adverse events at 12 weeks.
Results: The trial recruited 162 patients from 20 sites in 5 countries: Denmark 11%, France 4%, Germany 17%, Spain 6% and UK 62%. At baseline: mean age 74, male 58%, previous stroke 14.2%, onset to randomisation 13 days, ischaemic stroke 89%, stroke severity (NIHSS) 9.9, tube feeding 58%, PAS 4.8, DSRS 7.6.
Discussion: STEPS is the first large scale international randomised controlled trial for the treatment of dysphagia. The results will be presented and ongoing studies using the Phagenyx® system discussed.
DARS (Dopamine Augmented Rehabilitation in Stroke): Longer-term results for a randomised controlled trial of Co-careldopa in addition to routine occupational and physical therapy after stroke
Ford G1, Bhakta B2, Cozens A3, Hartley S4, Holloway I4, Meads D5, Ruddock S4, Santorelli G4, Sackley C6, Walker M7, Farrin A4
1 Division of Medical Sciences, Oxford University, Oxford, UK
2 Department of Academic Rehabilitation Medicine, University of Leeds, Leeds, UK
3 Rehabilitation Medicine, Grampian Health Board, Aberdeen, UK
4 Clinical Trials Research Unit, University of Leeds, Leeds, UK
5 Academic Unit of Health Economics, University of Leeds, Leeds, UK
6 Academic Physiotherapy Department, Kings College London, London, UK
7 Division of Rehabilitation and Ageing, University of Nottingham, Nottingham, UK
Introduction: Dopamine is a key modulator of striatal function and learning. Small trials of dopamine agonists after stroke have provided equivocal evidence on motor recovery.
Methods: DARS was a multi-centre, randomised, double blind, placebo controlled trial, with stroke in-patients randomised to receive 6 weeks of co-careldopa or placebo in combination with occupational and physical rehabilitation. The primary outcome was the proportion of patients walking independently at 8 weeks (Rivermead Mobility Index score of ≥7). Secondary outcomes assessed physical functioning, mood, carer burden and cost-effectiveness at 8 weeks, 6 and 12 months.
Results: 593 patients and 165 carers were recruited from UK stroke rehabilitation units between April 2011 and March 2014; 308 patients were randomised to Co-careldopa, 285 to placebo. Ability to walk independently at 8 weeks was slightly lower in the Co-careldopa group, though this was not significant (OR 0.78, 95% CI 0.53, 1.15). There were no significant differences for Barthel Index, Nottingham Extended Activities of Daily Living, ABILHAND or modified Rankin Score-up. No difference was observed in GHQ-12 between groups at 8 weeks and 12 months, but at 6 months those in the Co-careldopa group indicated significantly better general health (mean difference (MD) −1.33, 95% CI −2.57, −0.10). Carers in the placebo group reported significantly greater burden at 6 (MD 5.05, 95% CI 0.10, 10.01) and 12 months (MD 7.52, 95% CI 1.87, 13.18).
Discussion: Co-careldopa in addition to routine therapy is not effective in improving walking, physical functioning or mood following stroke. However, carer burden may be lower.
Is evaluation of psychosocial effects of an arts based creative engagement intervention during in-patient stroke rehabilitation possible? A feasibility randomised controlled trial (RCT)
Morris J1,2, Kelly C2,3, John A1, Joice S4, Mead G5, Kroll T1, Donnan P6, Williams B7
1 Social Dimensions of Health Institute, University of Dundee, Dundee, UK
2 Allied Health Professions Directorate, NHS Tayside, Dundee, UK
3 Healthcare Arts Trust, Dundee, UK
4 School of Psychology, Massey University, Palmerston North, New Zealand
5 Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
6 Population Health Sciences, Medical Research Institute, University of Dundee, Dundee, UK
7 Nursing, Midwifery and Allied Health Professions Research Unit, University of Stirling, Stirling, UK
Introduction: Qualitative studies suggest art participation in rehabilitation may improve post-stroke psychosocial outcomes. This study examined feasibility of conducting an RCT to evaluate such an art intervention.
Method: Design: Feasibility randomised controlled trial. Population: Stroke survivors admitted for in-patient rehabilitation. Intervention Group (n = 41): 4–8 Creative Engagement Intervention (CEI) sessions to create a piece of artwork. Control Group: (n = 40) usual care and art portfolio to view. Outcomes: Stroke Impact Scale – social participation, communication, emotion; Positive and Negative Affect Schedule (PANAS); Visual Analogue Self-Esteem Scale (VASES), Trait Hope Scale; General Self-efficacy Scale (GSES), Self-Efficacy for Art (SEfA); Recovery Locus of Control. Blinded assessment: Baseline (T1), end of intervention (T2); 3 months (T3).
Results: Of 198 admitted stroke survivors, 81 (41%) were recruited. 88% (n = 71) completed T2 and 77% (n = 62) completed T3 assessments. CEI mean change was greater than controls between T1–T2 and T1–T3 for Emotion, PANAS and SEfA. CEI mean change T1–T2 was also higher than controls for Social Participation. At T2, after adjusting for baseline covariates, estimated between group differences for SEfA (p < 0.001) and VASES (p = 0.01) significantly favoured intervention and control groups respectively. At T3 after adjusting for baseline covariates estimated between group difference for SEfA (p < 0.001) and GSES (p < 0.04) significantly favoured intervention and control groups respectively.
Discussion: An RCT testing art participation in rehabilitation was possible and indicates art participation may benefit social participation, emotion, positive affect and self-efficacy for art after stroke. These potential effects warrant investigation in a fully powered RCT.
The Nottingham Fatigue After Stroke (NotFAST) Study: The frequency of fatigue and associated factors in stroke patients without depression
Hawkins L1, Drummond A1, Birks E2, Clark E3, Lagogianni C1, Lincoln N1, Milligan H4, Mistri A2, Sprigg N1, Tyrrell P4, Ward N3, Watchurst C3, Worthington A4, Worthington E1
1 Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
2 Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
3 Sobell Department of Motor Neuroscience and Movement Disorders, University College London, London, UK
4 Centre for Vascular and Stroke Research, University of Manchester, Manchester, UK
Introduction: Post-stroke fatigue is consistently reported as a major unmet need by stroke survivors that adversely impacts on rehabilitation and all aspects of daily life. Yet much of the research reported to date has been confounded by including patients with depression. The NotFAST study is the largest UK based study to investigate the frequency of post-stroke fatigue in patients without depression and to identify factors associated with it.
Method: NotFAST was a mixed methods multi-centre study recruiting participants diagnosed with first stroke who were not depressed. Assessments were conducted within 6 weeks of stroke and at 6 months post-stroke, comprising measures of fatigue, activities of daily living, mobility, cognitive function and mood. In addition, interviews were conducted with 20 participants reporting high levels of fatigue, exploring their experiences and coping strategies.
Results: The study completed recruitment of 371 participants from 4 UK sites by 31st March 2015. To date we have follow up data on 139 participants and final follow up data will be collected by October 2015. The initial main findings from both the qualitative study and quantitative study will be available for presentation in late 2015.
Discussion: It is anticipated that the results from the NotFAST study will be used to inform the development of evidence-based interventions for the management of post-stroke fatigue.
Comparison of functional electrical stimulation (FES) and ankle foot orthosis (AFOs) in stroke
Street T1, Swain I1,2,3, Taylor P1,2
1 National Clinical FES Centre, Salisbury District Hospital (NHS), Salisbury, UK
2 Odstock Medical Ltd, Salisbury, UK
3 Faculty of Science and Technology, Bournemouth University, Poole, UK
Introduction: Studies comparing the effects of FES and AFOs on walking ability often have confounding issues. These include providing physiotherapy to both interventions making it difficult to distinguish the relative benefits of either, the addition of TENS to the AFO group which may have a facilitatory effect, the length of treatment being too short to determine the benefits, and a significantly more impaired FES group in comparison to the AFO group. The current study seeks to address these issues by comparing AFO users prior to and post FES treatment without any additional treatments using a within subjects design.
Method: 29 AFO users with chronic stroke and dropped foot (average age 58, 16–79) were included. 10 metre walking speed was used to measure walking with an AFO prior to participants using FES. On a separate day their walking was measured with and without using FES which was repeated at follow up 18 weeks later.
Results: AFO was found to have a minimally clinically meaningful significant difference (0.05 m/s) to unassisted walking (p < 0.01). Using FES was found to have a highly significant, substantially clinically meaningful (0.13 m/s) difference from unassisted walking (p < 0.001). In comparison to use of an AFO, FES was found to have a clinically meaningful significant difference in walking speed (p < 0.01).
Discussion: The results suggest that FES leads to a significantly faster clinically meaningful walking speed difference compared to the use of an AFO in a clinical setting when there are no additional treatments.
Parallel 3B: Brag and Steal
**This abstract has been chosen for the British Stroke Research Group Highest Scoring Abstract Prize at the UK Stroke Forum 2015**
Caring for the carer: A stroke carer support project
McAlpine L
NHS Lothian, Stroke Unit, Western General Hospital, Edinburgh, UK
Others involved: Western General Hospital Integrated Stroke Unit and Chest Heart & Stroke Scotland Voices Of Carers Across Lothian (VOCAL)
Summary: Although there is extensive research on carer support interventions for unpaid carers of stroke survivors, there is no clear consensus on the method, timing or evaluation of such support. The Caring for the Carers: a stroke carer support project aimed to identify and address the unmet needs of carers to the stroke survivors within the integrated stroke unit of the Western General Hospital, Edinburgh. Due to the immediate onset of stroke, family members can become carers instantly, in contrast to the insidious onset seen in conditions such as dementia. The project setting offers the opportunity to access these carers in the very early stages of their journey and aims to address their varying support and information needs along the post-stroke care and rehabilitation pathway including the transition from inpatient to community services. Assuming the caring role whilst rehabilitation is ongoing is filled with uncertainty for these carers as improvements can continue in varying degrees for years after onset with no absolute predictors for recovery. An anticipatory care planning model was adopted considering the current and potential future needs of carers by equipping them with both the skills and the contacts in order to avoid future crisis. The project was developed in partnership with a variety of stakeholders: stroke staff from acute, rehabilitation and community settings; representatives from a variety of carer organisations including NHS, local authority and third sector and most importantly carers of stroke survivors. Evaluation of the project using a range of outcomes has been undertaken.
Selfhelp4stroke
Bryceland H
Chest Heart & Stroke Scotland, UK
Others involved: Chest Heart & Stroke Scotland, NHS Scotland, stroke service users and The University of Edinburgh
Summary: Self-management is a key component in stroke rehabilitation and can improve long-term health and wellbeing outcomes. Stroke service users have identified a need for long-term support and service provision is not equitable. We identified a need for an evidenced-based user friendly resource to support self-management following stroke. Acknowledging the increase in use of mobile technology we developed www.Selfhelp4stroke.org, a free interactive self-management website. Data from service users (questionnaires (n = 74); focus groups (n = 6)) informed content development. Analysis identified 5 themes: Self-management/Goal-setting, Keeping Healthy, Being Active, Emotional Support and Coping with Setbacks. Author groups were established (multi-disciplinary clinicians (n = 26); researchers (n = 5); service users (n = 21); 3rd sector representatives (n = 8)). Working in thematic groups, content, including multimedia and interactive components, was developed between March 2013–April 2015. Work was supported by service-user groups, accessible information group and overseen by a steering group. User feedback and clinician/researcher critical review informed the final resource prior to launch in June 2015. Descriptive statistics will be used to report user metrics e.g. hits, downloads and time on-line. Data from completed user evaluation questionnaires will be reported quantitatively (demographic data) and thematically (qualitative data). Selfhelp4stroke represents an organic progression in the delivery of contemporary and person centred stroke services.
Accessibility must include communication: An audit of communication access to shape our future stroke team education and environment development
Boyle O
Royal Hospital Donnybrook, Dublin, Ireland
Others involved: Speech and Language Therapy Department, Stroke Multidisciplinary Team
Summary: Patients must be enabled to make informed decisions about their care and receive accessible information about their condition/treatment. Multidisciplinary Team (MDT) members have a crucial role in this process, but need to be shown effective communication strategies for interacting with people with communication impairments. The aim of this audit was to identify areas of non-compliance to inform future education programmes and environment developments within our stroke unit. A ‘Connect UK’ tool was used to audit the accessibility of interactions, documents and environment for inpatients with communication impairment. Interactions between various MDT members and inpatients were observed. Sample written documents were provided by MDT disciplines, where possible. The ward environment was audited on 3 different occasions. An 80% target was deemed an indicator of compliance across areas audited. This target was not achieved in any area audited, with an overall average percentage of 47% in interactions (n = 9), 47% in documentation (n = 5), and 33% in environment (n = 3). As an example, key findings from interactions indicated relaxed interactions but limited use of strategies to overcome communication.
Implementation of an upper limb stroke rehabilitation programme within a community stroke service
Grant L, Gale L, Hallsworth S, Swain L, Hooban K
Community Stroke Discharge and Rehabilitation Service, Nottingham Citycare Partnership, Nottingham, UK
Summary: Stroke is a leading cause of disability in the UK and loss of upper limb (UL) function can be a severely debilitating consequence. Studies have shown that more focus is often given to lower limb rehabilitation despite 70% of patients experiencing altered arm function following stroke and 40% being left with a persistent lack of function. A service review in 2012 of the Nottingham Community Stroke Discharge and Rehabilitation Service identified an insufficient focus on upper limb rehabilitation. A programme for UL rehabilitation called GRASP (Graded Repetitive Arm Supplementary Programme) was identified through literature searches. The GRASP programme was implemented in a group format and during individual sessions in patient's homes. The pilot was completed within existing funding by innovative thinking to redistribute staffing resources. Outcome measures used to show a change in UL function were the Chedoke, and Visual Analogue Scales for confidence and recovery to provide a patient perspective. Positive results were shown using the Chedoke in both group and individual sessions. 23 of 29 patients showed an improvement in their score. Patient satisfaction questionnaires provided positive feedback following group sessions. This service development project has led to increased awareness within the team of the importance of UL rehabilitation. The GRASP is an appropriate programme to use in the community and has shown positive results in functional outcomes, self-confidence and satisfaction for patients. It is possible to increase intensity of UL rehabilitation within current resources.
The Creative Engagement Intervention (CEI) Protocol
Kelly C
Tayside Healthcare Arts Trust (THAT), Ardler Clinic, Dundee, UK
Others involved: THAT ST/ART Project, NHS Tayside Stroke Rehabilitation Units, University of Dundee, Visual Artists and stroke survivors
Summary: Tayside Healthcare Arts Trust's (THAT) ST/ART project was the originator of and contributor to the development of a Creative Engagement Intervention (CEI) Protocol for stroke inpatient rehabilitation using participatory visual arts activities. The ST/ART Project has worked in partnership with NHS Tayside since 2004 using the arts as a contribution to stroke survivors' recovery. The CEI was originally developed through THAT evaluation of annual 12 week programmes in inpatient stroke units. THAT evidence showed this approach was effective, popular with patients and staff and suggested benefits in participants' mood, socialisation, confidence and communication. The ST/ART Project CEI development work was used to underpin the ACES Study (Art as Creative Engagement for Stroke) research project and as part of that study in 2013–14 the ST/ART Project managed the delivery of the CEI Protocol in a 1 year feasibility RCT. The CEI Protocol is now a non-prescriptive 5 step process that allows the artist to tailor the arts activities to the participant's interests and rehabilitation goals. It has been shown, through the ACES Study, to be reliable and deliverable and to benefit a range of psychosocial outcomes. The ST/ART project has now adopted the CEI Protocol and developed the delivery and management of inpatient programmes to match this process. Our NHS partners are now even more committed to our involvement in the rehabilitation units and we are currently in discussions about how to expand the service. Future research developments of the CEI Protocol are also in discussion including a full RCT.
Family information/support group in an acute stroke/brain injury unit
Chan E
The National Hospital for Neurology and Neurosurgery (NHNN), University College London Hospital, London, UK
Others Involved: The team at the Acute Stroke/Brain Injury Unit and the Neuropsychology department at the NHNN
Summary: Between 25% and 54% of stroke caregivers experience significant burden. Caregiving for stroke survivors has been associated with higher rates of depression, anxiety, cardiovascular disease, a poorer quality of life and a greater restraint in social activities. In the sub-acute stage, family members are going through a very sudden period of psychological, social and financial change which can cause significant stress and trauma. However, family involvement on the ward is often reactive rather than proactive. The Family Information/Support group was established in our Acute Stroke Unit to proactively address the needs of family members of stroke survivors. The main aim of the group was to provide a forum to disseminate information and offer psychological support. The 1-hour weekly group was offered to all family and friends of stroke patients currently on the ward. The group was facilitated by the unit's clinical neuropsychologist and the rehabilitation assistant. Each session covered both psycho-education and general discussion. Topics covered included 1) what is stroke, 2) changes after stroke and 3) the impact of stroke on the family. The content was variable depending on the needs of the family members attending. Family members who attended the group reported that it was useful to have a better understanding of what happened, helpful to listen/talk to others with shared experiences and to feel supported. Family members who were identified as particularly vulnerable were followed-up with individualised therapy. Further links are being established with local neuro-rehabilitation units and community services to establish a clear service pathway for carers' support.
Parallel 4B: Acute High Scoring Abstracts
Risk of stroke associated pneumonia and the timing of dysphagia screening and assessment: A prospective cohort study
Bray B1, Smith C2, Cloud G3, Enderby P4, James M5, Paley L6, Tyrrell P2, Wolfe C1,7, Rudd A1,7 on behalf of the SSNAP Collaboration
1 Division of Health and Social Care Research, King's College London, London, UK
2 Stroke and Vascular Research Centre, Institute of Cardiovascular Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
3 St George's University Hospitals NHS Foundation Trust, London, UK
4 School of Health and Related Research, University of Sheffield, Sheffield, UK
5 Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
6 Royal College of Physicians, London, UK
7 National Institute for Health Research Comprehensive Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
Introduction: Although dysphagia screening and speech and language therapy (SALT) assessments are commonly performed after stroke, there is very little evidence of their effectiveness. We aimed to estimate the association between the time from admission to dysphagia screening and SALT dysphagia assessment and the risk of stroke associated pneumonia (SAP).
Method: Nationwide registry (Sentinel Stroke National Audit Programme) based prospective cohort study. Multilevel logistic regression models were fitted and included adjustment for age, sex, stroke type, pre-stroke functional level, place of stroke, comorbidity, stroke severity and level of consciousness.
Results: Of 63,650 stroke admissions, 55838 (88%) had a dysphagia screen and 24,542 (39%) a SALT dysphagia assessment. Patients receiving dysphagia screening beyond ≥5.75 hours (the 4th quartile) had a higher risk of SAP (adjusted OR 1.14, 1.03–1.24) than patients screened earlier. Risk of SAP increased in a dose-response manner with delays in SALT dysphagia assessment, an absolute increase of approximately 1% per day of delay. Compared to patients in the first quartile of time to assessment, those in the fourth quartile (≥49 hrs) had 2.01 (1.76–2.30) the adjusted odds of SAP.
Discussion: In patients with acute stroke, delays in both dysphagia screening and SALT dysphagia assessment are associated with increased risk of SAP. Due to the observational study design, the main limitation is the risk of bias from residual confounding. However this study provides the first prospective evidence from a large cohort study that rapid screening for and assessment of dysphagia may reduce the incidence of stroke associated pneumonia.
Clinical predictive risk scores for stroke-associated pneumonia (SAP): A systematic review of the literature
Kishore A1, Vail A2, Bray B3, Meisel A4, Smith C1 on behalf of the Pneumonia In Stroke ConsEnsus (PISCES) Group
1 Stroke and Vascular Research Centre, University of Manchester, Institute of Cardiovascular Sciences, Greater Manchester Comprehensive Stroke Centre Salford Royal Foundation Trust, Manchester, UK
2 Centre for Biostatistics, University of Manchester, Salford Royal Foundation Trust, Manchester, UK
3 King's College London, London, UK
4 NeuroCure Clinical Research Center, Center for Stroke Research Berlin Department of Neurology Charité Universitaetsmedizin Berlin, Germany
Introduction: Several risk stratification scores for predicting stroke-associated pneumonia (SAP) have been derived, based on clinical factors associated with developing SAP. As part of the Pneumonia In Stroke ConsEnsuS (PISCES) group initiative, we undertook a review of existing literature to evaluate the performance and utility of such scores for SAP.
Method: A systematic literature review of multiple electronic databases was undertaken, in accordance with Cochrane guidance. Published studies of hospitalised adults with ischaemic and/or haemorrhagic stroke which derived and validated an integer-based clinical risk score, or externally validated an existing score to predict occurrence of SAP up to 1 February 2015, were considered and independently screened for inclusion by 2 reviewers.
Results: 9 scores, identified among 8 derivation cohorts, were as follows: The Pneumonia score; VHA cohort score, AIS-APS, PANTHERIS, A2DS2score, ICH-APS (A), ICH-APS (B), ISAN score and PNA prediction score. Age was a component of all scores, and the NIHSS score in all except 1. Reported occurrence of SAP (6.7% to 34%) varied between cohorts, reflecting heterogeneity of study population and methods used. CDC criteria was the most commonly used diagnostic approach (50%). Performance was reported among 88% of the scores; discrimination and calibration of the available scores was comparable, with no single outstanding score. The A2DS2 score was the most externally validated in 5 independent cohorts.
Discussion: The clinical prediction scores varied in their simplicity of use and were comparable in performance. Utility of such scores for preventive intervention trials and in clinical practice remains uncertain and requires further study.
Cost-utility analysis of mechanical thrombectomy using stent retrievers in acute ischemic stroke
Ganesalingam J1*, Pizzo E2*, Morris S2, Sunderland T3, Ames D1, Lobotesis K4
1 Department of Stroke Medicine, Imperial College Healthcare NHS Trust, London, UK
2 Department of Applied Health Research, University College London, London, UK
3 Boehringer Ingelheim Ltd, Bracknell, Berkshire, UK
4 Imaging Department, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
*Authors contributed equally.
Introduction: Recently, 5 randomised controlled trials demonstrated the benefit of endovascular therapy compared to intravenous tissue plasminogen activator (IV-tPA) in acute stroke. Economic evidence evaluating stent retrievers is limited. We compared the cost-effectiveness of IV-tPA alone versus mechanical thrombectomy and IV-tPA as a bridging therapy in eligible patients in the UK National Health Service.
Methods: A model-based cost-utility analysis was performed using a lifetime horizon. A Markov model was constructed and populated with probabilities, outcomes and cost data from published sources, including one-way and probabilistic sensitivity analysis.
Results: Mechanical thrombectomy was more expensive than IV-tPA but it improved quality-adjusted life expectancy. The incremental cost per QALY gained of mechanical thrombectomy over a 20 year period was £7,061. The probabilistic sensitivity analysis demonstrated that thrombectomy had a 100% probability of being cost-effective at the minimum willingness to pay for a QALY commonly used in UK.
Discussion: Whilst the upfront costs of thrombectomy are high, the potential QALY gains mean this intervention is cost-effective. This is an important factor for consideration in deciding whether to commission this intervention.
The cost-effectiveness of Solitaire™ revascularisation device as an adjunct to IV-tPA compared to IV-tPA alone for acute ischaemic stroke in the United Kingdom
Lobotesis K1, Veltkamp R1, Carpenter I2, Hodgson R2
1 Imperial College, London, UK
2 York Health Economics Consortium, University of York, York, UK
Introduction: The clinical efficacy of Solitaire™ for the treatment of acute ischaemic strokes has been demonstrated in multiple clinical trials including SWIFT PRIME. The aim of this analysis was to evaluate the cost-effectiveness of Solitaire™ from the UK healthcare provider perspective.
Method: A Markov model was developed to compare treatment with Solitaire + IV-tPA versus IV-tPA alone over a lifetime time horizon. The model incorporated 3 phases; an acute phase (0–90 days), a rehabilitation phase (90 days to 1 year) and a rest of life phase (>1 year). The model health states were defined by modified Rankin Score (mRS). Patients were at risk of recurrent stroke after the acute phase. Within the rehabilitation phase, patients' health status could improve, maintain or deteriorate by a maximum of 1 mRS. During the rest of life phase, a patient remained in the same health state until a recurrent stroke or death. Clinical efficacy and safety data were taken from SWIFT PRIME. Resource use and health state utilities were informed by published data.
Results: Over a lifetime time horizon, Solitaire + IV-tPA led to improved quality of life and increased life expectancy when compared with IV-tPA alone. The higher treatment costs associated with the use of Solitaire were offset by long-term cost savings due to improved patient health status. Deterministic and probabilistic sensitivity analyses demonstrated that the results were robust to a wide range of parameter inputs.
Discussion: Solitaire + IV-tPA is a cost-effective treatment for acute ischaemic stroke compared to IV-tPA alone. This study was funded by Medtronic plc.
Evaluation of the novel medical imaging software e-ASPECTS for patient selection in stroke
Grunwald I1,11,12, Sinha D1, Day D2, Reith W3, Chapot R4, Papanagiotou P5, Konstas A6, Guyler P1, Tysoe S1, Warburton E7, Fassbender K8, Walter S8, Mueller N4, Essig M9, Heidenrich J10, Harrison M11, Hampton-Till J11, Greveson E12, Papadakis M12, Joly O12, Gerry S13
1 Southend University Hospital NHS Trust, Essex, UK
2 Addenbrooke's Hospital NHS Trust, Cambridge, UK
3 Department of Neuroradiology, Saarland University Hospital, Homburg, Germany
4 Department of Neuroradiology, Alfred Krupp Krankenhaus, Essen, Germany
5 Department of Neuroradiology, Bremen Hospital, Bremen, Germany
6 Huntington Memorial Hospital, Department of Radiology, UCLA, Los Angeles, USA
7 Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
8 Department of Neurology, Saarland University Hospital, Homburg, Germany
9 Department of Radiology, University of Manitoba, Winnipeg, Canada
10 Department of Diagnostic Radiology, Dalhousie University, Nova Scotia, Canada
11 Anglia Ruskin University, Chelmsford, UK
12 Brainomix Limited, Oxford, UK
13 Centre for Statistics in Medicine, University of Oxford, Oxford, UK
Introduction: The interpretation of a CT scan of acute ischaemic stroke patients in the acute setting requires experience and carries significant variability. The Alberta Stroke Program Early CT score (ASPECTS) is an established 10-point quantitative topographic CT scan score to assess early ischaemic changes on plain CTs of acute stroke patients. We compared the performance of the standardised and fully automated software, e-ASPECTS (Brainomix, www.brainomix.com) with 3 expert neuroradiologists.
Method: The baseline non-contrast enhanced CT scans of 132 acute stroke patients were evaluated by 3 expert neuroradiologists and e-ASPECTS using the ASPECTS method. Ground truth was determined by an independent core lab with access to follow-up CT/MR scans. e-ASPECTS is a standardised, fully automated ASPECTS scoring software tool that carries out a 3D registration/segmentation of ASPECTS regions and uses machine learning techniques for scoring. The sensitivity and specificity of e-ASPECTS to the 3 experts was compared by non-inferiority analysis.
Results: On average, e-ASPECTS deviated from the ground truth by less than one point (+0.8). For the 3 experts the deviation from the ground truth was +1.2, −0.7 and +1.1, respectively. Receiver operating characteristic (ROC) analysis on per region and per score basis showed that e-ASPECTS sensitivity and specificity is equivalent to the 3 experts.
Discussion: e-ASPECTS is statistically non-inferior and equivalent to expert neuroradiologists. e-ASPECTS is a valuable tool to assist patient selection for both intravenous and endovascular stroke treatment.
Analysis of the influence of service-related factors on symptomatic intracranial haemorrhages post-thrombolysis
Lee T, Coombes N, Devine J, Basset P
Northwick Park Hospital, London North West Healthcare NHS Trust, London, UK
Introduction: Thrombolysis for acute ischaemic stroke increases the risk of intracranial haemorrhage. There is currently limited information in the literature comparing the incidence of intracranial haemorrhages post-thrombolysis in-hours versus out-of-hours. This study aims to determine and compare the incidence of symptomatic haemorrhages post-thrombolysis (SICH) (defined as difference in pre- and post-thrombolysis NIHSS score of ≥4 and CT-confirmed haemorrhage) in-hours (Monday to Sunday 9 am–5 pm) and out-of-hours, as well as pre- and post-introduction of 24/7 clinical fellow cover.
Methods: Northwick Park Hospital maintains a database of all patients thrombolysed. This study included all patients thrombolysed between 1/2/2010 and 31/10/2014. Statistical analysis was done using Chi-squared test.
Results: During the study period, 1330 patients received thrombolysis. 140 patients were excluded due to insufficient NIHSS data or absence of repeat CT head. Of the 1190 patients included, 627 were thrombolysed in-hours and 563 out-of-hours. The incidence of SICH was higher out-of-hours compared to in-hours: 1.75% (11) versus 3.55% (20) out-of-hours (p = 0.052). In addition, it was found that 25 of 917 (2.73%) patients thrombolysed pre-introduction of 24/7 clinical fellow cover had a SICH compared to 6 of 273 (2.20%) post-introduction (p = 0.630).
Discussion: The incidence of SICH was low. There was no statistically significant difference between the incidences of SICH in-hours versus out-of-hours. However, SICH out-of-hours was almost double that of in-hours. This could be considered clinically significant. The findings of this study may guide other stroke centres in implementing 24/7 clinical fellow cover particularly outside of neuroscience centres.
Parallel 4C: Non-Acute High Scoring Abstracts
Prevalence and associations of small vessel disease markers in an ischaemic stroke and TIA cohort with atrial fibrillation: Baseline characteristics of patients in the CROMIS-2 study
Wilson D1,4, Shakeshaft C4, Charidimou A1,4, Ambler G2, White M3,4, Cohen H5, Yousry T3,4, Al-Shahi Salman R6, Lip G7, Brown M1, Jager H3,4, Werring D1,4 on behalf of the Clinical Relevance of Microbleeds in Stroke (CROMIS)-2 collaborators
1 Stroke Research Group, UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
2 Department of Statistical Science, UCL, London, UK
3 Lysholm Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, London, UK
4 Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London, UK
5 University College London Hospitals NHS Foundation Trust, London, UK
6 Division of Clinical Neurosciences, Centre for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh, Edinburgh, UK
7 University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK
Introduction: Imaging markers of small vessel disease (SVD) (Cerebral microbleeds (CMBs), white matter hyperintensities of presumed vascular origin (WMH) and cortical superficial siderosis (cSS)) have potential value in predicting the risk of oral anticoagulant (OAC)-related intracerebral haemorrhage (ICH). We investigated the prevalence of these markers within CROMIS-2. We hypothesised that CMBs are common and associated with other markers of SVD, age and hypertension.
Method: CROMIS-2 is a prospective, multicentre, inception cohort study of adults with AF started on OAC after recent ischaemic stroke (IS) or TIA. All participants have standardised brain MRI. 1 trained observer rated CMBs and WMHs using validated scales.
Results: 1,000 participants were analysed for CMBs, 690 also for WMH and cSS. The prevalence of ≥1 CMBs was 23% (95% CI 20 to 26%), severe WMH (≥2 Fazekas scale in periventricular or deep white matter) 28% (95% CI 25 to 32%), and cSS 0.72% (95% CI 0.1 to 1.4%). In univariate analyses, CMBs were associated with age (OR 1.03 per year; 95% CI 1.01 to 1.04), ischaemic heart disease (OR 2.23; 95% CI 1.59 to 2.31), previous IS (OR 1.99; 95% CI 1.29 to 3.08) and severe WMH (OR 2.96; 95% CI 1.96 to 4.45), but not with cSS (focal or disseminated) or hypertension. In multivariable logistic regression, age and severe WMH remained associated with CMBs.
Discussion: CMBs are common, but cSS is very rare in patients with ischaemic stroke or TIA associated with atrial fibrillation. CMBs are associated with increasing age and WMHs.
Hyoid compression of the internal carotid artery: Smoking gun or red herring? A case report and review of the literature
Anderton P1, Lindert R2, Sarrigiannis P2, Harkness K2, Stannard P3, Watson M4
1 Department of Stroke Medicine, Doncaster and Bassetlaw NHS Foundation Trust, Doncaster, UK
2 Department of Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
3 Department of Radiology, Doncaster and Bassetlaw NHS Foundation Trust, Doncaster, UK
4 Department of ENT Surgery, Doncaster and Bassetlaw NHS Foundation Trust, Doncaster, UK
Introduction: External compression of the internal carotid artery by the hyoid bone has been implicated in focal cerebrovascular symptoms and syncope. We present the case of a young woman with a prominent hyoid partially compressing her right internal carotid artery, who presented with recurrent episodes of left-sided neurological symptoms associated with head-turning, and intermittent syncope and pre-syncope.
Methods: Computerised Tomography (CT) angiography and dynamic carotid duplex revealed a normal right internal carotid artery lumen externally indented by a prominent hyoid bone. Transcranial Doppler (TCD) with simultaneous Electroencephalography (EEG) and beat-beat blood pressure (BP) monitoring (with and without head turning) were undertaken, as well as echocardiography, 24 hour electrocardiographic (ECG) monitoring, 24 hour BP monitoring, standard blood tests, Magnetic Resonance Imaging (MRI) of brain and tilt-table testing.
Results: Despite reporting symptoms on right head-turning during the test, combined TCD/BP/EEG monitoring demonstrated no significant reduction in either blood pressure or Middle Cerebral Artery blood flow and showed no EEG changes. Our patient exhibited a symptomatic vasodepressor response with 70 degree head up tilt following GTN provocation. Other cardiological tests, bloods and MRI were unremarkable.
Discussion: Despite a plausible mechanism, combined TCD/BP/EEG monitoring failed to confirm the relationship of the hyoid compression to symptoms in this patient and proved valuable in guiding future management. In particular, it suggested that hyoid reduction surgery, for which there is anecdotal evidence in the literature and which had been contemplated, would not be of value for this patient. A diagnosis of migraine and vaso-vagal syncope was made.
A multidisciplinary team effectiveness programme
Yates J, Sayers H, Crosbie B, Walker M, Fisher R
University Of Nottingham, East Midlands Academic Health Science Network, Nottingham, UK
We aimed to deliver a programme that promoted effective team-working in multidisciplinary community stroke teams, addressing an identified gap in training focused in this area. The effectiveness programme was developed in earlier pilot work conducted with community stroke teams in Nottinghamshire, adapting an evidence-based effectiveness framework developed with community mental health teams. Currently the programme is being rolled out at scale to other regions in the East Midlands, and was successfully completed with Northamptonshire Community Stroke Team. The programme included 5 workshops covering the components of an evidence based stroke care pathway, theories of team working, and theories of change and improvement. Focus groups were conducted to discuss how inputs, processes, and outputs contributed to how the team operated, and created a reflexive space where the team could discuss issues for improvement. Findings and recommendations were fed back to the team using a tailored effectiveness report. In addition presentations and handouts were provided as a resource to the team, to maintain momentum and sustain effective team working beyond the lifetime of the project. All participating team members reported that the programme would significantly influence their work. Using the feedback, the team set realistic goals and commit to sustainable improvements in team working and will be followed up after 6 months to explore their implementation and impact. The programme supported the team in reflective exploration of multidisciplinary team effectiveness. In providing opportunities to identify and address aspects of team working, provision of care to stroke patients will ultimately be improved.
Including physical fitness instructors within multidisciplinary acute stroke unit care
Smith M1, Hebson A2, Jagadamma K3, Baer G3, Buchanan D3, Jacobsen M3, Palmer N3, Price G3, Sykes K3, Cameron W1, Redpath A1, Halliday P1, Egan, L1, Peters A5, Macrae H2, Chaudhary A2, Irons L2, Mead G1,4
1 Stroke Unit, Royal Infirmary Edinburgh, UK
2 Edinburgh Leisure, Edinburgh, UK
3 Department of Physiotherapy, Queen Margaret University, Edinburgh UK
4 Department of Geriatric Medicine, University of Edinburgh, UK
5 AHP Research and Development, NHS Lothian, Edinburgh, UK
Others involved: Edinburgh Leisure, Chest Heart & Stroke Scotland, University of Edinburgh, Queen Margaret University, Edinburgh.
Summary: Aiming to increase the uptake of Exercise after Stroke (EAS) referral we employed an Edinburgh Leisure exercise professional, trained in stroke and funded by the Edinburgh & Lothians Health Foundation (ELHF), to join the multidisciplinary team in the acute stroke unit at the Royal Infirmary of Edinburgh. Our steering group included multiple key stakeholders. The project was funded for 12 months. The first 3 were spent on induction, developing the referral system, trying out exercise interventions and testing the outcome measures. The next 6 were spent operating the service at capacity, recruiting as many acute stroke patients as could exercise on the ward and then arranging to engage them again in the community setting, signposting them into the existing, evidence-based Edinburgh Leisure EAS pathway. The final 3 months were spent ramping down, following up participants, analysing data and considering future service delivery. We found a doubling of the referral rate and an almost 4-fold increase in the take-up of EAS compared to our previous use of our community EAS pathway in Edinburgh. Participants felt more confident to exercise independently beyond the 12 week follow-up. There were no reported adverse effects or negative reports and qualitative feedback was highly positive. This in-reach service helped overcome some of the challenges faced by people with stroke in accessing EAS and, having made the connection with the exercise professional on the ward, they were more likely to take part in local community exercise opportunities.
Development of a graphical dashboard for real-time analysis of Sentinel Stroke National Audit Programme (SSNAP) data
Hill A
St Helens and Knowsley Teaching Hospitals NHS Trust, Merseyside, UK
Others involved: Whiston Stroke Team
Summary: The Stroke Sentinal National Audit Programme Dataset contains valuable operational data but is limited by its lag time to reporting.
We have developed a realtime data dashboard which enables SSNAP data to be used to study the performance of our unit live. Data is entered onto the dashboard by using the SSNAP Export feature. A number of visual dials show how we are performing against each key component within a domain. We have subsequently extended the data dashboard beyond performance to look at outcome metrics, and used it to study door to needle pathways, referral times and a number of other key measures. This has enabled our team to undertake a forensic analysis of its service and work to improve many areas of our practice to improve performance. Our SSNAP performance has seen some of the largest improvements in the UK on SSNAP metrics over the last 3 quarters. We are predicting further improvements in Q4 2014 and Q1 2015.
Complementing SSNAP by looking at quality as well as quantity of stroke rehabilitation: Quality Statement 7
Jones R
University Hospitals Bristol NHS Trust, Bristol, UK
Others involved: South Bristol Community Hospital Stroke Rehabilitation Unit
Summary: An audit designed to go beyond SSNAP data to measure the quality and not just the quantity of stroke rehabilitation. Over 4 months, a team of physiotherapists, OTs and SLTs were asked to record data about each patient present on a stroke rehabilitation unit. Was therapy required, how much therapy was given, was the time spent with the patient goal orientated, could the patient have tolerated more therapeutic input? From this data we were able to compare the team's performance against the NICE quality statement, broken down into its constituent parts, to avoid the focus being entirely on the time and frequency elements. Patients are offered minimum of 45 min of each therapy that is required, patients are offered rehabilitation over a minimum of 5 days a week where required, patients are offered therapy at a level that enables them to meet their goals. Patients with stroke are offered therapy as long as they are continuing to benefit from it and patients are offered rehabilitation for as long as they are able to tolerate it.