Abstracts

WSC-1682 21: Challenges in Acute Stroke Trials Mobile stroke unit: Sending out a life boat H Audebert1 1 Department of Neurology, Campus Benjamin Franklin, Center for Stroke Research Berlin, Berlin, Germany Time to treatment is closely correlated with better effectiveness of intravenous thrombolysis. Start of treatment before hospital arrival bears the potential of earlier and more effective tPA therapy. This vision has become reality after implementation of first specialized stroke ambulances equipped with computed tomography and point-of-care laboratory. Two studies have shown that this approach is feasible, safe and leads to relevant time savings and a higher thrombolysis rate. Prehospital stroke work-up has also the potential to improve delivery to specialized stroke facilities and to start specific stroke treatments beyond thrombolysis – e.g. antihypertensive treatment of intracerebral hemorrhage. In addition, new therapeutic concepts including neuroprotective strategies may be most promising when started in the ultra-early time window of 60–90 minutes after onset. Studies such as the FAST-MAG trials have shown that prehospital study recruitment is feasible even with normal ambulance services. Specialized stroke ambulances may facilitate the conduction of prehospital stroke trials as more diagnostic equipment is available and informed consent can be directly retrieved by neurologists in the field. Honoraria from Lundbeck, Bayer, Pfizer, BMS, Sanofi, Takeda, Boehringer and Roche.

WSC-1681 40: Telemedicine and Teleneurology TeleStroke for prehospital stroke care H Audebert1 1 Department of Neurology, Campus Benjamin Franklin, Center for Stroke Research Berlin, Berlin, Germany Important decisions are made during prehospital care of stroke patients including choice of transport destination and possible start of treatment. While strong evidence exists that specialized stroke (stroke unit) care in hospitals is beneficial for patients, nonspecialized personnel mostly perform prehospital care. TeleStroke can provide neurological expertise on ambulances and specialists can then guide prehospital management. Currently, telemedicine is used for stroke identification at dispatch centers, transmission of stroke recognition scores from ambulances to hospitals and teleradiology in first stroke emergency mobiles. With advanced technology (e.g. 4G telecommunication standard), neurological examination via video-conferencing has become feasible in ambulances. This may change paradigms in the rescue chain of stroke patients because prehospital treatment becomes part of organized stroke care led by specialists.

WSC-1683 15: Collaborative Stroke Care 02: Mobilization Stroke and Continence Management Translating exercise and mobility interventions into community-based programs: The Italian adaptive physical activity program F Benvenuti1 Dipartimento Territorio-Fragilità, AUSL11, Empoli, Italy

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In chronic stroke survivors impairments lead to a sedentary life style which in turn, causes new impairments (e.g., muscle atrophy, cardiorespiratory deconditioning, altered joint range of motion), functional limita-

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tions and disability which further decrease activity levels. This vicious circle is worsened by nondisease conditions such as depression, lack of volitional pursuits, architectural barriers and lack of family and social support. There is published evidence derived from studies in rehabilitation and community settings that this vicious circle can be reversed by adapted physical activity (APA) programs. In spite of the published evidence the implementation of APA programs for chronic stroke survivors at community level is far form optimal. We present the experience of AUSL11 of Tuscany (994 km2, 230000 residents, 22% aged ≥65). We first investigated the safety and effectiveness of a 6-month community-based APA program for chronic stroke survivors aimed at improving muscle force, joint flexibility and cardio-respiratory function. We found that the program was safe, improved gait and balance function, activities of daily living, depression and quality of life. On the basis of these results we were encouraged to implement an APA program for chronic stroke survivors in community gyms/adapted spaces scattered in the 15 municipalities of Empoli Health Authority (AUSL11). Long-term data confirm the effectiveness and safety of the program. More evidence is needed to determine which factors influence participants’ adherence to APA and whether integration with rehabilitation program in the subacute phase of the disease may improve clinical outcomes.

WSC-1666 15: Collaborative Stroke Care 02: Mobilization Stroke and Continence Management Early mobility training – How do we decide when to begin? J Bernhardt1 AVERT Early Intervention Research Program, The Florey Institute of Neuroscience and Mental Health, Heidelberg, Australia

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Whether we should start mobility training in the first hours (or days) after stroke has been a topic of debate for the past 5–10 years. Across the world, opinion and practices vary. Patients with ischemic stroke are also managed differently to those with intracerebral hemorrhage. For example, it is more common for clinicians to be comfortable with the idea of commencing mobility training for people with ischemic stroke earlier than those with intracerebral hemorrhage. However, when we add treatment with rtPA to the mix, the picture once again becomes highly variable. So how do we make informed decisions about when it is safe to start mobility training after stroke? In this presentation, Julie will explore current concerns about the timing of mobility training in different populations of patients with stroke and review approaches to determining when to start training after acute injury.

WSC-1648 (SSO) Working Conference: Establishing SSO – Sharing of Practical Experiences Experience in use of the toolkit A Bezmarevic1, I Milojevic1 Stroke, Serbian Stroke Association, Belgrade, Serbia

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Serbia Stroke Association – Experience We heard for SSO in 2011 from SAFE. We thought that we could do something in our country. We had a many problems. But with experience of other we tried to solve them. At about the same time Toolkit was issued. Having read it, we realized that most of our problems and solutions are there. It was like student s book for us. And in 2012 we started to working. We issued acronym HITNO, something like FAST scale. We distributed more than 100000 leaflets (wast majority of neurologist, cardiologist ant

© 2014 The Authors. International Journal of Stroke © 2014 World Stroke Organization Vol 9 (Suppl. 3); October 2014; 2–15

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GP medical room, on streets) We participated in many events (like semifinal Device cup Serbia–Canada, we won!). But we are just at the beginning.

WSC-1652 36: Applying Emergency and Neurocritical Care to Patients with Severe Stroke Face-off: Optimists versus pessimists in the neurocritical care of stroke J Bösel1 1 Neurology, University of Heidelberg, Heidelberg, Germany Stroke patients who are affected so severely that they need mechanical ventilation and critical care have been associated with a very poor prognosis for decades. Numerous studies in the past have reported mortality rates between 50% and 80% or severe disability for patients with ischemic or hemorrhagic stroke who require mechanical ventilation. This raised considerably pessimism and led to questioning the usefulness of critical care in these patients. Several studies have demonstrated, however, that this pessimism and the associated self-fulfilling prophecies in the form of early do-not-resuscitate-orders have themselves led to clinical courses worse than expected and thus denied many patients a more favorable outcome. Furthermore, neurocritical care has evolved as a distinct speciality over the last 30 years and produced a better understanding and considerable progress in the care of severe stroke. Management elements such as a structured, rapid clinical assessment in the emergency room, timely adequate imaging, selection for acute therapies (e.g. recanalization), intubation and ventilation without delay, neuromonitoring, targeted temperature management, coagulation management, step-wise approach to raised intracranial pressure, anticonvulsive treatment, and individually chosen surgical procedures (e.g. external ventricular or lumbar CSF drainage, decompressive hemicraniectomy, hematoma evacuation) all contribute to an overall neurocritical care approach that may enable a favorable long-term outcome. Although the functional efficacy has not been demonstrated with sufficient study quality for most of these (and other) single treatment options, a growing body of evidence on thousands of patients exists demonstrating that dedicated neurocritical care, i.e. the combination of these elements, is superior to general critical or intermediate care in severe stroke.

WSC-1642 2: Uncommon Causes of Stroke Cervico cephalic arterial dissections: Management issues M G Bousser1 75010, Lariboisiere Hospital, PARIS, France

of rebleeding usually justifies endovascular treatment (parent arterial occlusion, stenting, stent assisted coiling) and sometimes surgical treatment (repair, bypass). In the absence of evidence from randomized clinical trials, cervicocephalic dissections remain a situation in which the bedside clinician should use, on a case by case basis, his best clinical judgment and adopt a stepped care approach in the minority of patients who deteriorate despite initial treatment.

WSC-1643 37: Uncommon Causes of Stroke Migrane and stroke M G Bousser1 1 75010, Lariboisiere Hospital, Paris, France Numerous observational studies and several meta-analysis have shown, firstly, a 1.5- to 2-fold increase in the risk of both ischemic and hemorrhagic stroke in patients with migraine particularly migraine with aura, and secondly, a higher prevalence of MRI brain lesions (white matter hyperintensities and cerebellar infarct like lesions). These findings have led to the conclusion that migraine was (through unknown mechanisms) an important risk factor for stroke. The major limitation of all these epidemiological studies concerns migraine itself because the diagnosis of migraine remains difficult and purely clinical, and because migraine with aura may be secondary to many conditions that are themselves causes of stroke. Furthermore, the facts that MRI lesions do not seem to progress over time and that migraine does not seem to be a risk factor for cognitive decline are reassuring. Nevertheless, epidemiological data linking migraine and stroke have some practical implications, both for stroke prevention, such as smoking cessation in patients with migraine with aura, particularly young women taking oral contraceptives, and for migraine treatment such as a contraindication for all vasoconstrictors (ergot derivatives and triptans). By contrast, the acute investigations and treatment of ischemic and hemorrhagic stroke as well as majors of secondary prevention are similar in subjects with and without migraine. The present available data suggest that migraine, as a primary headache disorder, even with aura, although painful and often detrimental for the quality of life, remains a benign condition.

WSC-1655 12: Stroke, Sleep and Autonomic Dysfunction Sleep and blood pressure interactions in relation to stroke P Cortelli1, F Naldi1, G Barletta1, F Baschieri1, F Provini1 Department of Biomedical and NeuroMotor Sciences (DIBINEM), Università di Bologna – IRCCS-ISBN, Bologna, Italy

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Arterial dissections in the neck and head have different patterns of presentations which raise a variety of management issues. The most frequent presentation in both intra and extracranial dissections is, usually in a young adult, that of an ischemic stroke, of any topography and severity. The second presentation, present in up to 30% of cases, is an acute neck or head pain, lasting a mean of 8–10 days and the third, occurring only in intracranial dissections, is an hemorrhagic stroke, subarachnoid hemorrhage. The therapeutic management varies according to the clinical presentation. In patients with pain or TIAs, the aim of treatment is to prevent cerebral infarction, using antithrombotic drugs and in some cases, hemodynamic measures and angioplasty stenting. In patients with acute cerebral infarction, the aim is to save as much brain as possible using stroke unit care, thrombolysis when feasible, antithrombotic drugs (heparin or aspirin) and, in a few selected cases, decompressive surgery. In patients with subarachnoid hemorrhage due to intracranial arterial dissections, the high risk

Arterial blood pressure (ABP) shows a sleep-dependent changes and decreases during the night in 95% of normotensive individuals, especially during the NREM sleep, by 10–20% from mean daytime values, a phenomenon generally referred to as ‘dipping pattern’. Given the role of sleep in integrating and modulating cardiovascular function, and in the regulation of ABP circadian rhythm, sleep disorders have long been investigated as possible risk factor for hypertension and cardiovascular disease (CVD) and stroke. OSAS is a paradigm of how a sleep breathing disorder can lead to a permanent dysregulation of the autonomic cardiovascular control, resulting in a chronic hypertensive state with a nondipping pattern of nocturnal ABP, and several studies have demonstrated that OSAS is a risk factor for stroke. Asleep systolic BP mean is the better predictor of cardiovascular events (including stroke) and is a predictor of outcome than either the awake or 24-hour BP mean. The insular cortex seems to play a central role in modulating baroreflex, its impairment has been related independently to less favorable outcome after ischemic stroke.

© 2014 The Authors. International Journal of Stroke © 2014 World Stroke Organization Vol 9 (Suppl. 3); October 2014; 2–15

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Abstracts

Stroke related autonomic imbalance may promote secondary brain injury through a shift to sympathetic predominance, associated with proinflammatory state, hyperglycemia and increased blood-brain barrer permeability. In acute stroke nocturnal brain activity is fragmented and impaired sleep architecture is associated with worse outcome; the presence of stage 2 of NREM sleep has a prognostic value in stroke outcome.

WSC-1671 15: Collaborative Stroke Care 02: Mobilization Stroke and Continence Management Home-based interventions for postacute rehabilitation of walking recovery – The evidence and recommendations for translating the evidence into clinical practice P Duncan1 Innovations and Transitional Outcomes, Wake Forest Baptist Health, Winston Salem, USA

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Mobility and balance problems are the most common physical disabilities poststroke. Two-thirds of all stroke survivors have significant limitations in walking and over 75% will experience a fall in 6 months. Evidence is increasing for the best interventions to improve mobility and balance in the intensive care unit, acute care settings, postacute settings and in community-based exercise programs. The purposes of the presentations are to review the evidence for interventions to improve mobility across the continuum of care. Each presenter will also discuss strategies for translating evidence-based interventions into clinical practice and communitybased programs to sustain mobility and health.

WSC-1679 7: Turkish Nurses/Collaborative Stroke Care (Cont’d) Stroke treatment and coordination of care for stroke patients Z Durna1 Nursing, Bahcesehir University School of Health Sciences, Istanbul, Turkey

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One of the well-documented approach to treat stroke patients is to treat them in a stroke unit. The stroke unit is a ward dedicated to stroke patients, with a mobile stroke team or within a generic disability service. One of the most important component of stroke unit is a dedicated multidisciplinary team and a coordinated care offered by team members. Specific stroke treatments can only be administered in stroke units. This lecture will present organization of a stroke unit and stroke treatments including thrombolytic drugs and endovascular devices.

patients and carers. The evidence base for improving continence in stroke survivors will be summarized and suggestions for health care strategies will be presented.

WSC-1661 25: Stroke in the Region – Stroke Epidemiology, Diagnosis and Treatment Options, Regional Differences and Future Suggestions for Collaboration Stroke in Iran M Farhoudi1, E Sadeghi-Hokmabad1, E Sharifipour1, K Mehrvar1, A Taheraghdam1, M Hasmilar1, D Savadi Oskoui1, M Yazdchi Marandi1, H Ayromlou1, A Pashapour1, M R Gheini2, M Mehrpour3, A Borhanhaghighi4, K Ghandhari5, F Khorvash6 1 Neurology, Neurosciences Research Center Tabriz University of Medical Sciences, Tabriz, Iran 2 Neurology, Tehran University of Medical Sciences, Tehran, Iran 3 Neurology, Iran University of Medical Sciences, Tehran, Iran 4 Neurology, Shiraz University of Medical Sciences, Shiraz, Iran 5 Neurology, Mashhad University of Medical Sciences, Mashhad, Iran 6 Neurology, Isfahan University of Medical Sciences, Isfahan, Iran Iran with population amounting to about 75 million is a great country in the Middle East. While stroke is the leading cause of mortality and disability worldwide, in Iran, unfortunately, its incidence is on the increase while the onset age of stroke is dropping. The annual incidence of stroke at various ages in Iran ranges widely from 23 to 265 per 100,000 population/year based on published reports, and the 28-day case mortality rate is reported as 19–31%. Intravenous thrombolysis as a globally approved therapy in ischemic stroke, has been provided discretely in some universities and some private hospitals since 2008. The main limit for this therapy in Iran is the lack of coverage by health insurance companies for tPA. Fortunately, the team working in Tabriz University of Medical Sciences, in close cooperation with Neurosciences Research Center (NSRC), and departments of neurology, emergency medicine, radiology, neurosurgery, as well as paramedics in Imam Reza Hospital, moved forward to systematic intravenous thrombolysis in eligible acute ischemic stroke patients since 2010. Until now, about 400 stroke codes have been activated and 112 intravenous and four intra-arterial thrombolysis have been performed. Other active centers in thrombolysis are Firoozgar Hospital, Tehran (70 cases), Ghaem Hospital, Mashhad (40 cases), Namazi Hospital, Shiraz, and Alzahra Hospital, Isfahan. Congress statement following the first International and the sixth National Iranian Stroke Congress, in November 2013, leaded to offer more motivation and assistance to stroke programs and the special focus, health policy makers should have, on promoting stroke patients’ health.

WSC-1678 15: Collaborative Stroke Care 02: Mobilization Stroke and Continence Management Assessment of bowel and bladder continence in stroke patients Z Durna1 Nursing, Bahcesehir University School of Health Sciences, Istanbul, Turkey

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Bladder and bowel problems are common following stroke and urinary incontinence can affect 40–60% of people admitted to hospital after a stroke, with 25% still having problems on hospital discharge and 15% remaining incontinent at 1 year. Problems in continence can have a huge impact on physical and psychological aspects of quality of life, for both

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© 2014 The Authors. International Journal of Stroke © 2014 World Stroke Organization Vol 9 (Suppl. 3); October 2014; 2–15

Abstracts

WSC-1639 34: Global Stroke Policies Joint WSO-WFN-WHO Session Global burden of stroke – An update V Feigin1, M H Forouzanfar2, R Krishnamurthi1, G Mensah3, M Connor4, D A Bennett5, A Moran6, M Naghavi2, R Sacco7, C Murray2 1 National Institute for Stroke and Applied Neurosciences, AUT University, Auckland, New Zealand 2 Institute for Health Metrics and Evaluation, University of Washington, Seattle, USA 3 Heart Lung and Blood Institute, NIH/NHLBI, Bethesda, USA 4 Division of Clinical Neurosciences, University of Edinburgh, Edinburgh, United Kingdom 5 Clinical Trial Service Unit and Epidemiological Studies Unit, University of Oxford, Oxford, United Kingdom 6 Division of General Medicine, Columbia University Medical Center, New York, USA 7 Miller School of Medicine, University of Miami, Miami, USA Background: A comprehensive and comparable data of stroke incidence, prevalence, mortality, and disability are lacking for most regions of the world. Methods: We applied the Global Burden of Disease 2010 Study comprehensive epidemiological data and analytical tool (DisMod-MR) to systematically analyze stroke burden on country and regional levels in 1990–2010. Results: From 1990 to 2010 there was a significant 12% (95% CI 6%, 17%) decrease in stroke incidence rates in high-income countries (HIC), and a 12%, albeit not statistically significant (95% CI –3%, 22%), increase in stroke incidence rates in low to middle-income countries (LMIC) regions. There was a statistically significant decrease in stroke mortality rates in both HIC (37%; 95% CI 31%, 41%) and LMIC (20%; 95% CI 15%, 30%). In 2010, the absolute number of people with first stroke (16.9 million), stroke survivors (33 million), stroke-related deaths (5.9 million) and disability-adjusted life-years (DALYs) lost (102 million) were high and had significantly increased since 1990 (40%, 46%, 20% and 16% increase respectively), with the bulk of the burden currently borne by LMIC. Over the last two decades, in HIC there were significant reductions in ischemic stroke (IS) incidence rates by 13% (95% CI 6–18%), mortality rates by 37% (95% CI 19–39%) and DALYs rates by 34% (95% CI 16–36%). Hemorrhagic stroke (HS) incidence rates in HIC were significantly reduced by 19% (95% CI 1–15%), mortality rates by 38% (95% CI 32–43%) and DALYs rates by 39% (95% CI 32–44%). In contrast, in LMIC there was a significant 22% increase in the incidence of HS (95% CI 5–30%) and 6% (not statistically significant) increase in the incidence of IS (95% CI –7%; 18%). Over 62% of new strokes (50% in HIC and 68% in LMIC), 69.8% prevalent strokes (60.5% in HIC and 78.3% in LMIC), 45.5% of deaths from stroke (27.4% in HIC and 52.8% in LMIC), and 71.7% DALYs lost due to stroke (53.8% in HIC and 76.8% in LMIC) occurred in people under 75 years of age. Interpretation: Although age-standardized stroke mortality rates declined worldwide over the last two decades, the absolute number of people suffering a stroke per year, stroke survivors, stroke related deaths and overall global burden of stroke (DALYs lost) are great and increasing. The bulk of stroke burden is borne by people younger than 75 years of age, especially in LMIC.

WSC-1645 27: Rehabilitation I: Update on the Evidence Long-term management of patients with stroke A Forster1 Academic Unit of Elderly Care and Rehabilitation, University of Leeds, Leeds, United Kingdom

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Longer-term outcome after stroke is poor for many, depression is prevalent, inactivity common and quality of life often deteriorates. Many carers are stressed and anxious. Whilst the early part of the stroke care pathway is based on an increasingly robust evidence base, strategies for longer-term care and support are ill-defined. Work will be presented demonstrating the challenges of life after stroke; this will include the identification of unmet needs and findings of qualitative investigation of adjustment after stroke from the perspective of the stroke survivors and their carers. Effective community-based interventions to improve outcomes and address unmet needs are required, but there is little information to guide service provision. A review of the evidence for the effectiveness of interventions in the longer-term after stroke will be reported. This review includes: a search of the Cochrane Library (until May 2014) for reviews that included community interventions for stroke survivors or carers at least 6 months poststroke; and a search of multiple databases to identify individual trials with a similar focus. Primary outcomes were quality of life, participation, mood and perceived health status. A narrative synthesis will be presented. The evidence base for improving outcomes for stroke survivors and their carers beyond the first 6 months after stroke will thus be summarized and suggestions for health and social care strategies and new avenues for research presented.

WSC-1654 19: Vasculitis Infective vasculitis of the CNS V Ganesan1 Neurosciences, UCL Institute of Child Health, London, United Kingdom

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This talk will focus on the role of infection in childhood and adolescent arterial ischemic stroke. Cerebrovascular involvement can be a feature of central nervous system infection, for example bacterial meningitis. The most common risk factors for childhood arterial ischemic stroke are nonatheromatous cerebral arteriopathies. Etiology of these is poorly defined; however, current evidence suggests that infections are the most commonly identified antecedent. Varicella zoster is particularly associated with childhood ischemic stroke, with a significantly higher rate of chickenpox in the 12 months preceding the stroke in cases compared with controls. Children with postvaricella cerebral infarction have distinctive characteristics: they tend to be young, previously healthy children, with chickenpox within the preceding 3–4 months, and a characteristic lesion pattern of focal stenotic disease of the proximal middle cerebral artery and basal ganglia infarction. Varicella vasculitis is an entity described largely in adults, with diffuse as well as focal neurological features, and more variable and extensive arterial involvement. The overlap between these entities is unknown. There are few data on disease biomarkers in postvaricella cerebral infarction; CSF antibodies appear to be the most sensitive investigation in varicella vasculitis. Other childhood infections are also associated with ischemic stroke; the recently completed VIPS study will provide data to elucidate this association.

© 2014 The Authors. International Journal of Stroke © 2014 World Stroke Organization Vol 9 (Suppl. 3); October 2014; 2–15

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Abstracts

WSC-0182 22: Collaborative Stroke Care 03: Meeting Stroke Patient and Family Needs in Palliative Care Advanced care planning with stroke patients and families T Green1 Faculty of Nursing, Foothills Medical Centre, Calgary, Canada

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Individuals who experience a stroke have a higher likelihood of having subsequent stroke events, making it imperative to plan for future medical care. In the event of a further serious health event, advanced care planning (ACP) can help family members and health care professionals (HCPs) make medical decisions for individuals who have lost the capacity to do so. Few studies have explored the views and experiences of patients with stroke about discussing their wishes and preferences for future medical events, or the extent to which HCPs engage in conversations around planning for such events. In this presentation, we will discuss the process of ACP, relevance to stroke care, and consider potential outcomes of ACP conversations.

WSC-1669 02: Primary Prevention Metabolic Syndrome and Insulin Resistance Insulin resistance and risk of stroke G J Hankey1 School of Medicine and Pharmacology, The University of Western Australia, Perth, Australia

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Insulin resistance is a reduced sensitivity of target tissues to insulin. Blood glucose concentrations rise, triggering a compensatory rise in insulin concentration. If pancreatic beta cells fail, blood glucose concentrations rise leading to prediabetes and type 2 diabetes. Diabetes (fasting blood glucose >7.0 mmol/l or HbA1C > 6.5%) doubles the risk of ischemic stroke (adjusted HR: 2.27, 95% CI: 1.95–2.65) and hemorrhagic stroke (HR 1.56, 1.19–2.05). Prediabetes (impaired fasting glucose: 5.6–6.9 mmol/l and/or impaired glucose tolerance) increases the risk of stroke by one quarter (adjusted RR 1.26; 1.10–1.43). Insulin resistance, as measured by the HOMA-IR index, increases the risk of stroke (RR 1.76, 95% CI: 1.15–2.70 for the highest vs lowest category; four studies, 8905 participants) but when measured by fasting insulin concentration, does not increase the risk of stroke (RR 1.18, 95% CI: 0.87–1.60 for the highest vs lowest category; RR 0.999, 95% CI: 0.99–1.01 for each increment of 50 pmol/l in insulin concentration), or ischemic stroke (RR 1.24, 95% CI: 0.88–1.76). Subgroup analyses suggest that insulin resistance may be a risk factor for ischemic stroke among men (vs women) and whites (vs blacks). The risk of stroke seems to rise progressively across the spectrum of insulin resistance, suggesting that hyperglycemia may be a continuous risk factor for stroke. Potential mechanisms by which insulin resistance may increase the risk of ischemic stroke include hypertension, endothelial dysfunction, inflammation and increased platelet activation and prothrombotic factors.

WSC-1670 11: Evidence Based Secondary Prevention Weighing up the benefits, harms and costs of drugs for secondary prevention G J Hankey1 School of Medicine and Pharmacology, The University of Western Australia, Perth, Australia

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Aspirin reduces early recurrent ischemic stroke vs control (2.42% vs 3.11%; OR 0.77, 0.69–0.87; ARR [absolute risk reduction] 0.69%) but

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most benefits are offset by increased symptomatic intracranial hemorrhage (1.00% vs 0.82%; OR 1.22, 1.00–1.50; ARI [absolute risk increase] 0.18%) and major extracranial hemorrhage (0.96% vs 0.56%; OR 1.69, 0.69–0.87; ARI 0.40%). Dual antiplatelet therapy reduces early recurrent stroke compared to single therapy (6.21% vs 8.96%; RR 0.69, 0.60–0.80; ARR 2.75%) without increasing major hemorrhage (0.52% vs 0.35%; RR 1.35, 0.70–2.59; ARI: 0.17%). Long-term aspirin reduces recurrent stroke vs control (3.90% vs 4.68%; RR 0.83, 0.72–0.96; ARR 0.78%) more than causing extracranial bleeding (0.25% vs 0.06%; RR 2.69, 1.25–5.76; ARI 0.19%). Clopidogrel is marginally more effective than aspirin (5.78% vs 6.30%; RR 0.91, 0.82–1.01; ARR 0.52%) and as safe (RR 1.00, 0.91–1.09). Dual antiplatelet therapy is more effective than aspirin (6.71% vs 8.05%; RR 0.83, 0.73–0.96; ARR 1.34%), but only aspirin plus dipyridamole is as safe (RR 0.74, 0.43–1.23); clopidogrel plus aspirin causes more major bleeding (4.87% vs 2.80% RR: 1.74, 1.37–2.21; ARI: 2.07%). Dual antiplatelet therapy is not more effective than clopidogrel (RR 1.01; 0.93–1.08) but aspirin plus dipyridamole is as safe (RR 1.15; 1.00–1.32); clopidogrel plus aspirin causes more major bleeding (1.94% vs 0.58%; RR: 3.34, 2.07–5.36; ARI: 1.36%). For patients with atrial fibrillation, warfarin reduces recurrent stroke vs control (8.9% vs 22.6%, OR 0.36, 0.22–0.58; ARR 13.7%) more than increasing major bleeding (5.8% vs 0.9%; OR 4.32, 1.55–12.10; ARI: 4.9%). The newer oral anticoagulants reduce recurrent stroke (4.94% vs 5.73%, RR 0.86, 0.76–0.98; ARR 0.79%) and major bleeding (5.71% vs 6.43%, RR 0.89, 0.77–1.02; ARR 0.72%) vs warfarin. Long-term blood pressure-lowering reduces recurrent stroke vs control (8.61% vs 9.95%; OR 0.78, 0.68–0.90; ARR 1.34%), as does lipid-lowering (10.5% vs 11.9%, OR 0.88, 0.78–0.99; ARR 1.4%) without major hazards.

Temperature and neurological disease: Where is the link? T Hemmen1, R Raman1, G Tafreshi2, M Concha3, K Rapp1, A Roldan4, J Grotta4, P Lyden5 1 Neurosciences, University of California San Diego, La Jolla, USA 2 Neurology, Scripps Mercy Hospital, San Diego, USA 3 Neurology, Sarasota Memorial Hospital, Sarasota, USA 4 Neurology, University of Texas, Houston, USA 5 Neurology, Cedars Sinai Medical Center, Los Angeles, USA Introduction: The purpose of ICTuS 2/3 is to determine whether the combination of thrombolysis and hypothermia is superior to thrombolysis alone for the treatment of acute ischemic stroke. The study is conducted in two stages: a Phase 2 study to assess the safety and feasibility of the protocol and demonstrate sufficient recruitment. This allows an interim analysis for futility; and a Phase 3 efficacy study will to follow if pre-specified milestones are achieved. Methods: ICTuS 2/3 is a prospective, randomized, single-blind, multicenter Phase 2/3 study. We aim to include 1200 patients in total treated within 3 hours of symptom onset with IV tPA, NIHSS ≥7 and ≤20 (right) and ≤20 (left hemisphere), age 22-82. Patients are randomly assigned to either hypothermia permissively targeted to 33°C or normothermia. Favorable outcome is defined as a 90-day Modified Rankin score (mRS) of 0 or 1. An interim analysis for efficacy and futility is planned after 400 patients. Other milestones include frequency of target temperature reached within 6 hours from symptom onset, favorable safety profile and sufficient study-wide enrollment. Results to date: The study includes 17 study sites in the US and Europe. Enrolment began January 2011. Currently, 111 subjects are enrolled. A safety review by the study DSMB and the FDA after the first 45 patients resulted in approval to expand the trial. Safety and recruitment milestones have been met. Conclusion: ICTuS 2/3 has achieved the initial safety and feasibly milestones of targeted recruitment. Phase 2 will continue until funding transitions to the NIH StrokeNET and, if funded, Phase 3 will begin in May

© 2014 The Authors. International Journal of Stroke © 2014 World Stroke Organization Vol 9 (Suppl. 3); October 2014; 2–15

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2015. ICTuS 2/3 remains the largest ongoing study of induced hypothermia for neuroprotection after stroke.

WSC-1644 36: Applying Emergency and Neurocritical Care to Patients with Severe Stroke The golden hour of stroke neurocritical care: Emergency Neurological Life Support (ENLS) 1

J C Hemphill Neurology, University of California San Francisco, San Francisco, USA

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Standardized education for neurological emergencies has lagged behind that for other emergency conditions such as cardiac arrest and trauma. Advanced Cardiac Life Support (ACLS) and Advanced Trauma Life Support (ATLS) are programs that are used worldwide in order to train providers in a standard approach to initial emergency evaluation and treatment of these conditions. Emergency Neurological Life Support (ENLS) is a new program developed by the Neurocritical Care Society (NCS) that provides a standardized curriculum and training for providers regarding how to approach patient evaluation and treatment in the first hour after a range of emergency neurological conditions. ENLS includes modules on acute stroke, including ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage. The presentation at the World Stroke Congress will explain the ENLS protocols for these conditions and how they may be used to improve patient care through standardized provider education.

WSC-1664 12: Stroke, Sleep and Autonomic Dysfunction Autonomic function during sleep in health and disease M Hilz1 Neurology, University of Erlangen-Nuremberg, Erlangen, Germany

References Chung et al. Int Urol Nephrol 2014 [Epub ahead of print]. Bernardi et al. Am J Respir Crit Care Med 2003; 167:141–9.

WSC-0349 11: Evidence Based Secondary Prevention Regional strategies in stroke prevention B Ince1 1 Neurology, Istanbul University Cerrahpasa Medical Faculty, Istanbul, Turkey Turkey has noted significant improvements in terms of health status, average life expectancy and health care system in recent years. Despite these advances, there are still important health problems especially related to the vascular disease. Turkey has a population of about 75 million with only 11% being over 60 years of age. Although the population is quite young in comparison to European Union and other high income countries, cerebrovascular disease is the second leading cause of mortality following ischemic heart diseases. In the population, hypertension, smoking, obesity, and diabetes are very common risk factors, but awareness of them in public is not enough yet. However some social campaigns and free health screenings did increase the awareness of the preventable risk factors. Another recent improvement was governmental regulations dictating to reduce the salt and fat content of bread, bakery products and all prepared food. Most successful campaign is the one against smoking. Turkey is the first country to attain the highest level of achievement in all measures of tobacco control. Comprehensive stroke centers for secondary prevention are present in six of seven geographical regions and 19 of 81 provinces of Turkey. Total number of these centers is only 34 and the distribution is not homogenous according to regions or population size. Although all stroke centers are able to perform thrombolysis and carotid surgery/stenting, an outpatient clinic is present in only 68% of them. Efforts need to be focused on further improvements for primary and secondary stroke prevention in Turkey.

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Normal sleep cycles comprise four nonrapid eye movement (NREM) stages and rapid eye movement (REM) sleep. Due to prominent deltaEEG activity, NREM stages 3 and 4 are termed ‘slow wave sleep’ (SWS). During NREM sleep, tonic sympathetic withdrawal and parasympathetic activation as well as baroreflex resetting contribute to stable, but lower heart rates (HR) and blood pressure (BP; i.e. ‘BP dipping’) than during wakefulness, and to regular breathing. Only in stage 2, environmental stimuli transiently increase sympathetic activity. During REM sleep, fluctuations in sympathetic and parasympathetic discharges and baroreflex sensitivity account for high HR and BP variability; respiration is irregular and men have spontaneous erections. During sleep, increased vasopressin release prevents nocturnal voiding. Sleep-related, respiratory disturbances, such as obstructive apneas, cause sympathetic activation with arterial hypertension and cardiac arrhythmias, and thus increase the risk of stroke. Among other sleep-related autonomic risk factors of stroke are attenuated or extreme BP dipping, nocturia or erectile dysfunction (Chung et al.). Conversely, stroke lesions may cause hyper or insomnia, compromise sleep architecture, reduce SWS, REM sleep and sleep efficiency, reduce or reverse nocturnal BP dipping, and increase frequencies of apneas with oxygen desaturation. In familial dysautonomia (also known as hereditary sensory and autonomic neuropathy type III) patients, we showed that apnea-induced oxygen-desaturation causes paradoxical peripheral vasodilatation with arterial hypotension, and bradycardia that may result in asystole (Bernardi et al.). Similar mechanisms might account for increased sleep-related cardiovascular complications or mortality after stroke.

WSC-1658 (SSO) Working CONFERENCE: Establishing SSO – Sharing of Practical Experiences Encouraging creation of SSO in Eastern Europe J Jansa1 Division of Neurology, University Medical Centre, Ljubljana, Slovenia

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Stroke Support Organisations (SSO) are raising their profile by supporting stroke patients and their families around Europe and globe. They also bridge the gaps between stroke patients, society and medical professionals. In 2004, 14 existing European SSO’s has created Stroke Alliance for Europe (SAFE). SAFE has several aims, but it also coordinates the efforts of national Stroke Support Organisations in Europe. In addition, it has facilitated the growth of new organizations in several East European countries. Some East European countries had no culture of SSO and others, like in Serbia, Bosnia and Hercegovina, SSO were discontinued due to political/economical situations in recent Yugoslavian war. There are several needs like considering medical side of stroke and access to stroke rehabilitation, long term support for patient and their families, luck of information material, along with fundraising issues and public acceptance of the ‘idea’ of SSO. SAFE strategy toward more visibility of SSO in East Europe included organization of two East European Conferences (Ljubljana, Budapest). By means of identifying stroke professionals in respective East European region, providing information of good practice (like Stroke Support

© 2014 The Authors. International Journal of Stroke © 2014 World Stroke Organization Vol 9 (Suppl. 3); October 2014; 2–15

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Abstracts

Organization Toolkit), providing some ‘know-how’ skills and sharing examples of best practice during workshops, the SSO’s are slowly emerging in East Europe.

WSC-1657 (SSO) Working Conference: Community Resources and Long-Term Follow Up Why we need follow up in community? J Jansa1 Division of Neurology, University Medical Centre, Ljubljana, Slovenia

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Stroke is leading cause of acquired Activity limitations and Participation restrictions worldwide. Activity limitations are difficulties that stroke survivors have while performing activities of daily life and Participation restrictions are problems that stroke survivors experience while involving into life situations within their environment. Initially, stroke patients should be treated in a dedicated stroke units and have additional 3–6 months (inpatient/outpatient) access to the multidisciplinary rehabilitation team. Vocational rehabilitation should be initiated when relevant to the patients’ condition. However, despite of the efforts of stroke patients and multidisciplinary rehabilitation intervention, it is well known that only 25% of stroke survivors return to the level of everyday participation of community-matched person without stroke. Also, the end of sustained rehabilitation program is usually not the point when stroke patients’ expectations and optimism about recovery are challenged. Small percentage of stroke survivors continues with rehabilitation after 6 months poststroke. Along with rehabilitation, and also beyond the rehabilitation, it is important to provide on-going and long-term support for stroke survivors and their families. This services should additionally support the stroke survivors to be »back in control« of their lives, despite of residual problems from stroke. This type of support is available via coordinated work of Stroke Support Organisations in the Community. Implementing long term follow-up in the community is crucial for keeping/improving the level of Health related quality of life for stroke survivors and their families. Nowadays, it still remains a challenge in settings with different economical situations and cultural expectations.

WSC-1656 28: Influencing Agendas to Increase Resources for Stroke Services and Research How SSO and patients increase research funding and improve research outcomes M Kara1 Stroke Association, Research Department, London, United Kingdom

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Service users are the only people who really understand how a condition affects their day to day life. They have a unique insight that allows them to identify and prioritize areas where research is required, as well as to assist with designing the research. Efforts have been made to involve stroke survivors in stroke research and this has helped move the field forward resulting in fewer strokes, better treatment and rehabilitation, but there is still work to be done. Public involvement in research is on the increase and many funding bodies require grant applicants to demonstrate how service users will be involved in the research project. However, it is important that researchers do not just pay ‘lip service’ to this requirement and recognize the value that service user involvement can bring to research. The Stroke Association is a stroke support organization that works with stroke survivors and their families in the United Kingdom to provide information, advice and support, as well as funding vital research into

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stroke. We place the stroke survivor at the heart of everything we do and this includes in all our research activities. The Stroke Association ensures that people affected by stroke have an opportunity to help choose the research we fund. Through our Service User Review Panel stroke survivors, carers and their family members can review all the applications that have been found to be scientifically sound through our peer-review process. Research can also benefit from having service users as co-designers of studies.

WSC-1684 30: Sinus Venous Thrombosis Overview of sinus venous thrombosis including anatomical details S Kaul1 1 Department of Neurology, Nizam Institute of Medical Sciences, Hyderabad, India Cerebral Venous Sinus Thrombosis (CVST) is a common cause of stroke in developing countries. With the advent of modern neuroimaging and the widespread availability of procoagulant work-up CVST is now recognized to be an important cause of stroke all over the world and in both genders. Presentation of CVST can be acute (