POSTERS Wednesday, 14 September
P1
The Enhanced Control of Hypertension ANd Thrombolysis strokE StuDy (ENCHANTED): Part B – rationale for a trial of early intensive blood pressure lowering after use of rtPA
Fuentes S1, Huang Y2, Wang J3, Sharma V4, Nguyen HT5, Pandian J6, Lindley R1, Stapf C7, Parsons M8, Levi C8, Chalmers J1, Anderson C1
1The George Institute for Global Health, Sydney, Australia, 2Peking University First Hospital, Beijing, China, 3Rui Jin Hospital, Shanghai, China, 4National University Hospital, Singapore, 5115 Hospital, Ho Chi Minh city, Vietnam, 6Christian Medical College, Ludhiana, India, 7Lariboisiére Hospital, Paris, France, 8John Hunter Hospital, Newcastle, Australia
Background: While INTERACT2 and other trials are addressing use of early intensive BP lowering in intracerebral haemorrhage (ICH), there is continued uncertainty about the role of such treatment in acute ischaemic stroke, particular with rtPA. Accumulating evidence indicates ‘inadequate control’ of BP ‘before’ and ‘after’ rtPA is associated with poor outcomes, and that the most favourable outcome is achieved with systolic levels of 141–150 mmHg associated with thrombolysis.
Aims: ENCHANTED Part B will assess whether early intensive BP lowering (systolic 140–150 mmHg) is superior to current guideline recommended BP management (systolic < 180–185 mmHg) in reducing the risk of death or disability in patients eligible for rtPA.
Methods: Randomised, open, blinded, controlled study with simple procedures in 3300 (1650 per group) patients to achieve >90% power to detect superiority of intensive treatment over standard BP control on 90-day death and any disability (mRS score 2–6).
Results: A start-up phase will commence across 50 sites in Australia, China, Korea, Singapore, Taiwan, and Vietnam during 2011.
P2
Impact of performing acute stroke CT angiogram and perfusion studies on renal function and door-to-needle time
Ingall T
Mayo Clinic, Phoenix, Arizona, USA
Background: Acute stroke patients (ASP) often have CT-perfusion and -angiogram studies (CTPAS) which could impair renal function, and require additional time to perform which could prolong door-to-needle times (DTNT).
Methods: We recorded serum creatinine levels (SCL) drawn prior to, and within 48 h after, CTPAS. Post-CTPAS renal impairment was defined as a rise in SCL of 0.5 mg/dl or more occurring within 48 h. We also calculated both the additional time taken performing CTPAS, and DTNTs for ASPs treated with intravenous tPA.
Results: Among 91 acute stroke patients having CTPAS, pre-CT SCLs were normal in 76 (84%), and increased in 15 (16%). None of the 91 patients developed post-CTPAS renal impairment. The additional time taken to perform CTPAS averaged 8.5 min, and the average DTNT in 20 patients treated with tPA was 63 min.
Conclusion: This study showed that CT studies with dye performed in acute stroke patients do not result in significant renal impairment, even if the pre-CT serum creatinine level is raised. While these CT studies required additional time to perform, this had no significant impact on the door-to-needle time for acute stroke patients receiving acute stroke treatment.
P3
The clinical reliability and predictability of acute CTP
Bivard A, Parsons M
John Hunter Hospital, Newcastle, New South Wales, Australia
Introduction: Computed tomography perfusion (CTP) imaging to measure infarct core and penumbra requires further clinical validation. We aimed to establish the optimal CTP parameters defining the ischaemic penumbra in acute stroke as clinically relevant to patient outcome.
Methods: Sub-6 h CTP and 24 h MRI were analysed from 314 consecutive ischaemic stroke patients. Using the validated CTP thresholds of a DT of 2 s to define the acute penumbra and a CBF of <40% within the DT 2 s lesion, a clinical outcome assessment was undertaken. These optimised acute CTP threshold-based volumes were then compared with 24-h DWI infarct volume, as well as 24-h and 90-day clinical outcomes for validation.
Results: Using CTP thresholds to define acute tissue pathophysiology, the volume of CTP mismatch tissue (i.e. between penumbral and core thresholds) salvaged from infarction correlated with clinical improvement at 24 h (R2 = 0.59 P = 0.04) and 90 days (R2 = 0.42, P = 0.02). Patients with larger baseline CTP infarct core volume (>25 ml) also had poorer recovery at day 90 (P = 0.039).
Discussion: The CTP infarct core and penumbral measures identified are strong predictors of clinical outcome.
P4
Validation of arterial spin labeling in 24-hour stoke patients
Bivard A, Parsons M
John Hunter Hospital, Newcastle, New South Wales, Australia
Introduction: Arterial Spin Labelling (ASL) is now available in routine clinical scanners and can be reliably used on MRI machines 3T and above. Conventional dynamic susceptibility sequences provide similar information to the ASL perfusion technique with the exception that ASL does not require intravenous contrast agents and can display absolute CBF changes.
Methods: Patients admitted to hospital with an acute stroke were scanned acutely using perfusion CT (CTP) and at 24 h using MR to acquire ASL and Perfusion Weighted Magnetic Resonance Imaging (PWI).
Results: Fifty patients qualified for this study, and at 24 h 21 showed hyperperfusion in the ischeamic area and 24 showed hypoperfusion on follow-up ASL imaging. Hyperperfusion was linked to penumbral salvage defined as the acute CTP mismatch, and 24-h DWI imaging and an improved outcome as measured by a difference between acute and 24-h NIHSS (average improvement 9). Patients with persistent hypoperfusion showed less improvement in NIHSS (mean improvement 3) and had a poorer 90-day outcome (mean mRS 4).
Discussion: ASL hyper or hypoperfusion was a strongly correlated to clinical outcome.
P5
Can the FAST and ROSIER adult stroke recognition tools be applied to childhood ischemic stroke?
Corrales AY1, Babl F1,2,3, Mosley I4, Mackay M1,2,3
1Royal Children's Hospital, Melbourne, 2Murdoch Childrens Research Institute, Melbourne, 3Department of Paediatrics University of Melbourne, Melbourne, 4Monash University, Clayton, Australia
Objectives: Stroke recognition tools improve diagnostic accuracy in adults. We set out to assess the applicability of adult stroke scales in childhood arterial ischemic stroke (AIS).
Patients and Methods: Children 1 month to <18 years with radiologically confirmed acute AIS presenting to a tertiary emergency department (ED) (2003–2008) were identified. The ROSIER (Recognition of Stroke in the Emergency Room) and FAST (Face Arm Speech Test) stroke recognition tools were retrospectively applied to determine test sensitivity.
Results: Forty-seven children with AIS were identified. Median age was 9 years. Median time from symptom onset to ED presentation was 21 h. The most common presenting symptoms were arm (63%), face (62%), leg weakness (57%), speech disturbance (46%) and headache (46%). The most common signs were arm (61%), face (70%) or leg weakness (57%) and dysarthria (34%). 36 (78%) children had at least one positive variable on FAST and 38 (81%) had a score of >1 on the ROSIER scale. Positive scores were less likely in children with posterior circulation stroke.
Conclusion: Presenting features of paediatric stroke appear similar to adults. Stroke recognition tools have fair to good sensitivity in radiologically confirmed childhood AIS but require further development and assessment of specificity.
P6
Clinical characteristics and cost of stroke: a study amongst patients in a Malaysian teaching hospital
Aziz NAA, Nordin NAM, Aziz AFA, Nur AM, Sulong S, Junid SMAS
Universiti Kebangsaan Malaysia
Background: Stroke is a major global public health problem causing huge burden to individuals, families and societies. There is a lack of research on economic impact of stroke in Malaysia.
Aims: To estimate inpatient cost of stroke and associated factors among patients in a tertiary teaching hospital.
Methods: Retrospective analyses of patients admitted to Universiti Kebangsaan Malaysia Medical Centre (UKMMC) between 2005 and 2008. Data on demography and clinical profiles retrieved from patients' medical records and cost evaluated from health provider's perspective using top-down costing approach.
Results: 813 patients analysed; mean age 63.5 (SD: 13.6) years, 55.7% males, 58.2% Cerebral ischaemia and 57.6% moderately severe stroke. Average length of stay was 7.0 (SD: 4.1) days and mean cost per patient/admission MYR4,032.46 (SD: 2,392.63) or 17% of the country's per capita GDP. Cost varied significantly by stroke subtypes and level of severity (P > 0.05). Multivariate analysis showed that cost per patient/admission were significantly influenced by stroke severity (severe stroke P < 0.001, moderate stroke P = 0.001) and stroke sub-types (hemorrhagic stroke P < 0.00, ischaemic stroke P = 0.016).
Conclusion: Direct medical cost of stroke is substantial. Efforts should focus on intensifying primary prevention activities and improving quality of acute care to reduce the impact of stroke in future.
P7
EXtending the time for Thombolysis in Emergency Neurological Deficits – the EXTEND trial progress
Donnan G*1,2, Davis S*3, Ma H4, Campbell B3, Christensen S5, Connelly A6, Churilov L1, Howells D1, Carey L1
1National Stroke Research Institute, Heidelberg, 2Florey Neuroscience Institutes, Parkville, 3Department of Neurology, Royal Melbourne Hospital, University of Melbourne, Parkville, 4Department of Neurology, Monash Medical Centre, Clayton, 5Department of Radiology, Royal Melbourne Hospital University of Melbourne, Parkville, 6Brain Research Institute, Heidelberg, VIC, Australia, *Co-chairs
Background: Thrombolysis in stroke is limited by the 4.5-h time window. Patient selection using physiologic imaging criteria may extend the therapeutic window.
Aim: To test the hypothesis that perfusion-diffusion mismatch identifies patients with favourable response to thrombolysis beyond 4.5 h.
Methods: EXTEND is a randomised, double-blind, placebo-controlled trial of intravenous alteplase vs. placebo in patients with ischemic stroke 3(4.5)–9 h from onset. Patients with ‘wake-up stroke’ are eligible if the midpoint of the time they went to sleep and awoke with the stroke symptoms is <9 h. Criteria for entry into the trial include perfusion–diffusion mismatch using a perfusion threshold of Tmax > 6s and a perfusion:diffusion lesion volume ratio of >1.2. Diffusion lesion volume must be <70ml assessed using fully automated software (RAPID, Stanford University). Patients will be assessed for reperfusion/recanalization at 24 h. The primary endpoint is mRS 0–1 at 90 days. Secondary endpoints include mRS shift analysis, reperfusion, recanalization, quality of life and depression scales. The trial is also investigating diet and lifestyle factors in stroke and depression.
Progress: Site recruitment commenced June 2010. There are now eight active sites in Australia and New Zealand with seven more opening shortly. Overseas sites will also be included to enhance recruitment.
P8
Withdrawn
P9
Assessment of risk factors for 28-day hospital readmission after stroke: evidence from the New South Wales (NSW) audit program
Kilkenny M1,2,3, Cadilhac D1,2,3, Longworth M4, Pollack M4,5, Levi C6
1National Stroke Research Institute, 2University of Melbourne, Melbourne, VIC, 3Translational Public Health Unit, STARC, 4Stroke Services NSW, Greater Metropolitan, 5Hunter Stroke Service, Hunter New England Area, 6Centre for Brain & Mental Health Research
Background: Understanding the factors that contribute to readmission after discharge from hospital following stroke are limited.
Aim: To describe the factors which contribute to hospital readmissions following stroke.
Methods: Medical record audits of 50 + consecutively admitted stroke patients from 35 NSW hospitals between 2000 and 2010. Multivariable analyses included adjustment for patient demographics, stroke severity and clustering by hospitals.
Results: Among 3328 patients, 6.5% were re-admitted within 28 days (mean age 75, 48% female, 92% ischaemic). Common reasons for readmission were stroke (n = 42) and cardiovascular disease (n = 30). Readmitted patients were more likely to be dependent prior to stroke (39% vs. 27% not re-admitted [NR]); more likely to be incontinent within 72 h (45% vs. 37% NR) and have a history of heart disease (34% vs. 28% NR) compared to NR patients. Following adjustment for demographics, stroke severity and hospital site, the readmitted patients had a greater odds of being dependant following discharge after the original admission than the NR patients (aOR 1.56 95% CI 1.00–2.42).
Conclusions: Audit data has provided insights into the patient profile and reasons patients are readmitted following a stroke admission. Further research is needed to confirm factors that are predictive of re-admissions to enable preventative actions.
P10
Australian stroke clinical registry: management and outcome of patients with transient ischaemic attack (TIA)
Cadilhac D1,2,5, Lannin N3,4, Anderson C3,4, Kilkenny M1,5, Lim J4, Levi C6, Price C7,8, Faux S9,10, Donnan G1,2
1National Stroke Research Institute a subsidiary of Florey Neuroscience Institutes, Heidelberg Heights, Victoria, Australia, 2The University of Melbourne, Australia, 3Sydney Medical School, The University of Sydney, Australia, 4The George Institute for Global Health, Royal Prince Alfred Hospital, Sydney, Australia, 5Southern Clinical School, Monash University, Clayton, Victoria, Australia, 6University of Newcastle & Hunter Medical Research Institute, Newcastle, Australia, 7John Hunter Hospital, Newcastle, Australia, 8National Stroke Foundation, Melbourne, Australia, 9St Vincent's Hospital, Sydney, Australia, 10University of New South Wales, Sydney, Australia
Background: Limited information exists on the quality of care for patients with TIA admitted to hospitals in Australia. Care recommendations are similar for TIA and ischaemic stroke (IS).
Aims: To describe the patterns of in-patient care and outcomes for TIA using data from the Australian Stroke Clinical Registry (AuSCR), from June 2009 to December 2010.
Methods: Online registry (www.auscr.com.au) with stroke type designated by clinical staff and confirmed by post-discharge ICD10 coding, with survivor follow-up by telephone or mail.
Results: Among 2598 care episodes (2529 patients) from 12 hospitals (mean age 72 years, 55% male, 65% Australian-born), 18% were TIA and 65% IS. Fewer TIAs were managed on a stroke unit (72% vs. 85% IS, P < 0.001) and received a care plan at discharge (44% vs. 58% IS P < 0.001), but receipt of anti-hypertensives medication on discharge was similar (80% vs. 82% IS). Most TIA patients (88%) were discharged home after a median length of stay of 3 days (IQR 1.5 days). Of the ICD10 principal diagnostic codes provided, 11/335 were stroke codes (e.g. I64).
Conclusion: Variations in the hospital care between patients with TIA and IS may have important implications that requires further investigation, including the impact of any discrepancies in the clinical definition of TIA and ICD10 hospital coding.
P11
Is it a disadvantage for patients with acute stroke to have atrial fibrillation? Results from the 2009 national stroke audit
Cadilhac D1,2,3, Kilkenny M1,2,3, Harris D4
1National Stroke Research Institute, Melbourne, VIC, 2University of Melbourne, Melbourne, VIC, 3Translational Public Health Unit, Stroke & Ageing Research Centre, Southern Clinical School, Monash University, VIC, 4National Stroke Foundation (NSF), VIC, Australia
Background: Few data are available about patients with stroke and atrial fibrillation (AF) in Australia.
Hypotheses: People with AF compared to those without AF have worse health outcomes following acute stroke.
Methods: Retrospective clinical audit of 40 consecutive patients with acute stroke admitted to 96 hospitals. Patients with pre-stroke/new onset AF were included. Patient characteristics, stroke subtype, modified Rankin Score and medication were reviewed. Multivariable analysis for outcomes including adjustment for patient clustering and stroke severity were undertaken.
Results: AF status known for 2,673 (81%) patients; 974 had AF. More patients with AF had a history of stroke/TIA (AF 42% v no AF 34%, P < 0.001) and were older (median age: 82 years vs. 74 years) than patients without AF. Few (28%) AF cases with ischaemic stroke were on warfarin prior to stroke onset; 42% of AF cases with ischaemic stroke were discharged on warfarin. Patients with AF had a 1.40 greater odds (95% CI 1.01–1.95) of being discharged to aged care and a 1.57 greater odds of dying in hospital (95%CI 1.12–2.20) than patients without AF.
Conclusions: People with stroke that have AF experience worse health outcomes. More research and use of evidence-based treatment is needed.
P12
A process for obtaining consent from acute stroke patients for participation in clinical trials
Blacker D
1,2
1Department of Neurology, Sir Charles Gairdner Hospital, Perth, 2The University of Western Australia, Perth, Western Australia
Background: Obtaining consent for participation in acute stroke trials has been a difficult process in Western Australia, with a ‘waiver’ of consent option being declined by local Human Research Ethics Committees (HREC) mainly related to a lack of guiding state legislation. Recently, approval of the START-EXTEND study was deferred until a process for obtaining consent could be devised.
Aims: The now approved consent process is outlined, with a view to this being a template for others to use in future studies, and to provide a published reference (in abstract form), that may assist with further HREC applications.
Results and Discussion: The process considers different clinical scenarios, ranging from virtually intact patients to comatose, or profoundly dysphasic subjects who could not comprehend or indicate consent. The focus is on the ‘in between’ situations, where comprehension is preserved, but expressive language or motor function are impaired. Witnesses are an intergral part of the process, along with a modified, ‘bullet-point’ patient information form in very simple language. (Examples for 2 trials are provided). If any party suspects lack of comprehension by the subject, then the default position is NOT to proceed.
P13
A new future strategy for ICH therapy; an endovascular option?
Blacker D
1,2
1Department of Neurology, Sir Charles Gairdner Hospital, Perth, 2The University of Western Australia, Perth, Western Australia
Background: There remain very few treatment options for intracerebral haemorrhage (ICH), beyond stroke unit care, and other ‘supportive’ therapies. A ‘breakthrough’ interventional treatment is desperately needed, and perhaps, novel approaches require consideration.
Aims: This presentation will propose the use of endovascular techniques to intentionally occlude the ‘parent’ artery that is supplying the bleeding vessel.
Methods: The rationale for this approach and patient selection criteria are discussed. Illustrations of the proposed technique are provided, and suggestions for the clinical approach are made. Patients with actively leaking vessels, as seen by contrast CT are likely to be the best candidates. In summary, a stent is deployed into the MCA main stem with the intent to selectively occlude the lenticulostriate ostia, proximal to the bleeding vessel. The intended result is a small lacunar infarct rather than a large expanding haematoma. Other elements of a ‘treatment package’, could include intensive blood pressure control, hypothermia and neuroprotective agents.
Discussion: This presentation will emphasise the need for the development of new approaches for ICH management
P14
The West Australian Intravenous Minocycline and TPA Stroke Study (WAIMATSS): A multi-centre, prospective, randomised pilot study of intravenous minocycline, 200 mg 12 hourly for 5 doses, compared with standard care, in patients with ischaemic stroke treated with intravenous tPA
Blacker D1,2, Prentice D3, Alvaro A4, Bates T2,5, Bynevelt M6, Hankey G2,3, Kelly A4, Beer C2,5, Kohler E3
1Department of Neurology, Sir Charles Gairdner Hospital, Perth, 2The University of Western Australia, Perth, 3Stroke Unit, Royal Perth Hospital, Perth, 4Department of Neurology, Fremantle Hospital, Freemantle, 5Stroke Unit, Swan District Hospital, 6Department of Radiology, Sir Charles Gairdner Hospital, Perth, Western Australia
Background: Intracranial haemorrhage (ICH) is the most feared complications of thrombolytic therapy for acute ischaemic stroke. In tPA treated rodents, minocyline is associated with a two fold reduction in ICH.
Aims: To test the hypothesis that patients treated with IV minocyline and tPA have fewer intracranial haemorrhages than those treated with tPA alone.
Methods: Patients treated with IV tPA up to 4.5 h after stroke onset will be randomised to IV minocycline 200 mg BID for 5 doses commencing no more than 6 h after symptom onset vs. standard post tPA care.
The primary endpoint is ‘any’ ICH identified on a follow up CT scan 24 ± 8 h after treatment. CT scans will be examined by neuroradiologists blinded to treatment Secondary endpoints include; ICH as defined by the ECASS criteria; day one, two and seven NIHSS, and days 30 and 90 modified Rankin and Barthel Index scores. An MRI substudy will compare ICH seen on MRIs performed between days five to seven post treatment.
Discussion: The study has ethics approval and is sposnsored by a Neurotrauma Research Program grant from the West Australian Institute for Medical Research. Recruitment is scheduled to commence in the second half of 2011.
P15
Safety and efficacy of exenatide as a neuroprotective agent in acute ischaemic stroke – a pilot study
Daly SC1,2, Bladin CF2,3, Chemmanam T3, Simpson RW4,5,6, Dear AE4,5, Gilligan A3, Loh PS3
1Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia, 2Eastern Health Clinical School, Victoria, Australia, 3Dept of Neurosciences, Eastern Health (Monash University), Melbourne, Victoria, Australia, 4Australian Centre for Blood Diseases, Monash University, 5Eastern Clinical Research Unit, Biotechnology Division, Monash University, 6Dept of Diabetes & Endocrinology, Box Hill Hospital, Melbourne, Victoria, Australia.
Background: Exenatide is a glucagon-like peptide-1 receptor agonist used to improve glycaemic control in patients with type-2 diabetes. Animal and in-vitro studies indicate that exenatide may be beneficial as a neuroprotective agent in treating acute ischaemic stroke.
Aims: To determine the safety and tolerability of exenatide in acute ischaemic stroke patients, its effect on glycaemic control, and on stroke biomarkers.
Methods: A prospective cohort pilot study was conducted in which participants were administered exenatide 5μg subcutaneously within 12 h of stroke onset, and then twice daily for the duration of their hospital stay.
Results: Eleven participants were recruited – 9 were included in analyses. 6/9 participants received tPA thrombolysis. No participants died; serious adverse events were unrelated to exenatide. Nausea (5 patients) and vomiting (4) were the most common adverse events, but were successfully managed with anti-emetics. Serum glucose concentrations remained stable at all time points (range 4.0–8.1mmol/l). The rate of hyperglycaemia was low (3.9%), especially during active treatment. Analysis of biomarker levels showed large variation both within and between patients.
Conclusion: Exenatide was safe in ischaemic stroke patients, and was effective in controlling glycaemic levels. These results support further testing of exenatide as a neuroprotective agent in acute ischaemic stroke.
P16
Thrombolysis for stroke at Campbelltown Hospital, where are we now, 2 years from initiation?
Dhar A1, Dr Levy S1,2,3, Gopinath S1,2,3
1University of Western Sydney, 2Campbelltown Hospital, 3Sydney South Western Area Health Service (SSWAHS), Sydney, NSW, Australia
Background: Campbelltown Hospital recently started a limited thrombolysis programme for cerebrovascular stroke. This aim of this study was to determine the efficacy of this new programme and make recommendations for improvement.
Methods: A retrospective audit of 366 patients who experienced a stroke at a 350 bed hospital from November 2008 to November 2010. Primary outcomes were treatment rate, treatment outcomes and adverse events. Secondary outcomes included time taken to present, door to needle time, exclusion criteria and protocol violations.
Results: During the study period patients received t-PA (10%). The main reason for exclusion was presentation after 3 h of symptom onset (26%). Mean time for presentation was 66 min, with the mean door to needle time being 97 min. Protocol violations occurred in 40% of patients. At discharge, 50% of patients had favourable treatment outcomes (NIHHS ≤ 1). There were no significant adverse outcomes due to treatment.
Conclusion: Campbelltown Hospital has developed an effective protocol for the administration of thrombolysis. This is evidenced by the high rate of favourable treatment outcomes and low complication rate compared to meta-analysis of international clinical practice studies. Recommendations have been made to improve the quality of the thrombolysis program.
P17
Middle cerebral artery transient ischaemic attack with low flow only on acute MR angiography and infarction only on late MRI
Hatch M1,2, Hjorth R1, O'Sullivan R3, Gerraty R1,2
1Epworth Healthcare, Richmond, 2Monash University, 3Richmond Diagnostic Imaging, Richmond, Victoria, Australia
Background: Transient ischaemic attack (TIA) is difficult to differentiate from acute stroke, with infarcts often seen on diffusion weighted imaging (DWI) MRI.
Methods: Detailed clinical assessment to determine full resolution of symptoms, and detailed examination to exclude persisting abnormalities are necessary to ensure recovery in suspected TIA. MRI methods, particularly DWI and MR angiography, are sensitive measures of early acute infarction and vascular occlusion and were used to assess a 41-year old man who presented with a TIA.
Results: On warfarin for aortic valve replacement he had sudden onset dysphasia and right weakness lasting 2 h. The brain MRI at 2.5 h showed no infarct on DWI, mild stenosis and slow flow in the left middle cerebral artery (MCA). At 4 weeks an MRI showed normal MCA flow, but a mature putaminal infarct.
Discussion: The pathophysiology of TIA is more complex than vessel occlusion theories of transient ischaemia can explain. While small acute infarcts in patients with TIA is now common with sensitive DWI imaging, this case illustrates the occult cellular consequences of TIA with progression to infarction despite resolution of vascular occlusion and occurring late enough that an initial MRI with DWI imaging was normal.
P18
Pure vestibular syndrome from a lesion in the nodule of the cerebellum
Pavlin-Premrl D1,2, Smith P3, Gerraty R1,2
1Epworth Healthcare, Richmond, 2Monash University, 3MIA Victoria, Melbourne, Victoria, Australia
Background: Acute vertigo can be due to stroke but is usually associated with clear cut central nervous system signs. Rarely a central lesion will precisely mimic a peripheral pathology.
Methods: As part of a prospective study of acute vertigo an 82-year old woman was assessed with a standardised battery of bedside vestibular function tests, including ophthalmoscopy, the Hallpike test and the Halmagyi head impulse test, and brain MRI.
Results: The patient presented with the acute vestibular syndrome and had right vestibular nystagmus, but a negative Halmagyi head impulse test and no other signs. CT of the brain was reported normal. Severe vertigo and vomiting persisted and delayed the MRI until 2 weeks following the onset of symptoms. Brain MRI showed a high signal abnormality in the nodule of the right cerebellum, with some oedema crossing to the medial left cerebellum, consistent with a subacute infarct. Follow up MRI confirmed this. Residual unsteadiness of gait persisted at 6 weeks, but the patient was able to walk and live independently.
Conclusion: Nodular infarcts can mimic vestibular neuronitis. The absence of an abnormal Halmagyi head impulse test is a strong clue to a central lesion.
P19
Two cases of spontaneous spinal epidural hematoma developing hemiplegia; another contraindication for intravenous tissue plasminogen activator therapy for acute ischemic stroke
Ishige N, Tanno H, Ozaki H, Fuse Y, Yoshida Y
National Hospital Organisation Chiba Medical Center, Chiba, Japan
Intravenous tissue plasminogen activator (tPA) treatment for acute ischemic stroke has been widespread use in Japan since 2005. Active hemorrhage must be ruled out before the injection of tPA.
Two cases of spontaneous spinal epidural hematoma developing hemiplegia are presented. In one case, tPA therapy was considered.
Case 1: A 67-year-old hypertensive male suffered from mild neck pain followed by severe right hemiparesis. Intravenous tPA therapy was initially considered at the emergency room, but not performed as MRA showed no causative abnormalities. Cervical MRI revealed C2-Th1 epidural hematoma. The hematoma evacuation operation was performed, and he recovered almost completely.
Case 2: A 74-year-old female suffered from neck pain and severe left hemiparesis. She was reffered to our hospital with a tentative diagnosis of cerebral infarction. Neurological signs were consistent with the Brown-Sequard syndrome. Cervical MRI revealed C4-C6 epidural hematoma, which was evacuated Only mild hemiparesis remained 2 months later.
Because the occurrence of spontaneous spinal epidural hematoma is rare, it is not easy to diagnose it in the many patients presenting with sudden onset of hemiplegia. The presence of neck pain and the lack of facial paresis may be important signs in the discrimination of cervical lesion from stroke.
P20
Temperature measurements using MR spectroscopy: validation and calibration in healthy volunteers
Lillicrap T1,2, Jyoti R1,2, Levi C3,4, Parsons M3,4, Spratt N3,4 Stanwell P3, Lueck C1,2
1Department of Neurology, the Canberra Hospital, Canberra, 2Department of Radiology, the Canberra Hospital, Canberra, 3Australian National University, Canberra, 4John Hunter Hospital, Newcastle, NSW, Australia, 5University of Newcastle, NSW, Australia
Background: Hypothermia is a potential neuroprotective strategy for the treatment of acute ischaemic stroke. Brain temperature, not body temperature, is relevant but brain and body temperature are not necessarily the same. We have developed a non-invasive method of measuring brain temperature using magnetic resonance spectroscopy (MRS). Previous testing on a phantom yielded an accuracy of ± 0.8°C.
Aims: To validate the use of MRS for measuring brain temperature in vivo.
Methods: A region of interest (ROI) was scanned 5 times in quick succession in 20 healthy volunteers' brains and the variability of temperature measurement was determined. In addition, external calibration of MRS temperature measurements was attempted by studying a ROI in the tongue and measuring oral temperature by thermometer.
Results: The average range of temperature measurement within each 5-scan series was 0.76°C (range 0.09°C to 1.41°C), and the average standard deviation was 0.31°C (0.05°C to 0.54°C). Attempts to derive MRS temperature data from the tongue have had limited success.
Discussion: MRS temperature measurement is feasible in vivo with an accuracy close to that achieved in the phantom. This suggests the technique will be useful as a tool to study temperature changes in stroke as well as neuroprotection using hypothermia.
P21
Responses of the Public to Acute Stroke Scenarios: Do they know what to do?
Hood K1, Mosley I1, Bray J1,2, Nicholas C1,3, Braitberg G1,3
1Monash University, 2Ambulance Victoria, 3Southern Health, Melbourne, Victoria, Australia
Introduction: Recognising stroke symptoms when they occur is a vital first step in acute stroke care. However recognition without appropriate action does little to reduce delays to treatment for stroke patients. We sought to evaluate responses of the public to stroke symptoms prior to and following Stroke Week, 2010.
Methods: The Stroke Action Test (STAT) a validated instrument with 21 stroke scenarios was used during face to face interviews. Participants were recruited from members of the public attending an out-patient clinic at Dandenong Hospital, Melbourne in September and November 2010.
Results: In total 179 participants were interviewed 89 prior and 90 following ‘Stroke Week’. The median correct score for the 21 stroke scenarios across all participants was 8 (IQ range 5–12). Overall, participants chose to call an ambulance for 41% of stroke scenarios, call a doctor 32%, wait an hour 22% with 5% waiting a day. No difference was identified between the Pre and Post ‘Stroke Week’ groups.
Conclusions: Improving stroke symptom awareness is important. However further initiatives may be required to facilitate the link between public awareness of stroke symptoms and knowing what to do if it occurs: Call an Ambulance.
P22
Spinal cord infarction related to artery of Adamkiewicz – ‘The Forgotten Stroke Syndrome’
Patel V, Griffith N, Cordato D, McDougall A, Capplen-Smith C, Beran R
The Liverpool Hospital, New South Wales, Australia
Background: Spinal cord infarction comprises <1% of all strokes. It is a recognised common complication of open repair but uncommon with endovascular repair of aortic aneurysm.
Hypotheses: Neurological examination of the patient with spinal cord infarction is as important as investigation with MRI.
Results: We report two cases of spinal cord infarction secondary to ischaemia of the artery of Adamkiewicz. One patient had elective endovascular abdominal aortic aneurysm (AAA) repair and the other had emergency endovascular AAA repair. Both had infra renal aneurysms and repairs. Clinical examination proved to be the most useful tool in diagnosis of spinal cord infarction; particularly the findings of a paraparesis with a sensory level sparing posterior column sensation – an ‘anterior 2/3rds of the cord syndrome’. In contrast spinal cord MRI had limited value and may not be feasible because of endovascular stent placement. Of our patients, one had an urgent MRI, which was marred by stent artifact. The other patient was improving and therefore MRI was not performed.
Conclusion: In the context of a clinical scenario suggestive of spinal cord infarction, neurology examination is more useful than spinal cord imaging with the currently available MRI techniques. Examination is cost effective, not marred by artifact and does not place the patient at risk of stent dislodgement.
P23
Young Stroke Mortality Audit
Putt D, Prentice D
Royal Perth Hospital, Perth, WA, Australia
Background: Data on the aetiology, clinical and radiological parameters surrounding death from stroke in young people is scarce.
Aims: To audit all stroke deaths under the age 65 admitted to any of the three major teaching hospitals in WA in the last 5 years and define any clinical or radiological parameters that may help predict which strokes in young people will be fatal.
Method: Young stroke deaths (defined as age <65) over the last 5 years were identified from a stroke database. Data relating to stroke risk factors, clinical markers, time from onset to death, stroke aetiology, direct cause of death, radiology, thrombolysis (or other intervention) and autopsies were collected.
Results: A total of 24 patients have so far been identified. The average age was 53. The youngest was 25 and had an autopsy. 12 were ischaemic and 12 were haemorrhagic. Eight were confirmed to die from malignant middle cerebral artery infarction. Fifty per cent of the ischaemic strokes were confirmed to have carotid artery occlusion secondary to thrombus.
Conclusions: The results so far suggest carotid artery occlusion secondary to thrombus is a major cause of stroke death in young people. More conclusions will be made when the audit has been completed.
P24
Multimodal treatment of post tissue plasminogen activator related intracerebral hemorrhage
Varma D, Chen C, Lee A
Flinders Comprehensive Stroke Centre, Adelaide, Australia
Background: Tissue Plasminogen Activator (tPA), a treatment for ischaemic stroke, carries a 2–3% risk of intracerebral hemorrhage (ICH), with poor functional outcomes and mortality of 45–85%. Evidence for treatment is scarce, mostly anecdotal and unimodal. Herein we report a case of post-tPA ICH, where a multimodal medical/surgical approach resulted in positive outcomes.
Hypothesis: Multimodal treatment for tPA related ICH decreases mortality and improves functional outcomes.
Methods:
Treatment: 4 units fresh frozen plasma (FFP), 2 units platelets, prothrombinex, vitamin K, left decompressive hemicraniectomy (DHC) with hematoma evacuation and cerebral cooling.
Results: A 62-year old male received tPA, post central retinal artery occlusion (ethics approved study). Pre-tPA deficit was right monocular blindness. Ten minutes after thrombolysis, dysphagia and right hemiplegia developed, progressing to GCS5. CT showed left posterior parietal intraparenchymal hemorrhage with shift and uncal herniation. Post treatment, the patient underwent rehabilitation. On day 39 post-operatively NIHSS was 7, with mild expressive dysphagia, mild right sided deficits requiring x1assist + walker. Three months post-operatively he walked normally.
Discussion/Conclusion: Prothrombinex, FFP, platelets and vitamin K enabled hemostasis to halt tPA effects. DHC with clot evacuation and cerebral cooling helped minimise cerebral edema, reverse mass effect and prevent herniation, whilst providing neuroprotection. This report provides impetus for larger similar trials.
P25
Resolution of essential tremor post thalamic stroke
Watts J, Alvaro T, Kelly A
Fremantle Hospital, Fremantle, Western Australia
Background: Essential tremor is a neurological condition characterised by tremor of the limbs. Previously known as benign essential tremor, the first word was removed due to the often debilitating nature of the condition. Until recently, aetiology was poorly understood however advances in post mortem movement disorder research have shown that the condition involves the cerebellar and cerebellothalamocortical circuits. Accordingly, surgical thalamotomy and deep brain stimulation are recognised therapies for essential tremor.
Case: Here we present the case of a 77-year old lady with a long history of essential tremor, primarily affecting her left side. Mrs BW presented to an emergency department in 2010 with left sided weakness and ataxia. MRI revealed a right thalamic stroke. She progressed well with multidisciplinary rehabilitation and was independent with her mobility on discharge. Of note, she had complete resolution of her essential tremor, and her tremor remained absent at last follow-up, 12 months post stroke.
Conclusion: This is an interesting case of cure of an essential tremor in which the right thalamic stroke has acted as a thalamotomy, and adds further weight to the involvement of cerebellothalamocortical circuits in essential tremor.
P26
Why patients are not receiving stroke unit care: Barriers and facilitators to stroke unit access
Wright L1, Godecke E2, Price C1
1National Stroke Foundation, Victoria, Australia, 2Edith Cowan University, Western Australia, Australia
Background: Stroke unit care (SUC) significantly reduces death and disability after stroke. The numbers of stroke unit (SU) beds increased between 2007 and2009, however the percentage of patients receiving SUC remained static (51%)
Aim: To identify the barriers and facilitators of SU access in Australia.
Methods: A twelve question online survey was developed exploring barriers and facilitators to SU access. All Australian stroke unit hospitals (68) were invited to participate. Survey results were collated and findings compared to SU access figures from the 2009 National Stroke Audit of acute stroke care.
Results: Fifty of the 68 hospitals (73%) responded. The greatest perceived barrier to SU admission were bed availability, bed management, ED culture, colleagues (‘SU consultants’) practice/application of guidelines and poor stroke unit staffing. The greatest perceived facilitators for SU admission were proactive staff, education, positive hospital policy/culture, registrar with responsibility for stroke and stroke unit guidelines.
Conclusion: The Australian Stroke Coalition has identified access to SUC as a priority. There are numerous barriers and facilitators identified by this survey. A systematic and evidence-based quality improvement approach to identifying and resolving barriers to SU access is clearly required to maximise the benefits of SUC.
P27
Efficacy of nurse led stroke education for paramedics in rural Victoria
Beltrame C1, Frost T1, Reid S2, Wright A1
1Latrobe Regional Hospital, Traralgon, Victoria, 2Rural Ambulance Victoria, Australia
Background: Accurate identification and timely transfer of stroke patients to hospital expedites proven therapies and should improve outcomes. Paramedics can deliver this service but may lack knowledge about the best instruments to use and services available.
Aim: To facilitate accurate diagnosis of stroke and early transfer of patients to the Latrobe Regional Hospital (LRH) emergency department (ED) using nurse-led education.
Method: A registered nurse working in the ED visited the 5 ambulance stations responsible for transferring patients to LRH. Education focused on: (1) use of the FAST instrument and Melbourne Ambulance Stroke Score to identify stroke; (2) benefits of prompt transfer and early notification of stroke to LRH; and (3) evidence supporting thrombolysis for stroke. Before and after the intervention ambulance officers were assessed on their knowledge of stroke and rated their understanding of local stroke services.
Results: Familiarity with stroke services was increased. Understanding of importance of expeditious transfer to ED was significantly improved. Gains were made regarding stroke diagnosis but there were considerable differences in competency. Understanding of evidence supporting thrombolysis remained poor.
Conclusion: Nurse led stroke education for paramedics in Gippsland has effectively enhanced skills and knowledge of local services. There continues to be significant variation in paramedic knowledge however that will be the focus of further education.
P28
Developing an evidence-based stroke unit in a private hospital
Adams J, Lawless K, Ekberg K, Infeld B, Gerraty R
Epworth HealthCare, Melbourne, Australia
Background: There is Level 1 evidence that stroke patients should be treated in a stroke unit. Previously in this private hospital in Melbourne, stroke patients have had 24 h access to neurologists and urgent CT. A geographically localised area within the neuroscience unit, providing cardiac monitoring was lacking. Participation in stroke research was minimal.
Aims: To develop an evidence-based, geographically localised stroke unit and participate in clinical trials and other stroke research.
Methods: A stroke unit working party was formed in November 2010. Areas for development were identified in line with the Clinical Guidelines for Stroke Management (2010) and a project plan detailed and commenced.
Results: Cardiac telemetry has been installed in the new geographically localised unit. Neurologist lectures have been presented to 100% of the nursing team on stroke diagnosis, CT and MRI radiology and thrombolysis. Senior staff members have completed an ECG short course and are championing education throughout the unit. The AVERT trial has commenced and the START-EXTEND thrombolysis protocol has been submitted to the ethics committee.
Discussion: Adoption of a clear project plan driven by evidence based guidelines will facilitate diagnosis and treatment, including trial participation.
P29
Top to toe, don't miss a thing
Terry L1, Mansfield D2, Burns D2, Meade D2
1Victorian Stroke Clinical Stroke Network, Melbourne, 2Southern Health, Dandenong Hospital, Dandenong, Victoria, Australia
Background: The Stroke Intervention Unit, Dandenong Hospital was established 2007, whereby opportunity arose to drive change and innovation through a new system. Dedication of the stroke inter-professional team facilitated development of ‘IASC’.
Traditional multidisciplinary team (MDT) environments were adapted into this newly proposed documentation model, promoting inter-professionalism and patient centred care. Patients are expected to be the beneficiary recipients of a united team, where discipline boundaries become more fluid, and promotion of their participation takes precedence.
Aims: Introduction of IASC aims to (1) Promote inter-professional patient centred care; (2) Meet National Stroke Guidelines.
Method: (1) Benchmark existing Acute Stroke Pathways state-wide; (2) Develop a Steering Committee/Working party to oversee implementation; (3) Develop / implement IASC with education package; and (4) Evaluate effectiveness of IASC.
Results: (1) Development of (a) IASC with education package; (b) Qualitative surveys, focus group and audit tools. (2) Retrospective data revealed gaps in service provision for mood, continence and patient education. (3) Post data currently being collected and it's anticipated results will indicate improvements in overall service provision.
Conclusion: The IASC replaced existing MDT documentation models for acute stroke patients within Dandenong Hospital. It promotes adherence to National standards, evidence based care and promotes patient involvement in their healthcare.
P30
A rare cause of embolic stroke in a patient with hereditary haemorrhagic telangiectasia
Yassi N1, Dowling R2, Yan B1,2, Mitchell P2
1Department of Neuroscience, Royal Melbourne Hospital, 2Department of Radiology, Royal Melbourne Hospital, Victoria, Australia
A 57-year old male patient with hereditary haemorrhagic telangiectasia (HHT) presented with an acute right middle cerebral artery ischaemic stroke and recent left calf vascular claudication. Investigations revealed a right Middle Cerebral Artery M2 occlusion, occluded left anterior tibial artery, hypoxaemia, and a large pulmonary arteriovenous malformation (PAVM), as well as right lower limb deep venous thrombosis. Closure of the PAVM was successfully performed with an Amplatzer(R) device. Catheter closure of PAVMs in patients with HHT is a recognised treatment modality to prevent recurrent ischaemic stroke, as well as other embolic and haemorrhagic complications
P31
Human plasma biomarker investigation of transient ischaemic attack (TIA) by 2D-differential in-gel electrophoresis (DIGE) and mass spectrometry: a pilot study
Djukic M1, Lewis MD1,2, Leung E1, Jannes J1,3, Hamilton-Bruce MA1,3, Chataway T4, Koblar SA1,3
1Stroke Research Programme, School of Medicine, University of Adelaide, The Queen Elizabeth Hospital Campus, Adelaide, Australia, 2School of Molecular & Biomedical Science, University of Adelaide, Australia, 3Department of Neurology, The Queen Elizabeth Hospital, Adelaide, Australia, 4Department of Human Physiology, Flinders University of South Australia.
Background: TIA precedes 15–30% of all ischaemic strokes, making the condition a common precursor and important warning sign for an imminent major stroke1,2. Accurate diagnosis and subsequent treatment of TIA is however made difficult by the presence of ‘TIA-mimic’ presentations.
Aims: To elucidate candidate plasma protein biomarkers associated with TIA and may be able to distinguish TIA from TIA-mimic conditions.
Methods: TIA and TIA-mimic patients were sourced from both a community-based rapid access TIA clinic and hospital-based rapid assessment TIA clinic. Blood plasma and clinical data was collected from patients who presented within 1-7 days of symptom onset, with all patients returning for a follow-up blood sample collection within 3 months. Plasma samples were subject to immunoaffinity depletion and protein expression analysis using 2D-DIGE, mass spectrometry and western blotting.
Results: Initial and follow-up plasma samples from six high-risk TIA patients, six well-defined TIA-mimic patients, and six healthy control volunteers have been subjected to immunoaffinity depletion and protein expression analysis using 2D-DIGE.
Discussion: Identification of differentially expressed spots will be performed by mass spectrometry and validated by western blotting, with the results to be presented at SSA AGM 2011.
P32
Low pooled likelihood ratios in meta-analysis of the ABCD2 score for early stroke risk following transient ischaemic attack
Sanders LM1,2, Srikanth VK1,2, Blacker DJ3, Jolley D4, Cooper K1, Phan TG1,2
1Stroke & Ageing Research Group, Dept of Medicine, Monash University, Clayton, Victoria, 2Monash Medical Centre, Southern Health, Clayton, Victoria, 3Dept of Neurology, Sir Charles Gairdner Hospital, Nedlands, WA, 4School of Public Health and Preventative Medicine, Monash University, Prahran, Victoria, Australia
Background: The ABCD2 score is recommended by several stroke guidelines to stratify stroke risk after TIA and aid in management decisions. There are however, conflicting reports regarding its accuracy in clinical practice.
Aims: To assess ABCD2 score predictive ability when dichotomised at commonly used cut-offs.
Methods: Medline, PubMed, Embase, conference programmes and manuscript references were searched for articles published January 2005 to May 2010. Authors were invited to contribute additional data. Using random effects meta-analysis, pooled positive (PLR) and negative (NLR) likelihood ratios were determined as estimates of predictive capacity for stroke at 2, 7, 30 and 90 days after TIA. Heterogeneity was evaluated using meta-regression.
Results: Data were available for 27 studies (13,443 patients). Dichotomising the score at 3 (0–3 low risk, 4–7 high risk), pooled PLRs at day 2, 7, 30 and 90 were 1.40 (95%CI 1.28–1.53), 1.43 (1.32–1.55), 1.30 (1.19–1.42) and 1.38 (1.29–1.48) respectively. Corresponding pooled NLRs were 0.39 (95%CI 0.30–0.50), 0.39 (0.30–0.50), 0.51 (0.23–1.15) and 0.41 (0.34–0.48). There was significant PLR heterogeneity across all cut-offs (P < 0.01, I2 > 50%). Random error explained the majority of NLR heterogeneity.
Conclusion: In this pooled analysis of likelihood ratios, the ABCD2 score had limited capacity to confidently assign risk of early stroke.
P33
Perineural vertebral ozone injections causing posterior circulation stroke: a case series
Schutz A, Kavalieros P, Reyneke E, Heard R, Whyte S, Sturm J, Crimmins D
Neurology Department, Gosford Hospital, New South Wales, Australia
Background: Therapeutic perineural infiltration of local anaesthetic, steroid agents and ozone for chronic neck and back pathology is becoming common practice on the NSW Central Coast. Patient self-referral (through community advertising programs), and GP referrals are mainstay, resulting in an explosion of patients exposed to these procedures over the last 3 years. This is despite a paucity of evidence regarding the short and long term efficacy.
Cases: We present two cases of stroke as a direct result of perineural infiltrations in the left C5/6 region in a radiology practice, and a single case arising from a GP administering therapy in the right C2/3 region in the absence of radiological guidance. All patients were in their sixties and all suffered posterior circulation strokes seen on MRI with varying degrees of clinical deficit.
Conclusion: Perineural infiltration with ozone has only marginal effect in acute and chronic settings. Proper patient selection is therefore paramount. We present these cases to highlight that these interventions are not benign, and can have devastating outcomes. Patient self referral to radiology practices and in-house ‘blind’ injections are clearly inappropriate, and may even engender a culture where GPs feel compelled to perform what has become a ‘common procedure’ in a community practice.
P34
Community awareness 7 years of stroke week on the central coast (2003–2010)
Watkins J, Burrows J
Central Coast Local Health Network, Gosford, NSW, Australia
Background: In 2003 the Stroke Team on the Central Coast commenced a campaign to improve stroke awareness within the community during Stroke Week.
Aim: Unite pre-hospital, acute, rehabilitation, community and local support groups to raise community awareness of the risk factors, signs and symptoms of stroke.
Method/Activities: Display stands were set up at Gosford and Wyong Hospitals and local shopping centres. Blood pressure and risk factors were assessed and results given to the consumer to provide to their General Practitioner (GP). Advice was provided to address modifiable risk factors and supplemented with health promotional material. Signs and symptoms of stroke were highlighted.
Results: Four local shopping centres were canvassed with 1090 community members screened, with analysis of people screened; blood pressures recorded; percentage of blood pressures greater than 140/90; percentage of diastolic readings greater than 90; and average age.
Conclusion: This poster illustrates health care and community services working together to promote primary prevention of stroke. The Team endeavours to: encourage use of the FAST principles; spare families the trauma of stroke through identification and modification of risk factors; heighten GP awareness of risk factors in their patients; highlight local support groups; strengthen the ties between community, pre-hospital, acute, rehabilitation, GPs and local support groups.
POSTERS Thursday, 15 September
P35
Between countries variation in in-hospital management of intracerebral haemorrhage in the INTERACT2 trial
Delcourt C1,2,3, Heeley E1,2,3, Huang Y4, Anderson C1,2,3
1The George Institute for Global Health, 2University of Sydney, 3Royal Prince Alfred Hospital, Sydney, Australia, 4Peking University First Hospital, Beijing, China
Background: Reports suggest that stroke management varies between countries. We used preliminary INTERACT2 study data to compare in-hospital management of intracerebral haemorrhage (ICH) between European and Chinese participating sites.
Methods: INTERACT2 is a randomised controlled trial of the effects of early intensive blood pressure lowering in patients within acute ICH and elevated systolic BP (150–220 mmHg). Descriptive statistics were used to test for differences in management 1436 patients from China and 295 patients from Europe.
Results: There were highly significant (P < 0.0001) regional differences in management, with higher proportions of patients in Europe receiving swallowing assessment (72.2% in Europe, vs. 12.6% in China), allied health care (84.8% vs. 8.4%), subcutaneous heparin (76.4% vs. 0.3%), vitamin K (4.2% vs. 0.7%) and recombinant Factor VIIa (2.7% vs. 0.6%), and less patients receiving mannitol (9.5% vs. 85.4%).
Conclusion: There is large regional variation in the Background: management of patients with ICH participating in INTERACT2. Differences in the availability of resources, local practice customs, and use of evidenced-based guidelines, are possible explanations.
P36
Socioeconomic disparities in stroke rates and outcome: pooled analysis of stroke incidence studies in Australia and New Zealand
Heeley E1, Wei J1, Carter K2, Islam S1, Thrift A3, Hankey G4,5, Cass A1, Anderson C1
1The George Institute for Global Health, Sydney, Australia, 2Department of Public Health, Wellington School of Medicine and Health Science, University of Otago, Dunedin, New Zealand, 3Department of Medicine, Monash Medical Centre, Southern Clinical School, Monash University, Clayton, Australia, 4The University of Western Australia, Crawley, Australia, 5Royal Perth Hospital, Perth, Australia
Background: There remains uncertainty regarding the significance of socioeconomic status (SES) in determining risks and outcomes in stroke.
Methods: Data were pooled from four methodologically ‘ideal’ stroke incidence studies in three cities (Perth, Melbourne and Auckland) in Australasia undertaken between 1995 and 2003. Population area (SES) measures from census statistics data were used to quantify socioeconomic variations in incidence and 12-month case-fatality of stroke.
Results: Annual age-standardised stroke incidence ranged from 77 (95% confidence interval [CI] 72–83) per 100,000 in the least deprived areas to 131 (95% CI 120–141) per 100,000 in the most deprived areas (rate ratio 1.70, 95% CI 1.47–1.95; P < 0.001). The population attributable risk of stroke due to socioeconomic deprivation was 19% (95% CI 12%–27%). Patients from the most deprived areas tended to be younger (mean age 68 years vs. 77 years, P < 0.001), had more co-morbidities such as hypertension (58% vs. 51%, P < 0.001) and diabetes (22% vs. 12%, P < 0.001), and were more likely to smoke (23% vs. 8%, P < 0.001). After adjustment for age, area level SES was not associated with 12-month case-fatality.
Conclusions: These data provide evidence that residents of more socially deprived areas have higher rates of stroke.
P37
Australian stroke genetics collaborative: genetic associations with ischaemic stroke functional outcome
Maguire J1,2,5,10, Holliday E1,3, Sturm J1,5, Golledge J9, Lewis M6,7, Koblar S6,7, Jannes J6,7, Hankey G8, Lincz L2, Moscato P2, Baker R8, Parsons M1,2, Scott R1, Attia J1,2, Levi C1,2
1University of Newcastle, Faculty of Health, 2Hunter Medical Research Institute, (HMRI), 3Centre for Clinical Epidemiology and Biostatistics, 4University of Newcastle, School of Biomedical Science, Newcastle, 5Neurosciences Department, Gosford Hospital, Gosford, New South Wales, 6University of Adelaide, South Australia, 7The Queen Elizabeth Hospital, Adelaide, 8University of Western Australia, Perth, 9James Cook University Townsville, Queensland, 10Neurology Department, John Hunter Hospital, Newcastle, New South Wales, Australia
Background/Aims: Emerging evidence suggests that genetic factors influence stroke occurrence, however, little is known about genetic influences on IS functional outcome. We aimed to identify genetic variants associated with long-term functional outcome (FO).
Methods: We conducted GWAS to examine single nucleotide polymorphisms associated with IS outcomes from 1230 cases. A sub-group (n = 503; n = 629) were followed longitudinally for FO at 3 months. Preliminary analysis: additive genetic model without adjustment. FO measures: mRs, GOS ≥2; Barthel ≥90 (favourable).
Results: SNPs were identified as associating with all 3 measures of functional outcome: mRs ch8 rs10505101 (P = 8.27E-07 OR: G allele= 0.47, 95% CI 0.35-0.64); GOS ch8 rs10505101 (P = 2.1 × 10−6, OR: G allele = 0.46, 95% CI 0.34–0.64) ch14 rs10143718 (P = 8.8 × 10−7, OR: A allele = 0.34 95% CI 0.23–0.53); BI ch8 rs2935545 (P = 5.25 × 10−6, OR: A allele = 0.56, 95% CI 0.43–0.72) ch17 rs7209700 (P = 2.1 × 10−6 OR: G allele = 0.55, 95% CI 0.43–0.70).
Conclusions: All three FO measures demonstrated association with aligned SNPs on ch8. These signals inhabit a region close to angiopoietin 1 gene coding for a glycoprotein gene involved in blood vessel remodelling, vessel stability and maturation. Further analyses and pooling of international GWAs data is underway.
P38
Levels of T cells and cytokines after acute ischaemic stroke
Sheikh N1, Yan J2, Hull R1, Greer J2, Read S1, McCombe P1,2
1Royal Brisbane & Women's Hospital, Brisbane, 2The University of Queensland, Centre Clinical Research, Queensland, Australia
Introduction: Inflammation at the site of infarct contributes to damage in acute ischaemic stroke (AIS). In some subjects there is size related immune suppression soon after stroke. The immune system can also participate in repair through regulatory T cells (Treg) in the weeks following stroke. We aimed to assess the post-stroke activation of the peripheral immune system by measuring levels of T cells and cytokines.
Methods: We recruited 60 patients with AIS (classified according to the Oxfordshire classification) and 57 age-matched healthy controls. Blood was collected on days 1, 7-10 and 21 post-stroke. Peripheral blood leukocytes (PBL) were isolated and subsets were identified by flow cytometry. Levels of IL-6, IL-10 and TGFβ were measured by ELISA.
Results: The percentage of activated T cells (and Treg cells) as well as levels of IL-6 and TGFβ were significantly increased at days 7 and 21. When patients were classified according to the Oxfordshire classification, there was no significant difference in the levels of T cells among the groups.
Discussion: We confirm that there is immune activation after stroke continuing for at least some weeks. The elevated level of Treg cells is of interest as they contribute to recovery in experimental stroke models.
P39
Digital map of Infarction in Patients with Hypoxic-Ischemic Brain Injury Post Arrest
Singhal S1, Wong K2, Ly J2, Ma H2, Phan T2
1Stroke and Ageing Research Group, Monash Medical Centre, Southern Clinical School, Monash University, 2Stroke Unit, Monash Medical Centre, Southern Health, Clayton, Victoria, Australia
Background: Hypoxic-ischemic brain (HIB) injury has been thought to result in infarction in ‘watershed’ zones, however there has been no formal evaluation of the topography of such lesions. This study aims to develop an understanding of the regional risk of infarction post HIB injury in patients post arrest.
Methods: We included patients with cardio-respiratory arrest between the years 2008 to 2010. The inclusion criteria were: age >17 years and a diagnosis of coma on admission. Infarcts were manually segmented on T2-weighted magnetic resonance images (FLAIR and diffusion weighted sequences) obtained >24 h after arrest. Segmented images were averaged to yield the probability of infarction at each voxel.
Results: Forty-one (mean age 51.5 years, range 17–81 years) were studied. In our atlas, the highest frequency of infarction on the diffusion-weighted and FLAIR sequences was within the caudate (probability 0.32), putamen (probability = 0.27), temporoparietal cortical involvement (P = 0.17) There was low probability of infarction in external ‘watershed’ zones (P = 0.07) and internal ‘watershed’ zones (P = 0.02).
Conclusion: We have created a probabilistic digital of HIB infarction. This approach is useful in establishing the spatial distribution of infarction in HIB injury post cardio-respiratory arrest.
P40
Can the public recall the components of the FAST (Face, Arm, Speech and Time) awareness campaign?
Bray J2,3, Mosley I3, Johnson R1, Trobbiani K1, Cadilhac D3,4, Lalor E1, Sison J1, Bolam B1
1National Stroke Foundation of Australia, 2Ambulance Victoria, 3Monash University, 4National Stroke Research Institute
Introduction: Since 2006 the National Stroke Foundation (NSF) have promoted stroke symptoms nationally using the FAST (Face, Arm, Speech, Time) campaign. Victoria is the only state that has provided funded and comprehensive media campaigns.
Aim: To examine trends in awareness of FAST and recall of its components in Victoria between 2007–2010.
Methods: Structured surveys were conducted using an independent, computer assisted telephone interviewing (CATI) program on random samples of adults (>40 years) in Victoria. Comparisons were made using chi-2 analysis.
Results: Overall awareness of the FAST message (prompted and unprompted) improved from 35% in 2007 to 43% in 2010 (P = 0.001). Recall of all four components has not significantly changed since 2007 (7% vs. 11% in 2010, P = 0.24). Although linear improvements were seen in recall of FAST symptoms (Face, Arm, Speech): any one (45% in 2007 to 59% in 2010, P < 0.001); any two (34% to 46%, P < 0.001); and any three (17% to 24%, P = 0.07). Recall was highest for Face, then Arm, Speech and Time last.
Conclusions: Important trends were observed in recall of campaign content. However, recall of all four FAST components may not be achievable within the current level of promotion. Targeted strategies may require review of demographic differences in recall.
P41
Authorship conundrums
Hamilton-Bruce MA1, Koblar SA2
1Stroke Research Programme, Neurology, The Queen Elizabeth Hospital, 2Stroke Research Programme, School of Medicine, University of Adelaide
Background: Scientific authorship impacts on academic appointment and promotion, research funding and professional reputation. However, authorship publication pitfalls as described in the scientific literature in a range of disciplines, including stroke, can affect these.
Aim: To explore authorship issues in science, including those related to honorary authorship and authors who are not attributed.
Method: The literature in scientific, social and legal databases was reviewed, frameworks within which scientific research occurs were summarised and cases described briefly.
Results: The literature review yielded articles covering a range of authorship issues, including those of definition and determination. The legal framework to address these includes legislative and case law, with reference to copyright and moral rights, as well as contract and tort law. The impact of these on authorship issues is described in case vignettes. General recommendations to avoid such issues include clarification and written expression of expectations prior to commencement of research, reference to relevant guidelines and having clear dispute resolution processes(1).
Conclusion: Insights from this exploration, together with recommendations from the literature, may help to minimise or avoid authorship publication pitfalls.
P42
The under-reported nature of Transient Ischaemic Attacks (TIAs): the need to take a qualitative research direction
Krawczyk V1,3, Hamilton-Bruce M2, Koblar S3, Panickar P4
1Centre for Sleep Research, School of Pyschology, Social Work and Social Policy, University of South Australia, Adelaide, SA, Australia, 2The Stroke Research Programme, Department of Neurology, The Queen Elizabeth Hospital & Basil Hetzel Institute for Translational Health Research, Woodville South, SA, Australia, 3The Stroke Research Programme, University of Adelaide, Discipline of Medicine, The Queen Elizabeth Hospital Campus, Woodville South, SA, Australia, 4The Hawke Research Institute, University of South Australia, Underdale, SA, Australia
Background: TIAs are often a forewarning to a stroke. With an ageing population, the incidence of stroke will significantly increase. Understanding social practices that hinder detection of TIAs or result in people delaying seeking medical attention is key.
Aim: Develop a social scientific research strategy to understand and address social practices that lead to the under-reporting of TIAs to health professionals.
Method: Research methods included a literature review, and electronic searches to determine public awareness of TIAs and how current TIA research aligns with social scientific examination.
Results: Research is quantitative focused. Public awareness of TIA is minimal. TIAs are under-reported by those who experience them. A significant discovery is that there is no research on the decision-making processes of individuals with TIAs to seeking medical care.
Conclusion: The quantitative focus of current research cannot offer a deep understanding into what social practices create conditions for TIAs to be under-reported. A qualitative exploration of the experiences of people who have had a TIA is required to find out what social practices are involved in the disease's under-reportage. Incorporating illness seeking behavioural theory into such research focuses attention on why and how the decisions of people with TIAs result in under-reporting.
P43
Circadian blood pressure variation and heart rate variability in patients with TIA or minor stroke compared with controls
Zhang WW1,2, Cadilhac D1,2, Churilov L1, Donnan G2,4, O'Callaghan C2,5, Dewey H1,2,3
1National Stroke Research Institute, Florey Neurosciences Institutes, Victoria, 2Department of Medicine, University of Melbourne, Victoria, 3Neurology Department, Austin Hospital, Victoria, 4Florey Neuroscience Institutes, Victoria, 5Clinical Pharmacology, Austin Health, Victoria
Background: The circadian blood pressure (BP) pattern and the relationship with autonomic nervous function in patients with TIA or minor stroke is uncertain.
Methods: Patients with TIA/minor stroke recruited within 7 days after onset and age-sex group matched control participants were assessed using a 24-h ambulatory BP monitor (Spacelab 90217) and an ECG-based Heart Rate Variability (HRV) test.
Results: 76 patients (mean age 68 years, 59% male) and 82 controls (mean age 66 years, 54% male) were recruited. No statistically significant differences were found on distribution of circadian BP patterns and HRV comparing patients and controls. A greater proportion of subjects with a history of hypertension (n = 79) had abnormal circadian BP patterns (risk difference −0.17, 95%CI −0.32 to −0.01, P = 0.04) and lower HRV (P < 0.05) than subjects without hypertension (n = 61).
Conclusion: Patients with TIA/minor stroke have similar HRV and circadian BP patterns when compared to controls. This differs from studies of acute stroke where impaired HRV and abnormal BP pattern are more likely to be present and treatment according to different circadian BP variations has been recommended. Further studies are needed to provide more information on the influence of autonomic nervous system and circadian BP patterns for TIA and minor stroke.
P44
Measuring muscle thickness after stroke using ultrasound
Fisher L1, English C1, Thoirs K1, McLennan H1, Bernhardt J2
1University of South Australia, Adelaide, South Australia, 2Florey Neuroscience Institutes, Heidelberg, Victoria, Australia
Background: A reduction in muscle size, of up to 20%, has been shown to occur six-12 months after stroke. Despite this, little is known about changes early after stroke. Ultrasound may be a useful measurement technique as criterion measures such as CT and MRI for repeated measurement of muscle size lack feasibility in the hospital setting.
Aims: To examine the test re-test reliability of ultrasound measures of muscle thickness in hospitalised people early after stroke.
Method: Blinded ultrasound measures of muscle thickness were taken at eight anatomical locations bilaterally (total 16 sites) in 29 participants within two weeks of stroke onset. Repeat measures were taken within 30 min of baseline measures.
Results: Intra-class correlation (ICC) scores ranged from −0.26 (lateral forearm, paretic side) to 0.95 (anterior thigh, non-paretic side). Only six sites had ICC scores and associated 95% confidence intervals within the acceptable range of 0.60 to 1.00. Limits of agreement based on Bland Altman analyses were wide; within the range of ± 25% and as high as 50% of the mean values of muscle thickness.
Conclusion: Further work is needed to identify and minimise sources of error before ultrasound measures can be used for accurate assessment of muscle thickness in hospitalised stroke survivors.
P45
Evaluation and update of Strokelink: a quality improvement program assisting clinical teams in bridging the evidence – practice gap
Hill K1, Herzig M1, Harris N2, Sebar B2, Wenham K2, Price C1
1National Stroke Foundation, 2Griffith University, School of Public Health
Background: StrokeLink is a team based quality improvement (QI) program launched in 2008 by the National Stroke Foundation (NSF) to facilitate reducing the gap between evidence (as outlined in the guidelines) and practice (as found in the national stroke audit).
Aim: To determine if StrokeLink is useful for teams to improve areas of stroke care and explore barriers and enablers of the programs.
Methods: Qualitative and quantitative methods were utilised involving three focus groups (13 participants), semi-structured interviews via phone or face-to-face with key stakeholders (11 interviews with 12 participants) and a survey to all participants (39 responses received). Data was thematically analysed.
Results: Participants recognise StrokeLink as a catalyst for reflection and improvement of stroke care. The credibility and expertise of the NSF staff working on Strokelink is seen as a strength of the program with the workshops and ongoing support in the form of advice, information and connections were instrumental in facilitating change. Lack of time and resources together with the non-engagement by key persons/groups within the care setting were identified as the barriers to implementing change. If data is available, progress demonstrated in the 2011 National stroke audit for sites participating in StrokeLink will be presented.
Conclusion: StrokeLink is an innovative program which provides useful support to stroke teams via data and QI processes to improve care. Currently StrokeLink is the only state wide QI program for stroke available in Australia.
P46
Can we trust the National Stroke Foundation Clinical guidelines?
Wright L, Kelvin H
National Stroke Foundation, Melbourne, Victoria, Australia
Background: Development of clinical practice guidelines for Stroke is complex and resource intensive. In Australia they are developed in accordance with the standards prescribed by the National Health and Medical Research Council (NHMRC). Three of the four guidelines developed by the National Stroke Foundation (NSF) over the last 8 years, have gained NHMRC approval.
Aim: To review the process used to develop the 2010 stroke guidelines.
Methods: After an initial review of the recommended NHMRC steps a survey was developed for the members of the guidelines expert working group (EWG). The survey included review of the appropriateness and usefulness of the methods for those steps that did not have specific NHMRC direction such as selection of the EWG; decision-making processes and working group (WG) operations.
Results: Twenty-three of 34 EWG members responded. Most (>90%) were satisfied with the methods used to select the EWG, chairs and sub-committee. The operations of the WG received very high satisfaction rates (>90%). While the decision-making processes used were more than acceptable to the EWG members surveyed, excellent methods to improve consensus-based decision making were provided.
Conclusion: The 2010 clinical guidelines for stroke management are an important evidence-based platform on which to base clinical practice. Adherence to robust evidence-based standards and processes is foundational to promoting robust evidence-based stroke care.
P47
Trends in patient demographics and outcome measures in a perth metropolitan stroke rehabilitation unit (SRU) from 1996–2010
Chan K1, Granger A1, Van V2
1Stroke Rehabilitation Service, Osborne Park Hospital, Perth, Western Australia, 2Sir Charles Gairdner Hospital, Nedlands, Western Australia
Background and Aim: There is increasing pressure to reduce hospital length of stay and hence health costs. We observed the trends in patient demographics and outcome measures over the last 14 years.
Methods: A prospective database was collected on all patients admitted to the unit. Data collected included patient demographics, stroke characteristics, length of stay (LOS) in referring hospital and SRU, and outcome measures such as Functional Independence Measure (FIM) and discharge destination.
Results: Data on 716 patients were analysed. There was no statistically significant trend in patients' age (r = −0.481, P = 0.07; mean 78.4; range 75.8–80.5) or admission FIM (r = 0.380, P = 0.22; mean 73.8; range 65.2–79.7). Mean LOS has not changed significantly in either SRU (r = −0.179, P = 0.52; mean 34.6 days; range 31.4–45.5) or the referring hospital (r= −0.377, P = 0.17; mean 17.8 days; range 12.9 − 23.9). FIM efficacy (r = 0.109; P = 0.74; mean 18.3; range 12.6–24.1) has not changed significantly. The proportion of patients discharged home (r = 0.360, P = 0.19; mean 58.95%; range 44.0–76.5) has not changed significantly.
Conclusion: SRU LOS has remained largely unchanged despite increasing administrative bed pressures. The recent introduction of an Early Supported Discharge program may have an impact on LOS at the tertiary referral site, and potentially the SRU.
P48
Patient preferences for stroke rehabilitation programs: A discrete choice experiment
Laver K1, Ratcliffe J1, George S1, Lester L2, Walker R3, Burgess L4, Crotty M1,5
1Department of Rehabilitation and Aged Care, Flinders University, 2Flinders Business School, Flinders University, 3South Australia Community Health Research Unit, Flinders University, 4Department of Mathematical Sciences, University of Technology Sydney, 5Department of Rehabilitation and Aged Care, Repatriation General Hospital, Adelaide, South Australia
Background: Recent approaches in stroke rehabilitation involve the use of technologies (such as virtual reality and robotics) and therapy provided at a more intense dose (for example, constraint induced movement therapy). It is currently unclear how acceptable these approaches are to stroke survivors. Discrete choice experiments (DCEs) are a technique that can be used to assess patient preferences and indicate the acceptability of particular characteristics of health care programs.
Aims: To apply DCE methods to assess patient preferences for the delivery of alternative configurations of stroke rehabilitation programs.
Methods: A DCE was conducted as a face-to-face interview to assess the priorities and preferences of 50 stroke survivors (from three South Australian rehabilitation hospitals) for stroke rehabilitation programs. The mean age of participants was 72 years and interviews took place approximately 3-4 weeks following stroke.
Results: Participants indicated strong preferences for a more traditional approach to therapy (such as therapy delivered one-to-one). While moderate intensity programs (3 h of therapy per day) appeared acceptable, participants were averse to very high intensity programs (6 h of therapy per day) and programs involving the use of technologies (such as therapy delivered via a computer).
Conclusion: New therapy approaches, particularly those involving new technologies, must be carefully introduced as stroke survivors appear to prefer more traditional models of service delivery.
P49
Upregulation of Npas4 expression is early and transient following focal cerebral ischemia in adult rodent brain
Leong WK1, Klaric T1, Lewis M1, Koblar SA1,2
1Stroke Research Program, School of Molecular and Biomedical Science, The University of Adelaide, 2School of Medicine, The Queen Elizabeth Hospital, Woodville, South Australia
Background: Stroke is the second leading cause of mortality after cardiovascular disease and the primary cause of adult disability in Australia. Following an ischemic insult, a complex and dynamic series of cellular and molecular events is initiated in the brain, one of which being the release of transcription factors such as the neuronal PAS domain protein 4 (Npas4). Npas4 plays pivotal roles in various brain developmental, physiological and injury events.
Aim: To investigate the spatial and temporal expression of Npas4 protein following ischemic stroke in a rodent model to gain insight into possible roles of Npas4 in the stroke brain.
Methods: Focal cerebral ischemia was induced in the rodent via 2-h middle cerebral artery occlusion. The brain was collected at different time points after reperfusion for Npas4 immunohistochemistry.
Results: Preliminary results demonstrate that robust upregulation of Npas4 protein expression is early and transient in the peri-infarct region. Interestingly, upregulation is restricted to certain structures in the ipsilateral (stroke-affected) hemisphere of the brain. The neural cell types in which Npas4 is expressed remain to be determined.
Conclusion: Our data indicate that Npas4 may play an important role following ischemic stroke.
P50
Withdrawn
P51
A very early rehabilitation trial (AVERT): ongoing phase III trial efficacy & cost effectiveness study AVERT Trialists' Collaboration
National Stroke Research Institute (a part of the Florey Neuroscience Institutes) Melbourne, Australia
Background: Getting patients out of bed within 24 h of stroke may be an important component of effective stroke unit care.
Hypothesis: Within a multi-centre, single blind, randomized controlled trial, we hypothesize that very early mobilisation will reduce death and disability and be cost effective.
Methods: Medically stable patients within 24 h of stroke, first or recurrent, infarct or haemorrhage, including those treated with rtPA are eligible. Patients with severe premorbid disability are excluded. Randomisation is stratified by site and stroke severity. Intervention, delivered by a nurse/physiotherapist team, commences <24 h and continues at least twice daily until discharge (or max 14 days). Control is standard care. Primary outcome: mRS at 3 months. Sample size: 2104 patients.
Progress: Thirty-two hospitals in Australia, New Zealand, Singapore, Malaysia, Scotland Northern Ireland and England participate. May 2011 recruitment: 958 patients (∼6% all admitted strokes). Subjects average age is 70 (SD13) years, 47% have moderate-severe stroke (NIHSS>7), 81% first stroke, 96% were living at home pre-stroke. 178 (19%) have been treated with rtPA. Major reason for ineligibility is hospital admission >24 h post-stroke (40%).
Conclusion: The trial is progressing well. 2011 will see expansion of the trial to 20 UK hospitals.
P52
Wii-based movement therapy promotes improved cardiovascular fitness after stroke
Thompson-Butel A1,2, Scheuer S1,2, Trinh T1, McNulty P1,2
1Neuroscience Research Australia, Sydney, Australia, 2University of New South Wales, Sydney, Australia
Background: Cardiovascular fitness is reduced after stroke resulting in aerobic capacity that is typically ∼50% of healthy controls. This compounds the extent of post-stroke disability, further limiting the independence of patients in activities of daily living.
Aim: To establish the effect of Wii-based movement therapy on cardiovascular fitness post-stroke.
Method: Nine male, three female patients aged 22–74 years, 5–91 months post-stroke (mean 22.5 months) with post-stroke hemiparesis undertook an intensive 2 week Wii-based movement therapy program for upper limb rehabilitation. One hour of formal therapy on 10 consecutive weekdays was augmented by home practice. Heart rate was recorded during early, mid and late therapy sessions using wireless telemetry. Function was assessed using the Wolf Motor Function Test (WMFT) and the Motor Activity Log (MAL).
Results: Peak heart rate increased over time, becoming 23% higher compared to resting rate (P < 0.008). A sport-specific gradient for peak heart rate, and a concomitant improvement in exercise endurance were also observed. Functional ability improved by 33% (WMFT) which transferred to everyday tasks with a 128% improvement (MAL) (both P < 0.001).
Conclusions: Wii-based movement therapy provides a cardiovascular challenge, mitigating the marked reduction in post-stroke fitness. This cardiovascular increase corresponded with a significant improvement in functional ability.
P53
A systematic review of participation measures post-stroke
Tse T1,2, Douglas J1,3, Lentin P4, Carey L1,2
1National Stroke Research Institute, Florey Neuroscience Institutes, 2LaTrobe University, Department of Occupational Therapy, 3LaTrobe University, Department of Human Communication Sciences, 4Monash University, Department of Occupational Therapy, Melbourne, Australia
Background: Participation can be severely affected following stoke.
Aim: To identify and critically review the measures currently used to assess participation in stroke research.
Methods: A systematic review of published articles involving post-stroke assessment of participation was conducted. Relevant articles published between January 2001 and December 2010 were identified through Medline, CINAHL, PsychINFO and ProQuest Central databases. Case studies, cohort studies, and randomised control trials were included. The most frequently used measures were identified and the psychometric properties evaluated. Four independent raters evaluated each measure relative to the International Classification of Functioning, Disability and Health (ICF) Core Set for Stroke (activity and participation categories).
Results: Twenty-nine measures were identified. The Stroke Impact Scale (SIS), London Handicap Scale (LHS), Assessment of Life Habits (LIFE-H), Frenchay Activity Index (FAI), Reintegration to Normal Living Index (RNL), and Activity Card Sort (ACS) were used most frequently. No single measure met criteria across all psychometric indices. The SIS, LIFE-H and the ACS covered the widest range of categories on the ICF Core Set for Stroke.
Conclusion: This review identified and critically evaluated six current and frequently used participation measures and information is provided to guide the selection of participation measures for clinical and research purposes.
P54
Depression screening in stroke patients: A comparison of alternative measures
Turner A1,2, Hambridge J3, White J3, Clover K2,4, Carter G2,4, Nelson L2, Alston M3, Hackett M5
1Heart Research Centre, Victoria, Australia, 2The University of Newcastle, NSW, Australia, 3Hunter New England Health Service, NSW, Australia, 4Calvary Mater Newcastle Hospital, NSW, Australia, 5The George Institute for Global Health, NSW, Australia
Background: Common measures of depression and psychological distress have not been well validated in a stroke population.
Aims: To determine the accuracy of five common screeners of depression or distress in detecting caseness for Major Depressive Episode compared to a clinician-administered structured interview for the DSM-IV as gold standard.
Methods: Seventy-two stroke patients were interviewed and completed the Hospital Anxiety and Depression Scale (HADS), Beck Depression Inventory-II (BDI-II); Patient Health Questionnaire-9 (PHQ-9); Kessler-10 (K-10), and Distress Thermometer (DT). Internal consistency of each measure was calculated. Each measure was validated against the gold standard using receiver operating characteristic curves, with comparison of the area under the curve (AUC) for all measures. Sensitivity and specificity for each measure was determined for established cut-points.
Results: Internal consistency was acceptable for all measures (Cronbach's α = 0.78–0.94). AUC's for the HADS, BDI-II, PHQ-9 and K-10 ranged from 0.81–0.89 with no significant difference between measures. The DT had an AUC of 0.73, significantly smaller than the BDI-II (AUC = 0.89, P < 0.05). The BDI-II and HADS demonstrated best balance between sensitivity (0.85) and specificity (0.75).
Conclusions: Apart from the DT, selected depression and distress measures performed adequately, with no significant difference between measures. Further evaluation is required in stroke patients.
P55
Ummm, about an hour? How accurate are physiotherapists at estimating therapy time in stroke rehabilitation?
Kaur G, English C, Hillier S
University of South Australia, Adelaide, South Australia, Australia
Background: Physiotherapists' accuracy in estimating therapy time is important to enable appropriate interpretation of findings of therapy dosage studies and, to determine how active people are post stroke in therapy sessions.
Aim: To determine how accurate physiotherapists are at estimating total therapy session duration, and the time that stroke patients spend engaged in physical activity vs. the time spent inactive.
Methods: Cross sectional, comparative, observational study. Eight physiotherapists, two physiotherapy aides and fourteen stroke patients were included as participants. Therapists' estimations of therapy time were compared to video-recorded time of the same therapy sessions.
Results: Intraclass correlation coefficient (ICC) scores comparing therapist-estimated and video-recorded data for total therapy time, active time and inactive time for all sessions were 0.95 (95% CI 0.91–0.97), 0.91 (95% CI 0.84–0.95) and 0.76 (95% CI 0.58–0.87) respectively. The mean difference (standard deviation [SD]) between video-recorded and therapist-estimated total therapy time, active time and inactive time was 7.7 (10.5), 14.1 (10.3) and −6.9 (9.5) min respectively. Bland-Altman analyses revealed a systematic bias of overestimation of total therapy time and active time, and underestimation of inactive time by therapists.
Conclusion: Physiotherapists systematically overestimated total therapy time and active time but underestimated the inactive time.
P56
Selection for inpatient rehabilitation following acute stroke: a systematic review of the literature
Hakkennes S1,2, Brock K3, Hill K1,4
1La Trobe University, Bundoora, Victoria, Australia, 2Barwon Health, Geelong, Victoria, Australia, 3St Vincent's Health, Fitzroy, Victoria, Australia, 4Northern Health, Epping, Victoria, Australia
Background: There is considerable variation in practice with regards to access to inpatient rehabilitation following stroke.
Aims: The objective of this study was to identify patient related factors that have been found to correlate with functional outcomes post acute stroke to guide clinical decision making with regard to selection for rehabilitation following acute stroke.
Methods: We systematically searched the scientific literature between 1966 and January 2010. Eligible studies included systematic reviews of prognostic indicators, studies of prognostic indicators of acute discharge disposition and studies of rehabilitation admission criteria following acute stroke.
Results: Of the 8895 studies identified, 83 papers, representing 79 studies, were included in the review. The methodological quality of the included studies was generally poor. Age, cognition, functional level following stroke and continence were found to have a consistent association with outcome across all three-research areas. Gender and side of stroke appeared to have no association.
Conclusion: This review highlights a number of important prognostic indicators and rehabilitation selection criteria that may assist clinicians in improving selection procedures and standardising access to inpatient rehabilitation following stroke. Further high quality studies and reviews of prognostic indicators and clinician decision making with regards to rehabilitation acceptance are required.
P57
A pilot study investigating the effect of a 6 week ‘Physio chi’ programme on balance, mobility and quality of life in community ambulating persons after stroke
Hefferon R1, Kirkman A1, Goodes L2, Singer B3
1School of Physiotherapy, University of Notre Dame, 2Neurotrauma Research Program, WA Institute for Medical Research, 3Centre for Musculoskeletal Studies, School of Surgery, University of Western Australia
Background: Deficits in balance and mobility can restrict participation and reduce quality of life following a stroke. ‘Physio Chi’, a modified version of Tai Chi, may offer a safe, appropriate exercise option for stroke survivors.
Aims: This pilot study aimed to evaluate the outcomes of a short course of Physio Chi on balance, mobility and quality of life post stroke.
Methods: Five community dwelling subjects (mean age 62 ± 5.36 years, 13.3 ± 13.9 years post stroke), undertook a six-week Physio Chi programme. One-hour sessions were conducted twice weekly by a qualified physiotherapist. Postural sway (Pro Balance ®), mobility (Timed up and go) and quality of life (SS36-QOL) were assessed prior to, during and at 12 weeks following completion of the programme. A random effects model analysis compared group means across each phase.
Results: Statistically significant reductions in medio-lateral (1.52ordm;, P = 0.004) antero- posterior (1.18ordm;, P = 0.028) and overall sway (0.42ordm;, P = 0.010) were recorded post intervention. Mean TUG times improved from 24.7 to 21.81 s (P = 0.024). All participants reported and maintained improvement trends in quality of life.
Conclusions: Physio Chi can improve balance and mobility in long-term stroke survivors and may promote better quality of life. Larger trials are needed to confirm these initial findings.
P58
Quality in acute stroke care, patients' age and age-proxy variables. What factors influence the provision of early mobilisation following acute stroke?
Luker J1, Bernhardt J2,3, Grimmer-Somers K1
1International Centre for Allied Health Evidence, University of South Australia, South Australia, 2School of Physiotherapy, La Trobe University, Victoria, 3Stroke Division, Florey Neuroscience Institutes, Melbourne, Victoria, Australia
Background: Evidence supports the early commencement of rehabilitation to optimise stroke outcomes. However early rehabilitation is frequently suboptimal. It remains unclear why some patients receive good quality care and others do not.
Aim: To explore factors associated with the provision of early stroke rehabilitation.
Methods: Our retrospective record audit investigated the quality of care for 300 adults consecutively admitted to South Australian metropolitan hospitals with acute stroke in 2009. Quality of care was determined by compliance with two early rehabilitation process indicators. Predictor variables were patients' age, gender, comorbidities, stroke severity, pre-morbid independence, weekend admission and stroke unit admission. Univariate modelling investigated variables associated with early rehabilitation and with age (age-proxies). Logistical stepwise multivariate models were used to account for confounders.
Results: The provision of early rehabilitation was poor in our sample. Many independent variables, including patients' age, were related to care compliance. However the true determinants of early rehabilitation were confounded by variables which were age-proxies. Multivariate modelling to account for confounders found different drivers for each process indicator: (1) Mild stroke severity was a determinant of early first mobilisatio; (2) Low comorbidity levels were a determinant of early physiotherapy rehabilitation.
Conclusion: Complex factors influence the provision of early stroke rehabilitation, with different variables possibly influencing different processes of care.
P59
Interdisciplinary care in stroke rehabilitation
Klaic M1, Lunt A2
1Monash University, 2Peninsula Health, Melbourne, Victoria, Australia
Background: Interdisciplinary care is a client-centred team approach comprising many disciplines who discuss and problem-solve beyond the scope of individual expertise. Peak national and international bodies recommend an interdisciplinary approach to stroke rehabilitation, however, interpretation and implementation of this model of care varies widely within Victorian sub-acute stroke settings.
Aims: (1) To present findings from a systematic literature review on interdisciplinary models of care in stroke rehabilitation; (2) To highlight the key features of successful interdisciplinary models of care.
Methods: A systematic literature review was completed, including a meta-analysis, on interdisciplinary models of care in stroke rehabilitation.
Results: Utilising PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses), a total of 18 studies were included in the final synthesis. Quality was variable with inconsistent definitions and implementation processes and poor study design. Only three studies were suitable for meta-analysis. We found that interdisciplinary models of practice in stroke rehabilitation: (1) Increase the likelihood of discharge home; and (2) Enhance team member satisfaction.
Conclusion: Interdisciplinary stroke rehabilitation benefits clients, carers and clinicians. However, implementation of this model of care has been challenging due to resource limitations, management practices and lack of evidence. This presentation will challenge stroke rehabilitation providers to reflect on current interdisciplinary practice and consider areas for improvement.
P60
Neural substrates of short and long-term semantic facilitation of naming in aphasia
MacDonald A1, Heath S1, McMahon K1, Angwin A1, Nickels L2, Copland D1
1The University of Queensland, Brisbane, Queensland, 2Macquarie University, Sydney, NSW, Australia
Background: We examined the neural mechanisms underpinning semantic facilitation of naming in aphasia which are currently unknown.
Methods: Five persons with aphasia (PWAs; AV age 55 years, >2 years post-stroke) and 18 controls (AV 57 years) participated. PWA stimuli consisted of two sets of pictures (long-term facilitation, LTF; short-term facilitation, STF) unable to be named at baselines, and one un-facilitated set consistently named at baselines. Prior to fMRI, all participants completed two sessions where LTF items were presented on three occasions with a question (e.g., Does it bark?). During fMRI, all stimuli sets were presented for overt naming, however, STF items were initially presented with a semantic question prior to overt naming.
Results: For controls, LTF was associated with decreased activity in the left middle temporal gyrus, and STF with increased activity in the right lingual, right superior temporal and left inferior occipital gyri. For PWAs, both LTF and STF were associated with increased activity in right and/or left prefrontal cortex and middle/inferior temporal gyri.
Conclusions: For controls, LTF was consistent with a priming effect through semantic mechanisms, while STF implicated episodic/object recognition mechanisms. For PWAs however, both LTF and STF were consistent with increased phonological-semantic processing.
P61
Feasibility of self-assisted computer screening of depression symptoms in stroke patients
Mavratzakis A1, Turner A1,2, Baker A1, White J3, Nelson L1, Hambridge J3
1The University of Newcastle, NSW, Australia, 2Heart Research Centre, Victoria, Australia, 3Hunter New England Health Service, NSW, Australia
Background: The Patient Health Questionnaire-9 (PHQ-9) has been increasingly used for depression screening in stroke patients due to its brevity and strong psychometric properties. The first two items (PHQ-2) can also be used as an ultra-brief screen.
Aims: Feasibility of using self-completed computerised PHQ-2 and PHQ-9 scales with stroke patients was examined by observing assistance required during screening.
Methods: Thirty-eight stroke patients participating in an intervention trial were observed as they completed the computerised depression screen. A research assistant recorded observations of assistance required with the computer and the questions, with behavioural criteria guiding standardised classification.
Results: Two-thirds of participants required assistance with the computer, either continual (29%), a lot (10%) or some (32%). The remaining third required no assistance (29%). Assistance was primarily verbal guidance with survey prompts rather than physical assistance. Twelve patients (32%) required a high level of question assistance at some point throughout the survey, with all cases involving clarification of PHQ item 1. Additional sub-group analyses were carried out.
Discussion: Many stroke patients are able to self-complete an electronic depression screening tool with minimal assistance. Room for improvement exists, however, for the refinement of tools and content delivery to enable higher rates of independent self-completion.
P62
Results of the OPH stroke early supported discharge service: the first 6 months
Tucak C, Morgan P, Granger A, Viandante C, Cream A, West D, Chan K, Jones D
Stroke Rehabilitation Service, Osborne Park Hospital, Perth, Western Australia
Background: Launched in November 2010, the Stroke Early Supported Discharge (ESD) program at Osborne Park Hospital is part of expanded stroke rehabilitation services.
Aim: To provide early stroke specific rehabilitation at home, in mild to moderate stroke patients as an alternative to in-patient care.
Method: Data collected included patient demographics, length of stay (LOS) and outcome measures at admission and discharge to the program including functional, depression and patient/carer satisfaction scales.
Results: In the first 6 months to 30 April 2011, 18 patients with a mean age of 74 were enrolled in the ESD program. The average LOS was 30 days. On average, patients were reviewed within 3.83 days and discharged into ESD within 4 days of referral. Clinical improvements were noted in outcome measures including: Functional Independence Measure (median admission 105.64, median discharge 114.89,% change 8.8); Berg Balance Scale (median admission 47.43, median discharge 51.88,% change 9.4); Modified Barthel Index (median admission 92.44, median discharge 95.17,% change 2.9); Caregiver Strain Index (median admission 7, median discharge 4.5); Geriatric Depression Scale (median admission and discharge 5.5).
Conclusion: Our ESD program has demonstrated encouraging outcomes with the shift of stroke specific rehabilitation from hospital to home.
P63
Setting up a new stroke early supported discharge service: the Osborne park hospital experience
Tucak C, Morgan P, Viandante C, Cream A, West D, Granger A, Chan K, Jones D
Stroke Rehabilitation Service, Osborne Park Hospital, Perth, Western Australia
Background: The National Stroke Foundation clinical guidelines 2010 offer Level 1 evidence for use of an Early Supported Discharge (ESD) program in mild to moderate stroke patients.
Aim: To provide suitable patients in the North Metropolitan Area Health Service with ESD as part of expanded stroke rehabilitation services.
Method: The service entry criteria, patient flowchart and forms were developed in weekly team meetings. Suitable multidisciplinary outcome measures, also acceptable to the Department of Health, were identified and integrated into existing data collection systems. The service is promoted through development of a pamphlet and poster and use of the intranet, letters, presentations and press releases.
Results: The service was created with multidisciplinary input establishing the referral and management pathways, data requirements and clinical input within a 4 month period. The new service has quickly become an established referral pathway, as evidenced by an increase in referrals. The team has been able to support the South Metropolitan Area Health Service in establishing their stroke ESD service.
Conclusion: It is possible to rapidly establish an ESD service using a multidisciplinary approach. Active promotion of the service has quickly led to increased referrals and awareness of the program.
P64
Improvements in service with a dedicated physiotherapy stroke outpatients clinic
Tucak C, Granger A
Stroke Rehabilitation Service, Osborne Park Hospital, Perth Western Australia
Background: A dedicated Physiotherapy Stroke Outpatient Clinic was set up at Osborne Park Hospital as part of recently expanded stroke rehabilitation services.
Aim: This clinic was established in September 2010 to facilitate seamless patient flow from inpatients to outpatients and to link in with the new Stroke Early Supported Discharge service.
Method: Data was reviewed from the year prior to the service starting, including delay from referral to first appointment, number of appointments, length of stay (LOS) and outcome measures. This was compared to the first 6 months' data of the new service.
Results: The delay from referral to first appointment has decreased significantly from an average of 25.57 days previously to 3.85 days. With longer, more frequent appointments patients received on average 12.82 appointments over an average LOS of 9.24 weeks compared to an average of 10.75 appointments over an average LOS of 15.85 weeks previously. Clinical outcome measures now routinely collected are unfortunately not available from the baseline cohort for comparison.
Conclusion: These results show that this stroke specific clinic has significantly reduced the delay in starting outpatient therapy, providing greater treatment intensity and thus reducing LOS, with excellent outcomes still being achieved.
P65
An fMRI investigation of semantic and phonological naming treatment in aphasia
van Hees S1,2, Copland D1,2, Angwin A2, de Zubicaray G3, McMahon K4
1University of Queensland Centre for Clinical Research, 2University of Queensland School of Health and Rehabilitation Sciences, 3University of Queensland School of Psychology, 4University of Queensland Centre for Advanced Imaging, Queensland, Australia
Background: It is not known whether there are different brain mechanisms underlying different treatments for naming impairments post-stroke.
Aim: To examine brain activity associated with successful semantic (meaning-based) vs. phonological (sound-based) treatments of word retrieval using functional Magnetic Resonance Imaging (fMRI).
Methods: Three participants with aphasia received 12 treatment sessions, with MRI scans before and after treatment. Sessions alternated between a phonological and semantic-based treatment. During the scan, participants overtly named 30 ‘known’ items, 30 ‘unknown’ items treated using phonological treatment, and 30 ‘unknown’ items treated using semantic treatment. Activations for successfully named items post-treatment were compared with incorrectly named items pre-treatment.
Results: Results differed among the three participants; however, all three participants showed decreased activation in the right middle temporal gyrus for items treated with phonological therapy. Additionally, two participants both showed decreased activity in motor regions when naming items treated with semantic therapy.
Conclusions: Different approaches to naming therapy may rely on different underlying neural mechanisms. However, this may depend on an individual's locus of breakdown and lesion location.
P66
Withdrawn
P67
The role of occupational therapy in a Stroke EARLY Supported Discharge team: a function based approach
Jones D, Bourgault C
Osborne Park Hospital, Perth, Western Australia
Background: In November 2010 Osborne Park Hospital launched a Stroke Early Supported Discharge (ESD) program in line with the National Stroke Foundation Clinical Guidelines 2010. Occupational Therapy (OT) ESD services are central to a holistic and comprehensive discharge plan and community re-integration.
Aims: To increase functional independence of stroke survivors resulting from ESD OT intervention.
Methods: The clinical specialist ESD OT completes intensive, stroke specific and patient goal directed interventions. The Functional Independence Measure (FIM), Modified Barthel Index (MBI) and the Lawton Instrumental Activities of Daily Living Scale (IADL) are outcome measures used to demonstrate functional improvements following stroke ESD intervention.
Results: In the first 6 months of the program, all 18 patients that were enrolled in the Stroke ESD program received Stroke ESD OT intervention in their homes. Following intervention, functional improvements from admission to discharge were noted: FIM = 9.25 point increase, 8.8% change, MBI = 2.72 point increase, 2.9% change, IADLs = 0.53 point increase, 3.3% change.
Conclusion: The role of the Stroke ESD OT is to provide function based interventions aimed to improve the stroke survivor's functional independence and reduce hospital length of stay. Patients in the program have demonstrated functional improvements according to the above outcome measures.
P68
The effect of progressive resisted strengthening of the thoracic extensors in stroke: a single case study
Perriman D1,2, Scarvell J1,2, Smith P1,2, Hughes A1,3, Lueck C1,3
1College of Medicine and Biology, Australian National University, 2Trauma and Orthopaedic Research Unit, The Canberra Hospital, 3Department of Neurology, The Canberra Hospital
Background: Weakness of the back extensors following stroke has been attributed to decreased function. The effect of progressive resisted strengthening (PRS) of the back extensors after stroke has not been reported.
Aim: To examine the effect of PRS of the thoracic erector spinae (TES) in a person with stroke.
Methods: Single-subject AB design on a 71 year-old male three years after CVA. Baseline measurements taken at 0 and 12 weeks and then at 24 weeks following 12 weeks of PRS (3 × per week). Outcome measures included four physical function tests (10 m walk, timed up and go, × 5 sit to stand, and the stair test) and the motor assessment scale (MAS) for stroke. 6 h (normal day) thoracic spine angle and movement frequency were measured with the flexible-electrogonimeter. A pedometer measured the mobilisation rate.
Results: The MAS was unchanged. However, physical function tests improved considerably and stairs were only possible after PRS. The mean thoracic angle was reduced and the range of movement was increased. Mobilisation rate and the frequency of spinal movement increased but coronal frequency during walking decreased.
Conclusions: Strengthening TES improved function, range of movement and mobility and induced greater trunk stability during gait. Further study is warranted.
P69
Social work interventions in an early supported discharge program
Viandante C
Osborne Park Hospital Stroke Rehabilitation Service, Perth, Western Australia
Background: The Stroke Early Supported Discharge (ESD) program was implemented at Osborne Park Hospital (OPH) in November 2010. The role of Social Work in ESD was established to provide seamless discharge planning and follow-up post discharge from the hospital setting.
Aims: To provide ESD Social Work interventions to support the stroke survivor and carer through the provision of a comprehensive service. This includes assisting with carer stress and counselling.
Methods: The Caregiver Strain Index (CSI) is used to provide carer stress scores on admission to and discharge from the ESD program, along with a data base indicating whether the stroke survivor or their carer required counselling.
Results: Ten ESD referrals had a CSI completed on admission and discharge. Four indicated high levels of carer stress upon admission to ESD. Two had increased scores upon discharge. Four were referred for ongoing counselling. No stroke survivors required hospital readmission.
Conclusion: Whilst these results are from a small group, they suggest the importance of an expanded and flexible Social Work role in the follow-up and support of carers and stroke survivors in a community ESD setting. Identifying and managing carer stress is a crucial part of ensuring success of such a program.
P70
Aphasia therapy and Early Supported Discharge: maintaining evidence based practice through flexibility of service delivery
West D, Cream A, Burnell D, Bridle R
Speech Pathology Department, Osborne Park Hospital, Western Australia
Background: Current principles of rehabilitation of aphasia in the early post stroke phase are based on intensity of therapy. The Early Supported Discharge (ESD) model promotes therapy in the home. Staffing levels allocated to such a programme can provide a challenge to service delivery.
Aim: To provide ESD patients with aphasia a minimum of 5 h aphasia therapy per week.
Method: The traditional speech pathology service of individual therapists responsible for a dedicated caseload was changed to a ‘pool’ of trained therapists. Patients received a mix of home-based therapy and group sessions within the hospital. The integrity of treatment protocols and goals was maintained through speech pathology team meetings.
Results: Six patients received aphasia therapy in the ESD program from Nov 2010-April 2011. Two patients received a single visit. Total number of hours of aphasia therapy to the remaining four patients was 106.5. Mean number of weeks in ESD was 6.25. Mean number of hours therapy per week was 4.3 h per patient.
Conclusion: Intensity of aphasia therapy can be provided to clients of ESD through a restructured approach within the existing speech pathology department. Therapy quality and intensity is maintained in accordance with evidence based practice.
O30
Genome-wide association studies of ischaemic stroke and large artery atherosclerosis
Holliday E1,10,12, Maguire J1,2,8,9, Biros E3, Golledge J3,4, Lewis M5,6, Koblar S5,6, Jannes J5,13, Hankey G7,14, Baker R7,14, Parsons M8, Sturm J9,10, Lincz L11, Moscato P1,12, Scott R1,11,12, Attia J1,10,12, Levi C8
1Centre for Bioinformatics, Biomarker Discovery and Information-Based Medicine, University of Newcastle, NSW, Australia, 2School of Nursing and Midwifery, University of Newcastle, NSW, Australia, 3Vascular Biology Unit, School of Medicine and Dentistry, James Cook University, Queensland, Australia, 4Department of Vascular Surgery, The Townsville Hospital, Queensland, Australia, 5Department of Medicine, University of Adelaide, South Australia, Australia, 6ARC Centre for the Molecular Genetics of Development, University of Adelaide, South Australia, Australia, 7Royal Perth Hospital, Western Australia, Australia, 8Centre for Brain and Mental Health Research, University of Newcastle, NSW, Australia, 9Department of Neurosciences, Gosford Hospital, New South Wales, Australia, 10School of Medicine and Public Health, University of Newcastle, NSW, Australia, 11School of Biomedical Sciences and Pharmacy, University of Newcastle, NSW, Australia, 12Information-based Medicine Program, Hunter Medical Research Institute, NSW, Australia, 13Queen Elizabeth Hospital, Adelaide, South Australia, Australia, 14School of Medicine and Pharmacology, University of Western Australia, Australia
Background: Recent genome-wide association studies (GWAS) have not consistently detected replicable genetic risk factors for ischaemic stroke (IS), potentially due to aetiological heterogeneity of this trait.
Aims: To identify and replicate genetic risk variants for IS and one of its major, heritable subtypes (large artery atherosclerosis: LAA) via GWAS.
Methods: We performed GWAS of IS and LAA using 1162 IS cases (including 421 LAA cases) and 1244 population controls from Australia.
Results: Evidence for a genetic contribution to ischaemic stroke risk was established, but this was stronger and more significant for LAA. The genetic contribution to small vessel disease and cardioembolic stroke was less significant than for overall ischaemic stroke. A novel LAA susceptibility locus was detected on chromosome 6p21.1 (two SNPs with P < 5 × 10−8) and replicated in an independent Wellcome Trust (WTCCC2) cohort of 844 LAA cases and 5972 population controls. The 6p21.1 locus showed markedly diminished association with the broader IS phenotype in both the Australian and WTCCC2 cohorts.
Conclusion: This study suggests a genetic risk locus for LAA and supports the analysis of aetiological subtypes to better identify genetic risk alleles for ischaemic stroke.
O72
Arterial ischaemic stroke in children with heart disease
Hutchinson D1, Cardamone M5, Cheung M1,3,4, Mackay M1,2,3,4
1Department of Cardiology, Royal Childrens Hospital, 2Department of Neurology, Royal Childrens Hospital, 3Murdoch Children's Research Institute, 4Department of Paediatrics, University of Melbourne, Melbourne, Victoria, 5Sydney Childrens Hospital, Sydney, New South Wales, Australia
Aims: To describe the spectrum of cardiac disorders, timing in relation to interventional procedures and outcome in children with cardiac disease and arterial ischemic stroke.
Methods: Retrospective case ascertainment by ICD 9-10 searches from 1993 to 2010.
Results: Seventy-seven children were identified. 53% were <1 year. Cardiac lesions include complex cyanotic congenital heart disease (61%), simple acyanotic lesions (13%), aortic and complex acyanotic lesions (10%), infective endocarditis or myocarditis (6%), cardiomyopathies (6%) and primary arrhythmias (4%). Stroke occurred within 7 days of cardiac procedures in 48 (62%) of children which included open heart surgery (30), cardiac catherisation (11), left ventricular assist device (4), pacemaker insertion (2) and transplantation (1). Perioperative stroke rates varied by diagnostic category being less common with simple acyanotic (6 per 1717 operated cases) and more common with complex acyanotic (10 per 903 cases) or complex cyanotic (13 per 1360 cases) (P = 0.04). Thirteen children died, 54 (84%) of survivors had neurological deficits and 13 (20%) had epilepsy.
Conclusions: AIS in the paediatric cardiac population most commonly affects infants with complex congenital cyanotic heart defects during the peri-procedural period. Prospective cohort studies are required to determine effective primary and secondary prevention intervention strategies.
O81
Does small aneurysm size predict intraoperative rupture during coiling?
Muthusamy S1,2, Yan B1,3, Dowling R3, Mitchell P3
1Department of Neurology, The Royal Melbourne Hospital, 2Department of Medicine, The University of Melbourne, 3Department of Radiology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
Background and Aims: Aneurysm size is a possible risk factor for intraoperative rupture (IOR) during coiling procedures. We sought to clarify if aneurysm size ≤4 mm predicts IOR.
Methods: Between January 1997 and August 2010, 689 aneurysms in 595 patients were treated by coiling at a single institution. Forty-one were excluded from statistical analysis due to missing data leaving 648 aneurysms in 562 patients. Demographic, clinical, and procedural outcomes were collected. We compared the rate of IOR in small aneurysms (≤ 4 mm) with larger aneurysms (>4 mm).
Results: The overall rate of IOR was 5.6%. Aneurysms ≤4 mm were more than twice as likely to rupture on table compared to larger aneurysms (10.1% vs. 4.3%; P = 0.008). Also, ruptured aneurysms were more prone to IOR compared to unruptured aneurysms (8.1% vs. 2.2%; P = 0.001). Aneurysm size ≤4 mm was a risk factor in small, ruptured aneurysms only (P = 0.006). Further, IOR was associated with higher rates of 30 day mortality.
Conclusion: Aneurysm size ≤4 mm a risk factor for IOR in ruptured but not unruptured aneurysms. This additional risk must be considered when planning the management of small, ruptured aneurysms.
O89
Imaging predictors of clinical deterioration in cerebral venous thrombosis
Yii IYL1,2, Mitchell PJ1, Dowling R1, Yan B1,2
1Royal Melbourne Hospital, 2The University of Melbourne, Melbourne, Australia
Background: Cerebral venous thrombosis (CVT) is a rare form of stroke and has a highly variable clinical course. There is limited information on clinical deterioration in these patients, and imaging predictors of deterioration in CVT patients have not been adequately studied.
Aim: We aimed to investigate the radiological predictors of clinical deterioration in CVT patients.
Methods: From 1997–2010, 106 consecutive patients were included based on a confirmed diagnosis of CVT. The following clinical data were collected: patient demographics, risk factors, clinical presentation, radiological findings, treatment and clinical deterioration.
Results: Of the 106 patients, there were 77 females and 29 males, with a mean age of 43 years (range 19–79 years). Overall, 34% of the CVT patients developed clinical deterioration during hospital admission. Univariate analysis showed venous infarcts as a predictor of clinical deterioration (OR = 4.24; 95% CI, 1.7–10.4; P = 0.001). Hyperintensity on diffusion-weighted imaging, parenchymal haemorrhage, vasogenic oedema, midline shift and clot location were not predictive of clinical deterioration.
Conclusion: Our study showed venous infarcts were associated with clinical deterioration in CVT patients. The findings suggest that close monitoring is recommended in this group of patients as they may require more aggressive therapy.
