Oral Presentations BASP Breakfast Session Cochrane Systematic Review of interventions for deliberately altering blood pressure in acute stroke Krishnan K, Bath P, Blood Pressure in Acute Stroke Collaboration Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK Introduction: It is not clear whether blood pressure should be altered actively during the acute phase of stroke. This is an update of a Cochrane review first published in 1997 and subsequently updated in 2001 and 2008. Method: Published and unpublished randomised controlled trials of vasoactive drugs that aimed to alter blood pressure within 1 week of acute ischaemic or haemorrhagic stroke are included. We searched the Cochrane Stroke Group Trials Register, the Cochrane Database of Systematic Reviews, MEDLINE, EMBASE, other databases and review articles, and identified 26 trials including 16,644 patients. The primary outcomes are death or dependency and first blood pressure after randomisation. Secondary outcomes include on-treatment blood pressure and heart rate, early neurological deterioration, early and late death, quality of life and length of stay. Results: The results will be available for presentation in quarter 4, 2014.
Fibrinolytic activity of alteplase and tenecteplase in acute ischaemic stroke Huang X1, Moreton F1, Kalladka D1, Cheripelli B1, Siddiqui A2, Tait R3, Muir K1 1 Institute of Neuroscience and Psychology, University of Glasgow, Glasgow, UK 2 Neuroradiology, Southern General Hospital, NHS Greater Glasgow & Clyde, Glasgow, UK 3 Haematology, Glasgow Royal Infirmary, NHS Greater Glasgow & Clyde, Glasgow, UK
agent tenecteplase has theoretical advantages over its precursor. We compared the fibrinolytic activity of these 2 agents in acute ischaemic stroke patients, and explored whether there was an association between the coagulation parameters, recanalisation and intracerebral haemorrhage (ICH). Method: Venous blood samples from a sub-group of participants in the Alteplase-Tenecteplase Trial Evaluation for Stroke Thrombolysis (ATTEST) study were obtained at baseline, 3–12 h, and 24 ± 3 h post thrombolysis for analysis of plasminogen, PAI-1, D-Dimer, Factor V, Fibrinogen, and FDP, in addition to routine coagulation assays. A generalised linear model was used to compare the differences. Results: 30 patients were recruited in this sub-study (Alteplase = 14, tenecteplase = 16). Compared to baseline, alteplase caused significant differences in Fibrinogen (p = 0.002) and PT (p = 0.014) at time point 2, while no difference was seen in the tenecteplase group. Hypofibrinogenaemia in the alteplase group persisted at 24 h (p = 0.01). There was a trend towards less consumption of plasminogen (p = 0.06), and less likelihood of activating PAI-1 (p = 0.076) with tenecteplase compared with alteplase. In logistic regression analysis, recanalisation was associated with high D-Dimer (p = 0.015) and FDP (p = 0.024) level post-thrombolysis; significantly increased FDP (>10 fold) post-thrombolysis was associated with the occurrence of ICH (p = 0.046). Discussion: In this small sample of patients, tenecteplase caused less disruption to the coagulation system, consistent with reduced incidence of ICH seen in the ATTEST study. D-dimer or FDP may have a role in predicting ICH and recanalisation.
Introduction: Alteplase, the current licensed drug for stroke thrombolysis, may be limited by its pharmacological profile. The modified thrombolytic
Peter Bladin Prizewinner Multi-modal CT in acute stroke: Wait for a serum creatinine before giving intravenous contrast? No? Ang T1,4, Levi C1,4,6, Ma Henry2,9, Hsu C5,10, Campbell B3,8, Donnan G7,8, Davis S3,8, Parsons M1,4 1 John Hunter Hospital, New South Wales, Australia 2 Monash Medical Centre, Melbourne, Australia 3 Royal Melbourne Hospital, Melbourne Australia 4 University of Newcastle, New South Wales, Australia 5 China Medical University, Taichung, Taiwan 6Hunter Medical Research Institute, New South Wales, Australia 7 Florey Neuroscience, Institute, Victoria, Australia 8 University of Melbourne, Melbourne, Australia 9 Monash University, Melbourne, Australia 10 National Health Research Institute, Taiwan Introduction: Multimodal CT to guide decision-making for thrombolysis is increasingly used but there remains a perceived risk of contrast-induced
nephropathy (CIN). At our centre, patients being assessed for thrombolysis have multimodal CT (total contrast dose 150 ml for perfusion CT and CT angiopathy) without waiting for baseline serum creatinine, so as not to delay treatment. We routinely give intravenous saline 80–125 mL/hour for the first 24 hours after multimodal CT. We investigated the incidence of CIN, defined as a 25% or more increase in baseline creatinine levels within 72 hours of contrast administration, and persistent renal impairment in patients receiving multimodal CT. Method: We analysed 667 patients who underwent, multimodal CT studies for evaluation of acute ischaemic or haemorrhagic stroke at a tertiary referral stroke centre during the last 5 years. Retrospectively, we analysed serial creatinine levels (baseline to day 3) and later values (≥ day 4). The incidences of CIN and/or development of persistent renal impairment (>25% in serum creatinine after day 4) were documented. Results: None of the 667 patients developed symptomatic renal disease or required dialysis. Of 601 patients with serial creatinine measurements between baseline and day 3, 17 (2.8%) developed CIN. None had a clinically significant deterioration in renal function. All but 2 of the CIN
© 2014 The Authors. International Journal of Stroke © 2014 World Stroke Organization Vol 9 (Suppl. 4); November 2014; 5–56
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patients had improvement in renal function after day 4. Of the 667 patients (all had baseline and a repeat serum creatinine ≥ day 4), only 5 (0.7%) had a persistent >25% increase in serum creatinine, none were symptomatic (in fact, none had an eGFR 6 mL increase in volume on repeat imaging) from a logistic regression model with time of diagnostic scan as a linear term and random intercepts and slopes for the cohorts. Results: 23 cohorts provided data on 3,925 patients (median age 67 years, 67% past history of hypertension, 5% on anticoagulant and 15% on antiplatelet drugs at onset, median NIHSS 12, median time to diagnostic scan 2.2 h and median time to repeat scan 26.5 h). 786 (20%) patients developed ICH growth. The predicted probability (at 95% confidence interval) of ICH growth according to the time of the diagnostic scan was: 25.7% (22.5–29.3) at 1 h, 21.1% (17.8–24.9) at 3 h, 15.4% (11.4–20.5) at 6 h, 7.8% (4.1–14.2) at 12 h, and 1.8% (0.5–6.7) at 24 h. Discussion: The risk of ICH growth declines with increasing time of diagnostic scan after ICH symptom onset, but it persists up to 24 h. We will present a prediction model at UKSF.
Continue versus withdrawal of pre-stroke antihypertensive therapy in the first week after acute stroke: A randomised controlled trial Scutt P, Woodhouse L, Krishnan K, Bath P, for ENOS Investigators Stroke, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK Introduction: It is not known whether to continue or temporarily withdraw existing antihypertensive drugs in patients with acute stroke. Method: In ENOS, 2097 hospitalised patients with an acute ischaemic or haemorrhagic stroke and elevated systolic blood pressure were randomised to continue or stop, for 7 days, antihypertensive drugs that they had been taking prior to their stroke. The primary outcome was the modified Rankin Scale at 90 days. Other prospective outcomes included discharge destination, activities of daily living and cognition. Results: Functional outcome at day 90 did not differ between the treatment groups (adjusted common odds ratio for worse outcome with con-
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tinue 1·05; 95% confidence interval [CI], 0·90 to 1·22; p = 0·55). Compared with patients who stopped treatment, those who continued it were less likely to be discharged home (56·9% vs 62.6%; p = 0·008) or have moderate/good activities of daily living (Barthel Index ≥60; 59·2% vs 64·7%; p = 0·031); they also had lower cognition scores (Telephone Interview for Cognition Scale-M; p = 0·011) at 90 days. Pneumonia was more commonly reported as a serious adverse event in patients randomised to continue treatment (8.4% vs 6.0%; p < 0.05), and was associated with taking tablets in the presence of dysphagia. Discussion: Immediate continuation of pre-stroke antihypertensive drugs is associated with more disability, cognition and pneumonia. In dysphagia patients, immediate continuation of treatment may lead to pneumonia.
Do thrombolysis door to needle times vary according to the speciality of the thrombolysing consultant? Sivagnanaratnam A, Devine J, Craig T, Foster L, Bathula R, Cohen D Stroke Unit, Northwick Park Hospital, London, UK Introduction: Assessments for thrombolysis and decisions to thrombolyse need to be made in a safe, but speedy manner. Time is brain and one of the ways in which the assessing physician can help the patient is by reducing the door to needle (DTN) time. This study aimed to establish the impact of the speciality of the thrombolysing consultant on DTN times. Method: This large London HASU used a thrombolysis proforma and electronic patient records to record various thrombolysis data prospectively. We looked at the data for the year 2013 which included stroke severity, time of arrival, time to CT head, time the bolus dose of Alteplase was given and the home speciality of the thrombolysing consultant. A total of 369 patients were thrombolysed during this period and DTN times were calculated using the above data. Mood’s median test was used in statistical analysis. Results: DTN times were analysed for consultants with a background in stroke medicine, emergency medicine and geriatric medicine. Median DTN times were 33 minutes (208 patients), 30 minutes (144 patients) and 27 minutes (17 patients), respectively. We showed that there is no significant difference in DTN times between the specialities. Discussion: The absence of a significant difference in DTN times between the different specialities has implications for service planning and delivery. This large study also showed that the DTN times are low among all participating specialities.
Economic crises and cerebrovascular mortality: A worldwide study Maruthappu M1,2, Tariq Z3, Shalhoub J1, Williams C3,4, Zeltner T5,6, Davies A1, Atun R1,2 1 Imperial College London, London, UK 2 Harvard University, Boston, USA 3 University of Oxford, Oxford, UK 4 The Economist, London, UK 5 Special Envoy for Financing to the Director General of the World Health Organization (WHO), Geneva, Switzerland 6 University of Bern, Bern, Switzerland Introduction: The economic downturn has generated significant concern, being associated with unemployment rises, reduced health spending and
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worsened population health. Insights into the impact of economic downturns on specific conditions remain limited. We sought to determine the effect of changes in unemployment and government healthcare expenditure on cerebrovascular mortality. Method: Data were obtained from the World Bank and World Health Organisation. Multivariate regression analysis was used to assess the effect of changes in unemployment and government healthcare expenditure on cerebrovascular mortality. Country-specific differences in infrastructure and population were controlled for. 1–5 year lag analyses and robustness checks were conducted. Results: Across 99 countries, between 1981 and 2009, every 1% increase in unemployment resulted in 187 excess deaths per 100,000 population (CI: 86.6–288, p = 0.0003). For every 1% rise in healthcare expenditure, per 100,000 population, 869 cerebrovascular deaths were prevented (CI: 383– 1354, p = 0.0005). The association between unemployment and cerebrovascular mortality remained statistically significant for 5 years subsequent to the 1% unemployment rise, while the association between healthcare expenditure and cerebrovascular mortality remained significant for 2 years. These relationships were shown to be independent of changes in Gross Domestic Product (GDP) per capita, inflation, interest rates, urbanisation, nutrition, education and out-of-pocket spending. Discussion: Rises in unemployment and reductions in healthcare expenditure are associated with significant increases in cerebrovascular mortality globally. At a policy level, austerity measures are likely to exacerbate cerebrovascular mortality, whereas initiatives that bolster employment and maintain public expenditure may minimise deteriorations in cerebrovascular mortality during economic crises.
Medication adherence post-stroke: An exploratory study of stroke unit nurses’ perspectives of potential problems affecting patients early after discharge Gibson J, Coupe J, Watkins C School of Nursing and Caring Sciences, University of Central Lancashire, Preston, UK Introduction: Poor medication adherence (MA) after stroke is very common and may lead to recurrent stroke or to iatrogenic harm. Nurses working in stroke units may have opportunities to identify and address stroke survivors’ potential MA problems. The aim of this study was to explore UK stroke unit nurses’ experiences and views of opportunities and challenges in preparing patients to manage their medication at home post-stroke. Method: We recruited 15 registered nurses from 1 acute and 1 rehabilitation stroke unit between June and November 2013 via purposive sampling. We conducted individual or small group (2–3) semi-structured interviews to explore beliefs about practical and motivational factors which might affect post-stroke MA, and methods of identifying and addressing post-discharge MA problems. Interviews were audiotaped and transcribed. Thematic analysis was undertaken using NVivo software. Results: Practical factors included: post-stroke dysphagia, dexterity, co-ordination and mobility problems, cognitive impairment, visual impairment, polypharmacy and lack of knowledge. Motivational factors included: depression, preventive nature of medications, concerns about side effects and denial of stroke diagnosis. Factors which were thought to indicate risk of poor MA included living alone and a history of poor adherence. Interventions to address potential MA problems included individualised assessment and planning, multidisciplinary communication, carer involvement and practical measures relating to drug formulation, presentation and regime simplification. Discussion: Nurses play a complex role in promoting post-stroke MA, but this work tends to be unsystematically implemented and documented. Further work is needed to develop, validate, and evaluate methods for assessment and management of post-stroke MA problems.
The impact of stroke service reconfigurations on provision of evidence based stroke care: Controlled before and after analysis Ramsay A1, Morris S1, Hoffman A2, Hunter R3, Boaden R4, McKevitt C5,6,7, Perry C4, Pursani N6, Rudd A5,6,7,8, Turner S1, Tyrrell P9, Wolfe C5,7, Fulop N1 1 Department of Applied Health Research, University College London, London, UK 2 Clinical Standards Department, Royal College of Physicians, London, UK 3 Research Department of Primary Care & Population Health, University College London, London, UK 4 Manchester Business School, University of Manchester, Manchester, UK 5 Division of Health & Social Care Research, King’s College London, London, UK 6 King’s College London Stroke Research Patients and Family Group, King’s College London, London, UK 7 National Institute of Health Research Comprehensive Biomedical Research Centre, Guy’s & St Thomas’ NHS Foundation Trust and King’s College London, London, UK 8 Guy’s and St Thomas’ NHS Foundation Trust, London, UK 9 The University of Manchester Stroke & Vascular Centre, Manchester Academic Health Science Centre, Salford, UK Introduction: In several countries, acute stroke services are being centralised to improve access to organised inpatient stroke unit care. Little is known about how reconfigurations affect patient care processes. We examined the effect of stroke service reconfigurations in two metropolitan areas of England (Greater Manchester and London) on the likelihood of patients receiving evidence-based stroke care. Method: We used a controlled before and after design. Care processes analysed were: admission to stroke unit within 4 h; brain scan within 3–24 h; aspirin within 48 h (if ischaemic); and physiotherapist, nutrition, and swallow assessments within 72 h (if eligible); data were drawn from 2008 to 2012 national audits. We ran logistic regression on whether patients underwent appropriate care against time (pre/post reconfiguration), area (London/Manchester/non-reconfigured area), and interactions between time and area, controlling for age, sex, and stroke diagnosis. Between-hospital variations were analysed at area level. Results: Post-reconfiguration, the likelihood of receiving evidence-based stroke care increased in all areas. London and Manchester improved significantly more than non-reconfigured areas on processes related to the first hours following stroke (Brain scan within 3 h: Manchester between area difference in difference = 6.76%, 95% confidence interval 6.00–7.52; London = 1.90%, CI 1.12–2.69. Stroke unit within 4 h: Manchester = 2.92%, CI 2.14–3.70; London = 2.41%, CI 1.61–3.22). Variation data indicated more general improvements in London than in Greater Manchester. Discussion: External factors, e.g. national policy, may have supported general improvements observed across all regions. Reconfigurations may have supported greater improvements in the first hours of care. Betweenhospital variations may explain significantly greater reductions in patient mortality seen in London compared with Greater Manchester.
© 2014 The Authors. International Journal of Stroke © 2014 World Stroke Organization Vol 9 (Suppl. 4); November 2014; 5–56
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Parallel 2d: Late Breaking Trials and Other Well Designed Studies INTERSTROKE: The importance of conventional and emerging risk factors for stroke in different regions of the world and in different ethnic groups: A case control study Langhorne P1, O’Donnell M2, Chin S3, Zhang H4, Xavier D5, Avezum A5, Mathur N6, Yusuf S3 for the INTERSTROKE Collaborators 1 ICAMS, University of Glasgow, Glasgow, UK 2 NUI, Galway, Ireland 3 PHRI, McMaster University, Hamilton, Canada 4 Beijing Hypertension League Institute, Beijing, China 5 St John’s Medical College and Research Institute, Bangalore, India 6 Institute of Cardiology, Sao Paulo, Brazil Introduction: Stroke is a major global health problem, yet no single standardised study has examined the risk factors for stroke and its subtypes in different ethnic populations in different regions of the world. Any effective global strategy to reduce stroke requires a large, systematic study of traditional and emerging risk factors within defined ethnic groups and geographical locations for each of the stroke subtypes. Method: INTERSTROKE is a large, global, standardised, case-control study coordinated from Canada that is examining the role of conventional and emerging risk factors for stroke. Its aims were to recruit over 24000 participants (12000 stroke cases and 12000 matching controls) from 32 countries, including 2000 from the UK. Results: By December 2013, over 27011 participants had been recruited (13604 cases and 13407 matched controls) including 1985 from UK sites. Analysis is underway with full reporting expected in 2015. Discussion: The final results of INTERSTROKE are expected to have enormous implications for our understanding of risk factors for stroke around the world including recent data from the UK.
The Stroke Oxygen Supplementation (SO2S) study: A multicenter randomised controlled trial of the effect of routine oxygen supplementation on key outcomes at one week Roffe C1,2 on behalf of the Stroke Oxygen Study Collaborative Group 1 Stoke Stroke Research Group, North Staffs Combined Healthcare NHS Trust, Trentham, UK 2 Institute for Science and Technology in Medicine, Keele University, Stoke-on-Trent, UK Introduction: Routine oxygen supplementation early after stroke was associated with a significant improvement in neurological recovery in the stroke oxygen pilot study. The Stroke Oxygen Supplementation (SO2S) study was designed to confirm this and to assess whether oxygen supplementation had a longer-term effect on functional outcomes. Here we report the outcomes of SO2S at 1 week. Methods: Adult patients with a clinical diagnosis of acute stroke were eligible for enrolment within 48 hours of symptom onset, if they had no clear indications for, or contraindications to, oxygen treatment at a rate of 2–3 L/min. Randomisation was to 1 of 3 treatment groups: continuous oxygen for 72 hours, nocturnal (21:00–06:00) oxygen for 72 hours or to the control group who received no oxygen therapy unless needed for clinical indications outside of the trial. The SO2S study is funded by the NIHR-HTA programme (09/104/21). Results: Between 2009 and 2013, 8003 patients were recruited to the SO2S study. Data for 1 week follow-up were available for 7936 patients (median
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age, 74 range 19–100 y; 4398 (54.9%) men; median NIHSS score at baseline 5, range 0–34). We will report the effect of oxygen treatment on neurological recovery, complications and mortality at 1 week. There will be 2 main comparisons, first oxygen (continuous and nocturnal combined) versus control, and second nocturnal oxygen versus continuous oxygen. Discussion: The results of this analysis will show the early effects of routine oxygen supplementation on neurological recovery and early complications after stroke.
Motor and functional outcome 5 years after stroke equals performance at 2 months: Results from the CERISE follow-up study Meyer S1, Verheyden G1, Brinkmann N2, Dejaeger E3, De Weerdt W1, Feys H1, Jenni W4, Lincoln N5, Putman K6,7, Schuback B4, Schupp W2, De Wit L6 1 KU Leuven, Department of Rehabilitation Sciences, Leuven, Belgium 2 Fachklinik Herzogenaurach, Herzogenaurach, Germany 3 University Hospital Pellenberg, Pellenberg, Belgium 4 RehaClinic Zurzach, Zurzach, Switzerland 5 Institute of Work, Health and Organisations, University of Nottingham, Nottingham, UK 6 Department of Medical Sociology and Health Sciences, Vrije Universiteit Brussel, Brussels, Belgium 7 School of Health, University of Central Lancashire, Preston, UK Introduction: Although much is known about the recovery of patients up to 6 months after stroke, there has been little research on long-term recovery. Method: This follow-up study of the CERISE project (Collaborative Evaluation of Rehabilitation In Stroke across Europe) included consecutive patients from 4 European rehabilitation centres, that were assessed on admission to the rehabilitation centre, at 2 and 6 months and 5 years after stroke with the Barthel Index (BI), Rivermead Motor Assessment Gross Function (RMA-GF), Leg/Trunk (RMA-LT) and Arm (RMA-A) scales. Recovery patterns were analysed using linear mixed models. Results: 532 patients were included in this study (mean (SD) age at stroke onset: 69 (10) years, 53% male, 84% ischaemic strokes, 57% left sided impairment). Linear mixed models, corrected for age, gender, type and severity of stroke, revealed a significant improvement for all 4 outcome measures from admission to 2 months (P < 0.0001), and from 2 to 6 months (P < 0.0001). On the contrary, all 4 measures showed a significant deterioration between 6 months and 5 years (P < 0.0001). Interestingly, no significant differences exist between scores at 2 months and 5 years after stroke. Discussion: The long-term assessment revealed deterioration in motor and functional performance after 6 months, with a return to the motor and functional level measured at 2 months. Strategies to prevent this long-term deterioration should be considered and evaluated.
© 2014 The Authors. International Journal of Stroke © 2014 World Stroke Organization Vol 9 (Suppl. 4); November 2014; 5–56
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Does the use of Nintendo Wii SportsTM improve arm function and is it acceptable to patients after stroke? Trial of WiiTM in stroke – TWIST Adie K1, Schofield C1, Berrow M2, Wingham J1, Freeman J3, Humfryes J4, Pritchard C1 on behalf of the TWIST research group 1 Research, Development and Innovation Unit, Royal Cornwall Hospital Trust, Cornwall, UK 2 Peninsula Clinical Trials Unit, Plymouth University Schools of Medicine and Dentistry, Plymouth, UK 3 Independent statistician 4 Lay Member Introduction: Many stroke patients experience loss of arm function requiring rehabilitation, which is expensive, repetitive and does not always translate into ‘real life’. Nintendo Wii SportsTM (WiiTM) may offer task specific training that is repetitive and motivating. TWIST investigated feasibility, efficacy and acceptability using WiiTM to improve affected arm function for patients after stroke. Method: This multicentre study incorporating a randomised controlled trial (RCT) (N = 240), qualitative study (N = 18) and health economics analysis compared use of Nintendo Wii SportTM games (WiiTM) versus arm exercises in patients receiving standard rehabilitation in a home setting within 6 months of stroke with arm weakness. Results: There was no significant difference in primary outcome of affected arm function at 6 weeks follow-up in intervention and control group using the Action Research Arm Test (ARAT) and no significant difference in secondary outcomes including occupational performance using the Canadian Occupational Performance Measure, quality of life using the Stroke Impact Scale. The qualitative study found that WiiTM was enjoyed by most participants. The favourite games were bowling and tennis, least played was boxing. No significant adverse events related to study intervention were reported. The cost effectiveness analysis showed that the WiiTM was more expensive than arm exercises. Discussion: TWIST was the first UK RCT assessing the feasibility, cost effectiveness and acceptability of WiiTM in stroke rehabilitation. Although WiiTM was well received by participants, it did not show superiority of arm function compared to arm exercises at 6 weeks or 6 months and was more expensive than arm exercises.
A patient-specific prediction instrument using functional recovery curves as a management tool after stroke Douiri A, Grace J, McKevitt C, Rudd A, Wolfe C Division of Health and Social Care, King’s College London, London, UK Introduction: Functional recovery prediction is an important aim for stroke survivors. This study develops, validates and assesses the clinical utility of a patient-specific tool for monitoring the progression of functional recovery after stroke. Method: Data were collected from 495 patients after first-ever stroke between August 2002 and October 2004 from the South London Stroke Register in order to develop and refine the prognostic model. Functional recovery was assessed weekly using Barthel Index (BI) up to 52 weeks after stroke. Patient-specific recovery curves were developed using generalised linear mixed models. Predicted recovery curves performance was assessed by internal and temporal cross-validation using 2 different prospective cohorts between the period of 2005 and 2011. Prognostic effectiveness and clinical utility of recovery curves to classify different functional outcomes at different time points were also evaluated. Results: Patient age, gender, NIH Stroke Scale score, Glasgow Coma Scale score and stroke subtype were identified as good independent predictors of recovery and change over time. Predictive accuracy of the recovery curves in the external cohorts was acceptable (root mean squared error of
3.32) BI points up to 52 weeks after stroke. The prognostic accuracy to classify poor recovery at 3 months was also satisfactory, 94% (95% CI [90.9–96.9]) with an acceptable clinical significance measured by positive likelihood ratio (LR+:7.9 [6.0–10.3] and LR-: 0.09 [0.04–0.21]). Conclusion: A recovery curves prediction tool could support health care professionals with decision making in management of patients with a poorer recovery than expected.
Prevention of Decline in Cognition after Stroke Trial: Final results of a factorial randomised trial of blood pressure and lipid lowering (PODCAST) Bath P1, Blackburn D2, Krishnan K1, Ford G3, Ballard C4, Burns A5, Mant J6, Passmore P7, Pocock S8, Reckless J9, Stewart R4,10, Wardlaw J10, for the PODCAST Investigators 1 Stroke Trials Unit, University of Nottingham, Nottingham, UK 2 University of Sheffield, Sheffield, UK 3 Newcastle University, Newcastle, UK 4 King’s College Hospital, London, UK 5 University of Manchester, Manchester, UK 6 University of Cambridge, Cambridge, UK 7 Queens University, Belfast, UK 8 London School of Hygiene and Tropical Medicine, London, UK 9 University of Oxford, Oxford, UK 10 University of Edinburgh, Edinburgh, UK Introduction: Stroke and dementia are common, economically costly to society, and devastating to patients and their families. Elevated blood pressure (BP) and cholesterol are common after stroke and may be associated with increasing cognitive decline. Critically, it is unknown whether BP and cholesterol should be lowered intensively, or moderately as per current guidelines, questions that PODCAST has addressed. Methods: PODCAST was a prospective, randomised, open-label, blinded end-point, partial-factorial, controlled, phase IV trial (http:// www.podcast-trial.org/). Patients comprised those with ischaemic or haemorrhagic stroke who did not have significant cognitive impairment at 3–7 months post index event. The interventions were: intensive (target systolic BP is 30 days) disabling stroke, fatal MI and death was 1.0%. This compares favourably with results from ACST-1, which reported a peri-operative risk of 1.7%. Discussion: ACST-2 participants are on appropriate SPT therapies both peri-procedurally and in the longer term. The peri-procedural serious complication rate is low.
040 Perceived psychosocial stress: A risk factor for TIA? Booth J1, Lawrence M1, Connolly L1, Fraser H2, Dunipace L3, Joice S4, McAlpine C3, Chalmers C5 1 Institute for Applied Health Research, Glasgow Caledonian University, Glasgow, UK 2 NHS Fife, Fife, UK 3 NHS Greater Glasgow & Clyde, Glasgow, UK 4 Tangata Massey University, Palmerston North, New Zealand 5 NHS Lanarkshire, Lanarkshire, UK Introduction: No research has explored the association between perceived psychosocial stress and transient ischaemic attack (TIA)/minor stroke, yet public perception highlights stress as a key risk factor for stroke. This study examined perceived psychosocial stress in people experiencing transient ischaemic attack/minor stroke. Method: A mixed–method study involving a cross sectional survey of perceived stress in three groups of adults (n = 1405): those attending TIA clinics diagnosed with TIA (n = 670); TIA clinic attendees receiving a non-TIA diagnosis (n = 341); treatment room (TR) control group (n = 394). Each clinic attendee completed a structured questionnaire. Qualitative interviews to explore perceptions in detail were undertaken with a sub-set of 16 participants who received a diagnosis of TIA. Results: Survey data showed the TIA group were older and less deprived than the non-TIA and TR control group. They were less likely to believe stress to be a cause of their TIA. Perceived psychosocial stress was common in all groups but the TIA group reported less stress at home, at work and less financial stress than the non-TIA and TR control groups. Qualitative analysis indicated that psychosocial stress was not perceived to be associated with an increased risk of TIA/minor stroke but was reported to increase following a TIA diagnosis. Discussion: Perceived stress was not a significant risk factor for TIA; however it may increase as a result of a TIA/minor stroke diagnosis. The period following diagnosis may be an optimal time to intervene to reduce perceived stress, contributing to effective secondary prevention of stroke.
041 Clinical relevance of short-runs of atrial tachy-arrhythmia: A UK wide survey of stroke physicians and cardiologists
Results: 205 clinicians responded to the survey (130 stroke physicians, 64 cardiologists and 11 other). Regarding the diagnosis of AF, a single 12-lead ECG was accepted by 87% of responders. In contrast, only 45% would accept a single episode lasting
Fibrinolytic activity of alteplase and tenecteplase in acute ischaemic stroke Huang X1, Moreton F1, Kalladka D1, Cheripelli B1, Siddiqui A2, Tait R3, Muir K1 1 Institute of Neuroscience and Psychology, University of Glasgow, Glasgow, UK 2 Neuroradiology, Southern General Hospital, NHS Greater Glasgow & Clyde, Glasgow, UK 3 Haematology, Glasgow Royal Infirmary, NHS Greater Glasgow & Clyde, Glasgow, UK
agent tenecteplase has theoretical advantages over its precursor. We compared the fibrinolytic activity of these 2 agents in acute ischaemic stroke patients, and explored whether there was an association between the coagulation parameters, recanalisation and intracerebral haemorrhage (ICH). Method: Venous blood samples from a sub-group of participants in the Alteplase-Tenecteplase Trial Evaluation for Stroke Thrombolysis (ATTEST) study were obtained at baseline, 3–12 h, and 24 ± 3 h post thrombolysis for analysis of plasminogen, PAI-1, D-Dimer, Factor V, Fibrinogen, and FDP, in addition to routine coagulation assays. A generalised linear model was used to compare the differences. Results: 30 patients were recruited in this sub-study (Alteplase = 14, tenecteplase = 16). Compared to baseline, alteplase caused significant differences in Fibrinogen (p = 0.002) and PT (p = 0.014) at time point 2, while no difference was seen in the tenecteplase group. Hypofibrinogenaemia in the alteplase group persisted at 24 h (p = 0.01). There was a trend towards less consumption of plasminogen (p = 0.06), and less likelihood of activating PAI-1 (p = 0.076) with tenecteplase compared with alteplase. In logistic regression analysis, recanalisation was associated with high D-Dimer (p = 0.015) and FDP (p = 0.024) level post-thrombolysis; significantly increased FDP (>10 fold) post-thrombolysis was associated with the occurrence of ICH (p = 0.046). Discussion: In this small sample of patients, tenecteplase caused less disruption to the coagulation system, consistent with reduced incidence of ICH seen in the ATTEST study. D-dimer or FDP may have a role in predicting ICH and recanalisation.
Introduction: Alteplase, the current licensed drug for stroke thrombolysis, may be limited by its pharmacological profile. The modified thrombolytic
Peter Bladin Prizewinner Multi-modal CT in acute stroke: Wait for a serum creatinine before giving intravenous contrast? No? Ang T1,4, Levi C1,4,6, Ma Henry2,9, Hsu C5,10, Campbell B3,8, Donnan G7,8, Davis S3,8, Parsons M1,4 1 John Hunter Hospital, New South Wales, Australia 2 Monash Medical Centre, Melbourne, Australia 3 Royal Melbourne Hospital, Melbourne Australia 4 University of Newcastle, New South Wales, Australia 5 China Medical University, Taichung, Taiwan 6Hunter Medical Research Institute, New South Wales, Australia 7 Florey Neuroscience, Institute, Victoria, Australia 8 University of Melbourne, Melbourne, Australia 9 Monash University, Melbourne, Australia 10 National Health Research Institute, Taiwan Introduction: Multimodal CT to guide decision-making for thrombolysis is increasingly used but there remains a perceived risk of contrast-induced
nephropathy (CIN). At our centre, patients being assessed for thrombolysis have multimodal CT (total contrast dose 150 ml for perfusion CT and CT angiopathy) without waiting for baseline serum creatinine, so as not to delay treatment. We routinely give intravenous saline 80–125 mL/hour for the first 24 hours after multimodal CT. We investigated the incidence of CIN, defined as a 25% or more increase in baseline creatinine levels within 72 hours of contrast administration, and persistent renal impairment in patients receiving multimodal CT. Method: We analysed 667 patients who underwent, multimodal CT studies for evaluation of acute ischaemic or haemorrhagic stroke at a tertiary referral stroke centre during the last 5 years. Retrospectively, we analysed serial creatinine levels (baseline to day 3) and later values (≥ day 4). The incidences of CIN and/or development of persistent renal impairment (>25% in serum creatinine after day 4) were documented. Results: None of the 667 patients developed symptomatic renal disease or required dialysis. Of 601 patients with serial creatinine measurements between baseline and day 3, 17 (2.8%) developed CIN. None had a clinically significant deterioration in renal function. All but 2 of the CIN
© 2014 The Authors. International Journal of Stroke © 2014 World Stroke Organization Vol 9 (Suppl. 4); November 2014; 5–56
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patients had improvement in renal function after day 4. Of the 667 patients (all had baseline and a repeat serum creatinine ≥ day 4), only 5 (0.7%) had a persistent >25% increase in serum creatinine, none were symptomatic (in fact, none had an eGFR 6 mL increase in volume on repeat imaging) from a logistic regression model with time of diagnostic scan as a linear term and random intercepts and slopes for the cohorts. Results: 23 cohorts provided data on 3,925 patients (median age 67 years, 67% past history of hypertension, 5% on anticoagulant and 15% on antiplatelet drugs at onset, median NIHSS 12, median time to diagnostic scan 2.2 h and median time to repeat scan 26.5 h). 786 (20%) patients developed ICH growth. The predicted probability (at 95% confidence interval) of ICH growth according to the time of the diagnostic scan was: 25.7% (22.5–29.3) at 1 h, 21.1% (17.8–24.9) at 3 h, 15.4% (11.4–20.5) at 6 h, 7.8% (4.1–14.2) at 12 h, and 1.8% (0.5–6.7) at 24 h. Discussion: The risk of ICH growth declines with increasing time of diagnostic scan after ICH symptom onset, but it persists up to 24 h. We will present a prediction model at UKSF.
Continue versus withdrawal of pre-stroke antihypertensive therapy in the first week after acute stroke: A randomised controlled trial Scutt P, Woodhouse L, Krishnan K, Bath P, for ENOS Investigators Stroke, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK Introduction: It is not known whether to continue or temporarily withdraw existing antihypertensive drugs in patients with acute stroke. Method: In ENOS, 2097 hospitalised patients with an acute ischaemic or haemorrhagic stroke and elevated systolic blood pressure were randomised to continue or stop, for 7 days, antihypertensive drugs that they had been taking prior to their stroke. The primary outcome was the modified Rankin Scale at 90 days. Other prospective outcomes included discharge destination, activities of daily living and cognition. Results: Functional outcome at day 90 did not differ between the treatment groups (adjusted common odds ratio for worse outcome with con-
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tinue 1·05; 95% confidence interval [CI], 0·90 to 1·22; p = 0·55). Compared with patients who stopped treatment, those who continued it were less likely to be discharged home (56·9% vs 62.6%; p = 0·008) or have moderate/good activities of daily living (Barthel Index ≥60; 59·2% vs 64·7%; p = 0·031); they also had lower cognition scores (Telephone Interview for Cognition Scale-M; p = 0·011) at 90 days. Pneumonia was more commonly reported as a serious adverse event in patients randomised to continue treatment (8.4% vs 6.0%; p < 0.05), and was associated with taking tablets in the presence of dysphagia. Discussion: Immediate continuation of pre-stroke antihypertensive drugs is associated with more disability, cognition and pneumonia. In dysphagia patients, immediate continuation of treatment may lead to pneumonia.
Do thrombolysis door to needle times vary according to the speciality of the thrombolysing consultant? Sivagnanaratnam A, Devine J, Craig T, Foster L, Bathula R, Cohen D Stroke Unit, Northwick Park Hospital, London, UK Introduction: Assessments for thrombolysis and decisions to thrombolyse need to be made in a safe, but speedy manner. Time is brain and one of the ways in which the assessing physician can help the patient is by reducing the door to needle (DTN) time. This study aimed to establish the impact of the speciality of the thrombolysing consultant on DTN times. Method: This large London HASU used a thrombolysis proforma and electronic patient records to record various thrombolysis data prospectively. We looked at the data for the year 2013 which included stroke severity, time of arrival, time to CT head, time the bolus dose of Alteplase was given and the home speciality of the thrombolysing consultant. A total of 369 patients were thrombolysed during this period and DTN times were calculated using the above data. Mood’s median test was used in statistical analysis. Results: DTN times were analysed for consultants with a background in stroke medicine, emergency medicine and geriatric medicine. Median DTN times were 33 minutes (208 patients), 30 minutes (144 patients) and 27 minutes (17 patients), respectively. We showed that there is no significant difference in DTN times between the specialities. Discussion: The absence of a significant difference in DTN times between the different specialities has implications for service planning and delivery. This large study also showed that the DTN times are low among all participating specialities.
Economic crises and cerebrovascular mortality: A worldwide study Maruthappu M1,2, Tariq Z3, Shalhoub J1, Williams C3,4, Zeltner T5,6, Davies A1, Atun R1,2 1 Imperial College London, London, UK 2 Harvard University, Boston, USA 3 University of Oxford, Oxford, UK 4 The Economist, London, UK 5 Special Envoy for Financing to the Director General of the World Health Organization (WHO), Geneva, Switzerland 6 University of Bern, Bern, Switzerland Introduction: The economic downturn has generated significant concern, being associated with unemployment rises, reduced health spending and
© 2014 The Authors. International Journal of Stroke © 2014 World Stroke Organization Vol 9 (Suppl. 4); November 2014; 5–56
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worsened population health. Insights into the impact of economic downturns on specific conditions remain limited. We sought to determine the effect of changes in unemployment and government healthcare expenditure on cerebrovascular mortality. Method: Data were obtained from the World Bank and World Health Organisation. Multivariate regression analysis was used to assess the effect of changes in unemployment and government healthcare expenditure on cerebrovascular mortality. Country-specific differences in infrastructure and population were controlled for. 1–5 year lag analyses and robustness checks were conducted. Results: Across 99 countries, between 1981 and 2009, every 1% increase in unemployment resulted in 187 excess deaths per 100,000 population (CI: 86.6–288, p = 0.0003). For every 1% rise in healthcare expenditure, per 100,000 population, 869 cerebrovascular deaths were prevented (CI: 383– 1354, p = 0.0005). The association between unemployment and cerebrovascular mortality remained statistically significant for 5 years subsequent to the 1% unemployment rise, while the association between healthcare expenditure and cerebrovascular mortality remained significant for 2 years. These relationships were shown to be independent of changes in Gross Domestic Product (GDP) per capita, inflation, interest rates, urbanisation, nutrition, education and out-of-pocket spending. Discussion: Rises in unemployment and reductions in healthcare expenditure are associated with significant increases in cerebrovascular mortality globally. At a policy level, austerity measures are likely to exacerbate cerebrovascular mortality, whereas initiatives that bolster employment and maintain public expenditure may minimise deteriorations in cerebrovascular mortality during economic crises.
Medication adherence post-stroke: An exploratory study of stroke unit nurses’ perspectives of potential problems affecting patients early after discharge Gibson J, Coupe J, Watkins C School of Nursing and Caring Sciences, University of Central Lancashire, Preston, UK Introduction: Poor medication adherence (MA) after stroke is very common and may lead to recurrent stroke or to iatrogenic harm. Nurses working in stroke units may have opportunities to identify and address stroke survivors’ potential MA problems. The aim of this study was to explore UK stroke unit nurses’ experiences and views of opportunities and challenges in preparing patients to manage their medication at home post-stroke. Method: We recruited 15 registered nurses from 1 acute and 1 rehabilitation stroke unit between June and November 2013 via purposive sampling. We conducted individual or small group (2–3) semi-structured interviews to explore beliefs about practical and motivational factors which might affect post-stroke MA, and methods of identifying and addressing post-discharge MA problems. Interviews were audiotaped and transcribed. Thematic analysis was undertaken using NVivo software. Results: Practical factors included: post-stroke dysphagia, dexterity, co-ordination and mobility problems, cognitive impairment, visual impairment, polypharmacy and lack of knowledge. Motivational factors included: depression, preventive nature of medications, concerns about side effects and denial of stroke diagnosis. Factors which were thought to indicate risk of poor MA included living alone and a history of poor adherence. Interventions to address potential MA problems included individualised assessment and planning, multidisciplinary communication, carer involvement and practical measures relating to drug formulation, presentation and regime simplification. Discussion: Nurses play a complex role in promoting post-stroke MA, but this work tends to be unsystematically implemented and documented. Further work is needed to develop, validate, and evaluate methods for assessment and management of post-stroke MA problems.
The impact of stroke service reconfigurations on provision of evidence based stroke care: Controlled before and after analysis Ramsay A1, Morris S1, Hoffman A2, Hunter R3, Boaden R4, McKevitt C5,6,7, Perry C4, Pursani N6, Rudd A5,6,7,8, Turner S1, Tyrrell P9, Wolfe C5,7, Fulop N1 1 Department of Applied Health Research, University College London, London, UK 2 Clinical Standards Department, Royal College of Physicians, London, UK 3 Research Department of Primary Care & Population Health, University College London, London, UK 4 Manchester Business School, University of Manchester, Manchester, UK 5 Division of Health & Social Care Research, King’s College London, London, UK 6 King’s College London Stroke Research Patients and Family Group, King’s College London, London, UK 7 National Institute of Health Research Comprehensive Biomedical Research Centre, Guy’s & St Thomas’ NHS Foundation Trust and King’s College London, London, UK 8 Guy’s and St Thomas’ NHS Foundation Trust, London, UK 9 The University of Manchester Stroke & Vascular Centre, Manchester Academic Health Science Centre, Salford, UK Introduction: In several countries, acute stroke services are being centralised to improve access to organised inpatient stroke unit care. Little is known about how reconfigurations affect patient care processes. We examined the effect of stroke service reconfigurations in two metropolitan areas of England (Greater Manchester and London) on the likelihood of patients receiving evidence-based stroke care. Method: We used a controlled before and after design. Care processes analysed were: admission to stroke unit within 4 h; brain scan within 3–24 h; aspirin within 48 h (if ischaemic); and physiotherapist, nutrition, and swallow assessments within 72 h (if eligible); data were drawn from 2008 to 2012 national audits. We ran logistic regression on whether patients underwent appropriate care against time (pre/post reconfiguration), area (London/Manchester/non-reconfigured area), and interactions between time and area, controlling for age, sex, and stroke diagnosis. Between-hospital variations were analysed at area level. Results: Post-reconfiguration, the likelihood of receiving evidence-based stroke care increased in all areas. London and Manchester improved significantly more than non-reconfigured areas on processes related to the first hours following stroke (Brain scan within 3 h: Manchester between area difference in difference = 6.76%, 95% confidence interval 6.00–7.52; London = 1.90%, CI 1.12–2.69. Stroke unit within 4 h: Manchester = 2.92%, CI 2.14–3.70; London = 2.41%, CI 1.61–3.22). Variation data indicated more general improvements in London than in Greater Manchester. Discussion: External factors, e.g. national policy, may have supported general improvements observed across all regions. Reconfigurations may have supported greater improvements in the first hours of care. Betweenhospital variations may explain significantly greater reductions in patient mortality seen in London compared with Greater Manchester.
© 2014 The Authors. International Journal of Stroke © 2014 World Stroke Organization Vol 9 (Suppl. 4); November 2014; 5–56
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Parallel 2d: Late Breaking Trials and Other Well Designed Studies INTERSTROKE: The importance of conventional and emerging risk factors for stroke in different regions of the world and in different ethnic groups: A case control study Langhorne P1, O’Donnell M2, Chin S3, Zhang H4, Xavier D5, Avezum A5, Mathur N6, Yusuf S3 for the INTERSTROKE Collaborators 1 ICAMS, University of Glasgow, Glasgow, UK 2 NUI, Galway, Ireland 3 PHRI, McMaster University, Hamilton, Canada 4 Beijing Hypertension League Institute, Beijing, China 5 St John’s Medical College and Research Institute, Bangalore, India 6 Institute of Cardiology, Sao Paulo, Brazil Introduction: Stroke is a major global health problem, yet no single standardised study has examined the risk factors for stroke and its subtypes in different ethnic populations in different regions of the world. Any effective global strategy to reduce stroke requires a large, systematic study of traditional and emerging risk factors within defined ethnic groups and geographical locations for each of the stroke subtypes. Method: INTERSTROKE is a large, global, standardised, case-control study coordinated from Canada that is examining the role of conventional and emerging risk factors for stroke. Its aims were to recruit over 24000 participants (12000 stroke cases and 12000 matching controls) from 32 countries, including 2000 from the UK. Results: By December 2013, over 27011 participants had been recruited (13604 cases and 13407 matched controls) including 1985 from UK sites. Analysis is underway with full reporting expected in 2015. Discussion: The final results of INTERSTROKE are expected to have enormous implications for our understanding of risk factors for stroke around the world including recent data from the UK.
The Stroke Oxygen Supplementation (SO2S) study: A multicenter randomised controlled trial of the effect of routine oxygen supplementation on key outcomes at one week Roffe C1,2 on behalf of the Stroke Oxygen Study Collaborative Group 1 Stoke Stroke Research Group, North Staffs Combined Healthcare NHS Trust, Trentham, UK 2 Institute for Science and Technology in Medicine, Keele University, Stoke-on-Trent, UK Introduction: Routine oxygen supplementation early after stroke was associated with a significant improvement in neurological recovery in the stroke oxygen pilot study. The Stroke Oxygen Supplementation (SO2S) study was designed to confirm this and to assess whether oxygen supplementation had a longer-term effect on functional outcomes. Here we report the outcomes of SO2S at 1 week. Methods: Adult patients with a clinical diagnosis of acute stroke were eligible for enrolment within 48 hours of symptom onset, if they had no clear indications for, or contraindications to, oxygen treatment at a rate of 2–3 L/min. Randomisation was to 1 of 3 treatment groups: continuous oxygen for 72 hours, nocturnal (21:00–06:00) oxygen for 72 hours or to the control group who received no oxygen therapy unless needed for clinical indications outside of the trial. The SO2S study is funded by the NIHR-HTA programme (09/104/21). Results: Between 2009 and 2013, 8003 patients were recruited to the SO2S study. Data for 1 week follow-up were available for 7936 patients (median
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age, 74 range 19–100 y; 4398 (54.9%) men; median NIHSS score at baseline 5, range 0–34). We will report the effect of oxygen treatment on neurological recovery, complications and mortality at 1 week. There will be 2 main comparisons, first oxygen (continuous and nocturnal combined) versus control, and second nocturnal oxygen versus continuous oxygen. Discussion: The results of this analysis will show the early effects of routine oxygen supplementation on neurological recovery and early complications after stroke.
Motor and functional outcome 5 years after stroke equals performance at 2 months: Results from the CERISE follow-up study Meyer S1, Verheyden G1, Brinkmann N2, Dejaeger E3, De Weerdt W1, Feys H1, Jenni W4, Lincoln N5, Putman K6,7, Schuback B4, Schupp W2, De Wit L6 1 KU Leuven, Department of Rehabilitation Sciences, Leuven, Belgium 2 Fachklinik Herzogenaurach, Herzogenaurach, Germany 3 University Hospital Pellenberg, Pellenberg, Belgium 4 RehaClinic Zurzach, Zurzach, Switzerland 5 Institute of Work, Health and Organisations, University of Nottingham, Nottingham, UK 6 Department of Medical Sociology and Health Sciences, Vrije Universiteit Brussel, Brussels, Belgium 7 School of Health, University of Central Lancashire, Preston, UK Introduction: Although much is known about the recovery of patients up to 6 months after stroke, there has been little research on long-term recovery. Method: This follow-up study of the CERISE project (Collaborative Evaluation of Rehabilitation In Stroke across Europe) included consecutive patients from 4 European rehabilitation centres, that were assessed on admission to the rehabilitation centre, at 2 and 6 months and 5 years after stroke with the Barthel Index (BI), Rivermead Motor Assessment Gross Function (RMA-GF), Leg/Trunk (RMA-LT) and Arm (RMA-A) scales. Recovery patterns were analysed using linear mixed models. Results: 532 patients were included in this study (mean (SD) age at stroke onset: 69 (10) years, 53% male, 84% ischaemic strokes, 57% left sided impairment). Linear mixed models, corrected for age, gender, type and severity of stroke, revealed a significant improvement for all 4 outcome measures from admission to 2 months (P < 0.0001), and from 2 to 6 months (P < 0.0001). On the contrary, all 4 measures showed a significant deterioration between 6 months and 5 years (P < 0.0001). Interestingly, no significant differences exist between scores at 2 months and 5 years after stroke. Discussion: The long-term assessment revealed deterioration in motor and functional performance after 6 months, with a return to the motor and functional level measured at 2 months. Strategies to prevent this long-term deterioration should be considered and evaluated.
© 2014 The Authors. International Journal of Stroke © 2014 World Stroke Organization Vol 9 (Suppl. 4); November 2014; 5–56
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Does the use of Nintendo Wii SportsTM improve arm function and is it acceptable to patients after stroke? Trial of WiiTM in stroke – TWIST Adie K1, Schofield C1, Berrow M2, Wingham J1, Freeman J3, Humfryes J4, Pritchard C1 on behalf of the TWIST research group 1 Research, Development and Innovation Unit, Royal Cornwall Hospital Trust, Cornwall, UK 2 Peninsula Clinical Trials Unit, Plymouth University Schools of Medicine and Dentistry, Plymouth, UK 3 Independent statistician 4 Lay Member Introduction: Many stroke patients experience loss of arm function requiring rehabilitation, which is expensive, repetitive and does not always translate into ‘real life’. Nintendo Wii SportsTM (WiiTM) may offer task specific training that is repetitive and motivating. TWIST investigated feasibility, efficacy and acceptability using WiiTM to improve affected arm function for patients after stroke. Method: This multicentre study incorporating a randomised controlled trial (RCT) (N = 240), qualitative study (N = 18) and health economics analysis compared use of Nintendo Wii SportTM games (WiiTM) versus arm exercises in patients receiving standard rehabilitation in a home setting within 6 months of stroke with arm weakness. Results: There was no significant difference in primary outcome of affected arm function at 6 weeks follow-up in intervention and control group using the Action Research Arm Test (ARAT) and no significant difference in secondary outcomes including occupational performance using the Canadian Occupational Performance Measure, quality of life using the Stroke Impact Scale. The qualitative study found that WiiTM was enjoyed by most participants. The favourite games were bowling and tennis, least played was boxing. No significant adverse events related to study intervention were reported. The cost effectiveness analysis showed that the WiiTM was more expensive than arm exercises. Discussion: TWIST was the first UK RCT assessing the feasibility, cost effectiveness and acceptability of WiiTM in stroke rehabilitation. Although WiiTM was well received by participants, it did not show superiority of arm function compared to arm exercises at 6 weeks or 6 months and was more expensive than arm exercises.
A patient-specific prediction instrument using functional recovery curves as a management tool after stroke Douiri A, Grace J, McKevitt C, Rudd A, Wolfe C Division of Health and Social Care, King’s College London, London, UK Introduction: Functional recovery prediction is an important aim for stroke survivors. This study develops, validates and assesses the clinical utility of a patient-specific tool for monitoring the progression of functional recovery after stroke. Method: Data were collected from 495 patients after first-ever stroke between August 2002 and October 2004 from the South London Stroke Register in order to develop and refine the prognostic model. Functional recovery was assessed weekly using Barthel Index (BI) up to 52 weeks after stroke. Patient-specific recovery curves were developed using generalised linear mixed models. Predicted recovery curves performance was assessed by internal and temporal cross-validation using 2 different prospective cohorts between the period of 2005 and 2011. Prognostic effectiveness and clinical utility of recovery curves to classify different functional outcomes at different time points were also evaluated. Results: Patient age, gender, NIH Stroke Scale score, Glasgow Coma Scale score and stroke subtype were identified as good independent predictors of recovery and change over time. Predictive accuracy of the recovery curves in the external cohorts was acceptable (root mean squared error of
3.32) BI points up to 52 weeks after stroke. The prognostic accuracy to classify poor recovery at 3 months was also satisfactory, 94% (95% CI [90.9–96.9]) with an acceptable clinical significance measured by positive likelihood ratio (LR+:7.9 [6.0–10.3] and LR-: 0.09 [0.04–0.21]). Conclusion: A recovery curves prediction tool could support health care professionals with decision making in management of patients with a poorer recovery than expected.
Prevention of Decline in Cognition after Stroke Trial: Final results of a factorial randomised trial of blood pressure and lipid lowering (PODCAST) Bath P1, Blackburn D2, Krishnan K1, Ford G3, Ballard C4, Burns A5, Mant J6, Passmore P7, Pocock S8, Reckless J9, Stewart R4,10, Wardlaw J10, for the PODCAST Investigators 1 Stroke Trials Unit, University of Nottingham, Nottingham, UK 2 University of Sheffield, Sheffield, UK 3 Newcastle University, Newcastle, UK 4 King’s College Hospital, London, UK 5 University of Manchester, Manchester, UK 6 University of Cambridge, Cambridge, UK 7 Queens University, Belfast, UK 8 London School of Hygiene and Tropical Medicine, London, UK 9 University of Oxford, Oxford, UK 10 University of Edinburgh, Edinburgh, UK Introduction: Stroke and dementia are common, economically costly to society, and devastating to patients and their families. Elevated blood pressure (BP) and cholesterol are common after stroke and may be associated with increasing cognitive decline. Critically, it is unknown whether BP and cholesterol should be lowered intensively, or moderately as per current guidelines, questions that PODCAST has addressed. Methods: PODCAST was a prospective, randomised, open-label, blinded end-point, partial-factorial, controlled, phase IV trial (http:// www.podcast-trial.org/). Patients comprised those with ischaemic or haemorrhagic stroke who did not have significant cognitive impairment at 3–7 months post index event. The interventions were: intensive (target systolic BP is 30 days) disabling stroke, fatal MI and death was 1.0%. This compares favourably with results from ACST-1, which reported a peri-operative risk of 1.7%. Discussion: ACST-2 participants are on appropriate SPT therapies both peri-procedurally and in the longer term. The peri-procedural serious complication rate is low.
040 Perceived psychosocial stress: A risk factor for TIA? Booth J1, Lawrence M1, Connolly L1, Fraser H2, Dunipace L3, Joice S4, McAlpine C3, Chalmers C5 1 Institute for Applied Health Research, Glasgow Caledonian University, Glasgow, UK 2 NHS Fife, Fife, UK 3 NHS Greater Glasgow & Clyde, Glasgow, UK 4 Tangata Massey University, Palmerston North, New Zealand 5 NHS Lanarkshire, Lanarkshire, UK Introduction: No research has explored the association between perceived psychosocial stress and transient ischaemic attack (TIA)/minor stroke, yet public perception highlights stress as a key risk factor for stroke. This study examined perceived psychosocial stress in people experiencing transient ischaemic attack/minor stroke. Method: A mixed–method study involving a cross sectional survey of perceived stress in three groups of adults (n = 1405): those attending TIA clinics diagnosed with TIA (n = 670); TIA clinic attendees receiving a non-TIA diagnosis (n = 341); treatment room (TR) control group (n = 394). Each clinic attendee completed a structured questionnaire. Qualitative interviews to explore perceptions in detail were undertaken with a sub-set of 16 participants who received a diagnosis of TIA. Results: Survey data showed the TIA group were older and less deprived than the non-TIA and TR control group. They were less likely to believe stress to be a cause of their TIA. Perceived psychosocial stress was common in all groups but the TIA group reported less stress at home, at work and less financial stress than the non-TIA and TR control groups. Qualitative analysis indicated that psychosocial stress was not perceived to be associated with an increased risk of TIA/minor stroke but was reported to increase following a TIA diagnosis. Discussion: Perceived stress was not a significant risk factor for TIA; however it may increase as a result of a TIA/minor stroke diagnosis. The period following diagnosis may be an optimal time to intervene to reduce perceived stress, contributing to effective secondary prevention of stroke.
041 Clinical relevance of short-runs of atrial tachy-arrhythmia: A UK wide survey of stroke physicians and cardiologists
Results: 205 clinicians responded to the survey (130 stroke physicians, 64 cardiologists and 11 other). Regarding the diagnosis of AF, a single 12-lead ECG was accepted by 87% of responders. In contrast, only 45% would accept a single episode lasting
