A Systematic Comparison of Different Techniques to Measure Clot Length in Patients with Acute Ischemic Stroke
Qazi, A1, 3 Eesa, M1, 2 Qazi, E1, 3 Goyal, M2, 1 Demchuk, A1, 4, 3 Menon, B1, 4, 3; 1. Calgary Stroke Program, Calgary, AB; 2. Department of Radiology, Calgary, AB; 3. University of Calgary, Calgary, AB; 4. Department of Neurology, Calgary, AB
Introduction: Clot length on CT/CTA has been used to predict recanalization with thrombolytic treatment in patients with acute ischemic stroke(AIS). We compared different techniques of measuring clot length on CT/CTA to identify the most reliable method. Methods: 4 1 patients with M1-MCA occlusions from INTERRSeCT, a prospective imaging based cohort study of AIS patients, were included. Hyperdense sign was measured on NCCT(5mm slice thickness). Clot length was measured on CTA at 3mm and 24mm-slices in the axial and coronal plane by:1) measuring the non-visualized segment of M1-MCA and 2) calculating ratio of residual lumen length within M1-MCA segment to length of contralateral patent M1-MCA segment. Two readers analyzed all images independently and were blinded to CTA when reading NCCT. Level of concordance between raters for each method was calculated using Cohen’s kappa for categorical variables and Intra-class Correlation Coefficient(ICC type2, single measure). A method has high inter-rater reliability if the level of concordance is high. Results: Measuring residual lumen ratio on CTA(3mm) is the most reliable technique for measuring clot length. Measuring length of hyperdense sign on NCCT is fairly reliable. Direct clot length measurements on CTA are only reliable if done on 24mm CTA slices using MIP. Conclusion: Reliability of clot length assessment and its interaction with treatment type in predicting recanalization depends on the type of imaging modality and technique used. CTA remains the best tool to measure clot length.
New Approaches to Fast Stroke Imaging with Magnetic Resonance
Yerly, J2 Lauzon, M1 Lebel, R3, 1 Sevick, RJ1 Barber, PA1 Frayne, R1; 1. University of Calgary/Foothills Medical Centre, Calgary, AB; 2. CIBM/CHUV-MR, Lausanne, Switzerland; 3. General Electric Healthcare, Calgary, AB
Background: A guiding maxim in acute ischemic stroke (AIS) treatment is ‘time is brain’. Rapid imaging and prompt diagnosis are essential. MR can provide important information but requires a long acquisition. In contradistinction, non-contrast-CT imaging can provide a rapid assessment of hemorrhage/ischemia. Decreasing acquisition time for MR would remove this drawback. Potentially the total scan time for a fast MR protocol might rival the time required for combined non-contrast CT, CTA and CT-perfusion scans. Methods: Application of emerging MR image acceleration techniques can speed-up AIS assessment. A combination of two approaches (parallel imaging-PI, and compressed sensing-CS) shows promise for reducing acquisition times by factors of ≥2×. In volunteers PI and CS techniques were evaluated individually and in combination. The most promising approach was used to accelerate imaging so that MR angiograms were collected in <30 s in patients. Results: Across a number of AIS imaging sequences and in volunteers, the combination of CS and the SENSE PI method performed the best of the evaluated acceleration techniques. The Sparse-SENSE method was used to successfully speed up time-of-flight MRA in a group of AIS patients. Image quality was preserved, and no major image artifacts were introduced. Figure shows an AIS patient with an occluded right middle cerebral artery. Conclusions: Accelerated MR imaging approaches hold much promise for reducing acquisition time in AIS. Acquisition time reductions of >2x are possible.
Validation of pCT-derived parameters on H215O-PET measured CBF in ischemic stroke
Heiss, W1 Zaro Weber, O1, 2 Sobesky, J2; 1. Max Planck Institute for Neurological Research, Cologne, Germany; 2. Center for Stroke Research and Dept. of Neurology, Charite Berlin, Berlin, Germany
Background: The accuracy of perfusion computed tomography (pCT) based relative maps of cerebral blood flow (rCBF-CT), cerebral blood volume (rCBV-CT), mean transit time (rMTT-CT) and time to peak (rTTP-CT) in acute stroke remains a matter of debate. We validated these relative maps on quantitative CBF measurement by 15O-water positron emission tomography (CBF-PET) with respect to penumbral flow (< 20 ml/100g/min). Methods: pCT was performed on a Philips 64-row CT scanner (6 mm slice thickness, 40 ml contrast agent, flow rate 4 ml/sec). Maps of rCBF-CT, rCBV-CT, rMTT-CT and rTTP-CT were calculated. CBF-PET was performed on an ECAT EXACT HR scanner (Siemens/CTI). In a region of interest-based approach, the performance of pCT was assessed using quantitative CBF-PET maps with respect to penumbral flow. The best PW threshold to detect penumbral flow was calculated for each imaging modality. Results: A good qualitative congruence was found for pCT derived maps. In a pooled analysis of 6 acute stroke patients (median time MRI to PET: 55 minutes; patients imaged within 6 hours after stroke) the best relative penumbral flow threshold was 0,53 on rCBF-CTP; 0,49 on rCBV-CTP; 1,10 on rMTT-CTP and 4.45 seconds on rTTP-CTP maps. Discussion: Several parameters obtained by pCT were closely related to CBF measured by PET and may be applied for detection of critically reduced regional perfusion. Critical hypoperfusion was well depicted by relative pCT in acute and subacute ischemic stroke. Among the commonly used pCT parameter maps, rCBF and rTTP maps showed the best estimate of penumbral flow. Our results validate perfusion values derived from pCT for imaging in acute ischemic stroke.
Optimizing Acute Stroke Imaging for Maximizing Information and Minimizing Acquisition, Post Processing and Interpretation Times: Analysis of Data From PROVE-IT, a Prospective Imaging Cohort Study
Menon, B; Almekhlafi, M; Demchuk, A; Goyal, M; University of Calgary, Calgary, AB
Introduction: To compare utility and efficiency of perfusion CT (PCT) with multiphase CTA (mCTA) in making treatment decisions in patients with acute ischemic stroke. Methods: mCTA (patent pending) is a new technique capable of identifying site of arterial occlusions and degree of pial collateralization distal to occlusion better than conventional CTA. Data is from PROVE-IT, an ongoing prospective cohort study of patients with acute ischemic stroke at our center. All patients undergo NCCT followed by mCTA and PCT. Two readers interpreted NCCT and mCTA by consensus. Results: In 70 patients (median age 67, 49.3% male), median baseline NIHSS was 10 (IQR 13), median onset to CT time in those with witnessed stroke onset was 101 mins (IQR 138) and median baseline ASPECTS was 10 (IQR 3). Acquisition and interpretation took < 3 mins for NCCT, < 5 mins for mCTA and 20 mins for PCT. Uncertainty for IV tPA treatment was present in 10.1% of patients with NCCT, 1.4% with mCTA and 15.9% with PCT. Uncertainty for IA treatment was present in 66.7% of patients with NCCT but only in 2.9% with mCTA. Patient motion affected image interpretation in 1.4% of patients with NCCT and mCTA when compared to 7.2% with PCT. Agreement between mCTA and PCT for IV tPA was seen in 91.2% patients (k=0.41, p<0.001). In 2 patients with sub-acute infarcts on NCCT, PCT suggested treatment. In 3 other patients, NCCT and mCTA suggested futile recanalization whereas PCT suggested treatment. These patients all had large infarcts on follow-up imaging. Conclusion: NCCT with mCTA is a robust tool for making IV and IA treatment decisions in patients with acute ischemic stroke. Whole brain coverage, speedy interpretation and being unaffected by patient motion are advantages in the acute stroke milieu when compared to PCT.
Periodic Limb Movements are Associated with White Matter Hyperintensities in High-Risk TIA and Minor Stroke Patients
Boulos, MI; Murray, BJ; Muir, RT; Wolfe, PJ; Jewell, DR; Black, SE; Swartz, RH; Sunnybrook Health Sciences Centre, Toronto, ON
Background: The clinical significance of periodic limb movements during sleep (PLMs) is unknown. PLMs are associated with transient but significant increases in night-time blood pressure and autonomic hyperactivity; emerging evidence suggests a link with vascular disease. While obstructive sleep apnea (OSA) may be associated with white matter hyperintensities (WMH), the relationship between PLMs and WMH is unclear. Methods: We prospectively recruited high-risk TIA or minor stroke patients who presented within two weeks of their acute cerebrovascular events. Patients underwent polysomnography as well as magnetic resonance imaging (MRI) or computed tomography (CT) of the brain. Polysomnography was scored according to criteria from the American Academy of Sleep Medicine. WMHs were assessed using the Age Related White Matter Changes (ARWMC) scale and infarction volume was calculated using Analyze 8.0 Software. Pearson or Spearman correlation coefficients were calculated between ARWMC and age, gender, infarction volume, vascular risk factors (VRFs), prior vascular events, polysomnography parameters, cognition and neurological status. Significant variables were entered into a linear regression model with ARWMC as the outcome. Results: Forty patients were assessed (mean age 66.3 years, 63% male, mean NIHSS 0.74). Twenty-one patients presented with stroke. VRFs included: hypertension (50%), hyperlipidemia (51%), diabetes (23%), and prior stroke (20%). The mean ARWMC score was 6.95 (range 0-22). ARWMC score correlated with PLM index (r=0.377, p=0.016) and presentation with acute stroke (rho=0.418, p=0.007), but not age, VRFs, infarction volume, apnea-hypopnea index or other variables. Linear regression analysis revealed that PLM index (β=0.377, R^2=0.142, p=0.016) had the strongest association with the ARWMC. Conclusions: PLM index was positively associated with the extent of white matter hyperintensities. Whether PLMs are implicated in the pathogenesis of WMHs or are simply a marker of vascular disease remains uncertain. Future studies should explore causality with vascular disease, and whether treatment of PLMs reduces incident vascular disease.
Interprovincial Collaboration for Creating Stroke Units in Western Canada
Kamal, N1 Suddes, M2 Collier, T3 Hill, MD2 Dawson, A4 Calder, J3 Harris, D1 LoChang, J1 Newton, D5 Foster, D6 Harrison, K4 Seeley, L7 Arsenault, S8 Hennessy, B9 Aikman, P1; 1. Stroke Services BC, Vancouver, BC; 2. Calgary Stroke Program, Calgary, AB; 3. Royal Inland Hospital, Kamloops, BC; 4. Fraser Health Authority, Surrey, BC; 5. Saskatoon Health Region, Saskatoon, SK; 6. Vancouver Island Health Authority, Victoria, BC; 7. Interior Health Authority, Kamloops, BC; 8. Vancouver Coastal Health Authority, Vancouver, BC; 9. Northern Health Authority, Prince George, BC
Background: Stroke Unit (SU) care holds the strongest evidence for reduced mortality and disability due to stroke. However, according to the 2011 Canadian Stroke Network’s National Stroke Audit, 23% of stroke patients in Canada were admitted to a SU with BC falling far behind the national average at only 4%. Method: Using the Improvement Collaborative methodology, a SU Collaborative was launched by Stroke Services BC, a program of the Provincial Health Services Authority. Faculty members were recruited from BC and the Calgary Stroke Program. The goal of the Collaborative is for teams to work towards the creation of new SUs or to improve SU care where SUs exist. The Collaborative has 4 Learning Sessions, a closing workshop, and bi-weekly webinars. Teams follow a structured 7-step framework: understanding current volumes; securing space; establishing the team; ensuring clinical best practice; creating processes for team communication managing transitions; ensuring patient engagement; and establishing quality improvement mechanisms. Pre and post self-reports of care against best practice is collected through electronic polling during the Learning Sessions. Teams submit outcome and process data and report on their progress. Results: Ten teams have enrolled representing the entire province of BC and Saskatoon. Teams are either working at the hospital or health authority level. Thus far, plans are under way for the creation of 64 new SU beds in BC, and 12 beds recommended for Saskatoon Health Region. Results will be presented demonstrating the progress made with respect to change in self-report of best practice, teams’ progress, and the impact on process and outcome measures. Conclusion: The creation of new SUs is possible through an interprovincial collaborative approach with participation from BC, the Calgary Stroke Program, and the Saskatoon Health Region. This is possible by utilizing the Collaborative approach and through a structured framework for creating new SUs.
Évolution du suivi des recommandations en soins infirmières, en trois éditions d’audit de l’AVC en Catalogne
Salvat-Plana, M1 Ramirez-Garcia, P2 Suñer, R4, 3 Ribera, A5, 1 Abilleira, S6 Gallofré, M7; 1. Stroke Programme, Health Department of Catalonia (Plan Directeur des Maladies Cérébrovasculaires. Département de Santé de Catalogne), Barcelonne, Spain; 2. Faculté des Sciences Infirmières. Université de Montréal, Montréal, QC; 3. Hospital Universitari Dr. Josep Trueta de Girona, Girona, Spain; 4. Faculté Sciences Infirmières. Université de Girona. Catalogne, Girona, Spain; 5. Unité d’Epidémiologie Cardiovascular. Hospital Vall d’Hebron, Barcelonne, Spain; 6. Stroke Programme, Health Department of Catalonia (Plan Directeur des Maladies Cérébrovasculaires. Département de Santé de Catalogne), Barcelonne, Spain; 7. Stroke Programme, Health Department of Catalonia (Plan Directeur des Maladies Cérébrovasculaires. Département de Santé de Catalogne), Barcelonne, Spain
Contexte: Trois audits de l’AVC ont été menés en Catalogne en 2005, 2007 et 2010. Ces audits évaluent un nombre limité des recommandations à l’aide d’indicateurs. Le but de l’étude est de décrire le suivi des recommandations spécifiques aux soins infirmiers en 2010, d’analyser l’évolution du suivi en 2005, 2007 et 2010 et d’identifier des facteurs reliés à ce suivi. Méthodes: Il s’agit d’une étude descriptive/correlationnelle. Six indicateurs spécifiques aux soins infirmiers ont été mesurés. Les données ont été collectées à partir des dossiers médicaux des patients admis dans 46 hôpitaux publics. L’évolution du suivi a été analysée à l’aide des chi-carrés et des modèles de régression ont été utilisés afin d’identifier les facteurs reliés à ce suivi. Résultats: Au total 2190 cas ont été évalués. Trois des six indicateurs évalués montrent un suivi >70%: mobilisation précoce (78,6%), réalisation d’un ECG basal (97%) et réalisation d’une glycémie basale (97,7%). Le dépistage de la dysphagie améliore au cours des trois audits (p<0,001). L’évaluation de l’humeur, s’est détériorée par rapport à 2007 (p=0,002). Les analyses ajustées pour les caractéristiques et la gravidité des patients montrent un majeur suivi du dépistage de la dysphagie parmi les cas admis en neurologie (OR: 5,28, IC 95%, 1,35 à 20,6) et/ou dans les centres de plus de 300 admissions/année par AVC (OR: 4,31, IC 95%, 1,04 à 17,8) ainsi que de l’éducation au patient/famille quand le patient est admis en fin de semaine (OR: 1,62 IC 95%, 1,03 à 2,54). Discussion: L’évolution dans le suivi des recommandations montre que la qualité des soins infirmières aux personnes ayant subi un AVC s’améliore progressivement en Catalogne. Toutefois, une amélioration de certaines recommandations est possible. Ainsi, il s’avère nécessaire de renforcer et promouvoir des interventions plus ciblées et spécifiques.
Improved Methods for Longitudinal Motor Mapping After Stroke in Mice: Automated Movement Tracking with Accelerometers, and Chronic EEG Recording in a Bilateral Cranial Window Preparation
Silasi, G; Harrison, T; Boyd, J; LeDue, J; Murphy, TH; University of British Columbia, Vancouver, BC
Longitudinal motor mapping through optogenetic stimulation of the mouse cortex can be used to reveal cortical reorganization following stroke. Here we present a refined set of procedures for repeated light-based motor mapping in ChR2-expressing mice implanted with a bilateral cranial window and a chronic EEG electrode. Light stimulation was delivered sequentially to over 400 points across both cortical hemispheres, and evoked movements were quantified on-line with a 3-axis accelerometer attached to each forelimb. Bilateral maps of forelimb movement amplitude and movement direction were generated at weekly intervals before and after photothrombosis targeted to the centre of the forelimb motor cortex. During baseline mapping, light pulses of ~2 mW produced well-defined maps that were centered approximately 0.7 mm anterior and 1.6 mm lateral from bregma. Map borders were defined by sites where light stimulation evoked EEG deflections, but not movements. Following stroke injury, which destroyed the majority of the forelimb representations in one hemisphere, we did not see the emergence of new cortical sites in the injured hemisphere. Instead, movements of the impaired forelimb could be evoked by stimulation of the ipsilateral (uninjured) hemisphere. Smaller strokes targeted to a portion of the forelimb motor map did not decrease the total area of forelimb motor representation but produced more disorganized maps as measured by the local spatial correlation of each map point. We demonstrate that our method may be used to chronically assess evoked motor output and post-stroke reorganization. In addition to providing a more complete assessment of forelimb function, our bilateral preparation affords a within-subject control for anesthetic levels during mapping by comparing motor output between the intact and injured hemispheres.
The Role of Neurovascular Coupling in Stroke Recovery
Lake, EM1 Stanisz, G1, 2 Stefanovic, B1, 2; 1. Sunnybrook Health Science Centre, Toronto, ON; 2. University of Toronto, Toronto, ON
Background: This work combines MRI with behavioral testing to assess the effect of well-timed, low-dose alpha5-subunit-GABA R antagonism (using L-655,708) on recovery in a well established model of focal ischemia. By administering a selective GABA-antagonist, we attempt to support the restoration of normal neuronal activity by ameliorating hypo-excitability in the chronic stage of recovery. Methods: 6 adult male Sprague Dawleys received intracortical injections of endothelin-1. MRI was performed prior to stroke and at weekly intervals following ischemia for 3 weeks. Beginning 7 days following stroke, and continuing for 14 days, animals received subcutaneous pills containing 1.5mg L-655,708 in 58.5mg of HPMV, NTreated=3, or 60mg of HPMV, NControl=3. Results: The pronounced deficit in reaching ability seen 1 week following ischemic insult improved significantly more (p=0.0097) in the treated group. MRI revealed apparent tissue re-growth and decreased necrotic volume in the treated group (p=0.0045). H&E staining indicated that the new tissue is vascularized and of dense and heterogeneous cellular composition.
Conclusions: The present work builds upon the finding that continuous, low-dose treatment with a novel GABA-antagonist in the chronic stage of stroke recovery may ameliorate some of the deleterious effects of ischemic injury. The current data show beneficial effects of this treatment on behavioral recovery in rats, in agreement with prior work done in mice, and provides characterization of structural changes within the stroke region.
Cholesterol Efflux Capacity is Inversely Associated with Severity of Carotid Atherosclerosis and Increases with Time Since Cerebrovascular Event
Doonan, RJ; Hafiane, A; Gorgui, J; Genest, J; Daskalopoulou, SS; McGill University, montreal, QC
Introduction: HDL is thought to exert its atheroprotective role by promoting cholesterol efflux from lipid-laden macrophages. Cholesterol efflux capacity (CEC) has been shown to be inversely associated with carotid intima-media thickness and presence of coronary artery disease. We assessed the hypothesis that CEC is associated with severity of carotid atherosclerosis and with cerebrovascular symptomatology. Methods: Symptomatic (n=114) and asymptomatic (n=41) patients with carotid stenosis were recruited from Vascular Surgery at the Royal Victoria and Jewish General hospitals, Montreal, Canada. Carotid Doppler ultrasound was performed and stenosis (50-79%, 80-99%) was graded according to velocities. Detailed information on symptomatology obtained. A blood sample was collected on the day of the ultrasound; HDL was obtained by polyethylene glycol precipitation after depletion of apoB-containing lipoproteins. CEC was determined by incubating HDL in cAMP-stimulated J774 mouse peritoneal macrophages for 6 hours. Specific cholesterol efflux was obtained by subtracting total efflux from efflux in non-cAMP stimulated cells. Differences in CEC were assessed using linear regression according to 1) stenosis, 2) symptomatology and, 3) timing of symptomatology. Results: Compared to patients with 50-79% stenosis (n=31), patients with 80-99% stenosis (n=124) had significantly decreased CEC (beta=-2.23, P=0.04) after adjustment for age, sex, apoAI, and systolic BP. CEC was not significantly different between symptomatic or asymptomatic patients. However, in symptomatic patients CEC increased with increasing time since cerebrovascular event. Specifically, compared to 0-30 days (n=72), CEC was non-significantly increased 31-90 days since event (n=31, beta=1.64, P=NS), while increased significantly ≥ 90 days since event (n=11, beta=4.48, P=0.01), after adjustment as described above. Conclusion: These results suggest that CEC is inversely associated with severity of carotid stenosis and that CEC increases with increasing time since symptomatic event. This may be related to remodeling of HDL during the acute phase reaction after a recent ischemic event.
Multi-modality Neuroimaging in a Porcine Model of Endothelin-1 Induced Cerebral Ischemia: Defining the Acute Infarct Core
d’Esterre, C1 Aviv, R1 Fainardi, E3 Lee, T4; 1. University of Calgary, Calgary, AB; 2. Sunnybrook Health Sciences Centre, Toronto, ON; 3. Azienda Ospedaliero-Universitaria di Ferrara, Ferrara, Italy; 4. University of Western Ontario, Robarts Research Institute, Lawson Health Research, London, ON
Background: CT perfusion (CTP)-derived parameters and MR-diffusion weighted imaging (DWI) are currently used to delineate infarct volume; however, reversibility of such defects has been demonstrated for both modalities. Methods: Ten domestic pigs had a CTP scan prior to intracranial injection of endothelin-1 (ET-1;0.01mL/kg) into the left striatum. CTP scans at 30min, 1hr, 1.5hrs were done to monitor ischemic progression. A second dose of ET-1 (0.01mL/kg) was injected at 2hrs from the first injection. Twenty minutes after the second ET-1 injection, 18F-FDG was injected(300-380MBq). The animal was moved to a 1.5T MRI scanner where DWI was performed. The animal was then moved back to the CT scanner for a final CTP/PET acquisition within 10 minutes of the DWI. The brain was quickly removed and stained with tetrazolium-chloride (TTC). The infarct volume defined by low intensity TTC stain, low CBF (<9.3ml•min^-1•100g^-1), low CBV (<1.07ml•100g^-1), DWI hyper-intensity and low 18F-FDG uptake were determined. Linear regression was used to correlate the infarct volume measured by each imaging modality to that by the histological gold standard. Results: R^2 values for CBF, CBV, DWI and FDG versus TTC-histology were 0.83, 0.69, 0.95 and 0.61, respectively. For the CBF and DWI parameters the slope of the fitted line was greater than 1, while the slope of the fitted line for the CBV and CBFxCBV parameters was less than 1. Mean normalized (relative to the histologically defined infarct) values were 1.38, 0.82, 0.99, and 0.67 for CBF, CBV, DWI and FDG, respectively. Conclusion: The CTP-CBF and the imaging gold standard DWI both overestimated the TTC-infarct core in 66% and 58% of cases, while CTP-CBV, CBFxCBV and FDG-PET all underestimated the final infarct volume in 100% of animals. The CBF/CBV mismatch was observed within 4/12 DWI lesions, and 3/12 TTC defined infarcts(Figure). The CBF/CBV mismatch may not represent penumbra during the acute stroke setting.
Quantitative CBF Measurement with CT Perfusion: Is it Correct to Correct the Partial Volume Averaged Arterial Input curve with Venous Output Curve
Lee, TY1, 2 Menon, BK2 Eesa, M2 Goyal, M2 Demchuk, A2 Frayne, R3; 1. Lawson Health Research Institute, London, ON; 2. Foothills Medical Centre, Calgary, AB; 3. Seaman Family MR Research Centre, Calgary, AB
Introduction: To accurately measure cerebral blood flow (CBF) with CT Perfusion, the partial volume averaged arterial input curve (AIF) is corrected by the ratio of the areas of the AIF and venous output curve (VOC). This correction method assumes that the VOC is dispersed (widened) with respect to the AIF but the areas underneath each are the same if the AIF is not partial volume averaged. We investigated the validity of this assumption in acute stroke patients. Method: Twelve CT Perfusion studies from stroke patients admitted from March to April 2013 in which the intracranial internal carotid artery or the basilar artery at level of the pons was visible in one or more slices were chosen. As the diameters of both artery segments (3.6 and 3.2 mm respectively) are larger than the limiting resolution (< 1 mm) of the scanner, AIF measured in them would be minimally affected by partial volume averaging and hence can be used to test the above assumption. A circular region of interest (ROI) of diameter 1.4 mm was placed in either the intracranial ICAs or the basilar artery to generate time density curves. The curve with the highest peak was accepted as the AIF. A similar sized circular ROI was placed at the posterior portion of the superior sagittal sinus in all slices. The venous curve with the highest peak was accepted as the VOC. The areas under the AIF and VOC were calculated. Results: The ratios of the AIF and VOC areas among the twelve CT Perfusion studies were significantly greater than 1.0 (P<0.01; mean ± SD: 1.8 ± 0.7) leading to CBF values that were 1.8 times smaller on average. Conclusions: Retrograde flow from collaterals likely causes breakdown of the VOC based partial volume correction method resulting in significant underestimation of CBF.
Intracerebral Hemorrhage in Rat Causes Edema and Raised Intracranial Pressure
Hiploylee, C; Colbourne, F; University of Alberta, Edmonton, AB
Background: Intracerebral hemorrhage (ICH) sometimes leads to life-threatening elevations in intracranial pressure (ICP) that arise from the hematoma mass effect and edema. Whereas not all patients experience large changes in ICP, it remains a significant concern and predictor of mortality. Animal studies commonly rely upon edema as a primary endpoint. However, the role of edema in affecting ICP and the importance of these variables are not clear in the common rodent ICH models. Methods: Radiotelemetry was used to measure ICP in freely moving, awake rats (Silasi, MacLellan and Colbourne, 2009). The widely used collagenase model was used to create a severe ICH that destroys much of the striatum. ICP readings were collected in the epidural space or in the center of the hematoma for 3 days. This comparison was to discern the optimal monitoring location. Additional studies, in progress, are evaluating changes in cerebral perfusion pressure in this setting, and the effects of hematoma size and model on ICP. Results: Severe ICH resulted in much higher water content (86.05% ± 1.12 SD, p<0.001) and ICP (10.92 mmHg ± 2.93 SD, p<0.001) than shams (77.85% ± 0.73 SD; 4.33 mmHg ± 2.43 SD) with no difference between epidural and intraparenchymal monitoring. Overall mortality is low but it appears to be related to high ICP (e.g., one rat that died ~15 hours after ICH had a peak ICP of ~23 mmHg). Finally, preliminary findings indicate that moderate sized lesions caused by collagenase or directly injecting blood results in fewer rats with an elevated ICP. Conclusion: ICP is elevated for days after a severe hemorrhage, but less so in the moderate-severity insults commonly used. Collectively, these results further define the face validity of these rat models and show that ICP can be used as a therapeutic target at least in severe ICH models.
Optogenetic Analysis of Function and Structure of Parvalbumin Neurons Following Transient Global Ischemia in Mice
Xie, Y; Chen, S; Murphy, TH; University of British Columbia, Vancouver, BC
Here, we apply a previously established optogenetic method (Chen et al, J Neurosci 2012(32): 13510-9) to investigate changes in excitability of PV neurons in the cortex following a 5 min period of global ischemia and reperfusion, which mimics brain ischemia during cardiac arrest. We pharmacologically defined that PV-ChR2 stimulation evoked local field potential (LFP) reflects both cell depolarization (downward LFP) and inhibitory synaptic transmission (upward LFP). Spontaneous LFP, PV-ChR2 and forepaw stimulation evoked LFP records were collected from the somatosensory cortex. Global ischemia first suppressed the spontaneous LFP along with suppression of forepaw stimulation evoked LFP (5.7% of baseline at 1 min) and PV-ChR2 stimulation evoked upward LFP (7.5% of baseline at 1 min). During ischemic depolarization occurred, PV-ChR2 simulation evoked downward LFP was suppressed (11.9% of baseline at 4 min). After reperfusion, the PV-ChR2 stimulation evoked downward LFP recovered (64.5% of baseline at 3 min) concurrently with the recovery of DC-EEG. In contrast, the putative inhibitory synaptic component recovered slowly and incompletely (58.1% of baseline at 55 min), which was coincident with the recovery of forepaw stimulation evoked LFP (81.9% of baseline at 55 min). Our data suggest that excitability of PV inhibitory neurons is suppressed during global ischemia and rapidly recovers during reperfusion, whereas inhibitory synaptic transmission exhibits prolonged suppression even with reperfusion. To assess PV-neuron structure in the same model, we expressed td-tomato specifically in PV neurons. We observed a dendritic blebbing in layer 1, as well as a swelling of cell somata in layer2/3 during global ischemia, which recovered within 5~10 min following reperfusion. The rapid recovery of cellular structure and excitability following reperfusion indicates that the prolonged suppression of PV neurons mediated inhibitory transmission is more likely due to failure of inhibitory synaptic transmission, rather than structural damage.
Brain Structural Correlates of Motor Function in Chronic Stroke
Borich, MR; Wadden, KP; Boyd, LA; University of British Columbia, Vancouver, BC
Stroke is the leading cause of adult disability and <50% of individuals regain full arm function. Neuroimaging techniques can provide a quantitative measurement of brain structure that may lead to new biomarkers of recovery after stroke. We aimed to characterize the relationship between measures of white and gray matter structure within the primary cortical motor output system and paretic arm function in chronic stroke. Twenty-seven individuals with chronic (>6months) stroke (mean age:65±9.7 years,6F) underwent a single magnetic resonance imaging scan and completed an assessment of upper extremity motor function (Wolf Motor Function Test or WMFT). A high-resolution T1 and a 60-orientation high angular resolution diffusion imaging scan were acquired and processed using the Freesurfer image analysis suite and ExploreDTI software package. Bilateral precentral gyral thickness and mean fractional anisotropy (FA) of the corticospinal tract were extracted for analysis. Fiber tractography was performed using a tensor-free fiber orientation algorithm. The WMFT consisted of fifteen timed movement tasks. A rate score was calculated for each task and averaged across all tasks bilaterally. Paired samples t-tests and multiple regression analyses were performed to examine hemispheric differences and evaluate the association between brain structure and arm function. Significant hemispheric differences in corticospinal tract FA and precentral gyral thickness were observed (both p<0.0005). WMFT scores also differed between paretic and non-paretic arms (p=0.003). Ipsilesional tract FA explained a significant amount of variance in paretic WMFT scores after accounting for age and post-stroke duration (R2=0.44, p=0.013). Cortical thickness did not explain an additional significant amount of variance in motor function. Hemispheric differences in measures of gray and white matter structural status were observed. Only ipsilesional descending motor output tract status was positively associated with paretic arm function in chronic stroke. These imaging techniques may be used in future work to predict and evaluate response to rehabilitation.
Detection and Quantification of Functional Lesions from Slowing in Resting-State MEG
Meltzer, JA1 Chu, R2 Braun, AR3; 1. Rotman Research Institute, Baycrest, Toronto, ON; 2. University of Toronto, Toronto, ON; 3. National Institutes of Health, Bethesda, MD, USA
Background: Improvement of cognitive abilities in the chronic phase of stroke recovery may arise from recruitment of new brain areas, or restoration of function in areas that were functionally damaged but not destroyed by the stroke. Measurement of cortical dysfunction in perilesional tissue could provide a means to identify candidate regions for restorative therapy, and to monitor the response to interventions. Perilesional tissue generates excess “slow wave” activity in EEG, but localizing this activity has been difficult. Methods: We measured neuronal activity in 25 patients with post-stroke aphasia, using magnetoencephalography (MEG). We used beamforming algorithms to estimate “virtual channel” signals at each voxel in the brain, as a linear combination of 275 sensors. We mapped two quantities related to signal complexity, namely median frequency (MF) and multiscale entropy (MSE). Decreases in these quantities may identify dysfunctional cortex. Results: Compared to controls, stroke patients exhibited significant decreases in MF and MSE in tissue surrounding the core lesion. MSE was a more specific indicator of perilesional abnormalities, as MF was also affected by general changes seen in aging. Furthermore, reduced complexity of resting signals in perilesional cortex was correlated with reduced responsiveness in a language comprehension task.
Conclusions: Perilesional “slowing” can be accurately mapped and quantified using MEG. This technique offers a new way to assess “functional lesions” in stroke and also progressive disease.
Telehealth for Speech-Language-Swallowing Post Stroke: 500 Camera Hours
Baird, AJ1 Smook, C2; 1. SpeechWorks Inc, Winnipeg, MB; 2. Northern Regional Health Authority, Thompson, MB
At 324,000 square kilometres, covering 52 percent of the province, the Northern Regional Health Authority (NRHA) is the largest geographical health region in Manitoba. Until 2008, there were no adult speech-language pathology services for the region and those requiring assessment and treatment post stroke were flown to Winnipeg for their rehabilitation services. In 2008, the region added 3 days of adult speech-language services per month, where the speech pathologist was flown into Thompson, Manitoba. Treatment effects could not be realized with these infrequent visits and options were investigated. A successful grant application to the Manitoba Patient Access Network provided the opportunity to investigate the impact of assessment and weekly treatment provided using telehealth services. The purpose of this presentation is to report the outcomes of those assessments and subsequent therapies. Participants for the program were selected from an existing caseload or were referred from health care providers both in either the acute or chronic phase. All participants with communication disorders were assessed using standardized tools, scheduled for weekly therapy sessions and given an iPad to complete homework activities. The NRHA staff was trained to screen for swallowing disorders and refer as indicated to speech-language services for recommendations. Of 31 participants, 11 were treated for aphasia, 8 were treated for dysarthria, 8 were treated for cognitive linguistic deficits, and 8 were treated for swallowing disorders post stroke. For those with aphasia, all post testing results trended upwards. Subjective improvements were reported with all those with dysarthria. There were no reports of pneumonias in participants assessed for swallowing disorders. Conclusions: Speech and language treatment provided once a week using telehealth produces positive outcomes in people post stroke in all stages of recovery. Providing these services by telehealth is an acceptable and cost effective solution for stroke treatment provided by speech-language pathologists.
Imaging Correlates of rTMS Treatment for Post-Stroke Aphasia: a Randomized Controlled Study
Thiel, A1 Anglade, C2 Hartmann, A3 Heiss, W4, 5; 1. Jewish General Hospital, Montreal, QC; 2. Universite de Montreal, Montreal, QC; 3. Rehanova, Cologne, Germany; 4. Max-Planck Institute for neurological researc h, Cologne, Germany; 5. McGill University, Montreal, QC
Background: Single case reports and small case series suggest that the effect of conventional speech and language therapy (SLT) for recovery of language from post-stroke aphasia may be augmented through modulation of activity in language networks by repetitive transcranial magnetic stimulation (rTMS). Here we report the results of a first randomized and controlled study in subacute post-stroke aphasia and the effect of rTMS on reorganization of language networks during the recovery process. Methods: We studied 24 right-handed patients with subacute post-stroke aphasia. Within 4-8 weeks after stroke, patients were randomized to a 10 day protocol of 20 minutes inhibitory 1Hz rTMS over the right posterior inferior frontal gyrus (pIFG) or sham stimulation followed by 45 minutes of deficit specific SLT. Language network activity was measured with O-15-water Positron Emission Tomography during verb generation before and after treatment. Total left and right hemisphere network activity was quantified by activation volume indices (AVI) with positive indices indicating larger networks in the left-hemisphere and negative indices larger volumes in the right hemisphere. Language performance was assessed using the Aachen Aphasia Test battery (AAT). Results: Global AAT score change, was significantly higher in the rTMS group (t-test, P=0.003). The rTMS effect was strongest for the subtest naming (2 factor RM-ANOVA, P=0.002) but a trend was also observed for comprehension, token-test and writing (P<0.1). Patients in the rTMS group activated proportionally more voxels in the left-hemisphere (positive AVI) after treatment than before compared to sham treated patients (2 factor RM-ANOVA, P=0.027 within group, P=0.045 between groups).There was a moderate but significant linear relationship between post-treatment AVI and global AAT score change (r2 = 0.19, P=0.04). Conclusions: Inhibitory rTMS over the right pIFG in combination with SLT favors the recruitment of left hemispheric language networks and significantly improves language recovery in subacute ischemic stroke.
Functional Electrical Stimulation Therapy for Upper-Limb Motor Recovery in Pediatric Stroke Patients with Severe Long-Term Impairment
Kapadia, NM1 Popovic, MR1, 2; 1. Toronto Rehabilitation Institute, Toronto, ON; 2. University of Toronto, Toronto, ON
Background: The average annual incidence of stroke in children is 2.7 in 100 000, many of which result in permanent residual cognitive and/or physical impairments. Successful clinical trials of adults have shown that functional electrical stimulation (FES) therapy can restore voluntary arm and hand function in people with severe stroke; however, the literature failed to identify trials in which FES was used in a paediatrics stroke population. As such, this study was designed to examine functional changes in the upper limb of severe chronic paediatrics stroke patients following intensive FES therapy, consisting of task-specific upper-limb movements with a combination of preprogrammed FES and manual assisted motion. Methods: Four severe chronic paediatric stroke participants were assessed using the Rehabilitation Engineering Laboratory Hand Function Test, Quality of Upper Extremity Skills Test, Paediatric Evaluation of Disability Inventory, and Assisting Hand Assessment. FES therapy was administered for 1 hour three times per for 16 weeks, for a total of 48 treatment sessions. Results: All participants improved on all measures. Subjects demonstrated an average increase on Rehabilitation Engineering Laboratory Hand Function Test components of 14.5 for object manipulation (P = .042), 0.78 Nm for instrumented cylinder (P =.068), and 14 for wooden blocks (P = .068) and an average increase on the grasp component of Quality of Upper Extremity Skills Test of 25.93 (P = .068). Conclusion: FES therapy with upper-limb training may be an efficacious intervention for paediatric patients with severe stroke.
A Longitudinal View of Emotional Vitality of Caregivers of Stroke Survivors
Barbic, SP; Bartlett, SJ; Rodriguez, A; Mayo, NE; McGill University, Montreal, QC
Background: Caregiver emotional vitality (EV) may be an important modifiable target for intervention by rehabilitation professionals to improve health outcomes of both caregivers themselves and the individual who experienced a stroke. Objectives: The overall aim was to contribute to the understanding of the stroke caregiving experience by taking a longitudinal view of EV. The specific objectives were to estimate the extent to which (i) caregiver EV changes in the first caregiving year; and (ii) estimate the extent to which caregiver characteristics and the functional profile of the care recipient impacts a caregiver’s EV in the first year. Methods: Data came from an inception cohort of caregivers (n=409) that was followed over the first post-stroke year. Group-based trajectory modelling (GBTM) was used to identify distinctive groups of individuals with similar trajectories. Time-specific EV was plotted from the first time of assessment (one month post-stroke) to 12 months. Dual trajectories were used to estimate concordance between trajectories of EV and baseline health-related characteristics of the caregiver and the care recipient. Results: Five trajectories of EV were identified. Four trajectories maintained their baseline low EV level, and one showed deterioration over time. Given the scoring range of the EV measure was 0-44 (with higher scores indicating higher EV), all trajectories had baseline means that fell below a total score of 30, with 78% of the sample having baseline scores of less than 18. Caregiver personal mastery was identified as a significant predictor of EV. Conclusion: EV in caregivers was on average very low in the first caregiving year. Personal mastery was identified as a component cause of EV for this sample, lending preliminary support for the need to incorporate regular assessment of caregiver EV and personal mastery throughout the caregiving experience.
Communication and Mobility After Locked-In Syndrome: a Review of Twenty-Five Cases
Beaudoin, N1 De Serres, L1 Martel, N1 Poissant, L1 Rochette, A2 Robert, G1 Nicolaidis, A1; 1. Institut de réadaptation Gingras-Lindsay de Montréal, Montréal, QC; 2. Ecole de réadaptation Université de Montréal, Montral, QC
Background: Persons afflicted with Locked-In Syndrome (LIS) present with the most severe level of disability that can occur following a stroke. Few Canadian data have documented the functional outcome of these patients. In this study, communication and mobility has been specifically addressed. Methods: Twenty-five patients presenting LIS had been followed by the rehabilitation team at the Montreal Gingras-Lindsay Rehabilitation Institute. The majority received specific training to access and use technology for optimal independence. We documented their neurologic and functional evolution over a period up to twenty years. Result: In spite of considerable motor disabilities, many patients achieved a high level of autonomy to communicate and to control a motorized wheelchair. Patients with incomplete LIS who had recuperated motor function of one hand were more likely to use a manual joystick. Classic LIS patients may recuperate minor movement of head and of one finger or one toe. Some of them succeed using a cephalic control to drive a wheelchair (40%) and a head mouse emulator to access a computer (25%). Others presenting even more limited movement need a more sophisticated interface. We will present a short video of two patients using computerized interfaces to activate a scanning system permitting combined computer-supported communication and safe wheelchair control. Conclusions: Advances in technology can improve autonomy for LIS patients. Considering the strong will to live expressed by those patients and their involvement in social and familial endeavors, access to rehabilitation for independent communication and mobility are strongly recommended for all LIS patients.
Accreditation Canada’s Stroke Distinction Program: a Quality Improvement Strategy
Martin, C1 MacIsaac, L2 Martin, G3 Bowman, D1 Basile, VS2 Chapman, S1 McCumber, T2 Jewitt, R1 Murray, J2 Jin, A1 Reinholdt, F2 Murphy, C1; 1. Stroke Network of Southeastern Ontario, Kingston General Hospital, Kingston, ON; 2. MacKenzie Health, Richmond Hill, ON; 3. Accreditation Canada, Ottawa, ON
Background: Accreditation Canada’s Stroke Services Distinction Program recognizes centres that demonstrate clinical excellence and outstanding commitment to leadership in stroke care and prevention in relation to Canadian Best Practice Recommendations for Stroke Care. Kingston General Hospital (KGH) and Mackenzie Health (MH), recently received Stroke Distinction Awards. Method: The Distinction program requires: 1) Achievement of evidence-based standards; 2) Achievement of performance indicator thresholds; 3) Implementation of current stroke protocols; 4) Completion of an innovative project; 5) Evidence of client and family education. Achievement of the award was a corporate priority with senior management support. Staff and leaders were engaged in the development of improvement plans and communication strategies to meet the rigorous requirements. Datasets were used to plan and monitor targeted improvements including attention to data quality through independent chart audit. Common quality improvement (QI) methodologies were used. Teams worked closely with the Accreditation Specialist in preparation for the survey. Results: At KGH, focused process improvements resulted in increased stroke unit utilization and dysphagia screening rates with decreased in-hospital stroke mortality and 30-day readmission rates. Sub-analysis of complication rates by age and stroke type provided information on those at most risk of complications, providing the basis for continuing QI. MH enhanced integration of best practice stroke care across the organization through policy implementation and staff engagement. Both centres realized data quality improvements (e.g. dysphagia screening). Heightened awareness of Best Practices and increased interprofessional team collaboration were observed. Collaboration with Accreditation Canada resulted in a quality improvement cycle for the process itself. The ongoing requirement to submit performance indicators semi-annually drives sustained QI. Conclusion: Pursuit of Stroke Distinction is a catalyst for driving change and improving stroke care delivery processes and outcomes. Participation in this program provides an effective means to prepare Ontario centres for 2013-14 Quality Based Procedures for stroke care.
Stroke Competency Framework: a Quality Improvement Approach to Healthcare Provider Education
Cole-Haskayne, A1 Garnier, S2 Grant, M1 Suddes, M1; 1. Calgary Stroke Program, Alberta Health Services, Calgary, AB; 2. St. Paul Healthcare Centre, St Paul, AB
Background: Healthcare provider education was one of seven key improvement themes that emerged from Alberta Stroke Improvement (ASI), a provincial quality improvement initiative in 2011-12. The ASI Education Working Group was established to develop a competency-based healthcare provider education framework and provide recommendations for implementation to the Cardiovascular Health and Stroke Strategic Clinical Network. Methods: A literature review and survey of existing competency frameworks was conducted. Stakeholder feedback was obtained at ASI learning sessions. Stakeholders requested that the framework focus on best practice, be inter-professional, link learning resources, identify core and advanced competencies, be applicable and accessible to urban and rural sites, provide direction around certification and facilitate performance management. Existing competency frameworks did not address all criteria. Process mapping was used to direct the development of a Canadian alternative. Stroke experts, clinicians, educators and managers from a variety of professional backgrounds and areas were involved in the development and review process. Results: The completed framework is based on a master competency list for stroke health care providers across the continuum of care. The master list ensured a standardized and coordinated approach to developing competency checklists that are specific to discipline and practice settings. Each competency is linked to key learning resources and knowledge transfer tools. Electronic learning resources are linked directly where available. The framework allows staff, educators and managers to select areas of focus and document progress toward achieving goals for performance accountability. Competencies suggested for orientation and ongoing professional development are differentiated. Conclusions: This framework standardizes expectations for competencies in stroke care and fulfills a quality improvement priority. The competency framework and recommendations for implementation and sustainability will be provided. The usability will be evaluated through focus groups and a representative sample will complete pre and post outcome measures to determine change in competence levels.
A Regional Assessment of the Economics of Stroke Care in Ontario
Meyer, MJ1 McClure, A2 O’Callaghan, C1 Kelloway, L1 Hall, R3 Bayley, M4 Teasell, R2; 1. Ontario Stroke Network, Toronto, ON; 2. Lawson Health Research Institute/ UWO, London, ON; 3. Institute for Clinical Evaluative Sciences, Toronto, ON; 4. Toronto Rehabilitation Institute, Toronto, ON
Background: In 2012, the Ontario Stroke Network (OSN) released an economic evaluation of stroke care in Ontario suggesting that better application of best-practices could result in up to $20M a year made available for re-investment in Ontario’s stroke system. The objective of this study was to replicate components of that evaluation in each of Ontario’s 14 Local Health Integration Networks (LHINs) to identify regional variation in current stroke care practices and costs of care. Methods: Data were collected from various sources including Canadian Institute for Health Information (CIHI) databases and Institute for Clinical Evaluative Sciences (ICES) reports. Data were used to estimate annual stroke incidence in each LHIN, to track current care pathways, and to infer opportunities to improve the provision of evidence-based, cost-effective care. Results: Wide variation was noted in many areas of stroke care across Ontario’s LHINs indicating numerous opportunities for improvement. On average, acute patients spent 31.5% of their length of stay in alternate level of care waiting for transfer to post-acute care (range 23% - 41%) and, on average, 18% of acute admissions were TIAs (range 12.6 – 28.7). The estimated average direct cost of acute care ranged from $7,709 to $13,403 per patient across LHINs and the mean per diem direct cost of acute care ranged from $654 to $983. The average LOS in inpatient rehabilitation was 37.1 days (range 29.5 – 45.5). On average, 7% (range 4-12%) of patients in rehabilitation fell into the mildest rehabilitation patient group (RPG 1160); costing an estimated total of $2.5M annually. Conclusion: Regional data confirm previous research suggesting that variation in stroke care exists between Ontario’s LHINs and that opportunities exist in all regions for better application of evidence-based, cost-effective care.
Impact of Culturally Congruent Evidence-Informed Chronic Disease Management Program on Hypertension Management in First Nation Communities in Ontario
Tobe, S1 Von Sychowski, S2 Kandukur, K2; 1. Sunnybrook, Toronto, ON; 2. Heart and Stroke Foundation of Ontario, Toronto, ON
Objectives: The objective of the Aboriginal Hypertension Management Program (AHMP) is to demonstrate a sustainable, evidence-informed chronic disease management program that enables knowledge integration into the practices of primary care providers and improve management of essential hypertension in first nation communities. Design and Methods: The Studywas conducted in five first nation communities in Ontario. The program was implemented on-reserve in collarboartion with local health care organizations. The chronic disease management toolkit included culturally congruent tools for both health care providers (flowsheet, BpTRU, database repository) and patients (posters, educational video and booklets). All the tools were developed based on the feedback from clients and health care provider from the participating communities. We intially piloted the program and tools in two communities as a pilot and then later expanded to five more communities. Local systems change principles were then applied in each of the interprofessional team’s implementation of the evidence-informed AHMP, to adapt to local circumstances. Results: In total, 231 patients were enrolled in five first nation communities, and of these, 177 had a diagnosis of hypertension. Mean BP at baseline was 130.8/75.0 mmHg, compared to the end-of-study recorded BP of 132.0/74.7 mmHg. Although there was no statistically significant change in mean BP over all, a sub-analysis showed statistically significant change in mean BP among those whose SBP was 140-159 at baseline (n=20) with a mean change of SBP of 15.3 mmHg. There was also a mean change of SBP of 27.75 mmHg among those with SBP >160 mmHg at baseline (n=4). Conclusion: There was a significant blood pressure lowering among those with elevated systolic blood pressure at baseline after introducing an evidence-informed, interprofessional culturally congruent, chronic disease management program for hypertension in first nation communities.
A Geoinformatic Analysis of the Impact of Telestroke on Access to Stroke Thrombolysis in Ontario
Jewett, L2, 3, 1 Connolly, BJ1 Sahlas, DJ1; 1. McMaster University, Hamilton, ON; 2. Population Health Research Institute, Hamilton, ON; 3. Hamilton Health Sciences, Hamilton, ON
Background: Ontario is Canada’s most populous province, with 13,366,300 people in the 2011 census. The Ontario Stroke System is comprised of 11 regional stroke centres and 17 district stroke centres and is further augmented by Telestroke linkages between many of these centres as well as 10 additional Telestroke sites. We undertook a geoinformatic analysis of access to stroke thrombolysis, in order to evaluate the impact of the Ontario Telemedicine Network’s Telestroke program. Methods: Population data by dissemination area was used (Statistics Canada, 2011) to overlay polygons created by Service Area Analysis using ArcGIS 10.1 (ESRI, 2012). The service areas are based on the Ontario Roads Network (DMTI, 2012) and Ontario Cartographic Boundaries (Statistics Canada, 2012). The established geographic regions are within predefined driving times, towards stroke centres. Service areas with and without the impact of the Telestroke program were compared. Results: Availability of stroke thrombolysis in designated stroke centres covers 96.03% of the province, leaving approximately 530,308 people in remote locations without access. 78.18% of the population are within 30 minutes of a regional or district stroke centre, increasing to 87.22% with Telestroke, an additional 1,208,786 people. 1.48% of the population have access only through the extended time window (between 3 to 4.5 hours), increasing to 2.16% with Telestroke, for an additional 91,313 people. Conclusion: The vast majority of people in Ontario have access to stroke thrombolysis, which is significantly augmented by Telestroke. The Ontario Telemedicine Network’s Telestroke program increases the overall number of people with access to stroke thrombolysis as well as provides more rapid access to hyperacute stroke treatment for over a million people, with direct benefits impacting approximately 1 in 10 people in the province.
Vancouver Island Health Authority’s (VIHA) Strategic Plan to Ensure All Patients Receive Care in Stroke Units
Foster, D1 Crisp, R1 Kamal, N2; 1. Vancouver Island Health Authority, Victoria, BC; 2. Stroke Services BC, Vancouver, BC
Background: VIHA serves 768,000 people and faces significant population growth of people over 75 years by as much as 17% by 2020. Further issues facing VIHA include a large rural area with islands and large water inlets. There are 2 tertiary hospitals, 1 regional hospital, 5 community hospitals, and 5 rural/remote hospitals. A strategic approach is needed for acute stroke care in order to plan appropriately for the population growth and VIHA’s diverse geography. Methods: VIHA’s strategic approach plans for three stroke units to serve the entire population. Victoria General Hospital will be a comprehensive level 1 stroke centre with both a stroke unit and a rehabilitation unit. It will co-locate stroke patients from South Vancouver Island. Nanaimo Regional General Hospital will provide intermediate stroke services for the Central Island with an acute stroke cluster and a rehabilitation unit. Campbell River and District Hospital will also provide intermediate stroke services with an integrated stroke cluster serving the North Island and Comox valley. These changes will be supported through participation in a Stroke Unit Collaborative organized by Stroke Services BC with participation from across BC and Saskatchewan. Collaborative Faculty are from BC and Calgary. Results: There have been tremendous strides made towards the creation of stroke units. To date, beds have been committed at three sites with teams working towards best practice. These sites have had strong participation in the Stroke Unit Collaborative with over 25 stroke champions traveling to Vancouver to attend the face-to-face Learning Sessions, and attendance at the bi-weekly webinars. Conclusions: The creation of stroke units within a health region is possible through internal and external enablers. The internal enablers include executive support, hospital buy-in, stroke champion teams at each site, and education initiatives. The external enablers include interprovincial Stroke Unit Collaborative, Canadian Best Practice Recommendations, and research grants.
An in-vivo, MRI-Integrated Real-Time Model of Active Contrast Extravasation in Acute ICH
Aviv, RI1 Huynh, T2 Ramsay, D3 Huang, Y4 Liu, R2 Hynynen, K4; 1. Sunnybrook Health Sciences Center, Thornhill, ON; 2. Sunnybrook Health Sciences Center, Toronto, ON; 3. London Health Sciences, London, ON; 4. Sunnybrook Research institute, Toronto, ON
Purpose: The spot sign or contrast extravasation (CE) within an intracranial hemorrhage (ICH) is strongly associated with hematoma formation and growth. CE is emerging as the single most important contributor to morbidity and mortality in ICH but represents a spectrum of contrast leakage. An animal model of CE is important to test existing and novel therapeutic interventions to inform present and future clinical studies. The purpose of this study was to create the first animal model of CE in acute ICH. Materials and Methods: Animal experiments were performed in accordance with institutional guidelines and approved by the Research Institute Animal Care Committee. Each hemisphere of 18 Yorkshire male swine was insonated with an MR-guided focused ultrasound system after infusion with 0.08ml/kg of Perflutren lipid microspheres without and with mean arterial pressure elevation using 15mcg/kg/min phenylephrine infusion. Following insonation dynamic contrast enhanced (DCE) MRI quantified the rate of contrast leakage. Animals were sacrificed after 2 hours and brains subjected to histopathological examination. Results: Two distinct patterns of CE were created. Active CE demonstrated brisk contrast leak with well delineated margins, visible early on DCE. Post contrast leakage (PCL) demonstrated slower accumulation of CE becoming more confluent on a delayed post contrast T1. Median (IQR) CE KPS was significantly elevated compared to PCL (11.3; 6.3-23.2 vs 3.8; 1.1-3.1ml/min/100g; p<0.001). CE demonstrated a median (IQR) DCE contrast volume of 0.4; 0.1-1.3cm3 compared to PCL (0.04; 0.02-0.1cm3; p=0.01). The median (IQR) final hemorrhage volume was significantly higher for CE compared to PCL (0.7; 0.4-1.6 vs 0.4; 0.06-0.7cm3; p= 0.02). Significant correlation was seen between increasing burst length and rate of contrast leak (KPS) (ρ=0.5 (95% CI 0.08-0.8); p=0.02). Conclusion: We describe a novel MRI-integrated real-time swine ICH model of acute hematoma growth and contrast extravasation.
Implementation of the Revised Provincial Acute Stroke Redirect Protocol in Urban and Rural Settings
Stiell, IG1 Smaggus, K2 Clement, CM3 Sharma, M4 Socha, D5 Silvilotti, M6 Jin, A6 Perry, JJ1 Lumsden, J7 Martin, C8 Froats, M1 Dionne, R2, 1 Trickett, J9; 1. University of Ottawa, Ottawa, ON; 2. Regional Paramedic Program for Eastern Ontario, Ottawa, ON; 3. Ottawa Hospital Research Institute, Ottawa, ON; 4. McMaster University, Hamilton, ON; 5. Hastings-Quinte EMS, Bellville, ON; 6. Queen’s University, Kingston, ON; 7. Champlain Regional Stroke Network, Ottawa, ON; 8. Stroke Network of Southeastern Ontario, Kingston, ON; 9. The Ottawa Hospital, Ottawa, ON
Background: The Ontario Stroke Redirect Protocol was recently revised to allow EMS to bypass to designated stroke centers if total transport time would be <2 hours and total time from symptom onset <3.5 hours. We sought to evaluate the impact, effectiveness, and safety of the revised Protocol. Methods: We conducted a 12-month multicentre, prospective cohort study involving all pre-hospital patients presenting <6 hours with possible stroke symptoms. Participating were 1,000 BLS and 300 ALS paramedics of 9 land EMS services, operating in a catchment area of 10 rural counties and 5 cities. Paramedics completed a record form for each case and, initially, a second paramedic independently completed the form. Outcomes and data analyses included redirect sensitivity and specificity, patient outcomes, adverse events, and interrater reliability with the kappa statistic. Results: We enrolled 1,277 eligible patients with 99% paramedic compliance in form completion. Of these, 755 (61.2%) met the redirect criteria and had these characteristics: mean age 72.0 (range 16-101), male 51.1%, mean time scene-to-hospital 16.7 min (range 0-92) with 15.1% >30 mins. The prehospital adverse event rate was 14.7% (23.0% for those with transport time >30 mins) with the most common events being hemodynamic instability and drop in GCS. At the hospital, the 755 patients had a mean NIH Stroke Scale score 8.7, 23.8% received thrombolysis, 69.3% were admitted, 87.3% survived to discharge, and had a mean modified Rankin Score 2.3. Paramedics showed 97.9% accuracy in interpreting the criteria and excellent interrater agreement with kappa values ranging from 0.56 to 0.90 for redirect criteria and 0.94 for need to transport to a stroke centre. Conclusions: In a large urban-rural area with 9 EMS services, we demonstrated accurate, safe, and effective implementation of the revised provincial Stroke Redirect Protocol. These revisions will allow more stroke patients to benefit from early treatment.
Predictors of Stroke Recurrence in Patients with Recent Lacunar Stroke: Secondary Prevention of Small Subcortical Strokes (SPS3) Trial
Bakheet, MF1 Hart, RG2 Pearce, LA3 Benavente, O4; 1. Hamilton General Hospital, Hamilton, ON; 2. McMaster University, Hamilton, ON; 3. Biostatistics Consultant, Minot, ND, USA; 4. University of British Columbia, Vancouver, BC
Background: Among participants in the Secondary Prevention of Small Subcortical Strokes randomized trial, we sought to identify patients with high vs. low rates of recurrent ischemic stroke. Methods: Multivariable analyses of 3020 participants with recent MRI-defined lacunar strokes followed for a mean of 3.7 years with 243 recurrent ischemic strokes. Results: Prior symptomatic lacunar stroke or TIA (HR 2.2, 95%ci 1.6,2.9), diabetes (HR 2.0, 95%ci 1.5,2.5), black race (HR 1.7, 95%ci 1.3,2.3) and male sex (HR 1.5, 95%ci 1.1,1.9) were each independently predictive of recurrent ischemic stroke. Recurrent ischemic stroke occurred at a rate of 4.3%/yr (95% CI 3.3, 5.5) in patients with prior symptomatic lacunar stroke or TIA (15% of the cohort), 3.1%/yr (95%CI 2.6, 3.9) in those with >1 of the other 3 risk factors (27% of the cohort), and 1.3%/yr (95%CI 1.0,1.7) in those with 0 to 1 risk factors (58% of the cohort). There were no significant interactions between treatment effects and stroke risk status. Conclusion: In this large, carefully followed cohort of patients with recent lacunar stroke and aggressive blood pressure management, prior symptomatic lacunar ischemia, diabetes, Black race and male sex independently predicted ischemic stroke recurrence..
Cardiopulmonary Fitness is Associated with Regional Cerebral Grey Matter Perfusion and Density in Adults with Coronary Artery Disease
Swardfager, W1, 2, 3 MacIntosh, BJ1, 2 Herrmann, N1, 2 Crane, DE1, 2 Saleem, M1 Ranepura, N1 Oh, PI1, 2, 3 Lanctôt, KL1, 2, 3; 1. Sunnybrook Research Institute, Toronto, ON; 2. Heart & Stroke Foundation Centre for Stroke Recovery, Toronto, ON; 3. Toronto Rehabilitation Institute, Toronto, ON
Purpose: Cardiopulmonary fitness is associated with reduced risk of stroke, and it can confer neuroprotective and cerebrovascular benefits. Patients with coronary artery disease (CAD) present with a cluster of vascular risk factors placing them at a greatly increased risk of stroke; however, there is a paucity of data relating fitness with neuroimaging findings in patients with CAD. The purpose of this study was to identify brain regions in which cerebral blood flow (CBF) and grey matter (GM) density may be associated with cardiopulmonary fitness, and with the change in fitness after 6 months of exercise. Methods: CAD patients undertook 6 months of an exercise-based cardiac rehabilitation program. Subjects underwent magnetic resonance imaging at baseline, and peak volume of oxygen uptake (VO2Peak) was measured using an exercise stress test at baseline and after 6 months. T1-weighted structural images were used to perform voxel-based morphometry (VBM) on GM. Pseudo-continuous arterial spin labeling (pcASL) was used to produce whole brain CBF images. VBM and CBF data were tested voxel-wise using VO2Peak and age as explanatory variables. Results: In 30 men with CAD (mean age 65±7 years), VBM and CBF identified 7 and 5 respective regions positively associated with baseline VO2Peak. These included the pre- and post-central, paracingulate, caudate, hippocampal regions, and overlapping findings in the putamen. VO2Peak increased by 20% at follow-up in 29 completers (t=9.6, df=28, p<0.0001). Baseline CBF in the left post-central gyrus and baseline GM in the right putamen predicted greater change in VO2Peak. Conclusion: Perfusion and density in multiple grey matter regions were associated with fitness at baseline and with greater fitness gains due to exercise. This study identifies new neurobiological correlates of fitness in older patients with cardiovascular disease. The possibility to identify novel mediators of the relationship between fitness and reduced stroke risk is suggested.
Prediction of Hematoma Expansion and Poor Clinical Outcome in Acute Intracerebral Hemorrhage: the PREDICT Hematoma Expansion Score
Huynh, TJ1 Demchuk, AM2 Dowlatshahi, D3 Gladstone, DJ1 Laupacis, A1 Kiss, A1 Hill, MD2 Molina, CA4 Rodriguez-Luna, D4 Silva, Y5 Czlonkowska, A6 Lum, C3 Boulanger, J7 Gubitz, G8 Bhatia, R9 Padma, V10 Roy, J10 Case, CS11 Jakubovic, R1 Symons, SP1 Aviv, RI1; 1. University of Toronto, Toronto, ON; 2. University of Calgary, Calgary, AB; 3. University of Ottawa, Ottawa, ON; 4. Hospital Universitari Vall d’Hebron, Barcelona, Spain; 5. Dr Josep Trueta University Hospital, Girona, Spain; 6. Institute of Psychiatry and Neurology of Warsaw, Warsaw, Poland; 7. University of Sherbrooke, Montreal, QC; 8. Dalhousie University, Halifax, NS; 9. All India Institute of Medical Sciences, New Delhi, DL, India; 10. AMRI Hospital Kolkata, Kolkata, WB, India; 11. Boston Medical Center, Boston, MA, USA
Objective: Predictive models of hematoma expansion in intracerebral hemorrhage (ICH) are important for risk stratification and guiding potential interventions. The spot sign is recently shown to potently predict ICH expansion and poor outcome however incorporation of other clinical variables may improve prediction. We sought to identify clinical and radiographic predictors of hematoma expansion and to develop a practical integrated clinical score for expansion prediction. We secondarily evaluated the prognostic significance of the score for 3-month poor clinical outcome prediction. Methods: 219 ICH patients ≤6 hours post-ictus were enrolled in the PREDICT study, a multicenter prospective ICH cohort study. Patients underwent baseline non-contrast CT, CT angiography (CTA), and 24-hour CT. 169 patients had 3-month modified Rankin Scale (mRS) measured. Multivariable logistic regression identified independent clinical, laboratory, and radiographic predictors of hematoma expansion (>6ml or >33%) and a clinical scoring system was developed from regression coefficients. Optimism adjusted c-statistic was examined using bootstrap internal validation. Prognostic significance of the score for predicting 3-month poor clinical outcome (mRS 4-6) was performed using logistic regression. Results: A multivariable model including CTA Spot Sign number, international normalized ratio (INR), baseline NIHSS, and time from ictus-to-baseline CT provided the greatest model fit and discrimination for hematoma expansion prediction (c-statistic: 0.803) and were incorporated in to a clinical prediction score. Observed probability of expansion ranged from low (7% - 12%) to high probability (76 - 100%) based on score strata. Bootstrap internal validation demonstrated an adjusted c-statistic of 0.755. The score independently predicted 3-month poor clinical outcome (OR 1.17, 95% CI 1.05 – 1.31; p=0.021) after adjusting for age, baseline Glasgow Come Scale, ICH volume, intraventricular hemorrhage presence, and INR. Conclusions: The PREDICT Hematoma Expansion Score strongly predicts hematoma expansion and poor clinical outcome in ICH and appears promising as a risk stratification tool for future potential interventions.
Vitamin K Antagonists versus Antiplatelet Monotherapy and Risk of Subdural Hematoma: Meta-analysis of Randomized Clinical Trials
Connolly, BJ1 Pearce, LA2 Hart, RG1; 1. McMaster University, Hamilton, ON; 2. Biostatistics Consultant, Minot, ND, USA
Background: Subdural hematomas (“the other intracranial hemorrhage”) are an important bleeding complication of anticoagulation with oral vitamin K antagonists (VKAs), but the risk associated with VKAs has not been defined. Purpose: To determine the risk of subdural hematoma associated with VKAs vs. antiplatelet agents. Data Sources: Randomized trials were identified by systematic review of the Cochrane Central Register of Controlled Trials and other published systematic reviews. Study Selection: Randomized trials published since 1980 comparing VKAs with antiplatelet monotherapy were included. Data extraction: Two reviewers independently extracted data on study design and subdural hematomas, with differences resolved by joint review and consensus. Results: We screened 1667 abstracts and identified 110 trial publications for full review. We obtained data from 8 randomized trials that included 10,535 participants, including unpublished data from 5 trials. Trial participants included patients with atrial fibrillation (4 trials), noncardioembolic stroke (2 trials), and heart failure/reduced left ventricular ejection fraction (2 trials). Mean participant age was 65 (range 61 to 82) years. The mean achieved INRs ranged from 2.1 to 3.2. Antiplatelet therapy was aspirin (dose range 75 to 1300 mg/d) except one trial each that tested trifusal 600 mg/d and clopidogrel 75 mg/d. There were 18 subdural hematomas in those assigned VKAs vs. 7 among those assigned antiplatelet monotherapy (hazard ratio 2.9, 95%CI 1.4-6.2, p< 0.05). The absolute rates of subdural hematoma during VKA therapy ranged from 1.2 to 3.5 per 1000 patient-years of observation. Conclusions: VKA use significantly increases the risk of subdural hematoma compared with antiplatelet monotherapy. The absolute increase with VKAs averaged 1.5 per 1000 patient-years.
Results from the Ontario Stroke Registry’s Audit of Secondary Stroke Prevention Clinics
Hall, R1 Khan, F1 Zhou, L1 Kelloway, L2 Sahlas, DJ3, 4 Silver, F7, 6, 5 Kapral, M7, 6, 5 Hall, R7, 2, 5; 1. ICES, Toronto, ON; 2. Ontario Stroke Network, Toronto, ON; 3. Hamilton Health Sciences, Hamilton, ON; 4. McMaster University, Hamilton, ON; 5. University of Toronto, Toronto, ON; 6. University Health Network, Toronto, ON; 7. Institute for Clinical Evaluative Sciences, Toronto, ON
Background: Secondary Prevention Clinics (SPCs) were established in Ontario in 2001 to expedite access to diagnostics, treatment, and risk factor education programs for patients at risk of stroke or recurrent stroke. There are currently 43 SPCs in the province. In 2012, the Ontario Stroke Registry conducted an audit of the care provided at Ontario SPCs. Methods: Information was collected on every patient that visited one of 40 SPCs between April 1, 2011 and March 31, 2012. The Case Record Form was developed through an inter-professional advisory committee, and data was collected through a web-based application. Sixteen best practice performance indicators were analyzed using the SPC data and administrative databases. Results: Of the 28,626 ED visits for suspected or confirmed stroke/TIA in Ontario, 21.3% were subsequently seen in an SPC. The audit sample included 16,167 patients with 16,487 initial visits and 7,126 follow-up visits. The median time from referral to the first visit was 14 days. Common risk factors were hypertension (62.4%), hyperlipidemia (52.4%), smoking (22.2%), and diabetes (20.5%). Ninety-four percent of patients had neuroimaging and 83.9% had vascular imaging completed prior to or at the SPC. The median time from the initial visit to carotid endarterectomy or stent was 28 days. Medication prescription rates, where indicated, were: antiplatelet therapy (94.4%); anticoagulant therapy (80.1%); antihypertensive therapy (68.0%); lipid-lowering agents (65.7%); smoking cessation programs/medication (20.0%). Approximately 10% of initial visits included cognitive screening. Readmission rates among ischemic stroke/TIA patients seen at SPCs were 1.8% within 30 days and 2.9% within 90 days of the SPC referral. Conclusion: The results show high rates of investigations and good outcomes compared to the expected course of a TIA/stroke following an ED visit. There are significant opportunities for improvement, particularly with respect to timeliness of access to SPCs, carotid interventions, smoking cessation, and cognitive screening.
People After Mild Stroke or Transient Ischemic Attack – An Overlooked Population from a Rehabilitation Perspective
MacKay-Lyons, M; Dalhousie University, Halifax, NS
Purpose: Although non-disabling stroke (NDS) and transient ischemic attack (TIA) are considered relatively benign conditions, they can actually signal further vascular events or death. Understanding the clinical presentation of NDS/TIA is important in identifying effective secondary prevention strategies. The purpose was to describe the baseline profile of participants enrolled in the Program of Rehabilitative Exercises and Education to avert Vascular Events after NDS and TIA (PREVENT) Trial. Methods: Prior to randomization (PREVENT program/usual care), 148 people early post-NDS/TIA underwent assessment of comorbidities, vascular risks, exercise capacity, and walking endurance. Results: Participants were 65+/-10 years of age, 66% male, body mass index of 30+/-6. Most prevalent co-morbidities were arthritis (39%), diabetes (21%), coronary artery disease (13%), and atrial fibrillation (12%). Resting systolic blood pressure was 132+/-18 mmHg. 2-year risk of second stroke or death was high in 11% and moderate in 34%. 23% scored <26 on Montreal Cognitive Assessment and 35% scored >10 on Hospital Anxiety and Depression Scale. Although all participants were described as ‘non-disabled’, 9% had low physical function and 13% moderate physical function (Short Physical Performance Battery). 28% were classified as inactive and 43% as moderately active (International Physical Activity Index), 39% had excessive fatigue (Fatigue Assessment Scale), and 58% were ‘poor sleepers’ (Pittsburgh Sleep Quality Assessment). On stress testing 8% were positive for ischemia. High variability was found in peak oxygen consumption (19.5+/-5.9 ml/kg/min, 36% to 147% of predicted) and 6-minute walk distance (males: 491+/-101 m, 86+/-14% of predicted; females: 406+/-92 m, 81+/-12% of predicted). Conclusions: A substantial proportion of this cohort demonstrated vascular comorbidities, hypertension, cognitive impairment, cardiac ischemia, and risk of second stroke. Clinical correlates included reductions in physical activity, activity tolerance, sleep quality, aerobic capacity and walking endurance - all potentially modifiable through exercise interventions.
Can we identify family caregivers in need of support from the health care system?
Cameron, JI1 Czerwonka, A1 Naglie, G2 Gignac, M3 Green, T4 Warner, G6 Bayley, M7 Silver, F5 Cheung, A5 Phillips, S8 Huijbregts, M2, 9; 1. University of Toronto, Toronto, ON; 2. Baycrest Centre for Geriatric Care, Toronto, ON; 3. Toronto Western Research Institute, Toronto, ON; 4. University of Calgary, Calgary, AB; 5. University Health Network, Toronto, ON; 6. Dalhousie University, Halifax, NS; 7. Toronto Rehabilitation Institute - University Health Network, Toronto, ON; 8. Capital District Health Authority, Halifax, NS; 9. Family Service Toronto, Toronto, ON
Background: Family caregivers play a central role in stroke survivors’ recovery, rehabilitation, and return to community living. Best practice guidelines recommend the provision of timely education and support for caregivers. The aim of this paper is to identify caregivers at risk for depression during the acute stroke phase and, therefore, in need of support from the health care system. The primary hypothesis is that caregivers will report more depression symptoms if they are caring for stroke survivors with more severe stroke and more stroke-related disability and the caregiver is female, younger, caring for a spouse, has less knowledge about stroke, less mastery, less social support, more fatigue, and caregiving has more of an impact on their daily life. Methods: Participants included caregivers who consented to participate in an ongoing trial. They were caring for survivors of their first stroke and had to be able to speak and read English. The baseline assessment, completed during the acute stroke phase, included: 1) indicators of stroke severity (e.g., Canadian Neurological Scale, Barthel Index); 2) demographic characteristics; and 3) standardized measures (e.g., Mastery, Stroke Knowledge, Caregiving Impact and Assistance, and Depression). Linear regression was used to test the study hypothesis. Results: Caregivers (n=299) were 74% female with a mean age of 58 years. They reported more depression symptoms when they had less mastery, experienced more fatigue, caregiving negatively impacts their life, and were younger and caring for a spouse (F (13,296) = 22.58, p<.001; adjusted R2=.48). Caregivers’ knowledge of stroke, level of assistance provided to the patient, patient illness severity and disability were not significantly related to caregiver depression. Conclusions: Young, spousal caregivers with less mastery, who are fatigued, and are not able to participate in everyday activities are more likely to report depression and need support from the health care system.
Evaluating the Impact of Stroke Survivor & Caregiver Support Groups on Successful Community Reintegration
Brown, G1 Belanger, A2 Martin, C1 Pratt, K2 Langstaff, C1 Brouillard, D2; 1. Stroke Network of Southeast Ontario, Kingston, ON; 2. Seniors Association - Kingston Region, Kingston, ON
Background: The human cost of stroke is universally understood to have significant and ongoing impacts on stroke survivors and caregivers. Effective community reintegration is a critical enabler of quality of life and enhanced function for these individuals, potentially reducing health system costs related to emergency room visits, hospital admissions and re-admissions. The Canadian Best Practice Recommendations for Stroke Care highlight the impact of “referrals to community agencies, such as stroke survivor groups…” on individuals and the health system. This project evaluated the impact of ongoing, professionally facilitated community stroke survivor and caregiver support groups. Methods: Pre-post comparative evaluation over a seven month period encompassed quantitative and qualitative domains including caregiver burden, caregiver well-being, stroke survivor well-being and overall satisfaction with the services offered. Evaluation tools included the Stroke Impact Scale, the Montgomery Borgatta Caregiver Burden Assessment tool, a participant questionnaire as well as individual and focus group interviews conducted by an objective third party. Results: Referral and activity rates increased with provision of system navigation and individual support. Positive effects of group participation were observed on self-reported dimensions of well-being, coping with anxiety, nervousness, depression and stressors for both caregivers and stroke survivors. Post-test scores improved on the Stroke Impact Scale in the areas of communication, memory and thinking and overall perceived recovery. A notable decrease was measured in both objective and subjective caregiver burden. Strong participant satisfaction and highly informative qualitative feedback from focus groups supported and enriched the interpretation of the quantitative findings. A positive relationship was observed between the desired outcomes and the provision of professional psychosocial facilitation within a supportive community infrastructure. Conclusions: Results support that professionally facilitated stroke survivor and caregiver stroke support groups may be significant contributors to perceived recovery, improved psychosocial outcomes and successful community reintegration for both caregivers and stroke survivors.
MRI-based Neuroanatomical Predictors of Dysphagia, Dysarthria, and Aphasia in Patients with a First Acute Ischemic Stroke
Flowers, HL1 AlHarbi, M2 Silver, FL3 Mikulis, D2 Chakravarty, MM4 Fang, J5 Martino, R1; 1. Department of Speech-Language Pathology, University of Toronto, Toronto, ON; 2. University Health Network, Toronto Western Hospital, Toronto, ON; 3. Toronto Western Hospital, Toronto, ON; 4. Research Imaging Centre, Centre for Addiction and Mental Health, Toronto, ON; 5. Institute for Clinical and Evaluative Sciences, Toronto, ON
Background: Dysphagia, dysarthria and aphasia occur frequently after stroke. We sought to identify MRI-based neuroanatomical predictors of these impairments early after ischemic stroke onset. Methods: We randomly selected 250 patients from a consecutive cohort of ischemic stroke patients with MRI scans (N=716) from the Registry of the Canadian Stroke Network’s database (2003–2008) in one stroke centre. We excluded patients with dementia, brain tumour, neurosurgical interventions, or contusions. We documented the presence of the acute lesion in 12 neuroanatomical regions of interest and extracted lesion volumes. We also identified concomitant neurological compromise, including brain atrophy, white matter disease, and prior covert stroke. Two raters independently extracted all data, resolving discrepancies by consensus. We computed logistic regression analyses to identify predictors for each impairment. Results: 160 patients met our eligibility criteria. Predictors of dysphagia included increasing lesion volume (OR 1.3, 95% CI 1.03–1.7), increasing age (OR 1.4, 95% CI 1.1–1.8), and lesions to the medulla (OR 6.3, 95% CI 1.5–26.6), pons (OR 4.5, 95% CI 1.5–13.3), insula (OR 4.2, 95% CI 1.6–11.5), and internal capsule (OR 3.5, 95% CI 1.5–8.5). Predictors of dysarthria included lesions to the pons (OR 7.9, 95% CI 2.7–22.9), internal capsule (OR 3.1, 95% CI 1.5–6.5), and insula (OR 2.6, 95% CI 1.2–5.8). Predictors of left-hemisphere aphasia included increasing lesion volume (OR 1.5, 95% CI 1.1–2.1) and lesions to the thalamus (OR 5.0, 95% CI 1.2–20.7), insula (OR 21.7, 95% CI 2.5–190.8), and superficial MCA territory (OR 3.3, 95% CI 1.04–10.5). Conclusions: We modeled neuroanatomical predictors of dysphagia throughout the brain and extended previous findings for dysarthria and aphasia in a large homogeneous sample of patients. Next, we will identify more discrete neuroanatomical regions using voxel-based lesion symptom mapping.
International Harmonization and Pilot Testing of the English Language Screening Test (LAST)
Flowers, HL1 Flamand-Roze, C2 Denier, C2 Roze, E3 Silver, FL4 Rochon, E1 Skoretz, SA1 Baumwol, K5 Burton, L6 Brookes, K5 McGovern, A6 Harris, G5 Tyson, S7 Langdon, C8 Major, K5 Shaw, S1 Martino, R1; 1. Department of Speech-Language Pathology, University of Toronto, Toronto, ON; 2. Service de neurologie, CHU Bicêtre, Assistance publique-Hôpitaux de Paris, Le Kremlin-Bicêtre, France; 3. Département de neurologie, CHU Pitié-Salpêtrière, Assistance publique-Hôpitaux de Paris, Paris, France; 4. Toronto Western Hospital, Toronto, ON; 5. Sir Charles Gairdner Hospital, Nedlands, WA, Australia; 6. Greater Manchester and Cheshire Cardiac & Stroke Network, Stockport, United Kingdom; 7. Stroke & Vascular Research Centre, University of Manchester, Manchester, United Kingdom; 8. Health Department of Western Australia, Perth, WA, Australia
Background: The LAST is a unique bedside tool, designed to rapidly and reliably evaluate aphasia during the acute phase of stroke. It may also complement stroke severity scales in the initial evaluation of stroke patients. The LAST was developed and validated in French and subsequently adapted into English in Canada. Our current objectives were to internationally harmonize the English LAST and to confirm its linguistic validity in multiple English speaking countries. Methods: We subjected the English LAST to three sequential evaluations. Following each evaluation, we collectively reviewed problematic items, selecting alternatives by expert consensus in four English speaking countries and in collaboration with the tool developers. 1. Experts in Australia, Canada, England, and the USA independently reviewed all 29 items for cultural acceptability and naturalness of language in multiple linguistic domains: phonology, semantics, morphology, and syntax. Each country proposed alternatives for unacceptable or unnatural items. 2. The harmonized version underwent pilot testing in healthy older native speakers in all four countries, with documentation of expected or deviant responses to each item. 3. Revised items underwent repeat testing in healthy older native speakers in all four countries, to achieve a final version. Results: 1. Of the original 29 items, we revised 10 following international expert review. 2. Pilot testing involved 76 participants (34 male; mean age 60 years, range 23-92; 51 with postsecondary education) and resulted in revisions to three items. 3. Repeat testing of the three revised items involved 36 participants (15 male; mean age 56 years, range 32-84; 30 with postsecondary education) and resulted in no further modification. Conclusion: We achieved international harmonization of the English LAST, ensuring linguistic naturalness and cultural appropriateness. We confirmed its linguistic validity in healthy older native speakers. Once validated in stroke patients, the English LAST will provide a much needed screening tool for aphasia.
Imaging and Baseline Predictors of Cognitive Performance in Minor Stroke and TIA Patients at 90 Days
Mandzia, JL1, 2 Smith, EE1, 2, 3 Horton, M1, 2 Hanly, P4 Barber, PA1, 2, 3 Godzwon, C1 Donaldson, E1 Asdaghi, N5 Patel, S1 Aram, H1 Coutts, SB1, 2, 3; 1. Calgary Stroke Program, Calgary, AB; 2. Department of Clinical Neurosciences, University of Calgary, Calgary, AB; 3. Hotchkiss Brain Institute, Calgary, AB; 4. Division of Respirology, Department of medicine,University of Calgary, Calgary, AB; 5. BC Centre for Stroke and Cerebrovascular Disease, Vancouver, BC
Background: Few studies have examined predictors of cognitive impairment following minor stroke and TIA. We examined clinical and imaging features associated with poor cognitive outcome at 90 days. Methods: TIA or minor stroke (NIHSS<4) patients underwent cognitive testing 90 days post event. DWI and white matter lesion volumes (WML) were measured on baseline MRI. Patients with pre-event mRS>1 or dementia were excluded. Z-scores were calculated for cognitive tests based on normative data; tests were analyzed as domains of memory (CVLT long delay free recall), executive function (EF; average of COWAS test FAS and Trails B) and psychomotor speed (PS; average of Trails B and Digit Symbol Coding). Depression was assessed using the Center for Epidemiologic Studies Depression Scale (CES-D). Presence of obstructive Sleep Apnea (OSA) was assessed using a Snoresat. Analyses were performed on the whole data set and then dichotomized based on cognitive score <1 SD below normal. A p-value of ≤0.016 was chosen for statistical significance, correcting for testing of 3 separate cognitive domains. Results: 86 patients were included, 74% male, 55% TIA, mean age 65.2+12.2 and 14.2+3.3 years of education. 62% were DWI positive. 27.9% had moderate to severe OSA. Median Z-scores were: memory 0, EF -0.12 and PS +0.2. Mean CES-D was 7.9+8. Cognitive scores were not significantly different based on diagnosis, cause and risk factors of stroke, OSA, DWI or WML volumes. EF scores correlated with baseline NIHSS (p=0.005) and 90-day CES-D (p=0.004), and were lower in patients with 90-day mRS >0 (p=.017). EF <1 SD was associated with baseline NIHSS (p=0.016) and 90-day CES-D (p=0.002). PS scores correlated with baseline NIHSS (p=0.01) and CES-D (p=0.001), and were lower in patients with 90-day mRS >0 (p=0.004). Conclusion: Stroke severity, disability and depression predict poor psychomotor and executive, but not memory test performance at 90 days.
Incidental Small Acute Brain Infarcts Are Rare in Neurologically Asymptomatic Community-Dwelling Older Adults
Batool, S1 O’Donnell, M2 Teo, K2 Dagenais, G3 Poirier, P3 Lear, S4 Wielgosz, A5 Sharma, M2 Stotts, G5 McCreary, CR1 Frayne, R1 Rangarajan, S2 Islam, S2 Yusuf, S2 Smith, EE1; 1. University of Calgary, Calgary, AB; 2. McMaster University, Hamilton, ON; 3. Laval University, Quebec, QC; 4. Simon Fraser University, Vancouver, BC; 5. University of Ottawa, Ottawa, ON
Introduction: Cerebral microinfarcts are tiny (<2 mm) infarcts seen in autopsied older persons. Emerging evidence suggests that MRI diffusion weighted imaging (DWI) can detect larger microinfarcts in their acute stage—prior studies report that 1-5% of cognitively impaired and 15% of cerebral amyloid angiopathy patients have small incidental DWI positive lesions, suggesting recent acute infarcts in the last 10-14 days. However, the prevalence of clinically silent acute infarction has not previously been reported from population-based studies. Methods: In the PURE-MIND study 803 stroke- and dementia-free participants age 40-79 were recruited from 4 Canadian sites. Participants were selected from population-based sampling within pre-defined postal code regions. A radiologist reviewed MRI DWI, ADC, FLAIR and T1-weighted sequences for evidence of DWI hyperintensity consistent with acute infarction, with hypointensity on ADC as a supporting criterion. A second reader reviewed any questionable scans, with final diagnosis by consensus. DWI and ADC were missing in 10/803 (1.3%). Results: There were 793 participants with MRI DWI: mean age 58.4±8.0 years; 260 (33%) were 60-69 years and 74 (9%) ≥70 years; 326 were men (41%); 145 had hypertension (18%), 48 had diabetes (6%) and 57 were smokers (7%). No definite DWI lesions were detected (0%; 95% CI 0% to 0.5%). Questionable faint DWI hyperintensities were seen in only 2/803 participants (0.3%; 95% CI 0% to 0.9%); however, in both cases the faint hyperintensity corresponded to a chronic-appearing T2-hypintense lesion without ADC hypointensity–a chronic small cavitated infarct, and a white matter T2-hyperintensity. Conclusion: In an unselected community population, incidental acute infarcts are rare on MRI DWI. Future research on incidental acute small infarcts should focus on at-risk populations.
Improving Patient Outcome in Hyper-Acute Practices through Real Time Audits
MacIsaac, L; Reinholdt, F; Mackenzie Health, Richmond Hill, ON
Background: Mackenzie Health, a District Stroke Centre, submits data to CIHI on key metrics for stroke. The data is reviewed monthly by the Stroke Quality Committee to monitor MH’s per-formance against provincial benchmarks. The percentage of patients receiving tPA within 60 minutes dropped to 7.7% in Q3 2011-2012, with an increase in median door to needle times to 70 minutes. The Committee recommended chart audits on every patient receiving tPA to identify barriers and facilitators to meeting the benchmark. Methods: The Clinical Educator and Clinical Nurse Specialist collaborated to build ED staff capacity. Their participation in protocols facili-tated real time education, support and feedback. Relevant research findings were provided by the CNS to promote understanding and generate buy-in. As a stroke expert, she was able to support patients and families and provide education. Chart audits were conducted and results shared with ED staff within 48 hours of thrombolysis. PDSA cycles were initiated to address barriers identi-fied in the audits. Results: Care of patients with acute stroke was optimized through staff en-gagement and uptake of best practices. Organizational awareness of stroke and benchmarks was heightened as the team involved various departments in PDSA cycles. Engaged ED staff demon-strated leadership in the development of tools to enhance care. Performance metrics improved with 56 percent of patients receiving tPA within 60 minutes and a decrease in median door to needle times to 59 minutes. Conclusions: Engagement of ED staff facilitated uptake of best practices in hyper–acute stroke. Notable was the transition from passive participation in the PDSA cycles to active leadership in the QI process. Staff demonstrated initiative and motivation in developing tools, fact sheets and a flow sheet to improve compliance and decrease barriers to best practice. This process enhanced team and inter-departmental collaboration benefitting pa-tients with stroke and their families.
Assessment of Delays in Presentation to Stroke Prevention Clinics After TIA or Minor Stroke: a Preliminary Analysis
Blacquiere, DP1 Bougoin, A2 Alhazzaa, M1, 3 Dowlatshahi, D1, 3 Perry, J1, 3 Sutherland, J1, 3 Sharma, M4; 1. University of Ottawa, Ottawa, ON; 2. Champlain Regional Stroke Network, Ottawa, ON; 3. Ottawa Hospital Research Institute, Ottawa, ON; 4. Population Health Research Institure, Hamilton, ON
Background: Prompt referral and assessment in outpatient stroke prevention clinics (SPC) are associated with a reduction in stroke risk after transient ischemic attack (TIA) or minor stroke. However, not all patients are seen within recommended times. We examined the records of patients referred to SPC after TIA or minor stroke to determine the frequency, degree and reasons for delays in referral, diagnostic testing, and carotid revascularization. Methods: Patient records were obtained for all de novo referrals to our regional SPC over a three-year period (n=3971). Demographic statistics were calculated and information regarding presentation, triage/referral, appointment time, investigation times and carotid revascularization was obtained. Delays between each time point were calculated based on institutional and national guidelines, and reasons for delays were adjudicated. 90-day outcomes including death, recurrent stroke/TIA, and hospital readmission were also determined. Results: Preliminary analysis has been conducted on the first 393 patients in our dataset. Of these, 327 were eligible for inclusion. The mean delay between local target and offered appointment time was 1.62 days (SD 3.25). 122 (31.0%) were seen outside of recommended institutional timeframes; reasons for delay included nonspecific presentations (7.3%), delays in appointment scheduling (6.1%) or interim hospitalization (3.1%). Of 14 patients undergoing revascularization, none had surgery performed within two weeks of symptom onset; common reasons included delays in surgical booking (50.1%) and interim medical complications (7.1%). Recurrent stroke/TIA within 90-days occurred in 4.3% of patients; all-cause hospital readmission in 10.7%, and death in 0.6%. Conclusions: Based on these preliminary results, delays in presentation to SPC are common; in many cases, delays are due to potentially amenable system factors. Ongoing analysis will confirm these findings in a larger cohort and attempt to determine demographic predictors of delay, such as site of presentation, age, gender, distance from SPC, and presenting symptoms.
Attainment of Treatment Goals in the Stroke Prevention Clinic
Al-Salti, A; Vieira, L; Cote, R; McGill University, Montreal, QC
Background: Control of vascular risk factors reduces the risk of recurrent stroke but few studies have assessed the attainment of treatment goals in the stroke prevention clinic (SPC). We sought to evaluate the attainment of current guideline-recommended targets in the McGill University SPC. Methods: This is a retrospective study of patients diagnosed in the McGill SPC with ischemic stroke or TIA from 2009 to 2010. Treatment goals were considered completely attained (CA) if at all follow-up visits and/or at the last documented visit goals were attained, partly attained (PA) if the goals were attained only at some of the follow up visits, not attained (NA) if the goals were never attained. Results: A total of 319 patients, qualified for the study. The average age was 69 and 55% were male. The table summarizes the results of the analysis. We defined optimal therapy as the control of all or some of the following three goals: hypertension, dyslipidemia and compliance with anti-thrombotic treatment.The control of individual risk factors, especially hypertension was good. However, optimal therapy was only achieved in 22% of patients.
Completely Attained (CA), Partly Attained (PA), Not Attained (NA) Conclusions: Our study showed that that there was reasonable attainment of therapeutic goals for stroke prevention in the McGill SPC over an average follow up of 15 months. Greater efforts will be needed in order to achieve optimal therapy.
Octogenarians Should Not Be Excluded From Acute Stroke Intervention Trials as Major Clinical Responses Common with Reperfusion
Nambiar, V; Almekhlafi, MA; Mishra, S; Desai, J; Eesa, M; Volny, O; Menon, BK; Demchuk, AM; Goyal, M; Morrish, W; University of Calgary, Calgary, AB
Background: Octogenarians were excluded from many intra-arterial acute ischemic stroke trials. This was based on the expected delays in achieving recanalization due to tortuous vascular anatomy and a perceived poor potential for recovery especially in those with existing disability. We sought to assess the safety of the stentrievers technology in this patient population. Methods: This study is part of a longitudinal cohort of acute anterior circulation stroke patients treated in our center between Jan 2011 to Dec 2012. Octogenarians were considered for IA stroke therapy in the absence of a pre-existing disability (Barthel index ≥90) or terminal illness. Results: The results are shown in the table. Octogenarians had a non-significant increase in the in-hospital mortality; all occurred in patients who did not reperfuse successfully. In a multivariable logistic regression, age did not impact NIH improvement in 24-hours. There was a non-significant trend toward increased puncture-to-recanalization times with increasing age (p 0.8; figure). Conclusion: Octogenarians can be treated in a safe and fast manner when selected carefully. The impact of age on long-term functional outcome was not assessed. Excluding these patients from randomized trials of acute stroke therapy may need to be revisited given the recent advances in the intra-arterial reperfusion technology and stroke patients care.
Achieving an IV Needle to Arterial Puncture Time under 60 Minutes in Acute Endovascular Stroke Therapy is Feasible
Mishra, S; Almekhlafi, MA; Nambiar, V; Desai, J; Volny, O; Eesa, M; Menon, BK; Demchuk, AM; Goyal, M; University of Calgary, Calgary, AB
Background: The importance of time in acute ischemic stroke management cannot be overemphasized. The IMS-III trial reports an 88-minute time interval from IV bolus administration to arterial groin puncture. We assessed the feasibility of achieving a shorter time interval in routine practice. Methods: This a longitudinal cohort of acute anterior circulation stroke patients treated in our center between Jan 2011 to Dec 2012. Times were prospectively collected at the times of patients’ presentations. Results: Out of 105 patients, 64 (60.6%) received IV tPA. The median age was 64 years with a median NIHSS score of 18(iqr 9). The onset to IV needle time was 130 minutes (iqr 111). All patients were treated via endovascular therapy with a median and mean times of IV needle to arterial puncture times of 46 and 49.7 minutes, respectively. Of all treated with IV tPA, 39 patients (60.9%) had the arterial puncture within 60 minutes of the IV bolus time. Endovascular recanalization was achieved in 78.1% resulting in a median 24-hour NIHSS score of 6 (iqr 11). Significant improvement in the 24-hour NIHSS scores (drop of 50% or more from baseline to 24 hours) was noted in 70.3%. Conclusion: An IV needle to arterial puncture time under 60 minutes was feasible in about 60% of patients treated with IV tPA and endovascular therapy in our cohort. Potential delays of this time interval in randomized trials may include the time needed to obtain consent for enrolment into the trial and the time to activate the endovascular team. Future trials should still aim to achieve a fast IV needle to arterial puncture time given the potential for significant clinical improvement when these times are shortened.
The Endocannabinoid Antagonist AM251 as a Method of Protection Prior to Global Cerebral Ischemia: Implication for Dopamine Function, Neuronal Survival and Behavior
Dunbar, MR; Azogu, I; de la Tremblaye, PB; Richardson, L; Plamondon, H; University of Ottawa, Ottawa, ON
Background: Implications for the endocannabinoid system in global cerebral ischemia has not been clearly defined. Ischemia produces an excitotoxic environment that is severely damaging to neurons, causing degradation of cell membrane and ultimately cell death. Contradictory research suggests both the benefits and adverse effects of endocannabinoid on neurological injury. Due to the excitotoxic nature of ischemic injury, and the mechanisms at play with endocannabinoid agonists, such as increased transmission of dopamine and glutamate, it is suspected that CB-1 endocannabinoid antagonists, such as AM251, may provide cell protection. Methods: 40 male Wistar rats were separated into 4 groups (n=10/group). The first group of rats were administered AM251 (2 mg/kg, i.p) 30 minutes prior to global cerebral ischemia (four vessel occlusion), while the second group were given AM251, 30 minutes prior to sham surgery. Finally the last two groups were given saline instead of AM251 and given either ischemia or the sham surgery. Behavioural testing included the open field test and elevated plus maze, which took place after a five day recovery period following ischemia. Immunohistochemical analyses were performed with tyrosine hydroxylase (TH) and dopamine receptor 1(DRD1) to compare dopamine function amongst groups. Thionin staining was used to evaluate post ischemic neuronal death. Results: Ischemia induced a significant reduction in dopamine within the mesolimbic circuit, including the ventral tegmental area, nucleus accumbens, CA3 & CA1 of the hippocampus, and basolateral amygdala. These reductions in dopamine transmission by global ischemia were partially or fully reversed by AM251 pretreatment. Furthermore, cell survival was increased in the CA1 from treatment with AM251. Behavioural results indicate that AM251 reversed emotional alterations associated with ischemia insult. Conclusion: The CB1 endocannabinoid antagonist AM251 facilitated recovery of deficits in dopamine function in the mesolimbic pathway, attenuated ischemic CA1 cell death and regulated emotionality when given prior global cerebral ischemia.
Carotid Artery Distensibility Evaluation with Dynamic MR Imaging
Boesen, ME1, 3 Frayne, R1, 3, 4 Yerly, J1, 3 Lebel, RM2, 3; 1. University of Calgary, Calgary, AB; 2. Applied Sciences Laboratory, GE Healthcare, Calgary, AB; 3. Seaman Family MR Research Centre, Calgary, AB; 4. Hotchkiss Brain Institute, Calgary, AB
Background: Carotid wall motion can provide insight into stroke risk. Detection of decreased arterial distensibility could potentially guide early intervention. We have implemented a retrospectively-gated black-blood MR acquisition to provide carotid wall images over the cardiac cycle to evaluate distensibility measures. Methods: Eight axial slices were prescribed over the carotid bifurcation in five volunteers. A standard black-blood MR acquisition was altered to retrospectively associate data acquired with different phases of the cardiac cycle. One image of the common carotid artery was reconstructed for each of sixteen phases. Left carotid artery cross-sectional areas were manually traced three times over on each image. Distensibility coefficients were calculated as: DC=2(Ds-Dd)/DdΔP where Ds and Dd are systolic and diastolic diameters and ΔP is pulse pressure. Results: Carotid pulsation over the cardiac cycle was clearly demonstrated (see Figure of carotid cross-sectional diameters over time). Maximum and minimum cross-sectional areas were used to derive Ds and Dd. Mean DC was found to be 31.9±10.8MPa-1. This finding falls within the range reported by Harloff et al. as 41.6±9MPa-1 using a different MR-based method (Eur Radiol, 2009; 19:1470).
Conclusion: Our proposed technique provides wall contrast and can demonstrate arterial dynamics over the cardiac cycle. Tested in five normal subjects, DC fall within the expected range. Our technique could also image the dynamics of carotid artery wall components to provide detailed investigations of distensibility and its relation to stroke risk.
Atrial Fibrillation Screening Using a Handheld ECG Device: Results from the Heart and Stroke Foundation (HSF) “Be Pulse Aware” Campaign
Boyle, KO1 Morra, D1 Dorian, P1 McCrorie, A2 Haddad, P1 Taylor, L2 Grima, E3 Newman, D1 Langer, A1 Chow, C1 Gladstone, D1; 1. University of Toronto, Toronto, ON; 2. Heart and Stroke Foundation, Toronto, ON; 3. Canadian Heart Research Centre, Toronto, ON
Background: Early detection and treatment of atrial fibrillation (AF) could prevent many strokes. New technology devices enable simple, rapid, inexpensive AF screening without requiring standard 12-lead ECG or medical personnel. We tested the feasibility and yield of a handheld ECG compared to manual pulse check at public screening events. Methods: As part of a HSF public awareness campaign, attendees at 4 community events (Toronto, Montreal, Calgary) were offered single time-point AF screening. A 30 second radial pulse palpation was performed by volunteer nurses/nursing students followed by a 30 second single lead ECG rhythm strip by trained personnel (Heart Check™; CardioComm Solutions, Inc.). The primary endpoint was AF detection by pulse check compared to ECG with central blinded cardiologist adjudication. Results: Of 1334 participants (mean age 63 +/-13 years; history of hypertension in 20%), AF was detected by ECG in 28/1334 (2.1%): 10/1334 (0.7%) newly-detected AF and 18/1334 (1.3%) previously-known AF. The prevalence of new AF increased from 6/747 (0.8%) in those aged ≥65 years to 3/197 (1.5%) in those ≥75 years and 2/75 (2.7%) in those ≥80 years. Of the new AF cases detected, 6/10 were potential anticoagulant candidates (CHADS2 score ≥1). Of ECG positive patients with previously known AF and CHADS2 ≥1, 4/11 were not anticoagulated. Manual pulse check had low sensitivity (43%) and poor positive predictive value (16%) for AF detection. An abnormal pulse was appreciated in only 12/28 ECG-confirmed AF cases (including only 1 of the 10 new AF cases). Conclusions: In a community screening setting, identification of AF with a handheld ECG device was feasible and superior to pulse check. AF screening programs have potential to identify guideline-based AF treatment candidates (both new AF cases and previously-diagnosed but untreated patients), with greatest yield in the elderly. Community AF screening should not rely on pulse checks alone.
A Novel Day-Unit Care Model for TIA and Minor Stroke Patients Improves Rapid Access to Care and Satisfaction with Care
Cayley, A2 Iyngarathasan, A2 Abraham, J2 Kalman, L2 Jaigobin, C2 del Campo, M2 Silver, F2 Casaubon, L1; 1. University of Toronto, Toronto, ON; 2. University Health Network, Toronto, ON
Background: About one in four ischemic strokes are preceded by a TIA; 43% of TIAs occur within one week before stroke. Patients with a TIA require urgent assessment and preventative treatment but often cannot access a Stroke Prevention Clinic in a timely fashion. Therefore, patients are often admitted to hospital for evaluation but it is unclear if inpatient evaluation is optimal or necessary for this patient population. Methods: We developed a high-risk TIA and Minor Stroke (TAMS) Unit to provide rapid access to patient assessment, investigations, initiation of prevention strategies, and stroke prevention education. The TAMS Unit patient assessments were based on a collaborative model led by stroke Nurse Practitioners and attending stroke Neurologists. We evaluated the feasibility of this care model and assessed patient satisfaction through a survey questionnaire. Results: Between Sept. 6, 2011 and Mar. 31, 2013, 265 patients were seen in the TAMS Unit. Median time from emergency department visit to TAMS Unit assessment was 1 day. The final diagnosis was TIA in 35% of patients and minor stroke (NIHSS < 4) in 30% of patients. For the satisfaction survey, 137 questionnaires were mailed out to patients seen in the first year after the unit opened, with 60 (44%) returned – 52 (38%) were complete and included in the analysis. Overall, 73% of patients strongly agreed and 27% agreed that they were satisfied with their over-all visit. Sixty percent of patients strongly agreed and 36% agreed that they were provided with information about their condition. Over-all, patients were satisfied with their consultations with the stroke NPs and neurologists. Conclusion: Our novel TAMS Unit is a feasible care model that provides rapid access to assessment and treatment of high-risk TIA and minor stroke patients. Overall, patients expressed strong satisfaction with the care they received.
Perfusion computed tomography for selection of patients with suspected acute ischemic stroke for thrombolytic therapy—a systematic review and meta-analysis
Burton, KR1 Dhanoa, D2 Aviv, R1 Moody, A1 Kapral, M1 Murray, K1 Laupacis, A1; 1. University of Toronto, Toronto, ON; 2. Fraser Health Authority, Surrey, BC
Background: perfusion CT (CTP) imaging is increasingly being used for the diagnosis of acute ischemic stroke (AIS) as it is cheaper and faster than magnetic resonance imaging (MRI). While data from systematic reviews of UCT and MRI have been used to populate AIS imaging cost-effectiveness studies, none currently exist that provide estimates of outcomes for patients selected by CTP imaging. Objectives: to determine the rates of outcomes (mortality, morbidity and symptomatic intracranial hemorrhage (SICH)) of AIS patients who are selected for thrombolytic therapy using CTP imaging. Methods: we performed electronic searches in MEDLINE, EMBASE, the Cochrane Library, PubMed, and Google Scholar up to August 2012, unrestricted by language of publication and study methodology. We also performed manual searches of included studies, bibliographies of relevant review articles and we searched the gray literature for unpublished studies, which included theses, patents, health technology reviews and conference proceedings. Two independent reviewers extracted study data and independently assessed risk of bias for each selected study. Results: fourteen studies met our inclusion criteria for a total of 479 patients. Mortality of CTP-selected AIS patients who were treated within 3 hours was 17.6% (95% CI, 12.2-23.6%). Mortality of all CTP-selected patients treated was 7.1% (95% CI, 1.8-15.5%). Favourable outcome (mRS score ≤ 2) for patients treated within 3 hours and beyond 3 hours was 30.7% (95% CI, 8.4%-59.4%) and 44.5% (95% CI, 0.6-29.5%), respectively. Rates of SICH for patients treated within 3 hours and beyond 3 hours were 5.4% (95% CI, 3.2-8.2%) and 4.7% (95% CI, 2.0-8.4%) respectively. Conclusions: the outcomes of CTP-selected AIS patients can be used in future studies of CTP imaging cost-effectiveness relative to other neuroimaging modalities within AIS patients.
Towards Patient-Tailored Perfusion Thresholds for Prediction of Stroke Outcome
Eilaghi, A1 d’Esterre, C2 Lee, T3 Jakubovic, R1 Brooks, J1 Liu, RT1 Zhang, L1 Swartz, RH1 Aviv, R1; 1. Sunnybrook Health Sciences Centre, Toronto, ON; 2. Robarts Research Institute, London, ON; 3. Robarts Research Institute, University of Western Ontario, London, ON
Background and Purpose: Multiple patient-specific clinical and radiological parameters impact upon traditional perfusion thresholds used to classify/determine tissue outcome. We sought to determine whether modified baseline perfusion thresholds calculated by integrating baseline perfusion and clinical factors better predicts tissue fate and clinical outcome. Methods: Computed tomography perfusion (CTP) within 4.5 hours of acute anterior circulation stroke onset, and 5-7 day follow-up fluid attenuated inversion recovery (FLAIR) MRI were obtained for 114 stroke patients. The ischemic region was operationally classified as infarct and non-infarct according to baseline computed tomography perfusion parameters and follow-up FLAIR images. Optimal thresholds transformed by clinical and radiological variables for grey matter and white matter tissue were determined in each region using a general linear mixed model. Performance of perfusion threshold for tissue fate and 90-day clinical outcome prediction was compared using accuracy, Akaike’s Information Criterion and logistic regression. Reproducibility of models was checked using bootstrapping. Results: Transformation of perfusion thresholds by clinical and radiological baseline parameters significantly improved tissue fate predictive models for both grey matter and white matter (p<0.001). The maximal accuracies for GM and WM in adjusted models were relative cerebral blood flow: 91%, 86%, absolute Tmax: 88%, 84%, relative mean transit time: 85%, 78% and relative cerebral blood volume: 74%, 73%. Transformed thresholds enhanced the clinical 90-day outcome prediction for cerebral blood flow, Tmax and mean transit time CTP maps. Conclusions: Transformation of baseline perfusion parameters by patient-specific clinical and radiological parameters significantly improves the accuracy of tissue fate and clinical outcome prediction.
Oxford County Blood Pressure Education Program
Gardner, LA1 Winter, J2; 1. Chief Nursing Executive, Alexandra Hospital, Ingersoll, ON; 2. Oxford County Cardiac Rehabilitation and Secondary Prevention Program, Alexandra Hospital, Ingersoll, ON
Program Summary: The Oxford Blood Pressure Education Program was developed to test the feasibility and effectiveness of an education and counselling intervention to improve blood pressure control among hypertensive individuals diagnosed within three months prior to recruitment, with no recent cardiovascular or cerebral vascular event, including those who were already taking antihypertensive medication. The program initially targeted Oxford county residents who did not have a family physician and sought treatment at a local emergency department. Each participant was encouraged to bring a support person or family member. The demands placed on family physicians in the community, coupled with the physician shortage, means that this educational component may be neglected or incomplete when a diagnosis of hypertension is made. The program was developed and implemented by the Oxford Stroke Strategy Working Group, and was piloted for 15 months in 2005 – 2006. Continued funding to 2007 – 2008 was received and the program was expanded to include any community member with hypertension and their family members, as well as any community member who has an interest in learning more about hypertension and management strategies. Again funded in 2011-12 through Ministry of Leisure and Recreation. Conclusion: The Oxford Blood Pressure Education Program is a feasible, community-oriented program compatible with chronic disease self-management, which was associated with reductions in blood pressure and other risk factors. These changes were significant statistically, clinically, and potentially, economically.
Frequent Atrial Premature Beats Predict Occult Paroxysmal Atrial Fibrillation in Patients with Cryptogenic Stroke: Results From the Embrace Multicentre Trial
Gladstone, DJ1 Spring, M2 Dorian, P3 Thorpe, K3 Panzov, V3 Hall, J3 Vaid, H1 O’Donnell, M4 Laupacis, A3 Côté, R5 Sharma, M7 Blakely, J1 Shuaib, A8 Hachinski, V9 Coutts, SB10 Sahlas, DJ11 Yip, S12 Teal, P12 Spence, J9 Buck, B8 Verreault, S13 Casaubon, L1 Penn, A14 Selchen, D1 Jin, A15 Howse, D16 Mehdiratta, M2 Mamdani, MM3 for the EMBRACE Steering Committee and Investigators17; 1. University of Toronto, Toronto, ON; 2. Trillium Health Centre, Mississauga, ON; 3. St. Michael’s Hospital, Toronto, ON; 4. McMaster University, Hamilton, ON; 5. McGill - Montreal General Hospital, Montreal, QC; 6. University of Ottawa, Ottawa, ON; 7. Ottawa Hospital, University of Ottawa, Ottawa, ON; 8. University of Alberta, Edmonton, AB; 9. University of Western Ontario, London, ON; 10. University of Calgary, Calgary, AB; 11. Hamilton Health Sciences, Hamilton, ON; 12. University of British Columbia, Vancouver, BC; 13. Université Laval, Quebec City, QC; 14. Vancouver Island Health Research Centre, Victoria, BC; 15. Kingston General Hospital, Kingston, ON; 16. Thunder Bay Regional Health Sciences Centre, Thunder Bay, ON; 17. Sunnybrook Research Institute and Li Ka Shing Knowledge Inst. of St. Michael’s, Toronto, ON
Background: Many ischemic stroke/TIA events are labeled ‘cryptogenic’ but may be due to undetected paroxysmal atrial fibrillation (PAF). To predict those most likely to have occult PAF, we investigated the association between atrial ectopic activity on Holter monitor and subsequent detection of PAF. Methods: We analyzed data from cryptogenic stroke/TIA patients without known AF enrolled in the 30-day cardiac monitoring arm of the EMBRACE trial. Participants had baseline Holter monitoring that did not reveal PAF, followed by ambulatory cardiac monitoring for up to 30 days to detect PAF. In a preplanned multivariable logistic regression analysis, we assessed the association between the following Holter and clinical variables on the outcome of PAF detection: #atrial premature beats (APBs)/24h, #runs of atrial tachycardia <30 seconds/24h, age, and #prior strokes. Results: Among cryptogenic stroke/TIA patients (mean age 73±9 years), the median #APBs/24h on baseline Holter was higher in patients who were subsequently found to have PAF vs. those without PAF detected (629 vs. 47 ). Compared to the overall PAF detection rate in the entire group, 45/287 (16%), PAF was found in 16/181 (9%) patients with infrequent APBs (<500/24h) and 20/52 (38%) patients with frequent APBs (>500/24h). PAF was found in 20/187 (11%) patients with 0-2 brief runs of atrial tachycardia and 21/70 (30%) patients with >2 runs. In the regression model, #APBs was the only statistically significant predictor of PAF (p=0.0016). The probability of PAF increased steadily with increasing #APBs (for every 100 APBs/24h the OR was 1.4 ) up to 900, above which there was no further discrimination. Conclusions: Elderly cryptogenic stroke/TIA patients with frequent APBs have a high probability of occult PAF and may be particularly ideal candidates for prolonged cardiac monitoring for PAF detection. Among those with >500 APBs/24h, 1 in 3 had PAF detected on 30-day monitoring.
The University of Alberta Hospital Door-to-Needle (DTN) Process Improvement Initiative; Significant changes Achieved Through Interdepartmental Collaboration
Halabi, M1 Ghrooda, E2 Taralson, C1 Khan, K2 Amlani, S1 Shuaib, A2 Jeerakathil, T2; 1. Stroke Program Edmonton Zone, Edmonton, AB; 2. Division of Neurology, University of Alberta Hospital, Edmonton, AB
Background: Shortening door to needle times (DTN) for ischemic stroke thrombolysis remains a challenge. The literature demonstrates that feedback on performance to multi-disciplinary stroke stakeholders can reduce DTN times. For 17 years our centre has failed to lower DTN times to sub 60 minutes. A new multifaceted process improvement initiative was implemented to streamline the DTN process Methods: April of 2012 marks the inception of the DTN initiative. Stakeholders from the Emergency Department (ED), Stroke Service, and Diagnostic Imaging (DI) were engaged and participated in this effort. Detailed process mapping was done collaboratively. Problem areas were identified. Specific solutions were devised, trialed, modified, and then re-trialed. Regular meetings were held with educators and managers to receive and provide feedback. In addition, a “Time in Motion Study” in the ED was undertaken with “In Real Time” chart reviews completed for all thrombolysed patients. Cases were discussed on a weekly basis within the stroke team and DTN data was regularly shared with stakeholders. Education sessions regarding this initiative were provided by the stroke team to ED and DI staff. Statistical analysis involved linear regression and calculation of DTNs and confidence intervals for 4 time periods spanning 13 months. Results: The DTN initiative has rolled out an increasing number of components over 4 time periods. Bottlenecks in the DTN process were identified then jointly and systematically managed resulting in a statistically significant declining trend in DTN (R = -2.43; p = 0.0006 for each subsequent month). DTN decreased significantly from 77 min (65,89) in April-July 2012 to 57 min (49, 65) in February-April 2013. Conclusion: The process improvement initiative enabled the development of a leaner process. This collaborative effort has aligned previously siloed departments allowing them to work towards a common goal. Future efforts will include engaging additional stakeholders such laboratory services.
Does Hospital Ischemic Stroke volume relate to Clinical Outcomes in the Ontario Stroke System?
Hall, R1, 2 Fang, J1 Hodwitz, K1 Saposnik, G3, 1 Bayley, M4; 1. Institute for Clinical Evaluative Sciences, Toronto, ON; 2. Ontario Stroke Network, Toronto, ON; 3. St. Michael’s Hospital, Toronto, ON; 4. Toronto Rehabilitation Institute, Toronto, ON
Better outcomes have been found among hospitals that treat high volumes of patients for specific surgical and medical conditions. We examined whether hospital ischemic stroke (IS) volume was associated with 30-day mortality to inform regionalization plans. Using FY 2005/06 to 2011/12 CIHI DAD we calculated the average annual IS patient volumes among Ontario acute hospitals admitting fifteen or more IS patients per year (N = 128). Hospitals were ranked based on average annual IS volume and stratified into terciles with approximately one third of patients in each tercile. Hospitals were classified as small (<130), medium (130 – 202) and large (>202). Multivariable hierarchical logistic regression was used to account for patient clustering within hospitals. Overall, 70,895 patients were hospitalized for IS. The mean (+/- SD) number of annual hospitalizations for ischemic stroke was 45(32) for small volume hospitals, 159(19) for medium volume hospitals and 300(78) for high volume hospitals. Higher volume hospitals admitted younger patients, mean (+/- SD) age 73.0 (13.9) years compared to 74.0 years (13.3) and 75.3 (12.6) years for medium and small volume hospitals respectively (p <0.0001). Patients at small volume hospitals demonstrated similar prevalence of comorbid conditions with exception of, diabetes, cardiac dysrhythmias, renal disease where small volume hospitals patients had lower prevalence (p < 0.0001). Overall 30-day risk-adjusted ischemic stroke mortality was 15.1%. Mortality was 1.38 times greater (OR 1.38, 95% CI 1.21, 1.57) for patients cared for in small hospitals compared to patients cared for in high volume hospitals. There appears to be an association between acute hospital IS volume and 30-day mortality in Ontario. Patients admitted to hospitals with annual IS volumes greater than 15 but less than 130 per year are 38% more likely to die within 30-days than patients admitted to hospitals that see on average 300 IS patients per year.
Developing a Regional Model for Acute Stroke Unit Care - Submitted on Behalf of the Fraser Health Stroke Strategy
Harrison, KJ1 Crozier, T2 Veldhoen, R2 Still, C2; 1. Fraser Health Authority, Langley, BC; 2. Fraser Health Stroke Strategy, Surrey, BC
Background: In Fraser Health, one of Canada’s largest and fastest growing health regions, stroke accounts for approximately 2100 hospital admissions annually—a figure that is anticipated to increase in response to our rising population. To address these realities while delivering the best in stroke care that aligns with national, provincial and regional initiatives, multi-program representatives from each of our 12 sites formed the Fraser Health Stroke Steering Committee (FHSSC). Since its inception in 2005, the FHSSC has been focused on the implementation of Acute Stroke Units (ASU) across the region that provide best care practices and improved patient outcomes by ensuring adequate front-line staffing of all professions, ongoing quality improvement, and reduction in acute length of stay. On June 26, 2012 the start of this regional vision was realised with the opening of 12 acute stroke beds at Surrey Memorial Hospital (SMH) which will increase to 22 beds by June 1, 2014 when the ASU moves into the new 36 bed Neurology Unit in the SMH Critical Care Tower. Methods: Fraser Health created a robust ASU with staff empowered to use quality improvement methodology to establish a model of care that will be replicated across the region. Results: Through employing the Plan-Do-Study-Act (PDSA) methodology, front-line staff incorporated Canadian Best Practice Recommendations to develop an acute care stroke model that has resulted in the standardization of the following components:
patient/family and staff education sessions
measurement and evaluation framework
clinical decision tools (e.g. depression screen)
Conclusion: This pilot project of the SMH ASU has allowed the FHSSC to develop a regional model for acute stroke care that can be implemented in other regional hospitals to ensure consistent, measurable and improved patient outcomes.
Effect of Onset Time of Contralesional Cortex Inhibition Following an Ischemic Lesion in Rats
Jean-Charles, L1 Mansoori, B1 Touvykine, B1 Morse, l2 Quessy, S1 Dancause, N1, 3; 1. Université de Montréal, Département de Physiologie, Montréal, QC; 2. Université de Montréal, Montréal, QC; 3. Groupe de Recherche sur le Système Nerveux Central, Montréal, QC
Following stroke, human imaging studies have shown that there is an early increase of activity in the contralesional hemisphere that progressively diminishes with time and recovery. Inhibitory neuromodulatory protocols have been applied to the contralesional hemisphere of stroke patients and can improve the function of the paretic limb. However, very few studies have initiated inhibition in the acute phase of recovery, when the contralesional activity is known to be at its highest. Thus, our aim was to investigate the effect of onset time, the time between the lesion and the beginning of the contralesional inhibition, on motor recovery after cortical lesions. We used a rat model of cortical lesion with micro-injections of a vasoconstrictor, endothelin-1. In the same surgical procedure a cannula was implanted in the contralesional cortex. An osmotic pump filled with muscimol, a GABA-A agonist, was connected to the cannula immediately (Group 0D), 3 days (Group 3D) or 7 days (Group 7D) after the lesion in 3 different groups. The pump continuously delivered muscimol for 14 days in all groups. Controls spontaneously recovered from lesions of similar size. The performance of both forelimbs was assessed with the Montoya staircase test. In all experimental groups, there was decrease of grasping function with the non-paretic hand during the inhibition, confirming the effectiveness of muscimol. For the paretic forelimb, there was an initial decrease of function after the lesion that progressively recovered with time. Group 0D recovered significantly better than controls by post-lesion day 28 but Groups 3D and 7D recovered only to the level of controls. These preliminary results suggest that contralesional inhibition initiated within hours after a cortical lesion is more beneficial to recovery of the paretic forelimb than the same inhibition protocol initiated 3 or 7 days following the lesion.
Visualization of Nestin Signals Following Ischemic Injury and in Neuroinflammatory Conditions
Krishnasamy, S1, 2 Weng, YC2, 1 Kriz, J2, 1; 1. University Laval, Quebec, QC; 2. Centre de recherche du CHUL, Quebec, QC
Introduction: Neruoinflammation is a process in which the brain responds to infections, diseases and injuries, it occurs due to hypoxia and ischemia to a number of bacterial and viral infections. The inflammatory process in the neurogenic regions of the brain greatly alters the microenvironment of the neural stem cells and thereby influences the fate of these Neural Progenitor Cells (NPGs). The mechanism, function and significance of the modulation of neurogenesis during inflammatory processes remain to be elucidated. To address these questions we generated a transgenic mouse model in which we can visualize the process of adult neurogenesis from the brain of live animals using bio photonic/bioluminescence imaging and high resolution CCD camera. Methods: Nestin-luc-GFP mice were subjected to 90 minutes of MCAO followed by a reperfusion period of 3 days, 7days and 14 days. To elucidate the chronic neruoinflammation Lipopolysaccharide (LPS) 5mg/kg body weight was injected to mice by intraperitoneally for every 3 days until 14 days. Results: In the acute CNS injury model we observed the up regulation of nestin bioluminescent signal at 24hrs, 3 days and 7 days, and signal was observed up to a month following the surgery. Chronic administration of LPS produce an up regulation of nestin signal at 24 hrs and gradually start declines after 72hrs and reached the baseline level at 14 days. Histological analysis of the brain sections 72 hrs and 7 days after stroke shows an increase of nestin and the nestin-driven GFP transgene expression in GFAP and DCX positive cells. Conclusions: The nestin reporter mouse represents a valid model to study neurogenesis in ischemic brain of live animals. In this study we took an advantage of Nestin-luc/GFP transgenic mice to study the ischemic injury induced gliogenesis and neurogenesis.
Enhanced Dynamic Contrast Enhanced (DCE) MR for Brain Perfusion Imaging
Lee, E1, 2 MacDonald, M1, 2 Frayne, R1, 2, 3; 1. Biomedical Engineering, Hotchkiss Brain Institute, University of Calgary, Calgary, AB; 2. Seaman Family MR Centre, Foothills Medical Centre, Calgary, AB; 3. Radiology and Clinical Neurosciences, University of Calgary, Calgary, AB
Background: MR perfusion measurements allow for derivation of tissue-level hemodynamic parameters (eg., cerebral blood flow) that are useful for diagnosis of cerebral ischemia. DCE approaches typically use fast T1-weighted MR imaging methods that exhibit, over a range, a near linear relationship between signal intensity and contrast agent concentration. This observation suggests the potential for more robust estimations of perfusion-derived parameters compared to other existing MR approaches, leading to better stroke detection and localization. Low blood volume in brain tissue (WM ~2% blood), however, poses a limitation to this approach. We propose a technique for maximizing observed signal changes (ΔS=Scontrast-Sbaseline) during the contrast agent bolus passage in less vascularized white matter tissues while preserving both spatial and temporal resolution. Methods: A DCE signal model was implemented that allowed the effects of three key parameters (contrast concentration, repetition time (TR) and flip angle (FA)) to be understood and modified to optimize ΔS. Imaging performed on a 3-T scanner confirmed predictions from the model using phantoms and stroke patients. Patients were scanned using the DCE method with two TR/FA combinations during a single contrast injection. Results: As expected, ΔS increases with increasing concentration, and was maximized for a specific (TR, FA) combination. In phantom and stroke patient studies, the longer TR acquisitions yielded a larger ΔS, consistent with predictions made by our model. Increase in ΔS by ~47% was readily observed in images for both the phantoms and stroke patients. Conclusions: Signal difference in DCE perfusion imaging in WM can be increased by careful selection of TR and FA. More robust changes in WM improve the precession of perfusion measures with DCE in acute stroke. In order to provide sufficient temporal sampling rates, however, longer TR DCE techniques will need to be implemented with accelerated imaging approaches.
Screening for High-Risk Comorbidities (Depression, Obstructive Sleep Apnea and Cognitive Impairment) in the Stroke Clinic: The Need, the Challenges and a Possible Solution (The Doc Screen)
Lien, K1 Sicard, MN1 Lanctot, K1 Murray, B1 Herrmann, N1 Thorpe, K2 Swartz, R1; 1. Sunnybrook Health Sciences Centre, Toronto, ON; 2. Applied Health Research Centre of the Li Ka Shing Knowledge Institute, Toronto, ON
Background: Treatable comorbidities such as depression, obstructive sleep apnea, and cognitive impairment (DOC) each affect up to 50% of patients post-stroke. Though these DOC conditions worsen outcomes and quality of life, the associations amongst them are understudied. Routine screening is recommended, but is onerous and cannot be applied in all cases. There is a need for brief, valid tests to screen for these three comorbidities during the clinical encounter. The objective of this research study is to develop a 1-page integrated screening assessment to identify high-risk patients for each of the DOC conditions in large-volume urgent TIA/stroke clinics. Methods: A literature review was conducted for screening tools of DOC comorbidities. More than 50 tests were identified but few met inclusion criteria of brevity and utility for broad clinical application. Results: The DOC screen is a novel screening tool that combines depression, apnea and cognitive screening tests (PHQ-2, STOP, and mini-MoCA, respectively). The screen has been designed such that less contributory cognitive tasks (distracters) have been replaced with mood and apnea questions to maintain validity of the delayed recall task. Additionally, it employs more sensitive executive function tasks (clock and abstraction). Scores for each disease can be assessed separately, and the total (out of 20) provides an overall “brain risk” score. Conclusion: Simple, reliable, evidence-based screening of DOC disorders is necessary and the novel screen may facilitate this. While brief screens have been studied individually, it remains to be seen if the integrated measures prove to be feasible and valid.
National Survey of Neurologists for TIA Risk Stratification Consensus and Appropriate Treatment for a Given Level of Risk
Perry, JJ1 Losier, J1 Sutherland, J2 Stiell, IG1 Sharma, M3; 1. University of Ottawa, Ottawa, ON; 2. Ottawa Hospital Research Institute, Ottawa, ON; 3. McMaster University, Hamilton, ON
Background: 5% of transient ischemic attack (TIA) patients have a subsequent stroke ≤7 days. The Canadian TIA Score uses clinical findings of TIA patients to calculate subsequent stroke risk ≤7 days. Our objectives assessed: 1) anticipated use; 2) component face validity; 3) risk strata for stroke ≤7 days; 4) actions required, for the Canadian TIA Score. Methods: We conducted a mail survey of 222 Canadian Neurologists listed in Scott’s Canadian Medical Directory via a modified Dillman technique. We used pre-notification, up to 3 survey attempts by letter mail (first with a $10 gift card) and a 4th by registered mail. We asked 41 questions including: demographics, face validity of the Score’s components (4-point scale), if physicians will use the Score (4-point scale), cutoffs (open percents) for minimal, low, high and critical-risk, and suggested actions for each risk stratum (4-point scale). We calculated descriptive statistics. Results: Response rate was 53.1%, predominately males (79.3%) with mean age 53.0 years. Components rated as “very important” or “important” were: first TIA (73.5%), ≥10 minutes duration (90.1%), history carotid stenosis (92.6%), antiplatelet therapy (52.1%), gait disturbance (40.5%), unilateral weakness (95.9%), vertigo (negative predictor) (23.2%), speech disturbance (94.2%), diastolic BP ≥110 (76.0%), atrial fibrillation (99.2%), infarction on CT (92.5%), platelets ≥400x109/L (39.7%), and glucose ≥15mmol/L (63.6%). 86.8% would use the Canadian TIA Score after validation. Using the 25th percentile (i.e. 75% of physicians would accept this degree of risk or more) defined: minimal-risk <1%, low-risk 1-5%, high-risk 5.1-15%, and critical-risk >15% for subsequent stroke ≤7 days. Suggested actions include minimal-risk: ECG, optimize blood pressure; low-risk: CT head, outpatient carotid imaging, echocardiogram; high-risk: immediate carotid imaging, hospital admission, and critical-risk: echocardiogram on same day. Conclusions: Neurologists will likely use a validated Canadian TIA Score. Most components have high face validity. Risk strata are definable with prescribed actions.
Community Exercise Partnership: Heart Wise Exercise for TIA and Minor Non-Disabling Stroke
Morris, MR1 Bourgoin, A1 Gocan, S1 Harris, J2 Woermke, H3 Dyks, T1; 1. Champlain Regional Stroke Network, Ottawa, ON; 2. The Ottawa Heart Institute-Heart Wise Exercise, Ottawa, ON; 3. Pembroke Regional Hospital, Pembroke, ON
Background: Physical activity (PA) is an important modifiable lifestyle factor in secondary prevention of stroke and vascular events. The success of a model that supports participation of patients in community exercise requires patient awareness, availability of appropriate and safe programs, systematic referral, and fitness leaders’ that are receptive to participants with vascular conditions. Methods: An innovative model was employed at Champlain Regional Stroke Prevention Clinics (SPC) to increase engagement in PA among patients with Transient Ischemic Attack (TIA) and minor non-disabling stroke (MNDS). This included fitness leader training, systematic PA prescription and referral to Heart Wise Exercise (HWE) community programs for patients seeking support with PA. University of Ottawa Heart Institute and Champlain Regional Stroke Network built on the HWE network of community exercise leaders to increase capacity and knowledge about stroke best practices. Results: Across the region, 157 exercise leaders at 24 HWE sites (11 rural, 13 urban) participated in targeted training for exercise after TIA/MNDS. Health care providers at all four SPC’s in Champlain implemented standardized exercise prescription pads which included Canadian Best Practice recommendations for PA and identified regional HWE programs. Fitness leaders who received training reported increased confidence in providing safe and suitable exercise routines. Successes seen in the stroke program have been replicated among regional diabetes programs. Challenges for program evaluation have included access to volumes of referrals and tracking program uptake. Conclusions: PA is an independent risk factor for stroke and other vascular conditions. As such, the systematic delivery of counselling, education and support for physical activity is an important vascular health prevention strategy. Research is needed to assess the impact of partnerships which couple standardized, patient-focused interventions with structured community programs supported by trained fitness leaders.
CTA Collaterals Can Be Used for Patient Selection in Proximal Anterior Circulation Occlusions Receiving IA Therapy
Nambiar, VK1 Sohn, S2 Quazi, E1 Mishra, S1 Quazi, A1 Kosior, J1 Demchuk, AM1 Hill, MD1 Goyal, M1 Menon, BK1; 1. University of Calgary, Calgary, AB; 2. Keim Yong University, Keimyong, Korea
Introduction: The presence of leptomeningeal collaterals are associated with improved outcome among patients with acute ischemic stroke. We sought to identify if the association between recanalization after endovascular acute stroke therapy and favorable clinical response is modified by the presence of good collateral flow assessed on baseline CT angiography (CTA). Methods: Data are from the Keimyung Stroke Registry, a prospectively collected dataset of patients with acute ischemic stroke from Daegu, South Korea. Patients with M1 segment middle cerebral artery (MCA) +/- intracranial internal carotid artery (ICA) occlusions on baseline CTA from May 2004 to July 2009 who had baseline MRI were included. Two readers blinded to all clinical information assessed baseline and follow-up imaging. Leptomeningeal collaterals on baseline CTA was assesed by consensus using the regional leptomeningeal score (rLMC). Results: Among 84 patients (mean age 65.2±13.2 years, median NIHSS 14; IQR 8.5), median time from stroke onset to initial MRI was 164 minutes. TIMI 2-3 recanalization was achieved in 39.3% patients and mRS 0-2 at 90 days in 35.8% patients. In a multivariable model, the interaction between collateral status and recanalization was relevant (p=0.048). Only patients with intermediate or good collaterals who recanalize show a statistically significant association with good clinical outcome. (Rate Ratio=3.7, 95% CI 1.2-11.5). Patients with good and intermediate collaterals who do not achieve recanalization and patients with poor collaterals even if they achieve recanalization do not do well. Conclusion: Results from our study suggest that a randomized controlled trial focused on achieving fast and effective recanalization using latest generation mechanical devices (stentrievers) among patients with good and intermediate collaterals assessed on CTA at baseline could provide confirmatory evidence for IAT in acute ischemic stroke.
Apixaban Versus Aspirin in Atrial Fibrillation Patients ≥ 75 Years Old: an Analysis From the AVERROES Trial
Ng, K; Shestakovska, OO; Eikelboom, JW; Connolly, SJ; Yusuf, S; Hart, RG; McMaster University, Hamilton, ON
Background: The AVERROES trial (mean participant age 70 years) compared aspirin with apixaban, a novel oral Xa inhibitor, in patients at moderate-to-high risk of stroke due to atrial fibrillation (AF) but were unsuitable for vitamin K antagonists (VKA). Most AF patients in the community are ≥ 75 years-old, and this age group has higher risks of both stroke and bleeding during antithrombotic therapy than younger AF patients. In these exploratory analyses, we characterize further the effects of aspirin and apixaban in elderly patients. Methods: The AVERROES trial (n=5599) included 1898 patients ≥ 75 years with AF. We compared baseline characteristics and evaluated the effect of apixaban compared with aspirin on stroke and major bleeding in patients ≥ 75 years versus patients < 75 years. Results: The absolute risk reduction for stroke with apixaban over aspirin in AF patients ≥ 75 years was 3.9%/year compared with 0.7%/year in AF patients <75. Apixaban was more efficacious for preventing strokes in patients ≥ 75 years (relative risk reduction 67%) compared with patients < 75 years (relative risk reduction 33%; P-value for age interaction = 0.04). Patients ≥ 75 years had higher CHADS2 score and lower mean GFR compared with patients < 75 years. Whilst the risk of major bleeding was higher in patients ≥ 75 years (2.2%/year on aspirin and 2.6%/year on apixaban) compared with patients < 75 years (0.7%/year on aspirin and 0.8%/year on apixaban), there was no significant interaction with age. Summary: Patients ≥ 75 years who are unsuitable for VKA treatment have substantially greater benefit from apixaban than aspirin compared with younger patients. Apixaban was not associated with a disproportionately greater risk of bleeding in patients ≥ 75 compared with younger patients despite the greater absolute risk of major bleeding and worse renal function.
The Effectiveness of Stroke/TIA Education Upon Discharge From the Stroke Unit at the Grey Nuns Community Hospital
Pfeiffer, TL1 Avoledo, S1 Morrison, L2; 1. Grey Nuns community Hospital, Edmonton, AB; 2. Stroke Program, Edmonton Zone, Edmonton, AB
Background: The Canadian Best Practice Recommendations for stroke care indicates “education is an integral part of stroke care that must be addressed at all stages across the continuum …” As part of the Alberta Stroke Initiative (ASI), a gap analysis completed in 2012 at the Grey Nuns Community Hospital (GNCH) Stroke Unit identified a lack of stroke education to patients upon discharge. As a result, the GNCH Stroke Unit created a discharge process for the standardized Stroke/TIA Information Package developed by the Stroke Program, Edmonton Zone. A pilot project evaluating the effectiveness of this process is currently underway. Methods: The new discharge process from the GNCH Stroke Unit consists of the bedside nurse providing education by reviewing the content within the Stroke/TIA Information Package with all Stroke/TIA patients. A checklist, secured to the front of the package, is completed by the bedside nurse and signed off by the patient. Patients are encouraged to review the information package and bring it to subsequent Stroke Prevention Clinic (SPC) appointments. The SPC clinic nurse reviews the information a second time with the patient and provides additional resources, as necessary. An anonymous questionnaire is provided to the patient during the SPC appointment to confirm education was provided and beneficial. Results: This Stroke/TIA discharge process is currently a pilot project at the GNCH Stroke Unit. Results have yet to be collected and analyzed, but patient questionnaires received to date report satisfaction with the education provided. The process has standardized Stroke/TIA information being provided onsite and has strengthened relationships between the acute unit and SPC. Conclusion: The GNCH Stroke Unit implemented Best Practice Recommendations by providing standardized discharge education to all Stroke/TIA patients. Evidence of similar activities suggests that this process will contribute to a safer and more informed discharge.
Acute Ischemic Stroke Care Path and Pre-Printed Orders Education
Ram-Ditta, D; Fraser Health Stroke Strategy, Surrey, BC
An InterProfessional team in Fraser Health developed an Acute Ischemic Stroke Care Path that utilized elements of 48/6 (Mandated by the BC Ministry of Health to assess 6 components in 48 hours). In addition, the carepath incorporated best practice standards from the Stroke Best Practice Guidelines 2010. The carepath presently is for nursing. It is being trialled at our only stroke unit and four cohort units in acute care for a period of 3 months. It will be revised and will be available for use in our medicine program. The education session has been designed to be interactive, fun, and meaningful. The intent of the sessions are to foster the nurses ability to critically think about why certain elements are important to assess and treat in the stroke patient. Even though there is a core curriculum, each cohort site’s needs have been assessed, and the education tailored to address the learning needs. A lesson plan has been developed for each session and is interprofessional in nature. The education is Interprofessional in nature and includes education from Physiotherapy, Occupational Therapy, Pharmacy, Speech Language Pathology, Pharmacy, Nursing and the Regional Stroke Coordinator. Even though the education is in progress, the evaluations has been very positive. The education is based on the needs of each cohort site, and incorporates members of the interprofessional team such as physiotherapy, occupational therapy, speech language pathology and pharmacy when the need has been identified by the manager and educator. The care path and pre-printed orders are also discussed.
Targeting the Rgma/Neogenin Pathway to Promote Neuronal Regeneration Following Stroke
Shabanzadeh, AP; University of Toronto, Toronto, ON
Membrane proteins play critical roles in many biological processes. Here we developed a series of peptides to alter the role of the extracellular ligand Repulsive Guidance Molecule RGMa and its receptor (Neogenin) on diseased neurons. To assess the role of these peptides in Stroke, we have used several in-vivo stroke models, including a thromboembolic stroke model in rats which utilizes a distal internal carotid artery occlusion with a clot, and a model of retinal artery stroke. To get insight into the cellular mechanisms involved after addition of our peptides, we developed in-vitro stroke models (Oxygen and Glucose Deprivation model). Here, we show that providing RGMa, to neurons promoted cellular survival in retinal and cerebral stroke models. Because we have showed that RGMa requires activation by the enzyme SKI-1, we also tested whether or not a specific inhibitor for this enzyme can promote functional recovery following Stoke (see images 1 and 2 ). Interestingly, animals treated with this inhibitor significantly neurological deficit improvement following MCAO. This was accompanied by a reduction of the infract volume and brain edema size. Together our results reveal that targeting the RGMa/Neogenin pathway may provide therapeutic opportunities for the treatment of Stroke.
Frequency of Atrial Arrhythmias in Stroke: Prolonged Monitoring of Cardiac Rhythm for Detection of Atrial Fibrillation After a Cerebral Ischemic Event (PEAACE) Study
Shuaib, A1 Ghrooda, E1 Yaseen, I1 Mohammad, A1 Dobrowolski, P1 Hasan, M1 Hussain, G2 Ahmad, A1; 1. University of Alberta, Department of Medicine, Division of Neurology, Edmonton, AB; 2. University of Alberta, Department of Medicine, Division of Cardiology, Edmonton, AB
Background: Recent studies suggest that prolonged cardiac monitoring may identify paroxysmal atrial fibrillation (PAF) in up to 18% of patients with cryptogenic stroke. PAF can also be a potential etiology where another potential mechanism is present. We prospectively monitored patients presenting with a TIA or stroke where preliminary investigations (including a Holter) did not show atrial fibrillation. Methods: Prospective non-randomized study of patients with TIA and acute stroke between July 2012 and May 2013 where Spider Flash-t™ Monitors (Sorin Group, Italy) were attached to the patients for prolonged monitoring. Clinical events were evaluated with a specifically designed ‘arrhythmia score’ and the recordings were initially reviewed by the study team and then by the study cardiologist. The duration and frequency of PAF was recorded and the results were conveyed to the referring stroke neurologist. Results: In 54 patients (duration of monitoring 10 (±4) days), there were 17 patients (31%) with PAF (AF >30 seconds 5 patients, AF >3 sec and <30 sec 12 patients). Paroxysmal atrial tachycardia was detected in additional four patients and atrial flutter in an extra two patients. In three PAF, was evident with concomitant symptomatic large vessel carotid disease. The diagnosis of PAF leads to initiation of anticoagulant treatment in 12 patients. Conclusions: Prolonged cardiac monitoring for detection of atrial arrhythmias increases the yield for PAF. Previous studies have focused on patients with cryptogenic stroke. Our study shows that PAF and other arrhythmias are present with similar frequency in patients where additional mechanisms may account for the etiology and often results in changes in treatment.
The “Doc” Screen: Rapid, Routine Screening for Depression, Obstructive Sleep Apnea and Cognitive Impairment is Feasible in Stroke/TIA Clinics
Sicard, MN1 Lien, K1 Lanctot, K1 Murray, B1 Herrmann, N1 Thorpe, K2 Swartz, R1; 1. Sunnybrook Health Sciences Centre, Toronto, ON; 2. Applied Health Research Centre of the Li Ka Shing Knowledge Institute, Toronto, ON
Background: Depression, obstructive sleep apnea and cognitive impairment (DOC) each affect 30-50% of patients post-stroke. They all impede recovery, increase morbidity and mortality, and worsen outcomes and quality of life. Best practice guidelines recommend routine screening; yet, all three are widely under-assessed, under-diagnosed, and under-treated. Detailed screening is too time-consuming, and cannot be used for everyone. A panel sponsored by the National Institute of Neurological Disorders and Stroke (NINDS) and Canadian Stroke Network (CSN) has emphasized the need to develop cognitive screening tools that can be applied in a 5-minute assessment. The objective of this study is to determine the feasibility of implementing a simple, evidence-based, clinical screening tool (DOC screen) to identify individuals at high-risk of depression, obstructive sleep apnea, and cognitive impairments in large-volume stroke/TIA clinics. The primary goal of this project is to determine whether 85% of eligible patients can complete the DOC screening assessment in ≤ 5minutes. Methods: All consecutive new referrals to the Sunnybrook Stroke Prevention Clinic who were English-speaking and non-aphasic were eligible to be screened. The clinical care team were trained in administering the screen and given a stopwatch. The total number of patients, number screened and the time for completion were logged. Results: Over eleven months, 934 new referral patients were seen at the Sunnybrook Stroke Prevention Clinic. 205 patients declined, were missed or were ineligible at first screen. Data from 729 screens have been collected; 86 patients were excluded (30 were untimed, 55 non-English-speaking and/or aphasic), and 643 patients were included. Feasibility analysis showed 89% (95% CI: 86.1%-91.0%) of eligible patients completed the screen in ≤ 5minutes (range 1.8-11.5 minutes, average 4.2 minutes, S.D. =1.45). Conclusion: Systematic screening of depression, obstructive sleep apnea, and cognitive impairment in ≤ 5minutes is feasible in a high volume stroke/TIA clinic using the DOC screen.
One-Year Experience of a Carotid Intervention Quality Assurance Initiative using a Carotid Revascularization Performance Feedback Letter
Somji, M1 Gould, L2 MacRae, L2 Carlino, K2 Murty, N1, 2 Szalay, D1, 2 Wells, J1, 2 Sahlas, DJ1; 1. McMaster University, Hamilton, ON; 2. Hamilton Health Sciences, Hamilton, ON
Background: Carotid revascularization, usually carotid endarterectomy (CEA) is a highly effective strategy for secondary prevention of stroke in patients presenting with symptomatic carotid artery stenosis. However, the absolute risk reduction is extremely dependent upon timing of surgery, with maximum benefit if CEA is performed within two weeks of symptoms. Data from the Registry of the Canadian Stroke Network indicates that median time to surgery in Ontario is 25 days, with only one-third of patients receiving CEA within 2 weeks. Methods: A quality assurance initiative including the development of a carotid revascularization performance feedback letter was designed in order to foster self surveillance of elements related to achieving target times. Data obtained through use of the feedback letter was analyzed in order to compare the duration of key time intervals between the index clinical event and subsequent carotid intervention. Results: Forty-three patients underwent carotid revascularization for symptomatic disease over a period of one year. Twenty-four patients were initially referred to a Stroke Prevention Clinic (SPC), whereas 19 patients were instead referred directly to either a vascular surgeon or a neurosurgeon. Mean time from index clinical event to surgery was 28 days for patients referred to a SPC compared to 53 days for those referred to a surgeon (p=0.005). Much of this delay was related to obtaining carotid imaging after initial presentation to a health care provider (6 vs. 17 days; p=0.02). Conclusions: Implementation of a carotid revascularization feedback letter revealed two distinct clinical pathways for patients presenting with symptomatic carotid artery disease. The clinical pathway involving referral to a SPC was associated with more efficiencies in achieving target times for best practice. This validates and emphasizes the importance of SPCs in managing this population at a high risk of stroke recurrence.
Dedicated Stroke Care Reduces Stroke Mortality Rates
Tebbutt, TD; Grand River Hospital, Kitchener, ON
Background: Grand River Hospital (GRH) has been a District Stroke Centre serving Waterloo/Wellington since 2003 and has been administering tPA since 2004. We implemented a 12 bed acute stroke unit in 2004. The 30 day stroke mortality rates at GRH have been higher than the provincial benchmark. This prompted quality improvement initiatives to decrease our stroke mortality rates. Methods: Chart audits were completed which indicated there was opportunity for improvement in our coding. A dedicated stroke coder was implemented and targeted education was provided to our hospitalists who care for patients on our acute stroke unit. Interdisciplinary staff training was implemented focusing on the Canadian Neurological Scale, dysphagia screening, early mobilization, DVT prophylaxis, falls assessments and safe transfers. Results: Results demonstrate a trend towards decreased mortality rates, decreased hospital acquired pneumonia and decreased readmission rates. GRH is now below the provincial benchmark for stroke mortality. Conclusion: Grand River Hospital was successful in significantly decreasing stroke mortality rates utilizing a multi-faceted approach. A designated stroke unit with dedicated interdisciplinary staff promotes stroke expertise and facilitates targeted stroke education. A dedicated stroke coder promoted improved quality of stroke data.
The Study of Hyperintense Flair Vessel (HVS) Sign Reversal On FLAIR MRI In Acute Strokes with Proximal Vessel Occlusions, Does It Make Us Any Wise?
Adatia, S1 Almekhlafi, M1 Nambiar, V1 Trivedi, A1 Sohn, S2 Menon, B1; 1. Foothills Medical Hospital, Calgary, AB; 2. Keimyong University, Daegu, Korea
Background and Purpose: Hyperintense vessels (HV) have been observed in fluid- attenuated inversion recovery imaging (FLAIR) MRI sequence in patients with acute ischemic strokes in region of diffusion positivity. They have been linked to slow flow in collateral arterial circulation and proximal arterial occlusions. We aim to study the reversal of HVS on 24 hours MRI and its relation to successful recanalization. Methods: We reviewed 148 patients from prospectively collected acute ischemic strokes with proximal occlusions on CTA. The HV sign was defined: presence of flair bright vessels on MRI in region of diffusion restriction. Two independent/blinded clinicians identified it. Its reversal was identified on 24 hours MRI. The recanalization grading (TIMI) was done on angiograms offered for therapy. Results: 98 patients had HVS sign.35 patients showed reversal. Interrator agreement was accepatble. (Kappa 0.92) Baseline characteristics like age, sex, NIHSS, diabetes and smoking was comparable. The patients were offered intravenous tpa, intra arterial therapy (lytic/ mechanical thrombectomy) or both based on case basis. 30/35 reversal group underwent IV wtih IA, all had successful recanalization (TIMI 2/3 on angiogram ). In the non reversal group, 38/63 patients had IV with IA. 16 showed complete recanalization (42%). (p<0.005) The initial infarct volume, infarct growth (24 hours) and mRS at 3 months was comparable in both. In the multivariate analysis model for prediction of reversal of this sign, successful recanalization emerged as the prime factor. (p=0.006; OR6.21) No effect of age, time to MRI, time to treatment was seen. Conclusion: The reversal of HVS after successful recanalization does indicate that these vessels represent sluggish flow due to proximal large vessel occlusions. This sign can be used as a surrogate marker for presence of large vessel occlusions. To our best knowledge, our group is the first ever to describe its reversal with recanalization.
Cerebral Microbleeds Causing Acute Focal Deficits: Evidence From a CADASIL Patient
Vitali, P; Boghen, D; Daneault, N; Guillon-Letourneau, L; Poppe, AY; Notre-Dame Hospital, Montreal, QC
Background: Cerebral microbleeds, thought to reflect minor leakage from fragile arterial microvessels, visualized on gradient-echo MRI sequences, are classically considered as clinically silent. However, some recent case reports provide evidence that microbleeds can cause focal neurological deficits. Nonetheless, the role of microbleeds in stroke-like manifestations of CADASIL is still largely unknown. Methods: We report a case of a 50 year-old gentleman with no vascular risk factors presenting with sudden onset of severe headache, vertigo, nausea, photophobia and horizontal diplopia. His past medical history was remarkable for migraine with aura and some transient stroke-like episodes. Interestingly, his mother died in her early fifties after suffering from a number of strokes. Neuro-ophthalmological examination early post-onset revealed left hypertropia, clockwise torsion of the eyes, right head tilt and counter-clockwise rotary nystagmus and upbeat nystagmus in primary position. This was interpreted prior to the MRI as consistent with an ocular tilt reaction possibly due to a lesion nearby the left Interstitial Nucleus of Cajal (INC). An extensive investigation of a posterior circulation stroke was carried out. Results: CT angiography and serological investigations for stroke in the young adult were normal. However, brain MRI showed classical radiological findings of CADASIL disease with extensive leucoencephalopathy involving both temporal poles and several old lacunar strokes. Notch3 mutation analysis is pending. Surprisingly, no acute ischemic lesion was observed on DWI sequences, in particular in the brainstem, excluding an acute ischemic stroke. However, gradient-echo sequences showed a pattern of multiple subcortical microbleeds. In particular, one microbleed was strategically located in the rostral midbrain, in a region next to the left putative INC. Conclusions: The observations in this single case support the view that microbleeds may be associated with acute focal neurological deficits and suggest a possible novel pathophysiological mechanism underlying the clinical spectrum of CADASIL disease.
Development of a Walk-in Code Stroke Protocol for Community Hospital Emergency Departments in Toronto
Willems, J2 Linkewich, E1 Sharp, S3 Tahair, N4 Olynyk, C5 Swartz, R1; 1. North & East GTA Stroke Network, Toronto, ON; 2. South East Toronto Stroke Network, Toronto, ON; 3. Toronto West Stroke Network, Toronto, ON; 4. Toronto Stroke Networks, Toronto, ON; 5. Toronto Emergency Medical Services, Toronto, ON
Background: Since 2005, the Memorandum of Understanding for Medical Redirect and Repatriation of Acute Stroke Patients within Toronto Area (MOU) ensures that acute stroke patients accessing Toronto Emergency Medical Services (TEMS) are screened for potential eligibility for hyperacute intervention and transported directly to a Regional Stroke Centre (RSC). The MOU supports coordinated access to time-sensitive stroke services not available at community hospitals. Not all patients activate EMS and instead use their own transportation to arrive at a community hospital emergency department (ED). For patients assessed by community ED physicians who require RSC services, the lack of a formal process for expedited transfer to a RSC has limited access to best care. Methodology: The Toronto Stroke Flow Initiative established the Toronto ED/EMS Working Group to develop a coordinated process to ensure equitable access to RSC services from community hospitals. Working with physician and staff from community hospital EDs, RSCs, Toronto EMS, and Toronto Stroke Networks, a new Walk-in Code Stroke Protocol (WCSP) was developed. The protocol, implemented on December 3, 2012 includes standardized screening criteria and communication protocols, clear target timelines and a system failure reporting mechanism to support quality improvement. Results: From December 2012 to March 2013, 50 patients were transferred from 12 community hospital EDs to RSCs under the new WCSP, representing 14% of acute stroke EMS transports. 90% of EMS pick-ups occurred within the 9-minute target time and 9 process-related issues were reported. Ongoing evaluation of the WCSP will monitor 1) system performance to ensure compliance and identify opportunities for improvement and 2) impact on patient outcomes including t-PA administration rates. Conclusions: An improved standardized system of coordinated and equitable access to hyperacute stroke services for patients who arrive at non-RSC hospitals has been achieved across Toronto. Tools and resources developed may be transferable to other hub-and-spoke stroke care settings.
Optogenetic activation of mouse cortical inhibitory interneurons is sufficient to increase local blood flow
Anenberg, E; LeDue, J; Murphy, TH; University of British Columbia, Vancouver, BC
Interplay between various cell types in the brain orchestrates the recruitment of blood flow in accordance with local activity. Coupling alterations in blood flow, and presumably oxygen delivery, with levels of neuronal activity is essential for normal brain function; however, the underlying mechanisms involved in this regulation are unclear. Studies suggest a role for astrocytes, pericyctes, pyramidal neurons and interneurons in controlling cerebral blood flow. Here we use optogenetic techniques, cell type selective excitation, to investigate whether direct activation of inhibitory interneurons can alter blood flow. By imaging through a polished reinforced thinned skull window, we have observed that direct photostimulation of inhibitory cells in vivo in VGAT-mhChR2-YFP BAC transgenic mice alters levels of cortical blood flow and activity. With 3.3 mW of 473nm light, 100ms of 100Hz 5ms stimulation led to a 9.15±1.08% increase in the laser speckle signal within 1.9 s (n=3). Similar increases in blood flow assessed by laser speckle (10.04±0.03%) were achieved with 4 s of sensory stimulation (n=2). Intrinsic optical signals were used to confirm that stimulation led to brain activation. The initial dip of the intrinsic signal, an indirect measure of activity composed largely of the deoxygenation of hemoglobin (Hb) (Frostig et al. 1990), reached its minimum of -0.021±0.018 ΔR/R% within 1.2 s (n=5). Signal overshoot, which is proposed to consist largely of HbO2 increase and deoxyHb decrease (Malonek and Grinvald, 1996) reached a maximum of 0.205±0.032 ΔR/R% within 3.2 s (n=5). Sensory stimulation led to an initial dip of similar amplitude to direct optogenetic stimulation (-0.020±0.004 ΔR/R% within 1.2 s) but a smaller overshoot (0.024±0.008 ΔR/R% within 4.8 s) (n=3). These data suggest that the activation of interneurons is sufficient to mediate elevations in cortical blood flow.
Characterization of the Regenerative Response of Endogenous NPCs Following an ET-1 Induced Focal Ischemic Injury in the Adult Mouse Cortex
Bartlett, RF; Roome, RB; Xiong, J; Vanderluit, J; Memorial University of Newfoundland, St. John’s, NL
Background: The neural precursor cell (NPC) population of the subventricular zone (SVZ) in the adult mammalian brain has been the subject of great interest, specifically for their potential to aid neural regeneration. NPCs have the ability to differentiate into the 3 cells of the central nervous system – neurons, astrocytes and oligodendrocytes. However, although NPCs migrate to the site of injury after an ischemic insult as differentiating neuroblasts, the majority of them undergo apoptosis and fail to contribute towards regeneration. Methods: To test if enhanced survival of these neuroblasts can assist in the repair of an infarct, we propose to selectively manipulate the expression of the anti-apoptotic gene, Mcl-1. Our lab has recently developed a reproducible focal ischemic injury model in the adult mouse forelimb motor cortex. Using this model, I am investigating the acute peak proliferative response of NPCs when they differentiate to neuroblasts and begin to migrate towards the focal ischemic injury. This can be achieved through the use of BrdU, a proliferation marker, and doublecortin, a marker for neuroblasts, immunohistochemistry. Additionally, I have further characterized the progression of the injury, this includes assaying the neuronal, glial and vascular health post injury. Results: I have shown how NPCs in the SVZ react to an ischemic insult during the first week post injury, this gives greater resolution than previously investigated NPC activity post ischemia. This is in conjunction with the cellular and vascular health assays to aid in understanding the response of neuronal and glial populations over the first week post injury. Conclusions: Characterizing this optimum time window for manipulation is crucial to determine when to transfect NPCs with Mcl-1 and assess the extent of neuroblast survival and possible regeneration. This will help identify a role for NPCs to promote neural repair in the adult brain following ischemic injury.
Functional Neuroimaging markers of Cerebral Small Vessel Disease effects on cognition
Dey, AK2, 4, 5 Turner, G2, 1 Black, SE3, 6, 7 Levine, B5, 6, 8; 1. Department of Occupational and Rehabilitation Sciences, University of Toronto, Toronto, ON; 2. Heart and Stroke Foundation Centre for Stroke Recovery, Sunnybrook Health Sciences Centre, Toronto, ON; 3. Centre for Stroke Recovery at Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON;. Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, ON; 5. Rotman Research Institute, Baycrest Centre, Toronto, ON; 6. Department of Medicine (Neurology), University of Toronto, Toronto, ON; 7. LC Campbell Cognitive Neurology Research Unit, Toronto, ON; 8. Department of Psychology, University of Toronto, Toronto, ON
Background: Cerebral small vessel disease (CSVD), characterized by distributed ischemic white matter damage, is associated with cognitive dysfunction and contributes to dementia risk. While most research investigating CSVD effects has focused on the relationship between structural imaging measures and cognitive decline, there has been relatively little research investigating the effects of CSVD on functional brain imaging measures in correlation with behaviour. Method: Here we present a systematic review of papers since 1990 that have studied the mechanism by which CSVD may affect cognition using functional neuroimaging techniques (8 fMRI, 6 EEG studies). Results: Converging evidence from fMRI studies suggest that relative to healthy controls, CSVD patients demonstrate impaired deactivation of the posterior cingulate cortex (PCC)/precuneus - a critical mode in the default mode network (DMN) - as well as decreased functional connectivity in several networks associated with attention, working memory and auditory and language processing. In contrast, enhanced connectivity to the PCC, mainly through the temporal-parietal cortex, has been reported and hypothesized to reflect a compensatory adaption. Delayed neurovascular coupling in the dorsolateral prefrontal cortex (DLPFC) has also been reported. Regarding electrophysiological measures, several studies have also reported a correlation between white matter damage and widespread slowing of EEG rhythmicity. Specifically, severity of ischemic white matter damage has been associated with increased delta power, decreased alpha2 power and a relative increase in theta/alpha1 band power ratio. Among event-related potentials (ERPs), N2 and P3 are of particular interest with prior research showing delayed latency in those with white matter damage. Conclusion: Building on the aforementioned results as well as studies of top-down attention regulation, future investigations should utilize a multimodal approach that combines the strengths of fMRI and EEG techniques and pair it with multivariate analytical tools that are more powerful than traditional univariate tests.
Total Plasma Adiponectin Concentrations and AdipoR1 and AdipoR2 Gene Expression are Associated with Features of Plaque Instability in Patients with Carotid Atherosclerosis
Gasbarrino, K1 Doonan, R1 Mantzoros, C2 Lai, C3 Veinot, J3 Daskalopoulou, S1; 1. McGill University, Montreal, QC; 2. Beth Israel Deaconess Medical Center, Boston, MA, USA; 3. University of Ottawa Heart Institute, Ottawa, ON
Background: With the increasing burden of atherosclerosis and stroke on society it is critical to understand the mechanisms for how carotid plaques become unstable and at risk to rupture. Evidence shows that low plasma levels of adiponectin, a vasculoprotective adipokine, are associated with coronary artery disease and carotid-intima media thickness. The current study investigated the association between circulating adiponectin and its receptors (AdipoR1/AdipoR2) and features of plaque instability. Methods: Patients scheduled for carotid endarterectomy were recruited from the Royal Victoria Hospital, Montreal, Quebec. Blood samples were collected pre-operatively to determine total adiponectin levels using ELISA. The area of maximum stenosis of each carotid plaque obtained was stained with hematoxylin and eosin and immunostained for the detection of CD68 (macrophages/foam cells), and von Willebrand Factor (vWF, neovascularization). Two vascular pathologists blindly categorized the plaques according to AHA classifications and semi-quantitative scales. Total RNA was extracted from the tissues and AdipoR1/AdipoR2 mRNA expression was analyzed via qRT-PCR. Results: Patients (n=190) with less infiltration of foam cells in their plaques had higher levels of total circulating adiponectin (12.26 ± 6.74 μg/ml) when compared to patients with greater infiltration (8.99 ± 6.97 μg/ml; p=0.010). AdipoR1 expression was significantly lower in plaques with neovascularization (p=0.023). AdipoR2 expression was found to be progressively lower in plaques with greater instability, with a significant difference between Grade 1 (most stable) and Grade 4 (most unstable) plaques (p=0.044). In addition, plaques that had an intact cap and no presence of thrombus had significantly higher expression of AdipoR2 than plaques with ruptured caps and presence of large thrombi (p=0.010). Conclusion: Patients whose plaques were characterized as unstable were found to have lower plasma levels of total adiponectin, and lower mRNA expression of AdipoR1 and AdipoR2. These results suggest a potential role for adiponectin and its receptors in the development of plaque instability.
Acidosis Overrides Oxygen Deprivation to Maintain Mitochondrial Function
Khacho, M; Tarabay, M; Khacho, P; Patten, D; MacLaurin, J; Park, D; Bergeron, R; Harper, M; Slack, R; University of Ottawa, Ottawa, ON
Mitochondria are dynamic organelles that undergo cycles of fission and fusion, in which the balance is critical for mitochondrial integrity and normal cellular function. Fission/fragmentation of mitochondria is an early event in injuries relevant to stroke and is believed to be a key contributor in the demise of neurons following an ischemic insult. Furthermore, studies have shown that promoting fusion restores neuronal viability during ischemia. Thus identification of strategies to promote mitochondrial fusion would provide invaluable therapeutic potential. Here we show that acidification of the extracellular milieu, a physiological consequence of hypoxia within the ischemic penumbra, triggers the rapid elongation of mitochondria in neurons. Acidosis-mediated mitochondrial elongation protects neurons from death in an in vitro model that mimics the ischemic penumbra. Elongation of mitochondria, in neurons allowed to undergo the natural course of acidification during hypoxia, is achieved through the activation of a dual program that both inhibits fission and promotes fusion. Preventing the pH-dependent elongation of mitochondria by inhibiting the fusion machinery results in mitochondrial fragmentation and a significant increase in neuronal death. Interestingly, mild acidosis is known to provide neuroprotection during ischemia, however the mechanism was not completely understood. We now propose that extracellular pH is a neuroprotective agent that acts as a physiological trigger to rewire the dynamics of mitochondria and promote survival.
Predicting Hemorrhagic Transformation in Acute Ischemic Stroke Patients: FLAIR vs. Quantitative Permeability Coefficient (KPS)
Gao, M1 Waa, S2 Leung, J3 Alharbi, M2 Mikulis, D3 Silver, F4 Kassner, A3, 5; 1. University of Toronto, Toronto, ON; 2. Department of Medical Imaging, University Health Network, Toronto, ON; 3. Department of Medical Imaging, University of Toronto, Toronto, ON; 4. Department of Neurology, University of Toronto, Toronto, ON; 5. Hospital for Sick Children, Toronto, ON
Background: Recombinant tissue plasminogen activator (rtPA) decreases mortality and improves functional outcomes in patients with acute ischemic stroke (AIS) but is also associated with a higher risk of hemorrhagic transformation (HT). Both FLAIR hyperintensity and quantitative permeability (KPS) MR imaging have been proposed to help identify patients at higher risk of HT. The purpose of this study is to compare the utility of FLAIR hyperintensity and KPS in predicting HT in patients with AIS treated with and without rtPA. Methods: Thirty patients with AIS were examined within a mean time of 3.6 hours of documented symptom onset. Both FLAIR and KPS MR imaging were performed. Two raters (blind to HT) independently identified FLAIR hyperintensity with reference to the DWI lesion. KPS coefficients in the stroke lesion were estimated for all patients, and the sensitivity and specificity for both FLAIR hyperintensity and KPS value in predicting HT were calculated. Results: FLAIR hyperintensity was identified in 12 patients (40%, 3HT, 9 non-HT). There was no statistical significant difference in HT occurrence between FLAIR positive and negative patients. The sensitivity and specificity of FLAIR hyperintensity in predicting HT were 0.3 and 0.55 respectively. Assessment of KPS in the lesions revealed a statistical significant difference between those who hemorrhaged and those who did not (P < .0001). ROC analysis produced a KPS threshold of 0.482 with a sensitivity of 1.00 (CI, 0.72-1.0) and a specificity of 0.80 (CI, 0.584-0.919). Conclusions: The results of this study suggest that FLAIR hyperintensites are frequent findings in AIS patients and are not associated with a higher HT risk with or without thrombolytic treatment. KPS, on the other hand, shows excellent potential as clinical adjunct in identifying patients at high risk of HT when considering them for thrombolytic therapy.
The Effect of β-Amyloid on the Severity and Prognosis of Hemorrhagic Stroke Patients
Nakase, T; Sasaki, M; Suzuki, A; Research Institute for Brain & Blood Vessels, Akita, Japan
Background: It has been investigated that β-amyloid (Aβ) might affect on the neurological severity of Alzheimer disease. Moreover, Aβ was reported to relate to the vulnerability of brain arteries. However, the influence of Aβ on the severity and outcome of acute stroke patients has not been fully understand. This study was aimed to explore the effects of Aβ on the neurological severity and the prognosis of acute intracranial hemorrhagic stroke (ICH) patients. Methods: Acute ICH patients were consecutively asked to participate in this study between June 2011 and September 2012. Then, consented patients were enrolled (n=52, average age 66.9 year-old). ICH lesion was confirmed by brain computed tomography on admission. Aβ40 and Aβ42 were measured from blood samples acquired on admission. Neurological severity was assessed by NIH stroke scale on admission and at one month. Results: The amount of Aβ40 was distributed between 2.7 and 96.6 pmol/L (mean±SD: 22.0±20.2 pmol/L). If all cases were classified into low and high amount of Aβ40 (Low40 group: less than 20 pmol/L and High40 group: higher than 20 pmol/L, respectively), the percentage of deep cerebral hemorrhage was significantly abundant in High40 group compared with Low40 group (p=0.021: 87.5% and 54.3%, respectively). The amount of Aβ42 was not detected in 67.3% of all patients (Low42 group). The average amount of Aβ42 in remaining 17 cases was 5.2 pmol/L (High42 group). The mortality was higher in High42 group compared with Low42 group (p=0.059: 23.5% and 5.7%, respectively). There was no significant relation between the amount of Aβ and the neurological severity. Conclusion: Aβ40 could affect on the fragility of deep brain arteries, and Aβ42 might influence on the vulnerability of neurons in the hemorrhagic stroke patients.
Spreading Depolarization After Stroke is Supported by the Alpha1 Isoform of Na/K-ATPase
Petrin, DA; Ventura, NM; Peterson, NT; Tse, MY; Andrew, R; Pang, SC; Jin, A; Queen’s University, Kingston, ON
Background: The mechanisms which promote spreading depolarization (SD) in the post-stroke brain remain unclear. We examined the role of Na/K-ATPase isoforms in supporting SD after stroke. Methods: Following focal cerebral ischemia in male C57BL/6J mice, 350 µm live brain slices were incubated in artificial CSF (aCSF) at 34 oC and then exposed for 20 minutes to either control solution (aCSF) or ouabain at 1 µM (to selectively block alpha2 and alpha3 isoforms of Na/K-ATPase) prior to SD induction by oxygen glucose deprivation (OGD). The propensity of the tissue to undergo SD was assessed by observing changes in SD onset latency and wavefront velocity as reflected in tissue light transmittance in the ipsi- and contralateral hemispheres. This was compared to SD induced by exposure to 100 µM of ouabain, in this case, blocking the alpha1,2 and 3 isoforms of Na/K-ATPase. The mRNA expression of the Na/K-ATPase isoforms ATP1a1 (alpha1), ATP1a3 (alpha3) and ATP1b1 (beta1) in the post-stroke brain was examined by real-time quantitative PCR. Results: Following stroke, OGD-induced SD was delayed by 33% (p < 0.001) and SD wavefront velocity was decreased by 42% (p = 0.016) in the peri-infarct tissue compared to the contralateral hemisphere. Blockade of all Na/K-ATPase isoforms with 100 µM ouabain abrogated these differences in SD onset and wavefront velocity but preferential blockade of the alpha2 and 3 isoforms with 1 µM ouabain did not alter SD characteristics compared to the control aCSF solution. ATP1a1 and ATP1b1 mRNA expression was diminished in the post-ischemic hemisphere, whereas ATP1a3 expression was unaffected by ischemia. Conclusions: Peri-infarct tissue has a decreased susceptibility to spreading depolarization. Blockade of the alpha1 but not alpha2/3 isoforms of Na/K-ATPase promotes SD in the post-stroke brain, and decreased expression of the alpha1 and beta1 isoforms may contribute to endogenous SD resistance in peri-infarct tissue.
Endothelin-1 Mediated Ischemic Injury in the Mouse Forelimb Motor Cortex is Associated with Specific and Measurable Behavioural Deficits
Roome, RB1, 2 Bartlett, RF1, 2 Jeffers, M1, 2, 3 Xiong, J1, 2 Corbett, D1, 2, 3 Vanderluit, J1, 2; 1. BioMedical Sciences, Faculty of Medicine, Memorial University of Newfoundland, St John’s, NL; 2. Heart and Stroke Foundation Centre for Stroke Recovery, Ottawa, ON; 3. Dept. Cellular & Molecular Medicine, University of Ottawa, Ottawa, ON
Background: Currently, there is excitement in manipulating neural precursor cells, as they migrate toward cortical infarcts and differentiate into neurons and glia. To assess functional recovery by neural regeneration after an ischemic injury, a reproducible focal injury model is required. Here, the ability of Endothelin-1 (ET-1), a vasoconstrictive peptide, was assessed in producing behavioural deficits post-ischemia. Though mice develop smaller infarcts than rats in response to ET-1, a wealth of transgenic mouse strains exist which can be used to study a variety of therapeutic interventions post-ischemia, making a focal ischemic injury model in mice attractive. Methods: A focal ischemic lesion was produced by intra-cortical injections of ET-1 into the forelimb motor cortex (FMC). Mice were tested on the mouse staircase and cylinder tasks at time-points post-surgery and euthanized at 2 or 4 weeks. Histology was performed to analyze the volume, shape and depth of the injury site. Doublecortin (Dcx) and BrdU immunohistochemistry was performed to label migrating NPCs. Results: Focal ischemic cortical injury is associated with behavioural deficits. Reaching deficits in the mouse staircase test correlated specifically with damage to the anterior FMC, highlighting functional subdivisions within the FMC. A sensitive novel analysis of the cylinder test, “paw-dragging”, predicted ischemic injury in the FMC as well. These deficits are linked to the number of ET-1 injections given and whether or not the injections damage the anterior forelimb motor cortex. BrdU and Dcx double-positive cells within the injury site indicated that NPCs had migrated successfully from the SVZ. Conclusion: Here, I have developed a reproducible model of focal ischemia with measureable behavioural deficits which lends itself to a variety of experimental regenerative therapies for the treatment of ischemic stroke. Deficits are pronounced acutely post-ischemia but persist over time with larger ischemic injuries.
What Strokes Tell Us About Consciousness
Shamy, MC; Glannon, W; University of Calgary, Calgary, AB
Background: Explaining what consciousness is, and how it may arise from the brain, has been a subject of human study for thousands of years. Given the localized loss of neurological function that is the hallmark of ischemic stroke, it is possible that lessons from the clinical study of stroke may help to explain both the nature of consciousness and its relationship to neuroanatomy. Methods: We address a series of questions around whether, and how, strokes affect consciousness. We relate the findings of clinical stroke medicine to the theoretical frameworks within which consciousness is currently analyzed: substance dualism (the brain and mind are causally non-interacting), property dualism (the mind is a product of the brain, but cannot be explained by brain processes), epiphenomenalism (the mind is a product of the brain but cannot interact with the brain), and physicalism (the mind is equivalent to physical properties of the brain). Results: We argue that the clinical neuroanatomy of ischemic stroke provides the basis for understanding consciousness as a function of the brain and as a function of brain functions. This theory unites physicalism and property dualism, and rejects structural dualism and epiphenomenalism. Conclusion: We propose a new theory of consciousness based on experience from stroke neurology. Moreover, we seek to bridge the methodological and linguistic gap that has for too long divided philosophy from clinical neuroscience.
Subunit-Specific Modulation of NMDAR Trafficking by Glycine in Central Neurons
Soares, CA1 Khacho, P1 Lee, KF1 Geddes, SD1 Bergeron, R1, 2 Béïque, J1; 1. University of Ottawa, Ottawa, ON; 2. Ottawa Hospital Reasearch Institute, Ottawa, ON; 3. Heart and Stroke Foundation Centre for Stroke Recovery, Ottawa, ON
NMDA type glutamate receptors are present at excitatory synapses and are composed of tetramers of GluN1 and GluN2 subunits (primarily GluN2A and GluN2B in hippocampus). These receptors are gated by the coincident binding of two agonists: glutamate and glycine. During neuronal ischemia, extracellular concentrations of these agonists rise dramatically, leading to sustained NMDAR activation and excitotoxicity. As NMDAR-dependent excitotoxicity is suggested to depend on subunit composition and subcellular localization of receptors, we sought to determine how the trafficking of distinct NMDAR subtypes is altered by sustained NMDAR activation. A treatment with a high concentration of glycine alone transiently depressed evoked NMDAR-mediated currents from CA1 pyramidal neurons. To identify potential subunit-specific rules of this behaviour, we developed a live-cell imaging assay to quantify surface NMDARs expressing phluorin-tagged NMDAR subunits. With this approach, we observed that glycine induced a preferential internalization of GluN2A-containing NMDARs. Intriguingly, evidence from both imaging and electrophysiological experiments suggests that the high glycine treatment induced a transient internalization of synaptic receptors, but a persistent internalization of extrasynaptic NMDARs. At present, it is unclear whether these trafficking behaviours represent natural neuroprotective strategies employed by neurons or rather whether they contribute to toxicity. The development of a mechanistic and molecular framework of these cellular phenomena will allow us to distinguish between these possibilities.
Pharmacological Inhibition of VEGFR-2 Has Differential Effects on Behavioral Recovery and Cortical Remapping Dependent on Presence or Absence of Diabetes During Stroke
Tennant, KA; Thompson, K; Lockhart, K; Brown, CE; University of Victoria, Victoria, BC
Diabetes is associated with a higher risk of stroke and a poor prognosis for recovery. Previously, our lab has shown that poor behavioral recovery of diabetic mice following photothrombotic stroke of the forelimb somatosensory cortex is due to deficits in remapping of lost cortical representations onto intact peri-infarct areas. We have recently used longitudinal in vivo two-photon imaging to show that the brain’s vascular response to stroke (increased blood flow velocity and dilation of vessels) takes weeks to normalize in diabetics, while the non-diabetic vascular response normalizes within days. Based on these data and our pilot studies showing abnormal expression of vascular endothelial growth factor (VEGF) and its receptors in the ischemic diabetic brain, we hypothesized that pharmacological inhibition of VEGF signaling at a clinically-relevant time point after stroke would lead to greater behavioral recovery and increased cortical remapping in diabetic mice. Diabetic and non-diabetic mice underwent behavioral testing for 10 weeks following photothrombotic stroke. Subcutaneous injections of SU5416, a selective inhibitor of VEGF receptor 2 (VEGFR-2), or vehicle were given every 3 days, beginning 3 days after stroke, for a total of 8 weeks. 14 weeks after stroke, voltage-sensitive dye imaging was conducted to resolve the extent of remapping of the forelimb sensory representations. SU5416 treatment of diabetic mice after stroke improved short and long-term behavioral recovery compared to vehicle-treated diabetics. This was associated with a trend towards improved cortical responsiveness to forelimb touch. In contrast, SU5416 treatment of non-diabetic mice after stroke caused a worsening of behavioral deficits and cortical responsiveness. In summary, these results suggest that inhibition of VEGFR-2 after stroke may be an effective treatment for diabetics. The fact that this treatment appeared to worsen both behavioral recovery and cortical rewiring in non-diabetics highlights the need to develop more specialized treatments for a heterogeneous clinical population.
Pharmacological Blockade of Volume-Regulated Anion Channels (VRAC) by DCPIB Provides Protection Against Hypoxic-Ischemic Neuronal Injury In vivo and in vitro
Turlova, E1 Zhao, L2 Alibrahim, A1 Wang, G2 Sun, H1; 1. University of Toronto, Toronto, ON; 2. Sun Yat-sen University, Guangzhou, China
Perinatal and neonatal hypoxic-ischemic brain injury often leads to acute mortality and chronic neurological morbidity in infants and children. Swelling-induced mediation of volume-regulated chloride channels (VRACs) is thought to be one of the non-glutamate mechanisms in cerebral ischemia, and CIC3 channel has been proposed as one of the candidates for VRACs. This study evaluates the importance of VRAC channels in neonatal hypoxic-ischemic injury model using a specific VRAC antagonist DCPIB as a pharmacological blocker.The cerebral hypoxic-ischemic injury was induced in P7 (postnatal, day 7) mouse pups. The Rice-Vannucci neonatal adaptation of Levine procedure with minor modifications was used to induce cerebral hypoxic-ischemic injury in neonatal mice. Twenty minutes prior to onset of ischemia, DCPIB was administered intraperitoneally to the animals. The mice, treated with DCPIB, showed a significantly reduced mean percentage of right hemispheric corrected infarct volume compared to the vehicle-treated mice. The treatment with DCPIB also improved functional recovery, as was evident by increased activity of blocker-treated group compared with vehicle-treated group. Additionally, this study provided supportive evidence of the ability of DCPIB to significantly block VRAC mediated cell death in vitro in PC12 cell line under oxygen-glucose depravation conditions, as determined by comparing intracellular chloride ion concentrations in cells treated with DCPIB and control group. These experiments demonstrate the pathophysiological role of VRACs in ischemic brain injury, and suggest the blocker as a potential, easily administrable therapeutic drug targeting VRACs in the context of perinatal and neonatal hypoxic-ischemic brain injury.
Evaluating Collateral Therapeutics in Animal Models of Stroke
Winship, IR; Ramakrishnan, G; Armitage, GA; Dong, B; Shuaib, A; Todd, KG; University of Alberta, Edmonton, AB
Collateral circulation provides an alternative route for blood flow to reach ischemic tissue during a stroke. Collateral blood flow is a critical predictor of clinical prognosis after stroke and response to recanalization, but data on collateral dynamics and the efficacy of collateral therapeutics is lacking. Here, I will discuss our work evaluating the efficacy of two novel approaches to blood flow augmentation during ischemic stroke to increase collateral circulation. Using high-resolution laser speckle contrast imaging (LSCI) and quantitative in vivo two-photon laser scanning micrsocopy (TPLSM) during middle cerebral artery occlusion (MCAo), we are able to optically record blood flow in leptomeningeal collaterals in clinically relevant animal models of ischemic stroke. We demonstrate that transiently diverting blood flow from peripheral circulation towards the brain via intra-aortic catheter and balloon induces persistent increases in blood flow through anastomoses between the anterior and middle cerebral arteries during thromboembolic MCAo. Increased collateral flow restores blood flow in distal MCA segments to baseline levels during aortic occlusion and persists for over one hour after removal of the aortic balloon. Similarly, intra-arterial (intra-carotid) administration of the nitric oxide donor sodium nitroprusside induces significant vasodilation and improves leptomeningeal collateral circulation without effecting systemic blood pressure. Given the importance of collateral circulation in predicting stroke outcome and response to treatment, and the potential of collateral flow augmentation as an adjuvant or stand alone therapy for acute ischemic stroke, this data provides support for further development and translation of collateral therapeutics including transient aortic occlusion.
Lifetime Stress Cumulatively Programs Brain Transcriptome to Impede Stroke Recovery and Is Ameliorated by Tactile Stimulation
Zucchi, FC1, 2 Yao, Y1 Ilnytskyy, Y1 Robbins, JC1 Soltanpour, N1 Kovalchuk, I1 Kovalchuk, O1 Metz, GA1; 1. University of Lethbridge, Lethbridge, AB; 2. University of Mato Grosso State, Caceres, MT, Brazil
Prenatal stress is a critical variable affecting lifetime health, including stroke risk and outcome in adulthood. Beneficial experiences may offset the influence of adverse early experience and programming of health outcomes by stress. Here we investigated if tactile stimulation attenuates the effects of early life stress on behaviour and recovery from ischemic lesion in a rat model. Prenatally stressed adult male rats underwent focal ischemic motor cortex lesion while being tested in skilled reaching and skilled walking. One group of rats experienced cumulative postnatal stress by restraint in adulthood. Tactile stimulation, as an analogue to human massage therapy was applied to attenuate adverse early influences and promote post-lesion motor recovery. Animals that experienced both prenatal stress and stress in adulthood displayed the most severe motor disabilities after the lesion. Additionally, tactile stimulation offset cumulative prenatal and postnatal stress by promoting recovery from ischemic lesion and reducing activity of the hypothalamic-pituitary-adrenal axis activity. Prenatal stress programmed brain gene expression linked to major cellular pathways and epigenetic markers of brain homeostasis. Cumulative effects of stress increased the diversity of pathways. Ischemic lesion mainly up-regulated gene expression patterns, while these were mainly down-regulated by tactile stimulation. Our results suggest that the second half of pregnancy in the rat represents a critical phase of fetal sensorimotor system development. Cumulative effects of adverse and beneficial lifespan experiences interact with disease outcomes and brain plasticity. These findings show that beneficial experience later in life can reverse programming by early adverse experience to modulate physiology, behaviour, transcriptome and cerebrovascular health. Acknowledgements: This research was supported by Alberta Innovates - Health Solutions (AI-HS; FZ and GM), Preterm Birth and Healthy Outcomes funded by the AHFMR/AI-HS Interdisciplinary Team Grant #200700595 (GM), Hotchkiss Brain Institute (FZ), Norlien Foundation (FZ), and the Canadian Institutes of Health Research (GM).
Fostering community participation for persons with aphasia and their family members: What we are doing, what we can do better in rehabilitation
Alary Gauvreau, C1 Anglade, C2, 3 Massicotte, J2 Perreault, C2 Kehayia, E4, 3 Michallet, B5, 3 Le Dorze, G2, 3; 1. Jewish Rehabilitation Hospital, Laval, QC; 2. University of Montreal, Montreal, QC; 3. Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal, Montreal, QC; 4. McGill University, Montreal, QC; 5. Université du Québec à Trois-Rivières, Trois-Rivières, QC
Background: Aphasia affects approximately 30% of stroke victims. Client-centered rehabilitation is offered for optimizing recovery and independence. However, after discharge, people with aphasia report not being ready to participate in their community. Their relatives also mention not knowing how to care and help their loved one. The aim was to understand how rehabilitation could improve outcomes for people with aphasia and their family members with respect to social participation. Methods: Eight persons with aphasia and eight of their relatives discussed their participation in shopping malls in each of two separate focus groups. Discussions were led by a speech-language therapist/researcher. Statements were recorded and available for viewing while the discussion went on. Later, all of statements were analyzed qualitatively. Results: Most participants expressed the need to easily access the physical environment and to communicate effectively for satisfying participation in shopping malls. Participants formulated few suggestions about improving rehabilitation in spite of minor dissatisfaction with their experience. However, a new vision of rehabilitation using shopping malls emerged throughout the analyses. For instance, assessment could include the personal experience of the person with aphasia in shopping malls. Goals could be set by patients according to their need for independence. Therapeutic activities could be held in malls, thus real-life settings. Speech-language therapists could evaluate the effects of therapy in authentic communication settings. Conclusions: If patients and their families do not feel adequately prepared for community participation, rehabilitation centers should consider an approach that is centered on the patient’s and family’s priorities and needs. In this perspective, the shopping mall could be used as a rehabilitation setting. In doing so, interdisciplinary stroke rehabilitation expertise could better serve people with communication limitations in real-life environments.
A Comparison of Rural versus Urban Stroke Survivors Treated with a Home-based, Specialized Stroke Rehabilitation Program
Allen, L1 Richardson, M1 McClure, A1 Meyer, M1, 2 Ure, D3 Jankowski, S3 Teasell, R4, 1; 1. Lawson Health Research Institute, ARGC, London, ON; 2. Western University, Department of Epidemiology and Biostatistic, London, ON; 3. St. Joseph’s Health Care, London, ON; 4. St.Joseph’s Health Care, Department of Physical Medicine and Rehabilitation, Parkwood Hospital, London, ON
Background: Rural living has been demonstrated to have an effect on a person’s overall health status, and rural residing individuals often have decreased access to health and specialized rehabilitation services. The aim of this study was to determine if there are differences in recovery from stroke between urban and rural-dwelling stroke survivors accessing an in-home, community-based, interdisciplinary, stroke rehabilitation program. Methods: Data from a cohort of 919 stroke survivors receiving care from three Community Stroke Rehabilitation Teams between January 2009 and December 2012 was analyzed. This program delivers stroke rehabilitation care directly in a person’s home and community. Physical, psychosocial, and caregiver outcomes were evaluated at baseline, discharge, and six month follow-up. A series of multiple linear regression analyses were performed to determine if rural vs. urban status was a significant predictor of discharge and 6-month health outcomes, controlling for scores at baseline. Results: The mean age of the cohort was 69.3(±13.1) years (55% male). Three hundred eighty-five (41.9%) individuals were classified as living in a rural area using the Rurality Index for Ontario. No significant difference on the Functional Independence Measure (FIM), the Stroke Impact Scale (SIS) Physical, Memory, Communication, and Social Participation domains, the Caregiver Assistance and Confidence Scale (CACS), or the Bakas Caregiver Outcomes Scale (BCOS) were noted at either discharge or follow up. Rural residence was a significant predictor of outcome for the HADS Anxiety (p=0.001) and Depression (p=0.039) subscales at discharge, with urban residents making slightly greater improvements. Rurality was also a significant predictor of outcome on the Emotion domain of the Stroke Impact Scale at both discharge (p=0.040) and follow up (p=0.0002), with rural residing individuals experiencing greater positive gains. Conclusions: When provided with access to a home-based, specialized stroke rehabilitation program, rural dwelling stroke survivors make and maintain functional gains comparable to their urban-living counterparts.
Perceptual Influences of Visuospatial Neglect During Negotiation of Obstacles
Aravind, G; Lamontagne, A; McGill University, Montreal, QC
Rationale: In our previous study1, we observed that individuals with visuospatial neglect (VSN) collided with moving obstacles while walking. Whether these collisions occurred due to perceptual deficits of VSN or locomotor deficits attributed to stroke, was unclear. In this study, we evaluated the ability of individuals with VSN to avoid moving obstacles during a joystick task uninfluenced by locomotor capacity. Methods: Twelve participants previously diagnosed with VSN post-stroke were assessed on the Bells test. They were also tested in a virtual environment with a target and 3 obstacles, one of which randomly approached from head-on, or 30° left/right. Participants were seated and pressed a joystick-button on perception of a moving obstacle (perceptuo-motor task) and proceeded towards the target while avoiding the obstacle using a joystick with their unaffected hand (joystick task). Detection times (perceptuo-motor task), collision rates and onsets of strategy (joystick task) were examined. Results: Based on number of omissions on the Bells test, participants were classified as VSN+ (Omission≥6,n=4), Inattention+ (6<omissions>3,n=4) and VSN- (Omissions<3,n=4). On average, detection times, delays in onset of strategies and collision rates were larger for contralesional and head-on obstacles compared to ipsilesional obstacles. A trend was observed where the VSN+ groups showed largest detection times, onset of avoidance strategies and rates of collisions, followed by the Inattention+ and VSN- groups. Conclusion: Along with persons with frank VSN, individuals with a history of neglect who test negative on the Bells test (Inattention + and VSN-) can show difficulties detecting and avoiding obstacles approaching from their neglected side and head-on. This suggests that the Bells test is not sensitive in detecting perceptual deficits involved during functional tasks such as obstacle-negotiation. Moreover, presence of collisions in a joystick-driven avoidance task not influenced by locomotor capacity, suggesting perceptual deficits do contribute to poor obstacle-avoidance abilities in post-stroke VSN.
Traduction et validation de l’Overt Behaviour Scale (OBS) en français: l’Échelle des comportements observables
Godbout, D; Gagnon, J; Ouellette, M; Drolet, J; Kelly, G; Simpson, G; Centre de réadaptation Lucie-Bruneau, Montréal, QC
Contexte: Les qualités psychométriques de l’échelle OBS sont reconnues. Elle est utilisée dans les études anglo-saxonnes évaluant les troubles du comportement de la clientèle cérébrolésée. La traduction et la validation de l’OBS s’imposait car il existe peu d’outils disponibles en français pour évaluer ces dimensions comportementales post atteintes cérébrales. Méthodologie:
Phase 1: Comité d’expert par méthode du consensus pour assurer la rigueur de la traduction/adaptation de l’instrument OBS nommé l’ÉCO (Échelle des comportements observables). Les deux versions (OBS/ÉCO) soumises (avec inversion des énoncés) aux cliniciens évaluant les clients présentant un trouble du comportement au moins léger.
Phase 2: les cliniciens complètent également une batterie de questionnaires et tests pour estimer la validité divergente et convergente de l’ÉCO.
29 participants (21H; 8F), âgés de 20 à 70 ans
Ayant subi une lésion cérébrale datant de 5 mois à 44 ans
suivis en 6 centres de réadaptation (et 1 association de TCC) à Montréal.
Instruments pour mesurer des concepts divergents): le NRS; l’Inventaire du fardeau; le questionnaire sur la qualité de vie
Instruments pour mesurer des concepts se rapprochant des troubles du comportements: le MPA I-4 et le SATCé
Résultats préliminaires: Les résultats aux indices de l’OBS sont fortement corrélés (r>.9) avec ceux obtenus à l’ÉCO. On ne détecte pas de relations significatives entre les résultats à l’ÉCO et le fonctionnement cognitif, affectif et moteur (NRS), le fardeau (IDF) ainsi qu’avec la qualité de vie (QPSQV) et les capacités (sous-échelle du MPAI-4). Des corrélations modérées sont relevées entre les données à l’ÉCO, celles à 4 des dimensions du SATC et aux mesures d’adaptation psychologique et de participation sociale incluant des énoncés comportementaux (du MPAI-4). Conclusions: Les résultats indiquent que l’ÉCO est une traduction valide de l’OBS. Les faibles corrélations entre les résultats à l’ÉCO et ceux obtenus aux mesures du fonctionnement suite au TCC vont dans le sens de sa validité divergente. Les corrélations plus fortes entre les résultats et les mesures d’adaptation psychosociale donnent des indices de sa validité convergente.
Perturbation Motor Corrections Correlate with Features of Reaching and Proprioception Impairments Post-Stroke
Bourke, TC; Queen’s University, Kingston, ON
Limb afferent feedback is used for perception of our limb geometry and for motor control. Stroke can damage sensory and motor regions of the brain leading to impairments of upper limb function. Our previous work found that deficits in position sense were independent of deficits in reaching performance. This independence is surprising given that limb afferent feedback plays an important role in voluntary motor action. The objective of the present study was to explore in more detail the relationship between sensory and motor impairments in subjects with stroke using three distinct behavioural tasks. Subjects with subacute stroke (n=18) and non-disabled controls (n=79) were assessed in a KINARM exoskeleton robot. A postural perturbation task measured how quickly subjects can respond to a perturbation and accurately return to their start target (no vision of hand following perturbation). A limb matching task assessed the perception of limb position by measuring the mismatch between one arm moved by the robot and the subject’s mirror matched limb configuration with their other arm (no vision throughout task). A visual-guided reaching task assessed the use of vision and proprioception to reach quickly and accurately to a target. Both arms were assessed in each task and a number of parameters captured the spatial and/or temporal aspects of task behaviour. In agreement with our previous results, reaching and position matching deficits were largely independent in this sample. Most impairments in reaching parameters were significantly correlated with impairments in perturbation corrections. In contrast, the majority of impairments in limb matching parameters were significantly independent of impairments in perturbation corrective parameters. One exception was that perturbation response endpoint error was significantly correlated with limb matching variability (r=0.43, p<8.8x10-4).
Overall these results suggest impairments in integrating feedback into motor corrections being related to motor impairments and independent of proprioceptive impairments.
Comprehensive Assessment of Disability Following Stroke: Initial Validation of the miFunction Scale
Burley, T; Green, T; University of Calgary, Calgary, AB
Background: Advances in thrombolytic therapy, endovascular intervention and specialized unit care for stroke have significantly reduced its mortality and morbidity delivering nearly eighty percent of survivors back to their homes and communities. Current established assessment tools are not sensitive enough to accurately identify differences in disability in the stroke population. Guided by the World Health Organization (WHO)’s International Classification of Functioning (ICF), researchers at the University of Calgary developed a functional outcome scale (miFunction) to assist with the comprehensive evaluation of disability following stroke, based on activity limitations. Methods: This is a pilot study, utilizing a cross-sectional validation and reliability design to assess the usefulness of the miFunction scale. The cross-sectional validation and reliability design involves sampling a target population of stroke survivors at a minimum of 60 days following their event. Two clinicians evaluate participants using the miFunction scale as an assessment of inter-observer reliability (Cohen’s Weighted Kappa). Further, the clinicians assign participants with a score on a previously validated instrument for assessment of stroke disability (Modified Rankin Scale) as an assessment of convergent validation (Pearson’s Correlation Coefficient). Results: Initial inter-observer reliability and convergent validation results will be presented. Implications for the incorporation of miFunction into a larger study for further evaluation will be explored. Conclusions: As science and technology for stroke management progress so too must the ability to assess short and long-term sequelae of this disease process and associated interventions. miFunction is a scale that approaches the evaluation of disability comprehensively, and in accordance with current, internationally accepted understandings of stroke.
Screening for the Blues: Implementing a Depression Screening Tool in the Acute Stroke Population
Cheung, T; Cayley, A; University Health Network, Toronto, ON
Purpose: As a Regional Stroke Centre of Ontario, we are committed to evidence-based practice and the promotion of nursing excellence through the implementation of RNAO’s Best Practice Guidelines. Depression is recognized as one of those best practice guidelines. Depression is known to have a debilitating effect on many areas of one’s quality of life. In the stroke population, depression affects 40% of all stroke patients. The screening and assessment of depression in the stroke population is currently not a regulated process on the stroke unit. Research indicates identification of depression is most critical in the acute phase of a stroke as it has been directly linked with post-stroke recovery. Approach: The approach utilized for this initiative was to implement two validated depression screening tools in the stroke in-patient population. The Patient Health Questionnaire (PHQ-9) was used for non-aphasic patients, and the Stroke Aphasic Depression Questionnaire (SADQ-10) was used for those with aphasia. Results: All nurses who worked on the in-patient unit received educational sessions on the two tools and implemented its use on all admitted stroke patients after day 3 of stroke onset. The results of this initiative include: increased nursing awareness of post-stroke depression prevalence; early detection and treatment of post-stroke depression; and improved inter-professional collaboration within the stroke team. Implications: Knowledge gained from this initiative resulted in a standardized, evidence-based approach to depression screening and assessment of stroke patients. Recommendations as a result of this initiative aim to encompass the psychosocial and mental health needs of this population to improve patient recovery outcomes, including smoother transition from acute care to the community; improving one’s capacity for rehabilitation; and decreasing length of hospital stay.
Talk Isn’t Cheap: Reviewing the Amount of Therapy Provided to Stroke Patients with Communication Disorders
Churchward, K1 Hill, MD2 Knox, D1 Lindland, K3; 1. none, Calgary, AB; 2. University of Calgary, Calgary, AB; 3. Alberta Health Services, Calgary, AB
Background: There is a threshold effect or a minimum “dose” of treatment required to demonstrate significant gains as measured by standardized tests of language impairment. Limited research exists regarding which patients (i.e. type and severity of communication deficits, time post stroke,) would benefit the most from high “dose” treatment. We investigated current speech-language treatment (SLT) received and outcomes achieved locally by stroke patients with communication deficits. Methods: A convenience sample of 70 English-speaking patients with first-ever stroke resulting in aphasia, apraxia of speech and/or dysarthria was recruited in the sub-acute stage (ie. 3-14 days post stroke). A speech-language assessment battery which included scoring of the AusTOMS for speech and language, the Western Aphasia Battery (where appropriate) and the ASHA Communication Quality of Life Scale was administered within 7 days of study enrolment and was repeated 12-14 weeks later. Severity was measured using the AusTOMs speech and/or language impairment scales. Speech-language pathologists and therapy assistants reported minutes of direct 1-1 SLT provided to study patients across the continuum of care (i.e. acute in-patient, tertiary in-patient, and community/outpatient programs) during the study period. Results: Patients in the greater severity group (n=8) received 29 min (15.2) of therapy per day compared to patients in the milder group (n=16) who received 9 min (7.8) of therapy per day. Overall, most (92 %) patients received less than 45 min of treatment per working day during the study period. Conclusions: The “dose” of therapy received by patients with communication disorders is related to the initial severity of their impairments. Patients with more severe communication impairment received more treatment than those with mild impairment. Overall, the dose of SLT received by the majority of patients is below the minimum amount of treatment recommended in the literature for aphasia.
Characteristics of Recovery After Stroke: a Focus on Cognitive, Mood and Physical Function
Cohen, EJ1 Danells, CJ1, 3 Moreno, HA2 McIlroy, WE2, 1; 1. Centre for Stroke Recovery, Toronto, ON; 2. University of Waterloo, Waterloo, ON; 3. Sunnybrook, Toronto, ON
Background: Most stroke recovery has been limited to individual domains of recovery. The changes across domains and interaction between these aspects of recovery, are likely important to gain a complete understanding of determinants of recovery post stroke. The objective of this work was to establish the association between different domains of recovery after stroke. Methods: Patients were selected from the Centre for Stroke Recovery Rehabilitation Affiliates Longitudinal Stroke database based on completion of assessments and time post stroke. At baseline (0-45 days post) there were 141 participants. The following assessments were selected: 2 minute walk (2mw), Berg Balance Scale(BBS), CES-D, FIM and MoCA. Determination of impairment was concluded by using measure specific cut-off scores. Results: At baseline, there was significant frequency of impairment in all measures (MoCA-83%, 2MW - 79%, BBS - 77%, FIM - 64%, CES-D - 33%). More than 45% of the individuals were impaired in 4 or more measures and 9% were impaired in only one domain. By 1 year after stroke the prevalence of impairments by domain decreased (MoCa-60%, 2MW - 39%, BBS - 26%, FIM - 7.7%, CES-D - 29%). Only 10% were impaired in more than 4 domains and 35% were impaired in only one domain. These relationships remained approximately the same after 2 years following stroke. Conclusions: Findings from this work emphasize the importance of multiple domains of recovery after stroke. The prevalence of individuals with impairment in multiple domains is important as such profiles may influence recovery. The work reinforces the need to understand the impact that changes in one domain may have on others. Knowledge of the multivariate nature of recovery may help to influence both assessments and interventions after stroke.
The Development and Integration of a Comprehensive Spasticity Management Clinic – Benefits to Patients, Physicians, Health Professionals, and Management
Czajka, T; Hammer, A; Hamilton Health Sciences-Regional Rehabilitation Centre, Hamilton, ON
The Comprehensive Spasticity Management (CSM) clinic located at the Hamilton Health Sciences, Regional Rehabilitation Centre, started as a clinic with physician and nursing resources. In January of 2013 we introduced Occupational Therapy and Physiotherapy consultation into these clinics. It has developed into a specialty clinic that operates, and shares health professional resources, within ambulatory activity that occurs at the Rehabilitation Centre. This presentation will outline how we developed the CSM clinic, and integrated it into existing patient care activity. It will describe the rationale and processes used to develop the clinic and promote the interdisciplinary approach between the Allied Health and Physician professionals. This includes the development of service delivery “teams”, common data collection systems, and common measurement systems that address the measurement of progress and incorporate patient goals. Preliminary results indicate that in a relatively short time, the clinic has successfully developed into a comprehensive approach towards the management of spasticity. Our data demonstrates continued gains in client progress and improvements in our attention to client centred goals. Initial results from our satisfaction questionnaire demonstrates that patients prefer a team approach and feel that it meets their clinical needs better. Our referral data demonstrates an increase in referrals, and stroke survivors represent the majority of new referrals. In addition this clinic has demonstrated benefits in other areas. These include improvements in the following: job satisfaction, professional growth, opportunity for inter-professional communication, patient care outside of the CSM clinic, transitions from inpatient to ambulatory therapy, and referrals to other ambulatory services. Plans for future activities have been initiated and will be described.
Recommendation for using dance as an adjunct therapy in stroke rehabilitation
Demers, M1, 2, 3 McKinley, P1, 2, 3; 1. McGill University, Montreal, QC; 2. Jewish Rehabilitation Hospital, Laval, QC; 3. Centre for Interdisciplinary Research in Rehabilitation of the Greater Montreal, Montreal, QC
Background: Dance can be use as an adjunct therapy in rehabilitation to target balance, functional mobility, mood, self-consciousness; a modified dance intervention was shown to be feasible and realistic in the context of functional intensive rehabilitation for individuals with sub-acute stroke. Despite the benefits attributed to dance for people with stroke, dance is not widely used in rehabilitation, because of the lack of clear criteria and guidelines in research on implementation of dance classes in clinical practice. The objective of this study is to provide evidence-based guidelines for implementing dance classes in a rehabilitation setting. Methodology: This presentation is part of a larger research study targeting the dissemination of knowledge about the therapeutic use of dance in post-stroke rehabilitation. Based on the Canadian Stroke Recommendations and the scientific literature on dance for individuals with disabilities, a dance intervention has been developed for individuals with sub-acute stroke, and specific guidelines have been identified that will serve to illustrate how a dance intervention might be constructed for people post-stroke. Results: When implementing a dance intervention designed for people with sub-acute stroke, the following specific elements must be taken into consideration: participant safety, choice of music and dance movements, inclusion of a learned two-minute choreography, and gradation of the exercise in order to include participants with poor sitting or standing balance, cognitive and/or language deficits, as well as hemiparesis. Conclusion: Based on the experience acquired by the development of a dance class for individuals with sub-acute stroke, a few recommendations are presented to ensure the safety and provide the right challenge for each participant. Those recommendations can facilitate the implementation of a dance class on a stroke unit.
The Use of Goal Attainment Scaling for Setting, Monitoring and Upgrading Language Goals in the Treatment of Chronic Aphasia
Duke, W1 Bains, R1, 2, 3 Ferdinandi, A1 Tittley, L1; 1. Columbia Speech and Language Services, Vancouver, BC; 2. Provedence Health Care, Vancouver, BC; 3. University of British Columbia, Vancouver, BC
Background: Speech-Language Pathologists have long struggled with translating results of standardized aphasia assessment batteries into specific, measureable, achievable, realistic and time-bound (SMART) goals. Most assessment batteries focus on categorizing aphasia type (BDAE-3 and WAB-R), outlining functional difficulties (CADL-2) or identifying affected psycho-linguistic processes (PALPA). None of these, however, provide a systematic framework to help clinicians set specific functional goals and monitor progress. Such assessments may also not have the sensitivity to measure the ongoing “subtle-but-important changes” (Schlosser, 2004) in functional communication that may occur many months or even years post-stroke for people in the chronic stage of aphasia. Goal Attainment Scaling (GAS) provides just such a clinical tool. Originally used in other clinical disciplines such as physiotherapy, geriatrics and mental health, it has been adapted for use with various communication disorders (Schlosser, 2004). Using a five point scale, GAS allows the clinician to set graduated, personalized target outcomes predicated upon the client’s observed baseline. Method: The authors have trialed the use of GAS for people with chronic aphasia within both a life-participation-focused group program and a recovery-focused intensive treatment program. Goals were established taking into account the desired outcome expressed by clients, therapist observations, and the expectations of therapists as to realistic achievable outcomes within a given time frame. Results: In both settings, GAS was found to be a useful clinical tool for goal setting, monitoring progress, and systematically increasing the challenge presented to clients with aphasia. Examples will be shared. Conclusions: GAS can help clinicians to set functional and measurable language goals for individuals with chronic aphasia, and can be a sensitive marker of change in functional communication.
Disclosure: All four authors receive income from Columbia Speech and Language Services, Inc., the agency at which the work described in this poster was completed.
Recovery From Action Naming Anomia in Chronic Aphasia: Study on Therapy Induced Neuroplasticity with 3 Participants
Durand, E1 Marcotte, K2 Ansaldo, A1, 2; 1. CRIUGM, Montreal, QC; 2. Universite de Montreal, Montreal, QC
Context: Approximately 30% of stroke survivors are left with persistent language impairments. Aphasia is a language deficit that results in communication disabilities; reduced social participation secondary to language loss may in turn lead to isolation, and depression. Anomia is the most frequent and pervasive aphasic symptom across aphasia types. Recovery from aphasia depends upon the brain’s potential to regain function. Aphasia therapy may contribute to triggering this potential; however, our understanding of the links between neuroplasticity and aphasia therapy remain limited. In our recent fMRI study, a group of participants with aphasia (PWA) recovered the ability to name nouns following Massed-Semantic Feature Analysis therapy (M-SFA); the recovery was correlated with neurofunctional changes reflecting therapy-induced neuroplasticity. The present study, reports the results of M-SFA with actions verbs and it unveils the neural substrates sustaining improved naming performance in a group of PWA and verb anomia. Methodology: A multiple single-case with repeated measures before and after therapy was used. Three participants with Broca’s aphasia received three weekly individual sessions of M-SFA, until 80% of improvement with treated action verbs was attained. Event-related fMRI and behavioral measures were collected at each point time. Results: All three participants have benefited from M-SFA therapy with a significant action naming improvement. No generalization was found with untreated verbs. However, participants’ families felt an improvement in everyday communication. Action naming improvement was associated with significant activation of semantic processing areas, areas involved in executive and mnemonic functions and areas of motor programming. Conclusion: This study provides evidence about the potential of a therapy to trigger brain plasticity and improve the ability to naming verbs in the case of chronic Broca’s aphasia. Moreover, neurofunctional data suggest that the recruitment of specific viable network is connected to the nature of the therapy.
Effects of a Dual Task on AFO-Supported Gait in Individuals with Poststroke Hemiplegia
Parker, K1 Clifton, K2 Adderson, J1 Mountain, A2 Eskes, GA2; 1. Capital District Health Authority, Halifax, NS; 2. Dalhousie University, Halifax, NS
Background: Individuals with post stroke hemiplegia are often prescribed an ankle-foot orthosis (AFO) to help maintain dorsiflexion during walking. Walking is an attentionally demanding task and the impact of wearing an AFO has not been evaluated under dual task conditions. The purpose of this study was to evaluate the effect of wearing an AFO on walking while under dual task conditions. Methods: Eighteen individuals (M(SD) age = 61.2 (14.2) yrs, 12 males) with post stroke hemiplegia and AFO use for at least 6 weeks were tested while walking with and without an AFO, with and without a secondary working memory task (auditory 2-back). Order of the 4 walking conditions was randomized. Mean and variability of gait temporal-spatial parameters were quantified with 2-4 walks per condition over an electronic walkway, GAITRiteTM. Results: Data were analyzed via a 2 (no AFO vs AFO while walking) x 2 (single vs dual task walking) mixed-factor ANOVA. Wearing an AFO improved velocity (54.4 vs 44.1 cm/s, p<.002) and step length (paretic side: 45.4 vs 41.1 cm, p<.01; non-paretic side: 41.6 vs 35.0 cm, p<.001). Performing the n-back task while walking reduced both velocity (51.6 vs 46.9 cm/s, p<.001) and step length (paretic: 44.6 vs 41.9 cm, p<.001; nonparetic: 39.7 vs 36.8 cm, p<.001), with equal interference seen in both no AFO and AFO conditions. Auditory 2-back performance (reaction time, accuracy) was equivalent across conditions. Conclusions: Wearing an AFO provides benefits to walking as measured by velocity and step length. Cognitive-motor interference (CMI) was evident during dual-task walking, confirming the attentional demands of walking. AFO use does not appear to increase nor decrease these attentional demands in practiced users, however, as seen by equivalent CMI across AFO conditions. Interventions aimed at reducing CMI during walking may be of benefit to optimize mobility in AFO users.
Hemiplegic Shoulder Pain Following Stroke: Risk Factors for the Different Etiologies and Their Outcomes
Fox, MA; Mountain, A; McDonald, A; Phillips, S; Dalhousie University, Halifax, NS
Background: Hemiplegic shoulder pain (HSP) has been estimated to occur in 48% to 84% of people with stroke. The etiology of HSP can broadly be described as neuropathic (HSP-Np) or musculoskeletal (HSP-Msk) in origin. This study is a retrospective chart review that seeks to identify risk factors and differences in outcomes for the different etiologies of HSP. Methods: Charts of 177 patients admitted to an inpatient tertiary stroke rehabilitation service during a three year period were reviewed. Stroke patients with HSP were identified and classified according to etiology (HSP-Msk or HSP-Np). Univariate statistical analysis was used to see if there were any identifiable differences in risk factors and outcomes for the goups with HSP and without. Results: Of the 177 charts reviewed (M:F 102:75) 62 patients (35%) had HSP. Of these 62 patients, 27 (44%) had HSP-Msk and 35 (56%) HSP-Np. In univariate analysis Chedoke McMaster stage of recovery of the hand and arm <4 (stratified verses > 4) at admission or discharge (p<0.0001) and the use of a mechanical lift at any time during admission (p=0.003) was associated with HSP. Sex, presence of diabetes, stroke etiology (hemorrhagic or ischemic), presence of neglect and discharge home were not different between the group with HSP and without. When the groups with HSP-Msk and HSP-Np were compared individually against the group without HSP the Chedoke McMaster stage of recovery at admission and discharge remained significant for both while use of mechanical lift remained significant only for HSP-Np (p=0.009). Conclusion: Hemiplegic shoulder pain is a common complication following stroke. In our retrospective chart review only Chedoke McMaster Stage of recovery at admission and discharge (HSP-Msk and -Np) and use of mechanical lift during admission (HSP-Np) were associated with hemiplegic shoulder pain.
Measurement of Functional Outcomes Using the Goal Attainment Scale in a Comprehensive Spasticity Management Clinic
Gallagher, S; Sasaki, A; Ismail, F; Boulias, C; West Park Healthcare Centre, Toronto, ON
Context: Spasticity is a component of the Upper Motor Neuron Syndrome which significantly impacts active or passive function. Focal spasticity can be treated effectively with chemodenervation; however, reduction of spasticity does not automatically imply treatment success. Evaluation of treatment outcomes should involve functional changes and goal attainment as opposed to measures of impairment and symptoms alone. One way of quantifying achievement of goals is through the Goal Attainment Scale (GAS). The GAS is a tool which scores the extent to which a patient’s goals are achieved in the course of their intervention. Both tasks and scores are individually set around one’s current and expected levels of performance. GAS allows measure of functional outcome, vs. traditional impairment level scales. The comprehensive spasticity management clinic at West Park Healthcare Centre (WPHC) began implementing the GAS with all patients in the fall of 2012. Findings: The GAS has been completed with 210 patients in the spasticity clinic at WPHC. The GAS is completed in the first clinic visit for new patients and at treatment visits for returning patients. 83% of our patients had achieved their goals at follow-up. Goals were scored as achieved if patients scored 0 or above on the GAS. 16% of patients could not complete the GAS due to cognitive or language deficits. 54% of the goals are classified as passive goals, and 46% as active goals. Clinical Relevance/Conclusion: GAS encourages communication and collaboration between multidisciplinary team members; and patient involvement. Goals are more likely to be achieved if patients are setting them.
Post-stroke Aphasia Therapy in Bilingual Speakers: Cross-Linguistic Transfer Effects
Ghazi Saidi, L; Ansaldo, A; CRIUGM, University of Montreal, Montreal, QC
Background: Among the most devastating consequences of stroke, aphasia is characterized by impaired language production and comprehension. In multilingual contemporary society, bilingual aphasia is becoming more and more frequent. Little is known about the most efficient procedures for triggering language recovery of bilinguals with aphasia. The question of which language to treat is a longstanding issue in the aphasiology domain. This issue is particularly relevant given that language therapy in a second language is not always available. There is evidence that language therapy effects can sometimes transfer across languages; however, the mechanisms favoring cross-linguistic transfer are poorly known. Aim: This paper reviews the evidence on cross-linguistic therapy effects in bilingual aphasia therapy, with a focus on those factors that can modulate cross-linguistic therapy (CLT) effects in bilinguals with aphasia. Methods: Collected from the following databases: Medline, ASHA, Cochrane, Aphasiology Archive, Evidence-Based Medicine Guidelines, NHS Evidence, PsycBite et Speechbite, with the key words bilingual, aphasia, cross-language, generalization, cognates, naming treatment, and transfer, fifteen articles (two systematic reviews and 13 case studies) with details on pre and post therapy bilingual aphasia profiles in adults suffering from anomia, describing therapy frequency and procedures in sufficient detail to make them replicable and discussing variables influencing the presence or absence of cross-linguistic transfer effects were analyzed. Results and Conclusion: Effects of word similarity, structural language overlap, therapy approach, language of therapy (L1 VS L2), cognitive control, and pre and post therapy proficiency factors are discussed, and a series of cues to develop intervention procedures favoring cross-linguistic transfer of therapy effects are proposed.
L’expérience de la réadaptation de l’AVC avec aphasie telle que vécue par les proches
Hallé, M1, 2, 3 Le Dorze, G1, 2, 3; 1. École d’orthophonie et d’audiologie, Faculté de médecine, Université de Montréal, Montréal, QC; 2. Centre de recherche interdisciplinaire en réadaptation du Montréal métropolitain (CRIR)- Centre de réadaptation Lucie-Bruneau, Montréal, QC; 3. Réseau provincial de recherche en adaptation-réadaptation (REPAR), Montréal, QC
Contexte: Les services de réadaptation doivent inclure les proches de personnes ayant subi un AVC comme le stipulent les “Recommandations canadiennes pour les pratiques optimales de soins de l’AVC”. Il est difficile de déterminer si de telles recommandations sont appliquées, entre autres pour les proches de personnes ayant subi un AVC avec aphasie. En effet, ces derniers présentent davantage de symptômes dépressifs que les proches de personnes ayant subi un AVC sans aphasie, bien que l’expérience clinique suggère qu’au congé de la réadaptation, ils sont satisfaits des services reçus. Une meilleure compréhension de leur expérience de la réadaptation favoriserait une offre de services adaptée à leur situation. Le projet visait donc à identifier les éléments déterminants dans l’expérience vécue par les proches de personnes aphasiques pendant la réadaptation. Méthodologie: 12 proches de personnes devenues aphasiques à la suite d’un AVC ont été individuellement interviewés moins de 3 mois après le congé d’une des phases de la réadaptation. Ces entrevues ont été analysées qualitativement. Résultats: La condition nécessaire à la satisfaction des proches envers la réadaptation est que les services doivent répondre à leurs besoins en tant qu’aidant, c’est-à-dire avoir ce qu’il leur faut pour prendre soin du survivant de l’AVC. Parallèlement, les proches ont d’autres besoins liés à leur bien-être personnel, tel que du support, et relationnel, tel qu’avoir une bonne communication avec la personne aphasique. Or, ils n’associent pas ces besoins à la réadaptation. Conséquemment, certains proches ressentent à la fois de la satisfaction envers les services de réadaptation et des difficultés d’ajustement à l’AVC avec aphasie. Conclusion: Les services de réadaptation devraient rendre explicite les différents rôles que peuvent prendre les proches afin qu’une offre de services visant aussi à répondre à leurs besoins personnels et relationnels paraissent légitime aux proches.
A Comparison of Stroke and Acquired Brain Injury Rehabilitation Randomized Controlled Trials
McIntyre, A; Kwok, C; Aubut, J; Janzen, S; Richardson, M; Hussein, N; Teasell, R; Lawson Health Research Institute, London, ON
Objective: The rehabilitative needs for acquired brain injury (ABI) and stroke survivors may have commonalities. Therefore, the objective was to compare the proportion of intervention-based randomized controlled trials (RCTs), their sample size, and methodological quality between the stroke and ABI rehabilitation literature. Methods: The Evidence-Based Review of Acquired Brain Injury (ERABI) and the Evidence Based Review for Stroke Rehabilitation (EBRSR) databases were used to identify all published RCTs in each corresponding field. RCTs were categorized, when possible, into motor, cognitive, medical complications, or psychosocial intervention groups. The number, sample size, and Physiotherapy Evidence Database (PEDro) score for each RCT was collected. Results: A total of 148 ABI and 965 stroke rehabilitation RCTs were identified. Of the RCTs for stroke, 625 were categorized as motor, 133 as cognitive, 108 as medical complications, and 99 as psychosocial intervention RCTs. Comparatively within ABI, 24 motor, 65 cognitive, 26 medical complications, and 33 psychosocial RCTs were found. While the emphasis within stroke literature is placed on motor studies (64.8%), the greatest concentration of ABI RCTs was within cognitive interventions (43.9%). Compared to ABI RCTs, stroke studies had both a higher mean sample size (P < 0.0001) and mean PEDro score (P = 0.0001). Conclusions: This study identified a potential for existing stroke literature to be used to supplement poorly studied areas in ABI and vice versa.
The Methodological Quality of Randomized Controlled Trials in Stroke Rehabilitation Literature
McIntyre, A; Janzen, S; Richardson, M; McClure, A; Hussein, N; Teasell, R; Lawson Health Research Institute, London, ON
Objective: To evaluate the methodological quality of intervention-based, randomized controlled trials (RCTs) published in the stroke rehabilitation literature using the Physiotherapy Evidence Database (PEDro) tool. Methods: All RCTs published from 1973 to 2012 from the stroke rehabilitation literature were reviewed and included. RCTs that could be appropriately categorized as either a motor, cognitive, medical complications or psychosocial were grouped. Each study was evaluated using the PEDro tool; scores for each of the 10 quality ratings (e.g., yes=1 or no=0) and the cumulative score (maximum10) were recorded to allow for individual item analysis. Results: A total of 1063 RCTs were included with an overall mean PEDro score of 6.2 ± 1.5. 62.5% of the total sample was rated as “good” quality (scores 6-8). Among all RCTs combined, the criteria least likely to be satisfied on the PEDro included: blinding therapists (9.8%), blinding participants (25.5%), intention to treat analysis (27.6%), and concealed allocation (34.9%). Conversely, baseline comparability (91.7%) and between-group results comparisons (94.7%) were the most frequently satisfied criteria. Of the 965 intervention-based studies (motor n=625, cognitive n=133, medical n=108, psychosocial n=99), psychosocial RCTs had the greatest mean PEDro score (6.6 ± 1.4). Medical complication intervention RCTs had the greatest proportion of “excellent” (14.8%; scores 9-10) and “poor” quality studies (6.5%; scores <4). Conclusions: The results indicate that certain quality criteria are often not satisfied and may introduce greater bias. Since the evidence provided from RCTs is used to guide clinical practices, the methodological quality of studies should be considered when interpreting results.
Anatomical Correlates of Proprioceptive Deficits Following Stroke in Humans: a Case Series
Kenzie, JM1 Semrau, JA1 Findlater, SE1 Herter, TM2 Scott, SH3 Dukelow, SP1; 1. The University of Calgary, Calgary, AB; 2. University of South Carolina, Columbia, SC, USA; 3. Queen’s University, Kingston, ON
Background: Proprioception refers to the ability to detect the relative position and movement of our body in space. After stroke, individuals with significantly impaired proprioception tend to have poor functional outcomes. Newer robotic techniques for measuring proprioception now provide more reliable and accurate quantification of proprioception than traditional clinical techniques. We are conducting a large prospective longitudinal study measuring proprioceptive recovery following stroke. Correlating this data with acute stroke neuroimaging (computed tomography and/or magnetic resonance) should eventually allow the prediction of proprioceptive deficits and the possibility of recovery based on neuroimaging. We present a preliminary case series from our larger ongoing study displaying the types of proprioceptive deficits that result from discrete stroke related lesions to areas of the brain classically thought to be involved in proprioception including the posterior thalamus, posterior limb of the internal capsule, primary somatosensory cortex and parietal association areas. Methods: Neuroimaging was performed on 10 subjects 2-10 days post-stroke. Assessment of proprioception and visually guided reaching in the upper extremities was completed using a KINARM robotic exoskeleton within the same time frame. Lesion location was compared with robotic task performance. Results: Subjects with thalamic damage demonstrated significant proprioceptive deficits with mild to moderate deficits in visually guided reaching. Damage to the posterior limb of the internal capsule resulted in varying degrees of proprioceptive and/or reaching deficits. Subjects with damage to primary somatosensory cortex (S1) and parietal cortex showed the most severe deficits in both proprioception and reaching tasks. Conclusions: Proprioceptive deficits were consistently observed following lesions of brain structures classically thought to be involved in proprioception. However, damage to similar areas in different patients did not necessarily result in identical deficits. In this sample, damage to S1 and posterior parietal cortex most significantly impacted performance on all robotic tasks.
Improving Rehabilitation Intensity - A Common Sense Approach
Lawhead, KE; Windsor Regional Hospital - Tayfour Campus, Windsor, ON
Background: Stroke patients should receive a minimum of 3 hours of direct task-specific therapy by an interprofessional stroke team a minimum of 5 days per week. Stroke patients on the Inpatient Rehabilitation Unit at Windsor Regional Hospital, were receiving 2-3 hours of therapy per day and the transfer of skills to their daily routine was sub optimal. Staff was frustrated as they often competed to see patients during peak times in the day, despite nursing reporting that there are times in the day and on weekends when patients are not engaged in activity. This has led to changes in our care delivery model to improve access to care and therapy intensity. Methods: A multidisciplinary working group undertook a LEAN approach to reduce inefficiencies and improve access to therapy. We reviewed a day in the life of a patient. We engaged Nursing, Physiotherapy, Occupational Therapy, Speech Language Pathology, Social Work, Psychology, Recreational Therapy and Dietary staff to create, pilot, and implement a variety of functionally based classes to address the gaps in service provision. Results: The access to treatment has increased from 2-3 hours/day to 5-6 hours per day for the majority of patients. The delivery of care model has become more efficient and interprofessional. Patients are engaged in their recovery and participating in activities outside of traditional therapy hours. Evening and weekend programs continue to expand as the Program develops. Conclusion: By implementing inpatient home exercise programs and group classes to supplement on on one therapy sessions, patients have increased access to care, education and have taken personal accountability for their recovery. Staff has increased the transfer of functional skills into daily routines. Interprofessional care has broadened throughout the Unit, and therapists use their time with patients to teach and practice the new and more complex skills.
The Frontal Lobes and Autobiographical Memory: A Focal Lesion Study
Levine, B5, 3 Khuu, W5 Black, SE3, 2 Schwartz, ML3, 2 Alexander, MP7; 1. Rotman Research Institute, Toronto, ON; 2. Sunnybrook Health Sciences Centre, Toronto, ON; 3. University of Toronto, Toronto, ON; 4. Department of Medicine (Neurology), University of Toronto, Toronto, ON; 5. Rotman Research Institute, Baycrest, Toronto, ON; 6. Harvard Medical School and Beth Israel Deaconess Medical Centre (Neurology), Boston, MA, USA; 7. Harvard Medical School and Beth Israel Deaconess Medical Centre (Neurology), Boston, MA, USA
Most research on the functional neuroanatomy of autobiographical memory has entailed functional neuroimaging, which is unable to distinguish regions that are activated in association with autobiographical memory tasks from those that are necessary for autobiographical memory task performance. In this respect, patients with focal lesions provide crucial information. We assessed the effects of focal frontal lesions due to strokes and tumors in distinct functional-anatomical sectors on autobiographical memory using the Autobiographical Interview (AI), which reliably separates categories of episodic and non-episodic autobiographical memory. Twenty-three focal lesion patients in the stable phase of recovery were included. Lesions were visualized and defined on computerized images. Patients were divided into medial polar (MP; N = 12) and right dorsolateral frontal (RDLF; N = 11) groups, according to dissociations based on prior studies of the effects of frontal lesions on cognition (left lateral patients were excluded due to the speech demands of the AI). Episodic and non-episodic (internal and external) detail scores were derived from text-based analysis of the transcribed protocols. MP patients generated significantly more details that were not pertinent to the specified event (external details) compared to control participants. Patients with RDLF lesions were only marginally significantly impaired for internal details. Lesion overlap of patients with an excess of external details indicated a focus in the left anteromedial prefrontal cortex. Production of external details was correlated with non-perseverative errors on the Wisconsin Card Sorting Test (WCST). In conclusion, focal frontal damage does not cause a significant decline in episodic autobiographical memory retrieval per se. Rather, MP lesions cause a deficit in the control and direction of retrieval and discourse lapses in global coherence. The maximal overlap in the anteromedial left prefrontal cortex corresponds with this region’s involvement in switching attention between internal (self) and external (environmental) stimuli.
Validation of a Novel Computerized Test Battery for Automated Testing
Levine, B1, 2, 3 Bacopulos, A1 Anderson, ND1, 4, 3 Black, SE2, 5 Davidson, PS6 Fitneva, SA7 McAndrews, M3, 9 Spaniol, J10 Jeyakumar, N1 Abdi, H11 Beaton, D11 Owen, AM8 Hampshire, A8; 1. Rotman Research Institute, Baycrest, Toronto, ON; 2. Department of Medicine (Neurology), University of Toronto, Toronto, ON; 3. Department of Psychology, University of Toronto, Toronto, ON; 4. Department of Medicine (Psychiatry), University of Toronto, Toronto, ON; 5. Sunnybrook Health Sciences Centre, Toronto, ON; 6. School of Psychology, University of Ottawa, Ottawa, ON; 7. Department of Psychology, Queen’s University, Kingston, ON; 8. Department of Psychology, University of Western Ontario, London, ON; 9. Toronto Western Research Institute, Toronto, ON; 10. Department of Psychology, Ryerson University, Toronto, ON; 11. School of Behavioral and Brain Sciences, University of Texas at Dallas, Dallas, TX, USA
Computerized tests offer an adjunct to standardized neuropsychological tests, especially for speeded information processing, attention, executive functioning, and memory, which are of primary importance in many brain diseases. We assessed the validity of computerized tasks of these capacities as compared to neuropsychological tasks. 134 healthy participants (mean age: 47.17; SD: 24.49; range 18–90) completed computerized and traditional neuropsychological batteries in a counterbalanced fashion. Partial Least Squares – Correlation (PLS-C, Krishnan et al., 2011) analysis resulted in one significant latent variable accounting for 93% (p<.001) of the cross-block co-variance (78% after accounting for age). Computerized tests contributing to the latent variable included visuospatial working memory, inhibition, fluid reasoning, and visuospatial planning from the Cambridge Brain Sciences battery (CBS; Hampshire et al., 2012), speed and working memory measures from the CogState battery (Maruff et al., 2009), and a face-name task (Troyer et al., 2012). Standardized tests that significantly contributed included WASI Block Design and Matrix Reasoning, the Rey Auditory Verbal Learning Test, Trail Making A and B, and the Symbol Digit Modalities Test. Based on this analysis, a reduced computerized battery (less than 30 min in duration) composed of the CBS and face-name tests was identified, which accounted for 61% of the variance in the full 2-3 hr neuropsychological test battery. Using PLS-Regression, we found that this reduced computerized battery was comparable to the full neuropsychological battery at predicting age (r’s = .78 and .75 for the neuropsychological and computerized batteries, respectively). In conclusion, an automated, 30-min computerized battery of tests of attention, memory, and executive functioning is comparable to a 2-3 hr battery of paper-and-pencil tests in terms of its latent structure and relation to age. Such a battery could be applied in large-scale testing or as a repeatable screening battery for assessing cognition where access to neuropsychological services is limited.
Using a Triage Tool to Facilitate Access to Rehabilitation for Persons with Stroke
Linkewich, E1 Sharp, S2 Willems, J3 Levy, C4 Tahair, N5 Bayley, M6; 1. North & East GTA Stroke Network, Toronto, ON; 2. Toronto West Stroke Network, Toronto, ON; 3. South East Toronto Stroke Network, Toronto, ON; 4. GTA Rehab Network, Toronto, ON; 5. Toronto Stroke Networks, Toronto, ON; 6. University Health Network - Toronto Rehab, Toronto, ON
Background: In creating a standard of care, the Toronto Stroke Flow Initiative (Stroke Flow) identified the need for standardized acute referral processes aligned to common rehab admission criteria. Stroke severity data from the National Rehabilitation Reporting System (FY12-13 Q1-3) indicated 60% of inpatient rehab admissions in Toronto were moderate, 17% mild and 22% severe. With a goal of improving access to timely and appropriate rehab, Stroke Flow established inpatient admission targets of 12% mild, 53% moderate and 35% severe. The triage tool emerged to support clinical decision making for early referral to appropriate rehab. Methods: Acute and rehab leaders considered the provincial expert panel recommendations and existing referral frameworks (Ottawa and Hamilton) in collaboratively developing the triage tool. Understanding that broader system changes are required for a full transition to the new model of rehab, initial implementation focused on patients with an early AlphaFIM® of 60-80. Communication and education to support this practice change facilitated the February 2013 implementation. Results: Baseline data (January - August 2012) for patients referred with an early AlphaFIM® of 60-80 indicated only 66% were accepted to rehab, 15% were declined and 8.5% had a decision pending. It is expected that transition barriers for this group should be minimal unless special needs are identified. Reasons for decline included: special needs that could not be met (10%); more appropriate for slow stream rehab (29%), and limited sitting tolerance and balance (14%). Monitoring of decline rates and reason for decline will be ongoing. Further evaluation will be conducted at 6 months post-implementation. Conclusion: The triage tool supports a standard of practice across organizations. A common standard of practice for rehab referral and management of patients with AlphaFIM® 60-80 have been established between referrers and rehab providers. This tool is transferable to other geographies.
Assessing Depressive Symptoms in Subarachnoid Hemorrhage and Treated and Untreated Unruptured Aneurysm Patients
Maher, ME1 Macdonald, R2, 1 Schweizer, TA2, 1; 1. University of Toronto, Toronto, ON; 2. St. Michael’s Hospital, Toronto, ON
Background: The CES-D and the HADS-D are two brief self-report scales that are valid and reliable for assessing depressive symptoms in many populations, including stroke. The goal of this study was twofold: 1) to determine the presence of depressive symptoms in aneurysmal subarachnoid hemorrhage (aSAH) compared to unruptured intracranial aneurysm (UIA treated and untreated) patients and 2) to determine which scale is best to use in these groups. Methods: 117 outpatients were recruited from the Neurovascular Clinic at St. Michael’s Hospital to complete both the CES-D and the HADS. We assessed 3 groups: aSAH (n=47), UIA treated (n=30) and UIA untreated (n=40). Cutoff scores of 16 (CES-D) and 8 (HADS-D) were used. Results: Proportions of patients scoring above cutoffs were: 42.6% (CES-D) and 19% (HADS-D) of aSAH, 40% (CES-D) and 23.3% (HADS-D) of UIA treated and 22.5% (CES-D) and 15% (HADS-D) of UIA untreated patients. aSAH patients scoring above the CES-D cutoff had average HADS-D scores below cutoff (average score= 7.30); UIA treated and UIA untreated patients above the CES-D cutoff had average HADS-D scores of 8.69 and 8.33 – only slightly above the cutoff point. Conclusions: Based on these results, the HADS scale may be preferential to use in aSAH and UIA (treated and untreated) patients. It requires less time to complete than the CES-D and measures symptoms of depression and also anxiety – which is highly prevalent in stroke populations. Previous research has shown that the CES-D is influenced by anxiety symptoms in addition to producing a high number of false positives in the general population. These factors may be reflected in the high number of patients in this study that fell at or above the CES-D cutoff.
Analysis of Fmri Neurofeedback of the Primary Motor Cortex as a Function of Time During Kinesthetic Motor Imagery
Mansur, A1 Chiew, M2 Tam, F3 Schweizer, TA1 Graham, SJ3; 1. Li Ka Shing Knowledge Institute, St. Michael’s, Toronto, ON; 2. FMRIB, Nuffield Department of Clinical Neurosciences, Oxford, United Kingdom; 3. Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON
Background: Functional MRI neurofeedback (fMRI-NF) is a novel tool that can enable self-regulation of brain activity. By depicting brain activation patterns during performance of imagined movements, fMRI-NF can potentially assist in determining whether patients with focal neurological deficits are candidates for motor imagery (MI) therapy. Previously, we performed fMRI-NF with kinesthetic MI in 13 right-handed healthy subjects and 5 controls. Subjects were instructed to mentally simulate a unilateral finger-tapping task while receiving NF from the primary motor cortices to increase a lateralization metric of brain activity. Only 6 out of 13 subjects were good responders, who showed increased activity in the task positive network that correlated with task performance. Here we focus on the differences in temporal evolution of brain networks recruited in the good and poor responders in left and right hand imagery tasks. Methods: Preprocessed data were subjected to a general linear model (GLM) to create parametric maps for both region-by-region analyses and whole-brain ANOVA analyses. Results: For right hand tasks, poor responders had minimal motor activation that was stagnant over the four runs of fMRI-NF. Conversely, good responders had high visual-spatial and motor activation from the first run with increasing involvement of the inferior frontal gyrus and thalamus over time. For left hand tasks, poor responders showed more activation than good responders. Conclusion: This work supports that good candidates for fMRI-NF involving imagery must possess strong visual-spatial and focused attention skills. Hemispheric differences in brain activity during fMRI-NF may have implications for use of fMRI-NF with MI therapy in populations with focal deficits. More research is required with a larger sample of left-handed and right-handed individuals, as part of assessing the role of fMRI-NF applied to MI and stroke.
Are the Randomized Controlled Trials in Stroke Rehabilitation Underpowered?
McIntyre, A; McClure, A; Richardson, M; Janzen, S; Hussein, N; Teasell, R; Lawson Health Research Institute, London, ON
Objective: Many stroke rehabilitation interventions produce small to moderately sized treatment effects. Randomized controlled trials (RCTs) that enroll a small number of participants may be unable to detect such effects and result in false, non-reproducible conclusions. Therefore, the objective was to determine the proportion of RCTs in the stroke rehabilitation literature that was sufficiently powered to detect a moderate treatment effect. Methods: Stroke rehabilitation RCTs published between 1973 and 2012 were included for review. Sample sizes from all RCTs were recorded. Where possible, RCTs were grouped based on intervention type (i.e., motor, cognitive, medical complications, psychosocial). To detect a moderate treatment effect of 0.5 with the significance level (alpha) set at 0.05 and power (1-beta) set at 0.8, a total sample size of 128 individuals (64 per group) is required. Results: 1063 RCTs met inclusion criteria with a mean sample size of 176.4±1002. 17.2% of all RCTs included a sample size of at least 128 individuals. 965 RCTs could be further classified as motor (n=625), cognitive (n=133), medical complications (=108), and psychosocial (n=99) interventions. The mean sample sizes among the groups varied considerably: motor x– = 87.4±574.4; cognitive x– = 329.1±1042.2; medical complications x– = 227.8±547.5; and psychosocial x– = 126.9±117.9. The proportion of RCTs that included a sample size of at least 128 individuals was 6.9% for motor, 19.9% for cognitive, 26.9% for medical complications, and 33.3% for psychosocial intervention RCTs. Conclusions: It appears as though a substantial portion of the stroke rehabilitation literature is underpowered. Larger trials, particularly for motor interventions, are necessary.
The Evolution of Stroke Rehabilitation Research
McIntyre, A1 Richardson, M1 Janzen, S1 McClure, A1 Hussein, N1, 3 Teasell, R1, 2, 3; 1. Lawson Health Research Institute, London, ON; 2. University of Western Ontario, London, ON; 3. St. Joseph’s Healthcare, London, ON
Objective: To examine the evolution of stroke rehabilitation literature with respect to number, sample size, and quality of randomized controlled trials (RCTs) over the last four decades (1973-2012). Methods: The Evidence-Based Review of Stroke Rehabilitation (EBRSR; http://www.ebrsr.com) is a review of RCTs in stroke rehabilitation. RCTs were categorized into one of five groups based on intervention type: motor, cognitive, medical complications, psychosocial, and “other”. Data on author(s), year of publication, sample size, and Physiotherapy Evidence Database (PEDro) score were compiled. Statistical analyses were conducted using GraphPad Prism (V6.01). Results: 1063 RCTs met inclusion criteria (motor n=625; cognitive n=133; medical complications n=108, psychosocial n=99, other =98) with motor intervention RCTs accounting for 58.8% of the total. The number of RCTs published each year grew between 1973 and 2012, with 35.9% all RCTs published in the last five years. Overall, motor studies had the smallest median sample size (median = 32; P < 0.017). Between two five-year time brackets, 1973-1977 and 2008-2012, there was no statistically significant increase in median sample sizes among all RCTs combined (P = .8427). Overall, psychosocial studies had higher mean PEDro scores when compared to motor (P = .002) and cognitive (P = .036), but not medical complication studies (P = .5913). Over time, PEDro scores for all RCTs increased from 5.2 ± 0.7 in 1973-1977 to 6.5 ± 1.5 in 2008-2012 (P = .008). Conclusions: The number of RCTs in stroke rehabilitation has increased significantly over the past four decades, with an associated increase in quality. Future reviews should more closely evaluate changes in number, sample size, and PEDro scores of specific interventions over time and assess the impact of study quality on reported outcomes.
’Training the Trainers’ - the Process of Effectively Moving Evidence-Based Functional Electrical Stimulation (FES) Into the Clinical Realm
Miller, S1 Gollega, A2 Dukelow, S2; 1. Alberta Health Services - Peter Lougheed Centre, Calgary, AB; 2. Alberta Health Services, Calgary, AB
Background: In March, 2012, an FES Work Group was formed with ‘champions’ from acute, tertiary and outpatient sites in the Calgary Zone of Alberta Health Services to develop practical skills in using functional electrical stimulation (FES) with stroke patients. The FES Work Group consisted of occupational therapists, physiotherapists and physiatrists with expertise in stroke rehabilitation. Methods: An initial meeting was held to determine timelines for knowledge transfer and establish the primary goal of the group which was to build a ‘critical mass’ of clinicians with practical experience using FES across the Calgary Zone. In house in-servicing was done to establish a baseline of theoretical and practical knowledge for the FES Work Group, capitalizing on existing knowledge and clinical experience of group members. Similar FES equipment was acquired across different sites to ensure consistent use in the Calgary Zone across inpatient and outpatient centres. A 2 day course was developed in-house with an external speaker with advanced training in the use of FES. FES Work Group members helped facilitate the course and assisted in the practical workshops. A survey was done of all participants to look at ways of improving the FES course. Following this, a 1 day course was developed, with in-house teaching by the FES Work Group. Results: The time from formation of the group to the development of an in-house course and consistent training of ~ 50 therapists across the Calgary Zone was ~ 1 year. Based on surveys of participants post 1 day course, > 90 % rated the course as excellent. The use of therapists as facilitators with the course was rated as a strength. Conclusion: The ‘train the trainers’ approach proved to be an acceptable method of practical knowledge transfer. This is a technique that could be applied in other geographic regions for evidence-based care.
Self-Identified Goals: Investigating Areas of Unmet Need for Individuals with Stroke Using the ICF
Nalder, EJ1 Bottari, C2 Damianakis, T4 Hunt, A3 Dawson, D1, 3; 1. Rotman Research Institute, Baycrest Hospital, Toronto, ON; 2. Université de Montréal, Montreal, QC; 3. University of Toronto, Toronto, ON; 4. University of Windsor, Windsor, ON
Background: Despite evidence for the efficacy of stroke rehabilitation in the chronic phase of recovery, many survivors report unmet service and psychosocial needs. A clear knowledge of the self-identified goals of stroke survivors is critical to ensure service planning is congruent with the priorities of service users. The International Classification of Functioning (ICF) core data set for stroke was developed to provide a common framework for describing health related experiences post-stroke. However, this framework has not been validated in terms of how it aligns with self-identified goals of stroke-survivors. This paper aims to 1) describe self-identified goals of stroke survivors and 2) determine the extent to which individuals’ goals link to the ICF. Methods: Data were collected from 24 participants with stroke on average 3.5 years post-event, as part of a larger randomised controlled trial. The Canadian Occupational Performance Measure (COPM) was used to elicit stroke-survivor’s goal statements. Qualitative content analysis was used to thematically analyse goals and map content to the ICF framework. Results: Twenty-four stroke-survivors identified 125 rehabilitation goals even many years post-event. All goals were readily classified using the ICF and indicated a need for supports to facilitate activity participation and manage residual impairments. Activity and participation goals were most common, particularly in the areas of community, social and civic life (n=19 goals) and mobility (n = 17 goals). Sixteen stroke-survivors also identified recovery goals related to impaired body functions; most common were neuromusculoskeletal and movement related functions, and mental functions each with 9 goals. Conclusions: Stroke survivors have complex and varied goals for rehabilitation which extend beyond the period of acute recovery. The ICF framework is a useful tool to illustrate the broad rehabilitation needs of individuals with stroke and may inform service planning and evaluation towards addressing the long-term needs of stroke survivors.
The HNHB Community Stroke Rehabilitation Model - a Component of an Integrated Stroke Recovery System that Crosses the Continuum From Acute to Community
Pagliuso, SA; MacRae, L; The HNHB Community Stroke Rehabilitation Working Group; Hamilton Health Sciences, Hamilton, ON
Background: A gap identified in the HNHB LHIN was the lack of access to community stroke rehabilitation, especially in rural areas. Therefore a working group(WG) was assembled to develop a Community Stroke Rehabilitation Service Model(CSRM) as a component of a stroke recovery system that crosses the continuum. The service model will be aligned with the Canadian Best Practices for stroke care and the Stroke Reference Group, provide improved access and be transferable to other LHIN communities. The goals of the model are achieving improved access to evidence based community outpatient stroke rehabilitation, improved client outcomes, reduction of hospital lengths of stay and integration of outpatient stroke services. Methods: In order to develop this model the WG engaged in the following process:
- Defining the ‘eligible’ population and identifying the number of individuals that would be eligible.
- Identifying client streams and best practice guidelines for each.
- Completing an environmental scan which revealed 8 models for review.
- Application of the HNHB LHIN’s Decision Making Framework (DMF) to evaluate the models.
- Rating each criterion in the DMF as to how they related to the LHIN and provincial priorities in the context of a CSRM and each criterion was weighted using Expert Choice software. Results: The WG have developed a model that incorporates the strengths of all the models reviewed. Which includes the following:
- Strong link with District and/or Regional Stroke Center, an ISU and with primary care
- Dedicated care coordination
- Time to first visit within 72 hours
- Consistency of Stroke Team Members
- Assessment for CSR within 24-48 hours
- Care Pathway based on Best Practice Recommendations that incorporate opportunities for reassessment
- Stroke Expertise
- Equitable Access
- Strong link with CCAC
- Standardized reporting requirements
Implementation of a pilot project and development of an evaluation framework.
“Normal” Functional Balance Does Not Necessarily Imply Recovered Standing Balance Control, as Measured with Posturography in Individuals with Stroke
Patterson, KK1, 2 Mansfield, A2, 1 Inness, E2, 1 McIlroy, WE3, 2, 1; 1. University of Toronto, Toronto, ON; 2. Toronto Rehab - University Health Network, Toronto, ON; 3. University of Waterloo, Waterloo, ON
Background: The Berg Balance Scale (BBS) is a functional balance measure commonly used during stroke rehabilitation1. However, BBS scores can improve without concomitant improvement in physiological postural control measures2. The purpose of this study was to compare forceplate measures of standing balance between individuals post-stroke scoring above and below a ‘normal’ BBS score. Methods: Demographic variables, BBS scores, Chedoke McMaster Stroke Assessment (CMSA) leg and foot scores and forceplate measures of quiet standing balance (percentage of body weight on the paretic limb and root mean square of centre-of-pressure for antero-posterior and medio-lateral displacement) were extracted from 168 inpatient rehabilitation charts. Individuals were divided into two groups: BBS score above or below a normative value (lower 95% CI for healthy adults3) and also categorized as within or outside the 95% CI for healthy adults for each forceplate measure4,5. BBS groups were compared with one-way ANOVAs and Fisher’s tests. Results: Forty-two (25%) individuals had BBS > normative value. These individuals had higher CMSA leg (5.6±0.9 vs 4.6±1.1, p<0.001) and foot scores (5.1±0.8 vs 4.2±1.2, p<0.001) and shorter length of stay (31 ± 11 days vs 40±15 days, p<0.001 ) than individuals with BBS < normative value. The two groups did not differ in age, days post stroke or the proportion of individuals scoring within the normative CIs for forceplate measures. Discussion: Individuals post-stroke achieving “normal” BBS scores are not more likely to exhibit recovered standing balance control as measured by posturography with respect to healthy CI values. These individuals may employ compensatory strategies that allow superior BBS performance which belies continued underlying balance impairment.
References: Blum L et al. Phys Ther. 2008;88:559-566. Garland SJ et al. Arch Phys Med Rehabil. 2003;84:1753-1759. Steffen TM et al. Phys Ther. 2002;82:128-137. Prieto TE et al. Biomedical Engineering. 1996;43(9):956-966. Mansfield A et al. Clin Biomech. 2011;26:312-317.
Influence of Knowledge of Perturbation on Standing Balance Post-Stroke
Pollock, C1 Vieira, T2 Gallina, A2 Ivanova, T1 Cantor, Z1 Garland, S1; 1. University of British Columbia, Vancouver, BC; 2. Laboratory for Engineering of the Neuromuscular System (LISiN), Politecnico di Torino, Torino, Italy
Background: The neuromuscular control of standing balance is known to be impaired after stroke. The purpose of this study was to explore the role of anticipatory reactions in responding to external perturbations. Methods: Subjects post-stroke, and age-matched controls, stood with each foot on a separate force platform. Subjects explored their anterior limits of stability (LOS) by leaning as far forward as possible about the ankles without lifting the heels. External loads of 2% of body weight were applied at the level of the hips to perturb the subject anteriorly. Ten loads were applied either by the investigator or were triggered by the subject. High-density surface electromyography of the calf muscles (multi-channel arrays covering soleus, medial and lateral gastrocnemius), center of pressure (CP) measurements, and electrodermal activity (EDA; measurement of physiological arousal) were taken. Results: Subjects post-stroke have lower LOS in the paretic leg compared to the non-paretic leg and healthy controls. During investigator-triggered external load drops, the CP excursion in people with stroke moved anteriorly similar to controls (~80% LOS), although the peak CP excursion was reached quicker in controls. In the subject-triggered condition, healthy subjects showed a reduction in the CP excursion; however, this was not demonstrated post-stroke. The relative activity of soleus compared to medial and lateral gastrocnemius was lower in the paretic muscle than in the non-paretic leg or controls. Both triggered conditions elicited an increase in EDA in stroke compared to controls. Conclusions: Subjects post-stroke had higher physiological arousal during the external perturbations in both types of triggered conditions. Whereas healthy subjects changed their motor performance when the perturbation was self-triggered, the subjects post-stroke did not. The soleus muscle appeared to be more compromised than the gastrocnemius heads. Together these findings further illustrate the impairments of neuromuscular control of standing balance.
Effect of Intensive Functional Electrical Stimulation Therapy on the Upper Limb Motor Recovery After Stroke: Single Case Study of a Chronic Stroke Patient
Kawashima, N1, 3, 2 Popovic, MR3, 2 Zivanovic, V3, 2; 1. Research Institute of National Rehabilitation Center for Persons with Disability, Saitama, Japan; 2. University of Toronto, Toronto, ON; 3. Toronto Rehabilitation Institute, Toronto, ON
Purpose: Previous successful randomized controlled trials show that functional electrical stimulation (FES) therapy can restore voluntary arm and hand function in people with severe stroke. The purpose of this study was to examine neuromuscular changes occurring in the upper limb of people with severe stroke following intensive FES therapy, consisting of task-specific upper-limb movements with a combination of preprogrammed FES and manual assisted motion. Methods: The patient was a 22-year-old woman who had suffered a haemorrhagic stroke 2 years earlier. FES therapy was administered for 1 hour twice daily for 12 weeks, for a total of 108 treatment sessions. Results: While maximal voluntary contraction level of the upper-limb muscles did not show significant improvement, the ability to initiate and stop the muscle contraction voluntarily was regained in several upper-limb muscles (approx. 5%–15% of the maximum voluntary contraction of the same muscle in the less-affected arm). A reduction in arm spasticity was also observed, as indicated by the reduction of H-reflex in the wrist flexor muscle (82.1% to 45.0% in Hmax/Mmax) and decreased Modified Ashworth Scale scores (from 3 to 2 for the hand and 4 to 3 for the arm). Coordination between shoulder and elbow joints during the circle-drawing test improved considerably over the course of FES therapy (at baseline, the patient was unable to draw a circle; however, she was able to do so proficiently at discharge). Conclusion: Improvements in upper-limb function observed in people with severe stroke following intensive FES therapy can be attributed to (a) regained ability to voluntarily contract muscles of the affected arm, (b) reduced spasticity and improved muscle tone in the same muscles, and (c) increased range of motion of all joints.
Change in Rehabilitation Clinicians’ Practices Related to Upper Limb Management Post-Stroke Over the Past Year: Do Changes Align with Best Practice Guidelines?
Purohit Jadav, R1, 2 Korner-Bitensky, N1, 2 Menon, A1; 1. McGill University, Montréal, QC; 2. Centre de recherche interdisciplinaire en réadaptation du Montréal métropolitain (CRIR), Montreal, QC
Background: Upper limb motor impairments are prevalent after stroke. Although there is a recent version of Canadian Best Practice Guideline 2010 (CBPG-2010) integrating precise and updated information about upper limb assessment and management post-stroke, it is unknown if occupational therapists (OTs) and physical therapists (PTs) have introduced any changes to their management of upper limb dysfunction. Thus, the aim of this study is to explore change (or lack thereof) in upper limb management post-stroke by OTs and PTs in a 12 month period in 2012, as well as facilitators and barriers related to change using a standardized tool, the Professional Evaluation & Reflection on Change Tool (PERFECT tool). (available online at www.strokengine.ca/) Methods: A convenience sample of 25 PTs and 25 OTs, working in inpatient stroke rehabilitation were recruited from two provinces in Canada. The PERFECT tool was administered using a telephone interview (30 to 45 minutes in duration). Content analysis was performed to examine changes in clinical practice over a 12 month period according to four components of patient management as measured using the PERFECT: problem identification, assessment, treatment and referral. Descriptive analyses identified the key facilitators of change; and whether changes were “evidence-based” or not. Results: The prevalence of change in all four areas of practices (problem identification, assessment, treatment practices and referral practices) related to upper limb management post-stroke will be presented. Additionally, key facilitators of evidence-based change are described. Conclusion/expected contribution: Millions of dollars have been spent in an effort to identify effective management of the upper limb post-stroke. This study contributes to our understanding of the uptake of the evidence specific to upper limb management post-stroke and assists in planning knowledge translation (KT) interventions that promote the implementation of evidence into practice.
Clinical-Research Platforms as a Model of Knowledge Translation to Promote Best Practices in Stroke Rehabilitation
Richards, CL1 Nadeau, S2 Fung, J3 Rossignol, S4 Doyon, J4; 1. Université Laval and CIRRIS Research Center, Quebec, QC; 2. Université de Montréal, Montreal, QC; 3. McGill Universityand CRIR Research Center, Montreal, QC; 4. Université de Montréal, Montreal, QC
Background: The Canadian Institutes of Health Research-funded Sensorimotor Rehabilitation Research Team unites researchers from Université de Montréal, Université Laval and McGill University, 3 Research Centers and the stroke units of 3 Rehabilitation Centers (RC) in Quebec. Led by 5 Principal Investigators (PIs), it includes 25 researchers (neuroscientists and clinical researchers) with expertise in the recovery of sensorimotor function and imagery of the brain and clinicians from the RCs. It aims to implement clinical-research platforms (CRPs) in the RCs to optimize rehabilitation and to develop and evaluate innovative therapeutic approaches. Methods: First, researchers and clinicians in all 3 RCs agreed to use common clinical outcome measures to document patient profiles and their progression in stroke rehabilitation. Then, to determine the gaps between current practice and best practices, clinicians responded to a questionnaire on the SurveyMonkey web-platform and patient charts were audited. Information on intensity and categories of therapy patients received was collected for each discipline over a 5-day week. Researchers agreed on standardised laboratory evaluation protocols and outcome measures of gait and balance analysis, evaluation of pain, and imagery. Results: In each RC, a baseline on the type and intensity of interventions has been documented. The gap analysis has identified areas for improvement with the help of the clinical researchers. More importantly, CRPs are being implemented as all the RCs are now collecting information on the patients using similar outcome measures, and patient evaluations in the laboratories have commenced to inform the clinicians. Conclusions: The CRPs, in addition to informing clinical practice, and creating a data bank of standardized outcomes, are now ready to embark in clinical research projects whereby the clinicians will carry out innovative interventions inspired by interactions among the team members. The challenge in upcoming years will be to demonstrate the benefits of these CRPs on rehabilitation outcomes.
The Proposed Quebec Rehabilitation Stroke Strategy: a Patient-Centered Approach From Onset to Community Integration
Richards, CL1 Clément, L2 Expert Committee2; 1. Université Laval and CIRRIS Research Center, Quebec, QC; 2. Quebec Ministry of Health and Social Services (MSSS), Quebec, QC
Background: As part of the development of the Quebec Stroke Strategy a Committee that brought together experts in different aspects of the rehabilitation continuum, from acute care to community integration, was given the mandate by the MSSS to propose optimal rehabilitation trajectories based on best practices. Methods: Members of the committee met 12 times, mostly by visio-conference and also worked in sub-committees between February 2012 and January 2013. In addition to reading previous reports and key publications, the committee invited experts to give presentations on subjects such as: stroke units, prevention, community integration, geriatric trajectories, and telerehabilitation. Perceptions of patients and caregivers as well as clinicians of the present rehabilitation continuum were obtained by focus groups and a web-based questionnaire, respectively. Results: The findings revealed numerous areas for improvement: communication, trajectories, evaluations, therapeutic approaches, length of stay in acute care and in-patient rehabilitation and outpatient rehabilitation services. The Committee proposes a patient-centered model inspired by the Canadian Stroke Strategy adapted to the Quebec system. Key elements include: well defined outcome measures, uniform best practices and trajectories, standardisation of the care and services offered, services to support persons post stroke and their caregivers living in the community. Structural elements are: stroke units, prevention clinics, a rehabilitation triage system, an early supported discharge system, a patient-support coordination system, systematic follow-ups and community integration programs with strong links to primary care services. Guiding principles include: patient empowerment and shared decision-making, caregiver participation, accessibility of services for all with a rehabilitation potential, continuity in evaluations, therapy and services, and long-term follow-up of patients to promote maintenance of gains. Conclusions: The committee report was submitted May 1st to the MSSS. Implementation of the recommendations will provide Quebec with a patient-oriented rehabilitation continuum based on best practices that promotes the community reintegration of persons post stroke.
Moderate Aerobic Exercise Acutely Increases Cerebral Blood Flow to the Insula and Hippocampus in Chronic Stroke
Robertson, AD1 Crane, DE1 Shirzadi, Z1 Rajab, S1 Marzolini, S2 Middleton, LE1 MacIntosh, BJ1; 1. HSF Centre for Stroke Recovery, Toronto, ON; 2. Toronto Rehabilitation, Toronto, ON
Background: Aerobic exercise, as a tool in stroke rehabilitation, improves peak aerobic fitness and functional performance. The purpose of this study was to assess the impact of acute exercise on regional brain perfusion. Two exercise intensities (i.e. light and moderate) were contrasted to offer insight into post-stroke exercise prescription. Methods: Six participants (56 ± 15 years of age; 2 women) were recruited at the chronic stage of stroke recovery (14 ± 3 months) and participated in three exercise sessions. The first session involved a symptom-limited cardiopulmonary assessment of peak fitness. Subsequent sessions involved 20-minute exercise bouts on a semi-recumbent cycle ergometer, randomized between 50 % (light) or 70 % (moderate) of peak work rate. Magnetic resonance imaging was performed using a pseudo-continuous arterial spin labeling protocol to quantify cerebral blood flow (CBF) prior to, and at two time points (~ 30 and 55 min) following, exercise. In this preliminary analysis, 7 brain regions were examined for changes in CBF over time, after a total grey matter normalization to remove global CBF effects. Results: In repeated-measures analyses, there was a significant time x intensity interaction in the hippocampi (P = 0.011, unadjusted), with elevated CBF following moderate-intensity cycling. In addition, the insula showed a trend towards the main effects of time and exercise intensity (P = 0.098, P = 0.069, respectively), with higher CBF being observed following the cycling bout, and in the moderate-intensity trial. No effect was noted in the middle frontal, precentral, or postcentral gyri; caudate nucleus; or precuneus regions. Conclusions: Preliminary results suggest that the insular and hippocampal brain regions have relative increases in CBF following cycling, which appear to last at least one hour post-exercise. Moderate exercise intensity may be necessary to achieve this increased perfusion. Funding: HSF Centre for Stroke Recovery Hakim Innovative Stroke Research Award.
Challenges in Opening the Black Box of Rehabilitation Services in Quebec
Poissant, L1 Rochette, A1 Ahmed, S2 David, I3 Lebrun, L3 Lindsay, P4 Swaine, B1; 1. Université de Montréal, Montréal, QC; 2. McGill University, Montreal, QC; 3. Centre de recherche interdisciplinaire en réadaptation, Montreal, QC; 4. Canadian Stroke Network, Toronto, QC
Background: The contribution of rehabilitation to reduce disability, limitations and restrictions of persons with stroke and facilitate the resumption of meaningful roles is well documented. While there is agreement that rehabilitation makes a difference, little is known on the type of services provided by the different rehabilitation providers across the continuum of care. Through partnership with the Quebec Ministry of Health and Social Services (MSSS), our team proposes to: i) capture gaps between current rehabilitation practice and the Canadian recommendations, and, ii) characterize rehabilitation services (who, when, what and how). Methods: An audit tool and a questionnaire were developed using various sources of information (experts, Stroke guidelines, INESS reports, etc). The audit tool will be pilot tested in six organizations (two acute care hospitals, two rehabilitation hospitals and two out-patient rehabilitation centres). The questionnaire will also be tested and sent to stroke managers of these organisations. Results: These pilot data will inform on the availability and quality of information required to assess rehabilitation services across the continuum in the rehabilitation process. It will also inform on the challenges in documenting potential gaps and variability to known stroke guidelines. Conclusions: This pilot project is a first step towards a provincial audit of rehabilitation services to be conducted in the fall to determine the portray of stroke rehabilitation pre-implementation of the stroke care continuum.
The influence of a single bout of aerobic exercise on speed of processing and muscle activity in stroke
Sage, MD1 Roy, E2 Brooks, D1 Beyer, KB2 McIlroy, W2; 1. University of Toronto, Graduate Department of Rehabilitation Science, Toronto, ON; 2. University of Waterloo, Kinesiology Department, Waterloo, ON
Background: Research in healthy individuals suggests that aerobic exercise may prime the central nervous system (CNS) and if delivered to stroke patients prior to neurorehabilitation may facilitate neurological recovery by augmenting the state of the CNS at the time of active rehabilitation. The objective was to provide an understanding of the influence of a single session of lower-limb aerobic exercise on upper-limb reaction time (RT) and amplitude of muscle activity within a stroke population. Methods: Fourteen stroke participants (mean age=54.9, median 56 days post-stroke) performed 20 minutes of lower-limb aerobic exercise (mean heart rate=54.4% of age-calculated max). Upper-limb simple and choice RT was evaluated pre-, during and immediately post-exercise using both limbs. Participants either extended their wrist or flexed their biceps (depending on functional ability) in response to a target arrow which pointed left or right (only one direction for simple RT). RT was measured using electromyography (EMG) onset. EMG activity was also used to evaluate amplitude of contraction. Results: During exercise, the non-statistically significant trend was for slower RT and maintenance of EMG amplitude. After exercise, mean simple RT was 21 and 15ms faster for the affected and non-affected arms respectively; however, across the group this was not statistically significant. Within-subject analysis revealed 3 individuals with significantly faster RT (≥19%) after exercise and 6 others with moderately faster RT (>3.5%). The threshold of 3.5% was considered significant change in previous studies of healthy adults. There were no significant relationships between individual characteristics and the effect of exercise. Conclusions: Exercise appears to facilitate information processing in some individuals after stroke; however, high variability appears to be impacting the ability to detect statistically significant group differences despite seemingly large RT changes. There is a need to reveal the individuals or task-related determinants that may account for the exercise effects after stroke.
Predicting Language Recovery after Stroke Using Variability of Performance and Complexity of Functional Connectivity
Schmah, T1 Duncan, ES2 Yourganov, G3 Zemel, RS4 Small, SL5 Strother, SC3; 1. University of Toronto, Toronto, ON; 2. Departments of Cognitive Science and Neurology, University of California, Irvine, CA, USA; 3. Rotman Research Institute, Baycrest, and Institute of Medical Science, University of Toronto, Toronto, ON; 4. Department of Computer Science, University of Toronto, Toronto, ON; 5. Departments of Neurology, Neurobiology and Behavior, and Cognitive Sciences, University of California, Irvine, Irvine, CA, USA
Background: A fifth of people with stroke have persistent aphasia. In a longitudinal study of aphasia treatment, we hypothesized that language improvement would be predicted by intra-individual variability (IIV) of performance and complexity of brain functional connectivity. Methods: 15 individuals with aphasia due to stroke completed 6 weeks of intensive therapy in which they repeated words and phrases presented audiovisually. Repetition accuracy was tested immediately before and after the treatment. All words were scored on a 5-point scale, with IIV measured by standard deviation. Immediately before treatment, we acquired whole-brain BOLD functional MR images, incorporating one “imitation” run, in which subjects viewed and repeated 4 audiovisually-presented syllables, and two “rest” runs. Metrics of complexity of functional connectivity included two estimates of intrinsic dimension of the voxel covariance matrix implemented in FSL Melodic (Beckmann & Smith): Laplace approximation to Bayesian evidence (LAP) and Minimum description length (MDL). Pretreatment performance mean and IIV, pretreatment fMRI metrics evaluated on task and rest runs separately, and age and time since stroke onset were evaluated for their power to predict improvement in mean repetition accuracy over the course of treatment. Results: Ordinary least squares regression, using fMRI metrics evaluated on imitation runs (only) together with the behavioral variables, explained 44% of the variance in improvement, in independent prediction of recovery using leave-one-out cross-validation. The significantly predictive variables were: mean and IIV of performance, and LAP (evaluated on imitation runs). Lower mean performance,higher IIV and higher LAP predicted greater improvement. None of the metrics of resting state fMRI were predictive of improvement. Conclusions: Aphasia treatment outcome can be predicted from pretreatment performance mean and IIV and pretreatment task-based fMRI, with higher IIV and higher complexity of functional connectivity associated with greater improvement.
Beckmann, C.F., Smith, S.M. IEEE Transactions on Medical Imaging, 2004
Influence of Cognitive Deficits on the Ability to Use Feedback for Arm Motor Recovery in Chronic Stroke
Subramanian, SK; School of PT and OT, McGill University, Montreal, QC
Background: Feedback provision during training is an essential component of motor learning that improves upper limb motor recovery in individuals post-stroke. Along with sensorimotor impairments, stroke survivors have cognitive impairments (depression, memory, attention, mental flexibility, problem-solving, visuoperception) which can influence motor learning. However, whether cognitive impairments limit the ability to use feedback for motor recovery remains unclear. We evaluated whether and to what extent cognitive deficits are associated with the ability to use feedback for upper limb motor learning and recovery. Methods: Participants (61.2±10yrs) practiced pointing movements in a random sequence 72times/session to 6 targets (12trials/target; 3sessions/wk; 4wks) either in a physical (PE;n=12) or virtual environment (VE;n=12).Terminal auditory feedback was provided about movement speed (knowledge of results) and trunk displacement (knowledge of performance). Changes in movement kinematics (movement speed, elbow extension (ElbExt), shoulder horizontal adduction (ShHor), shoulder flexion (ShFl) and trunk displacement) were assessed before, immediately after (POST) and 3mos (RET) after task practice. Depression and cognitive functioning were assessed with a comprehensive neuropsychological examination. Repeated-measures ANOVAs analyzed changes in kinematic outcomes. Multiple regression analyses estimated the strength of the association between kinematic changes (dependant variables) and cognitive scores (predictors). Results: Participants training in the VE tended to make faster movements and had greater improvements in kinematic measures (increased ElbExt, ShHor and ShFl ranges and less trunk displacement) compared to the PE group. Individuals who had fewer deficits in memory, cognitive flexibility and lower depression levels made greater improvements in kinematics immediately after training (POST). Kinematic improvements were retained (RET) better in those who had higher memory scores, visuoperception ability and lower depression levels. Conclusions: Cognitive ability was associated with the capacity to use feedback for upper limb motor learning and recovery. Information about cognitive deficits can help clinicians select the most appropriate interventions to maximize arm motor recovery post-stroke.
The Sensitivity and Specificity of the MoCA and MMSE as Compared to the Cognistat in a Stroke Rehabilitation Population
Friedman, L2 McClure, A2, 3 Speechley, M4 Teasell, R1; 1. Department of Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry, UWO, London, ON; 2. Lawson Health Research Institute, ARGC, London, ON; 3. St. Joseph’s Health Care, London, ON; 4. Western University, Department of Epidemiology and Biostatistics, London, ON
Objective: To identify the better of two commonly used screening tools for detecting probable cognitive impairment in stroke rehabilitation patients using Cognistat as the “gold standard”. Methods: Stroke patients admitted to an inpatient rehabilitation unit from August 2011 to March 2012 were screened for inclusion eligibility. At the time of admission, the Mini Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) were administrated by an occupational therapist, whereas the Cognistat was administered by a student investigator. Published cutoff scores of 24 for MMSE and 26 for MoCA were used to establish the presence of cognitive impairment. Results: 76 of 144 consecutive admissions (53%) met inclusion criteria and completed the study. 68 patients were excluded from the study: 44 aphasic, 9 non-English speaking, 4 refused to participate, and 11 did not participate for other reasons (i.e. too sick to continue). The mean age of the study sample was 67.6 (SD 15.1) years. Mean MMSE and MoCA scores were 26.5 (SD 3.4) and 20.9 (SD 5.3), respectively. The mean Cognistat composite score (sum score of all domains) was 62.9 (SD 10.1) out of a possible 82 points. When cognitive impairment was diagnosed as impaired in one domain of the Cognistat, MMSE sensitivity and specificity was 35.7% and 100%, respectively, while MoCA sensitivity and specificity was 90% and 33.3%, respectively. When diagnosis of cognitive impairment was defined as impairment in two domains of the Cognistat, MMSE sensitivity and specificity was 43.6% and 95.2%, respectively, while MoCA sensitivity and specificity was 90.1% and 19.1%, respectively. Discussion: MMSE had poor sensitivity and good specificity while MoCA had good sensitivity but poor specificity when compared to Cognistat as the gold standard. Based on these results, the MoCA appears to be the superior screening tool based on greater sensitivity.
Default-Mode Network’s Implication in Language and Therapy-Induced Recovery in Chronic Aphasia
Tremblay, FB1 Marcotte, K1 Durand, E1, 2 Ansaldo, A1, 2; 1. Université de Montréal, Montreal, QC; 2. Institut Universitaire Gériatrique de Montréal, Montréal, QC
The alteration of large-scale neural networks not primarily known to be implicated in language may explain the pervasive disorders occurring after stroke’s localised lesions, namely aphasia. It is observed that the default-mode network (DMN) is engaged in semantic processing and that the disruption of its functional connectivity is associated with cognitive and semantic disorders in different neuropathologies. Even though its implication in language production is still unclear, the DMN exhibits neuroplastic changes in conjunction with language recovery induced by therapy in chronic aphasia.
Nine subjects (5 men and 4 women) who have chronic aphasia secondary to a left-hemisphere stroke (between 4 and 25 years post-stroke) are matched with ten control participants (4 men and 6 women). All participants are right-handed native French-speakers. Subjects of the patient group engage in an intensive naming therapy targeting noun and verb production, the Semantic Feature Analysis (SFA). The groups undergo two fMRI sessions, prior- and post-treatment, during picture naming. Functional connectivity data is then processed using spatial Independent Component Analysis (sICA) in Nedica, a program designed to compute integration values in networks of interest: the DMN and the Language Network (LN). A disruption between the anterior and posterior subnetworks of the DMN is salient in the patients’ group. They all show significant improvement in object and action naming after SFA. While no significant concurrent change is observed in the LN, the DMN’s functional connectivity increases in conjunction with the behavioral improvement, and it is predictive of therapy benefits. Still, the integration values of the DMN and the LN are highly correlated during picture naming. Moreover, noun and verb naming exhibit distinctive functional connectivity within the DMN. Functional connectivity measures of the DMN unveil its contribution to semantic processing and its implication in language recovery after aphasia therapy.
Implementing a Formal Procedure for Team Decision-Making Based on an Algorithm for Screening Driving Ability and the Need for On-Road Assessment
Gauthier, J3, 1 Tremblay, L1 Couve, M1 Hazel, M2 Rioux, M2 Higgins, J3, 4 Beaudoin, N2, 3 Crabb, S2 Lachance, K2 Leclaire, H2 Gagnon, A2 Guerrera, R2 Patenaude, C4; 1. Institut de réadaptation Gingras-Lindsay-de-Montréal, Montréal, QC; 2. IRGLM, Montréal, QC; 3. Centre de recherche interdisciplinaire en réadaptation du Montréal métropolitain site IRGLM, Montréal, QC; 4. Université de Montréal, Montréal, QC
Background: According to a survey among rehabilitation professionals from the neurology programme at Institut de Réadaptation Gingras-Lindsay-de-Montréal (IRGLM), screening for driving ability and the need for on-road assessment is difficult and informing a client they should not be driving is a delicate matter and should not be the burden of one person. Since stroke typically causes an array of deficits that can affect driving ability, all rehabilitation professionals should be involved in the evaluation, in the decision making as well as in informing the client and their family. Methods: A variety of different tests routinely used by the team and validated in the literature to predict on-road driving performance were identified through a chart review and included in a decision-making algorithm. Only the most informative items from each of the tests were included based on Rasch analyses. Elements of this algorithm were integrated into a grid. Results: An algorithm detailing important aspects to be assessed for driving ability was developed and integrated into an interdisciplinary grid. A formal procedure comprising the systematic filling of the grid by all the members of the team was created. The procedure includes the systematic use of the algorithm for screening driving ability of the client thereby ensuring interdisciplinary assessments and identification of all possible deficits that could lead to an inability to drive and a team decision. Conclusion: A procedure for screening driving ability by the systematic use of an interdisciplinary grid that includes validated test items and based on a decision algorithm is now implemented. Decision-making is shared equally by all professionals involved in the client’s care thereby increasing the confidence of professionals in the decision making process and creating a united front for announcing a decision to a client.
Who benefits from intensive aphasia programs: Preliminary Outcomes from the InteRACT program
Wozniak, LA; Kostopoulos, EJ; Dalhousie University, Halifax, NS
Aphasia is a communication disorder affecting expressive language, auditory comprehension, reading and/or writing following brain injury. It has been reported that up to 35% of adults have symptoms of aphasia following stroke.
Intensive therapy for individuals with aphasia has been supported in the literature. However, little is known about the characteristics of individuals who attend these programs and what factors may predict who makes clinically significant changes when attending such a program. Since 2002, Dalhousie University has run the Intensive Residential Aphasia Communication Therapy (InteRACT) program. The 4.5 week program offers 100+ hours of speech and language therapy which facilitates community re-integration and promotes quality of life for individuals with aphasia and their communication partners. The program is structured with an interprofessional focus, providing physiotherapy and recreation therapy in addition to communication treatment. Individuals with aphasia must attend with a communication partner from home (family member or friend) to support carry-over of strategies and techniques when the individual returns home. Pre and post outcome data was analyzed for 71 patients who attended the program from 2002-2012. Results showed that individuals who attend the program tend to be middle age and predominantly male. Three outcome measures which assess the impairment, activity and participation levels of communication were analyzed; The Western Aphasia Battery (AQ), Communicative Activities of Daily Living and the Communicative Effectiveness Index, respectively. Clinical outcomes were analyzed for both statistical significance pre and post treatment as well as clinical significance. It was found that age, gender and time post onset of aphasia were not significant predictors of improved outcome on measures of language ability or functional communication. The results demonstrate that adults with aphasia in either the acute or chronic phase of recovery and of all ages can continue to show positive improvements in language ability with intensive treatment.
Pharmacists as Care Providers for Stroke Patients: a Systematic Review
Basaraba, J; George-Phillips, K; Mysak, T; Alberta Health Services, Edmonton, AB
Background: The role of the pharmacist has expanded to a more clinically oriented practice in a variety of healthcare settings. Although evidence supporting their role in the care of patients with other disease states is well established, minimal literature has been published evaluating pharmacist interventions in stroke patients. The purpose of this systematic review is to summarize the evidence evaluating the impact of pharmacist interventions on stroke patient outcomes. Methods: Study abstracts and full-text articles evaluating the impact of any pharmacist intervention on outcomes in patients with an acute stroke/TIA or a history of an acute stroke/TIA were identified. A meta-analysis was not performed. Results: Twenty-six abstracts and full-text studies were included. The included studies provided evidence supporting pharmacist interventions in multiple settings including: emergency departments, inpatient, outpatient, community pharmacy, and long-term care settings. In the majority of the studies, pharmacist care was collaborative with other healthcare professionals. Some of the pharmacist interventions included participation in a stroke response team, assessment for thrombolytic use, medication reconciliation, participation in patient rounds, identification and resolution of drug therapy problems, risk factor reduction, and patient education. Examples of outcomes include a reduction in time to thrombolytic administration, increased medication adherence, patient satisfaction, and blood pressure and/or lipid control. Conclusions: The available evidence suggests that a variety of pharmacist interventions can have a positive impact on stroke patient outcomes. Further research should be conducted to add to the current body of literature.
Delivering Cme Accredited Provincial Stroke Rounds in Ontario: How OREG Has Made it Work From 2008 - Present
Bursey, SJ1 Beal, J2 Edwards, EK3 Thornton, M4; 1. NEO Stroke Network, Sudbury, ON; 2. Southwestern Ontario Stroke Network, London, ON; 3. TBRHSC, Thunder Bay, ON; 4. Champlain Regional Stroke Network, Ottawa, ON
Background: In 2008, Ontario Regional Education Group (OREG) launched a stroke education series called Provincial Stroke Rounds delivered via videoconference. In its infancy, Rounds focused on acute care with Ontario’s stroke neurologists serving as expert presenters with the target audience being physicians. The initiative has evolved to attract full representation of an interprofessional stroke healthcare team. Both presenters and attendees have varied clinical/academic backgrounds and represent the stroke care continuum. Methods: Provincial Stroke Rounds occurs 6 times per year, as one hour didactic presentations. 11 Ontario Stroke Regions share hosting duties and collaborate with Ontario Telemedicine Network (OTN) to support registration; videoconference platforms; archiving; and technical aspects. The Northern Ontario School of Medicine (NOSM) provides accreditation with 1 Mainpro-M1 credit and 1 hour Accredited Group Learning Activity. Host regions follow a standardized step-by-step guide focused on consistent organization; promotion and delivery of the program. A promotional poster is created and disseminated and participant handouts are provided. Evaluation forms, consisting of short answer and likert scale questions, are scanned/collated at NOSM for summary report generation. Provincial education needs assessments have been conducted to determine learning needs. Results: 36 live Rounds have been offered since 2008, with 40-60 provincial sites joining each event. In 2012, approximately 1000 participants attended live events with 120 more accessing archived webcasts at a later date. The topics chosen are timely, relevant, evidence-informed and span the stroke continuum. Technological difficulties using videoconference are rare and mitigated quickly. Participants state overall satisfaction with the learning opportunity. Conclusions: Provincial Stroke Rounds enables a wide reach to both urban and rural communities in Ontario. By reducing professional isolation, and delivering timely and relevant stroke care topics, Rounds enjoys a loyal following. Next steps include enhancing the knowledge translational value of the evaluation questions to include “Intent to Change Practice”.
Patient and Family Passport for Stroke: Information about Your Care, Treatment and Recovery
Cole-Haskayne, AL; Beaver, L; Suddes, M; Darren, K; Foothills Medical Centre, Calgary, AB
Background: Stroke patients were given educational information throughout hospitalization. Duplicate and inconsistent information was provided. Expectations of information and topics to be covered were not set. Patient experience data showed opportunities for improving patient education and support. Stroke survivors felt they were not prepared for discharge and did not have the right information. Methods: A multidisciplinary improvement team across the continuum was established and based on feedback from patients the “Patient and Family Passport for Stroke” was created. The goal was to provide consistent information, improve patient centred care throughout the continuum and patient safety. The Passport follows Canadian Best Practice Recommendations, and Accreditation Canada standards for excellence in stroke care. Staff documentation expectations outlined the information to be covered throughout the stay. Results: 1500 Passports have been issued since May 2012. The Passport saves staff time by providing a complete package of education materials which can be individualized. It assists patients with recovery and provides needed resources throughout transitions. Passports have been well received by patients, and staff. Surveys were conducted to assess patient experience and satisfaction. A statistically significant increase in positive patient experience and higher rates of positive experience were shown compared to other Provincial zones. Patient experience ratings show positive results 71-93%, regarding: understanding the stroke information and resources, having needs and wishes acknowledged, participation, and being able to deal with life events. Conclusion: Numerous requests have been received for the passport which is now available electronically. Readmission rates for stroke related causes remains low and has not changed significantly in the last two years, but there has been a statistically significant reduction in the average length of stay on the acute stroke unit. The introduction and use of the Passport may have contributed to this by improving patient and family education and support.
Regional Acute Stroke Care in British Columbia’s Lower Mainland
Curry, M1, 2 Emes, D1 Hastings, R1; 1. Fraser Health Stroke Strategy, Vancouver, BC; 2. University of British Columbia, Vancouver, BC
Background: Fraser Health is British Columbia’s most-populated regional health authority serving over 1.6 million residents extending from the Vancouver suburb of Delta on the Pacific coast up the Fraser Valley to rural Boston Bar. Twelve hospitals operate in the region with all sites receiving cerebrovascular cases and with tertiary neurologic and neurosurgical care being provided at the Royal Columbian Hospital in New Westminster. Timely assessment and management of cerebrovascular disease has been shown to affect outcomes. Methods: All cases identified as possible acute strokes at the time of Emergency Department triage in Fraser Health were tracked starting in January 2013. The timing of initial symptom onset, emergency department arrival, triage assessment, emergency physician assessment, computed tomography and, if applicable, time of angiography and intravenous thrombolysis administration were tracked across all sites. Other markers of quality acute stroke care were also tracked including whether patients’ blood glucose levels were measured and recorded, whether a baseline electrocardiogram was recorded, whether antiplatelet therapy was initiated and whether a swallowing screen was performed. Results: To date 177 patients have been tracked. There was substantial variability in the time of various stages of assessment of acute strokes both amongst patients and across the various hospitals in Fraser Health. Recorded compliance with markers of quality acute stroke care was suboptimal. Conclusions: In a large health region substantial variability in the time to assessment of acute strokes exists. Areas for improvement in clinical care have been identified.
Knowing Each Other’s Work Across the Stroke Care System: Development of Essential Professional Conversations for Seamless Care
Darling, S1 Quant, S2, 5 Avinoam, G1 Fortin, J2 Skrabka, K8 Richardson, D3, 7, 4 Linkewich, B2, 6 Willems, J8 Sharp, S1, 5; 1. Toronto West Stroke Network, Toronto Western Hospital, University Health Network, Toronto, ON; 2. North & East GTA Stroke Network, Sunnybrook Health Sciences Centre, Toronto, ON; 3. Toronto Rehabilitation Institute, UHN, Toronto, ON; 4. Royal College of Physicians and Surgeons of Canada, Toronto, ON; 5. Department of Physical Therapy, Faculty of Medicine, University of Toronto, Toronto, ON; 6. Northern Ontario School of Medicine, Thunder Bay, ON; 7. Division of Physiatry, Faculty of Medicine, University of Toronto, Toronto, ON; 8. South East Toronto Stroke Network, St. Michael’s Hospital, Toronto, ON
Background: People with stroke (PWS) experience fragmented care since multiple health care providers (HCPs) are involved. System stakeholders also identified the time of patient transitions as an opportunity to significantly impact their quality of care. Specifically, verbal exchange between HCPs has been considered important for successful patient transitions by enabling exchange and clarification of unique patient information; familiarity with other practice environments; relationship development and collaboration. Hence, to develop a system-wide initiative to improve patient transitions, the Toronto Stroke Networks further explored HCP perceptions of the impact of conversations on the care that they provide and transition experiences for PWS. Methods: Using an Appreciative Inquiry approach, 20 HCPs from across the Toronto stroke system were interviewed regarding their conversations with other HCPs at the time of patient transitions. Interviews were analyzed for themes to inform the development of a system-wide initiative. Results: Themes identified included value in conversations, challenge of engaging in conversations in a complex stroke care system, and the need to enable and enhance conversations. Based on these themes, an adaptive change initiative called Essential Professional Conversations for Seamless Care (EPC) was developed and has been implemented within 4 Toronto acute and rehabilitation hospitals. Specifically, education and implementation tools were developed to enable and enhance conversations, effect positive change within the system, and improve transitions for PWS. Conclusions: The need to enable and enhance conversations amongst HCPs has been identified as a key component for optimizing transition experiences for PWS. This work has led to the development and implementation of EPC within Toronto. Anticipated outcomes from EPC include an increase in cross-system conversations, enhanced relational strength, increased comfort with/opportunity for interorganizational collaboration, greater efficiency/effectiveness of patient care, more individualized care using hopeful language, and increased comfort at the next stage of the care journey for PWS.
Value Creation from Interprofessional Collaboration Among Stroke Healthcare Providers Using Social Media Technology
Fortin, JE1 Skrabka, K2 Avinoam, G3 Willems, J2 Sharp, S3 Linkewich, E1; 1. North&East GTA Stroke Network / Sunnybrook Health Sciences Centre, Toronto, ON; 2. South East Toronto Stroke Network / St. Michael’s Hospital, Toronto, ON; 3. Toronto West Stroke Network / University Health Network -TWH, Toronto, ON
Background: The Toronto Stroke Networks (TSNs) Virtual Community of Practice (VCoP) utilizes a secure social media technology platform. It was built to support the interprofessional collaboration (IPC) goals of the TSNs Education and Knowledge Translation (KT) plan. This interactive KT model requires a dynamic and meaningful evaluation of value creation: “…learning enabled by community involvement and networking” (Wengar, 2011). A detailed evaluation is also needed to provide evidence to improve functioning, inform further development, and identify future directions of the VCoP. Methods: An evaluation framework was developed to assess the efficacy of the VCoP as a contributor to meaningful IPC of stroke healthcare providers across the TSNs. This framework integrates key developmental evaluation and knowledge translation principles. Values were assigned to participants’ descriptions of how specific aspects and experiences have influenced knowledge transfer and changes in practice. The VCoP was launched and advertised locally as a foundation for implementation of best practices. A screening process is used to ensure new members fit the target population of healthcare providers. Training sessions and activities were initiated across Toronto to build virtual competence and to prompt interprofessional networking and collaboration on the VCoP. Results: Preliminary results show increases in membership and feedback on the VCoP. Emerging themes emerged from initial feedback include: functionality, accessibility, and resources. Further results (quantitative and qualitative) will be captured to review 6 month outcomes. The cumulative effect of a set of narratives and value stories that inform further development of the VCoP and /or support effective collaboration on the VCoP will be the marker of efficacy of this tool. Conclusion: With increasing membership, preliminary results have concurrently informed the further development of the VCoP. The cumulative data at 6 months will provide a response to the hypothesis that the VCoP is an efficacious KT tool to support IPC.
Influencing System Change within North Simcoe Muskoka LHIN: Collaborating to Design a Model for Stroke Rehabilitation and Transition
Sooley, D; Tee, A; Central East Stroke Network - Royal Victoria Regional Health Centre, Barrie, ON
Background: Opportunities to advance stroke care were identified in North Simcoe Muskoka (NSM) Local Health Integration Network (LHIN) through development of a business case (NSM LHIN Stroke Rehabilitation Case for Change). In particular, the need for interprofessional stroke units, earlier access to rehabilitation, increased intensity of rehabilitation and increased community rehabilitation were identified. Planning for implementation of integrated stroke units is advancing in NSM LHIN; addressing the first three priorities. To influence system change and address the fourth priority of community rehabilitation, Central East Stroke Network (CESN) has collaboratively developed a NSM LHIN Stroke Rehabilitation and Transition Model. Methods: The strategic approach focused on designing an integrated system that supports effective transitions of stroke patients with an emphasis on linking care to appropriately resourced community rehabilitation and reintegration services. A Value Stream Mapping exercise engaged stakeholders in creating the desired future state. This was informed through best practices and sharing of patient stories. The future state map was then refined ensuring strategic alignment, considering local geography, demographics and resources, and was informed by leading practices from other jurisdictions. A community engagement strategy validated the draft model. Results: A NSM LHIN Stroke Rehabilitation and Transition Model was developed with input from healthcare leaders, front-line providers, persons with lived experience, their caregivers, community organizations and the general public. This preliminary model will now be used to guide planning of community rehabilitation services. It positions the LHIN well for future planning with regard to Health System Funding Reform which is expected to include community rehabilitation in future phases of Quality Based Procedures. Conclusions: The NSM LHIN Stroke Rehabilitation and Transition Model provides a framework to achieve best practice community rehabilitation and reintegration for stroke survivors. The methodology used in its development demonstrates the value of engagement and collaboration to design health system solutions.
The Benefits of Interprofessional Education (IPE) to Enhance Acute Stroke Car
Gill, S; Christie, L; Alves, M; Ellis, M; Kelly, J; Leone, A; Skinner, J; Skrabka, K; Willems, J; St.Michael’s Hospital, Toronto, ON
Background: A key feature indicated for successful organized stroke care is “specialized interest and expertise in stroke care amongst all group members of the multidisciplinary team” (Gibbon et al, 2002). The multidisciplinary stroke team at St. Michael’s Hospital worked collaboratively with Registered Nurses (RN’s) and Clinical Assistants (CA’s) to develop an interprofessional stroke education day. The education was driven by identified needs of front line stroke staff to help build on their current knowledge and expertise in stroke care. Methods: The Stroke Assessment and Treatment Team (SATT) delivered concurrent, rotational, interactive small group education sessions led by the: Clinical Nurse Specialist, Speech Language Pathologist, Registered Dietitians, Physiotherapist, and Occupational Therapist. RN’s and CA’s were split into separate groups to address different learning needs. At the end of the session, participants completed written evaluations that used a survey format with a five point Likert scale with opportunities for comments. Results: There were a total of forty-six RN and CA participants in the four sessions provided. They all completed a five point Likert scale to evaluate the organization, relevance, content, written materials and discussion/participation of the four sessions (87% response rate). Of those evaluations completed, 97.5% rated the sessions and the components as either excellent or very good. Written feedback was very positive with identified themes including applicability, new learning and desire for further education. Conclusions: Overall the Interprofessional Education (IPE) sessions were very well received by all staff. These sessions have created a positive momentum amongst clinicians caring for stroke patients. Partnering with front line staff in developing education that fits their needs is imperative to successful learning. The sessions were relevant, practical and included active participation which, are key principles in staff engagement and motivational learning.
A Tool to Assess Language Barriers to Stroke Services: the Communicative Access Measures for Stroke
Kagan, A1 Simmons-Mackie, N2 Victor, JC3 Mok, A1 Sharp, S4 Linkewich, B5 Willems, J6 Conklin, J7; 1. Aphasia Institute, Toronto, ON; 2. Southeastern Louisiana University, Hammond, LA, USA; 3. Institute for Clinical Evaluative Sciences, Toronto, ON; 4. Toronto West Regional Stroke Network, Toronto, ON; 5. North East GTA Stroke Network, Toronto, ON; 6. South East Toronto Stroke Network, Toronto, ON; 7. Concordia University, Montreal, QC
Background: Research and outcome evaluation targeting systems level change related to communicative access to information and decision making for patients with stroke and aphasia is limited by lack of an appropriate tool to quantitatively capture change. We developed and evaluated a set of web-based Communicative Access Measures for Stroke (CAMS). CAMS comprises three quantitative surveys for health care facilities from the perspectives of 1) policy makers, 2) frontline health care providers, and 3) people with aphasia (using a communicatively accessible pictographic version). Methods: CAMS development included extensive input from multiple focus groups with experts from the field of stroke, aphasia, and communicative access. All questions were trialed at a geriatric and long-term care rehabilitation hospital. The web platform for CAMS is comprised of forms specifically designed to minimize completion times using skip logic and range minimums and maximums. Usability of the web-tool was trialed at several health care facilities. Questions are answered using Likert-type scales and yes/no responses. To assess reliability, three groups of participants from health care facilities (six administrators/managers, 33 frontline staff and 25 participants with aphasia) completed the questionnaires on two occasions. Data were analyzed using kappa statistics and intraclass correlations for each item score on all questionnaires. Results: Examples of the content for each of the three measures, and online CAMS access link will be included. Reliability for items on the administrator and staff surveys was moderate to high (Kappa/ICCs ranging from 0.54 to 1.00). Although reliability was expectedly lower for the PWA survey, with a couple of items with test-retest ICCs < 0.15, most items had ICCs between 0.4 and 0.6. Conclusion: Preliminary findings suggest that CAMS has relevance for health care facilities with an interest in quality care improvements for patients with stroke and aphasia and others who ‘know more than they can say’.
Peer support for stroke survivors: A pilot evaluation
Kessler, D1 Egan, M1, 2 Kubina, L1; 1. Bruyere Research Institute, Ottawa, ON; 2. University of Ottawa, Ottawa, ON
Introduction: Peer support is a potentially cost effective way to enhance well-being and community reintegration of both recent stroke survivors and their peer supporters. Objectives: In-depth examination of a peer support program that provides acute care visits and telephone follow-up post-discharge. We examined a) type of support provided, b) benefits for the stroke survivor and their care partners, c) potential harms to the stroke survivors, d) impact of providing support on the peer supporter, and e) processes and resources required. Methods: Instrumental case study. Semi-structured interviews were carried out with 16 stroke survivors and 8 care partners immediately following hospital discharge and at 6-months post stroke to explore the type of support provided, perceived impact of the program, aspects of the program found to be particularly helpful, and areas for development. As well, interviews were carried out with 6 peer supporters, 3 program co-ordinators and 4 health professionals to gather feedback on the perceived impact of the program on the peer supporters, and the strengths and weaknesses of procedures used to select, train, monitor and support these individuals. In addition, administrative data were reviewed to determine program resource requirements. Results: Emotional, affirmation and information support were offered by the peer supporters. Peer visits were perceived as providing encouragement, motivation, validation and decreased feelings of being alone. However, the visits were not perceived as beneficial by all store survivors. The impact on the peer supporters included increased social connections, personal growth, enjoyment and the feeling that they had been able to make a difference in the lives of others. Involvement of the health care team and a skilled coordinator were crucial to the success the program. Program costs will be presented. Conclusion: Peer support is a valued service for some recent stroke survivors and a meaningful activity to longer term survivors.
Organized Stroke Care in Ontario: Impact on Hospitalization and Mortality
Lumsden, JE1 Hall, R2 O’Callaghan, C3 Meyer, M3 Khan, F2; 1. The Ottawa Hospital, Ottawa, ON; 2. Institute for Clinical Evaluative Sciences, Toronto, ON; 3. Ontario Stroke Network, Toronto, ON
Background: In 2000, the Ontario Ministry of Health and Long-Term Care implemented a system of stroke care consisting of 11 Regional Stroke Networks. The goal was to improve outcomes by reorganizing care to provide equitable access to evidence-based prevention and care. Using data from the Ontario Stroke Network’s Stroke Evaluation Program we sought to quantify the impact of Ontario’s Regional Stroke Networks on acute hospitalization and in-hospital mortality. Methods: Age and sex risk-adjusted annual admission and in-hospital mortality rates reported in the Ontario Stroke Evaluation Report were compared between 2003/04FY and 2010/11FY to estimate the number of stroke and transient ischemic attack (TIA) hospital admissions and in-hospital deaths avoided during the 8-year period. The BURden of ischemic STroke (BURST) Study data was used to estimate the cost impact associated with changes in stroke/TIA inpatient admissions. Cost estimates from hospitalization to 3 months were retrospectively estimated using BURST cost data and were indexed to the year of the stroke event using the Ontario Consumer Price Index for health and personal care. Results: Stroke/TIA inpatient admission rates decreased from 1.7 per 1,000 population in 2003/04FY to 1.3 per 1,000 population in 2010/11FY. This is equivalent to an estimated 3,779 fewer stroke/TIA hospital admissions in 2010/11FY and 16,061 total since 2003/04FY. Risk-adjusted in-hospital mortality rates declined from 14.3% to 11.4% resulting in an estimated 461 fewer deaths in 2010/11FY and 1,555 total since 2003/04FY. The societal economic impact of reducing stroke/TIA hospitalizations is an estimated $144 million in 2010/11FY and $581 million since 2003/04FY. Conclusions: During this 8-year period there were 16,000 fewer hospitalizations and 1,500 fewer in-hospital deaths observed than was expected for the Ontario population. Improvements in patient outcomes and health system sustainability have coincided with the development of Regional Stroke Networks to implement evidence-based stroke prevention and care across Ontario.
A Collaborative Regional Approach to Supporting Primary Care Providers in Improving Vascular Health
Murphy, C1 Steacie, A8 Gordon, J2 Kerr, J3 Langley, H4 Martin, C1 McIntyre, M5 Moore, K6 O’Leary, M7; 1. Stroke Network of Southeastern Ontario, Kingston General Hospital, Kingston, ON; 2. Ontario Renal Network, Kingston, ON; 3. Belleville Queen’s Family Health Organization/Family Health Team, Belleville, ON; 4. Southeast Regional Cancer Centre, Kingston General Hospital, Kingston, ON; 5. South East Local Health Integration Network, Belleville, ON; 6. Kingston Frontenac Lennox and Addington Public Health, Kingston, ON; 7. Self-Management Program of Southeastern Ontario, Kingston Community Health Centre, Kingston, ON; 8. Upper Canada Family Health Team, Brockville, ON
Background: Southeastern Ontario (SEO) has higher than provincial rates for vascular disease risk factors. Members of a SEO Health Collaborative began innovative work in 2011 to support quality improvements in vascular health within primary care. The needs of primary care providers in relation to improving vascular health were assessed and key priorities for action were identified. Opportunities to connect with new initiatives such as Ontario’s Health Links were pursued. Method: An environmental scan (ES) and Think Tanks were conducted across SEO targeting primary health care organizations in rural and urban areas. The findings were compiled into a report: “Vascular Health in Southeastern Ontario: A Focus on Primary Care”. The SEO Health Collaborative reviewed the findings and ranked the vascular health needs using a priority matrix. An action plan was developed to collaboratively begin to address key priorities. This plan included connecting with local Ontario Health Links. Results: The ES and Think Tanks identified local primary care organizations with well-functioning vascular health programs or services that could be shared. Common priority needs surfaced that informed the collaborative action plan. These included the need for an integrated vascular health program within primary care, a common methodology for continuous quality improvement, a mechanism to share successes across primary care organizations and navigation tools to assist in linking to healthy living programs. Improved use of the Electronic Medical Record was a mechanism frequently identified to help address these needs. Conclusion: The ES and Think Tanks provided direction for the development of a collaborative regional vascular health action plan with clear priorities. This provides the SEO Health Collaborative and primary care organizations a framework for leading change across SEO. Mechanisms and opportunities to further improve vascular health continue to arise in relation to ongoing collaboration with Health Links and the Ontario Integrated Vascular Health Coalition.
From Project to Program: The Central LHIN Stroke Prevention Strategy
Murray, J; Mackenzie Health, Richmond Hill, ON
Background: Mackenzie Health is a District Stroke Centre providing cross-continuum stroke services to York Region in Ontario A Stroke Prevention Clinic (SPC) was established in 2006, reducing the Transient Ischemic Attack (TIA) admission rate from 30% to 15%. In 2009, Mackenzie Health submitted a proposal to the Central Local Health Integration Network for funding under Aging at Home to support The Stroke Prevention Strategy: An Interdisciplinary and Community Approach to Emergency Diversion Through Stroke Prevention and Health Promotion. The purpose was to increase access to SPCs in the Central LHIN, reduce TIA admission rate as well as promote risk reduction and secondary stroke prevention. Method: Aligned with the Ontario Framework for Chronic Disease Prevention and Management, the model of care provides rapid triage, assessment and interventions for patients referred to the SPC based on the immediate period of high risk for progression to stroke and the high recurrence rate for stroke. Once stabilized, SPC patients are referred to local Cardiovascular Rehabilitation Programs (CVRP). Research demonstrates commonality in the risk factors for stroke patients and cardiac patients as well as comparable outcomes. A Community Liaison facilitates uptake of CVR programming, forming a bridge between clinic and community. Patients are further referred to community services as needed. Results: The three year project established:
a network of five hospital-based, NP-led SPCs;
three new community based CVRPs;
increased capacity for clinician and patient education in chronic disease self-management and
community-based blood pressure screening clinics for high risk populations.
A 4% reduction in TIA admission rate was realized. Conclusion: This project received base funding as of April 2012 becoming the Central LHIN Stroke Prevention Strategy.
A Large Community Hospital’s Multi-Disciplinary Approach to “Code Stroke”
Pawlowski, E; Hobbs, D; Halton Healthcare Services, Oakville, ON
Background: In the absence of a dedicated stroke response team, a large community hospital in Oakville, Ontario identified the need to develop a process to expedite identification and treatment to improve outcomes in admitted patients suspected of experiencing an acute stroke. Early identification and provision of therapies, where efficacy is clearly time dependent, can be achieved with a standardized process to elicit a coordinated team response. Methods: The development of a very specific algorithm that highlights the roles and responsibilities of the multi-disciplinary team is essential in ensuring efficient and timely diagnosis, and safe delivery of thrombolytics (tPA) to acute inpatients suffering a stroke.
Results/Discussion: The experiences of the development, implementation and sustainment of a “code stroke” policy in this large community hospital will be discussed. Specific challenges and solutions related to nursing recognition of stroke, timely access to diagnostic testing, physician response time and delivery of tPA will be highlighted. Conclusion: A “Code Stroke” systemic approach to assessing, diagnosing and initiating care assists in eliminating the logistical and human barriers that can affect the ability to deliver tPA in the absence of a dedicated stroke response team.
Evidence-Informed Knowledge to Practice: Implementation of Stroke Best Practices
Richardson, D1 Fortin, J2 Avinoam, G3 Skrabka, K4 Willems, J4 Sharp, S3 Linkewich, B2; 1. Toronto Stroke Network, University Health Network, Toronto, ON; 2. North and East GTA Stroke Network, Toronto, ON; 3. Toronto West Stroke Network, Toronto, ON; 4. Southeast Toronto Stroke Network, Toronto, ON
Background: The three Toronto Stroke Networks (TSNs) are comprised of 17 organizations and therefore an uncountable number of healthcare professionals across the stroke care continuum. The ‘Stroke Flow’ initiative provided a re-design of the stroke system, based on best practices. Collaboration to enable the advancement of stroke care is a priority of the Greater Toronto Stroke Coordinating Committee (GTSCC), which provides overarching coordination and stewardship for the combined Toronto networks. Methods: Guided by the Graham’s Knowledge to Action Cycle (KTA), armed with the results of the Stroke Flow project and a multipronged needs assessment from practitioners in the networks, an Education and KT Implementation plan was developed to promote improved quality of care and outcomes for people with stroke. A key strategic action towards implementation of Stroke Care Best Practice was the creation of an Education & Knowledge Translation (KT) Advisory. This team of invited experts in Education, Evaluation, KT and Health Quality was tasked with enhancing systems collaboration and ensuring well-matched approaches in KT and QI. A cross system implementation committee (CSIC), comprised of invited stroke champions from each organization provided grounding to their local context. Results: The Education and KT advisory committee approved the Education and KT Implementation plan with strategic feedback to ensure evidence informed implementation. Key directives included sectioned roll out, iterative feedback and “member checking”, and engagement of front line providers. Monitoring of the roll out with flexibility was recommended to ensure realistic implementation and timelines. CSIC member feedback resulted in adaption of deliverables to include a “hands-on” approach to training and orientation. Conclusion: Expert advice and member checking has provided insight on the initial roll out of the TSNs Education and KT Implementation plan. A structured evaluation will provide depth and direction on the actual value of the education and KT implementation.
L’aquisition des connaissances après le suivi d’une formation spécialisée en soins infirmiers aux personnes ayant subi un AVC, en Catalonge
Salvat-Plana, M1 Suñer, R3, 4, 2 Abilleira, S2 Gallofré, M2; 1. Pla Director Malaltia Vascular Cerebral. Catalan Stroke Programme, Barcelonne, Spain; 2. Stroke Programme, Health Department of Catalonia (Plan Directeur des Maladies Cérébrovasculaires. Département de Santé de Catalogne), Barcelonne, Spain; 3. Faculté Sciences Infirmières. Université de Girona. Catalogne, Girona, Spain; 4. Hospital Universitari Dr. Josep Trueta de Girona, Girona, Spain
Contexte: Depuis 2009, le groupe consultatif d’infirmières du Plan Directeur de Maladies cérébrovasculaires (PDMVC), en Catalogne, développe des stratégies pour améliorer la qualité des soins et services relatifs à l’accident vasculaire cérébral (AVC), comme la formation continue aux infirmières. Le but de cette étude est de connaître l’effet d’un programme de formation portant sur les soins aux personnes ayant subi un AVC sur les connaissances des infirmières. Méthodologie: Un devis avant-après avec un seul groupe a été utilisé. Les infirmières ont suivi un cours de 36 heures de formation sur les soins à donner aux personnes ayant subi un AVC. Les connaissances ont été évaluées avant et après à l’aide d’un questionnaire développé par les chercheurs (15 items, score 0-15 points). Les scores globaux entre les deux évaluations ont été comparés à l’aide des T-test et des chi-carré. Résultats: Une augmentation significative des connaissances des 35 (100%) participantes (p=0,000) a été observée entre l’évaluation initiale (9,1±1,95) et l’évaluation finale (11,6±1,35). Avant le cours, les infirmières travaillant dans une unité de l’AVC possédaient des connaissances supérieures (p=0,007) par rapport aux connaissances de celles travaillant dans des unités conventionnelles de neurologie et de médecine interne (moyenne: 10,2±1,2 vs 8,4±2,01). Les connaissances finales étaient similaires (p=0,1) dans les deux groupes (12,1±1,1 vs 11,3±1,4). Intra groupe, les connaissances des infirmières qui travaillent dans une unité de l’AVC ont augmenté de 1,8 (IC 95%: 1,2-2,5) points et les résultats du groupe qui ne travaille pas dans ces unités ont augmenté de 2,9 (1,7-4) points. Aucune différence n’a été notée en ce qui concerne les années d’expérience. Conclusions: Une augmentation significative des connaissances a été observée à la suite d’une formation spécifique en soins de l’AVC. L’acquisition des connaissances est plus élevée chez les infirmières travaillant dans les services moins spécialisés.
Engaging Rehab Providers in a discussion about Stroke Best Practices: The Edmonton Zone Rehab Summit 2012
Taralson, CL; Alberta Health Services Stroke Program Edmonton Zone, Edmonton, AB
Background: The Alberta Provincial Stroke Strategy (APSS) was mandated to advance stroke prevention and care in Alberta. In December of 2010, APSS released an interim report, revealing areas of success and opportunities for improvement. The APSS Provincial Rehabilitation Coordinator proposed a series of rehabilitation summits throughout the province, to encourage rehab providers to evaluate their practice in light of stroke best practices. Alberta Health Services (AHS) Edmonton Zone embarked on a day of review of Best Practice Recommendations. Participants from all stroke rehabilitation service delivery sites/programs across the care continuum were invited to discuss opportunities for improving practice. Although coming from different practice experiences and settings, participants identified common challenges. Methods: An invitation to the Summit was disseminated throughout the zone, with particular focus on programs providing stroke services. Over 60 participants from a variety of professions and settings participated. Keypad polling technology was used to allow participants to anonymously respond to how well their program/facility met each recommendation. Participants then identified and prioritized projects to improve zone delivery of stroke rehabilitation. A final report summarizing the Summit findings was generated by the facilitation team. Results: Polling results showed participants believed 13 of the 20 recommendations were regularly or consistently met in their area of practice. The remaining 7 were predominantly “don’t meet” or “seldom meet”. Six projects were developed with the aim of improving care. The connecting theme within these projects was “improve communication regarding stroke support programs throughout the zone, and provide referral processes/criteria to access these programs”. Conclusions: Engaging care providers in a face-to-face discussion increased awareness of available services and varying methods of service delivery across the zone. Common themes and purposes were revealed, as was a willingness to collaborate to enhance stroke patient care in the Edmonton Zone. On-going events of this kind are being considered.
Rehabilitation Early Supported Discharge (REDi) - Improving the Rehabilitation Service Model with Comprehensive and Coordinated Outpatient Services
Parsons, J; Vance, S; Ng, V; Just, E; Doull, K; Dawson, A; Strategy, F; Fraser Health, Surrey, BC
Background: Access to rehabilitation services after stroke is a key component of promoting functional recovery. Best practice indicates a continuum of care is most appropriate, including inpatient, early supported discharge and outpatient services designed to meet care needs in the least restrictive setting and promote optimal functional recovery. Fraser Health staff identified that stroke survivors utilized inpatient rehabilitation services longer than necessary due to limited availability, delayed access, and lack of coordinated outpatient services. Methods: The REDi pilot aimed to shift the rehabilitation care delivery model to support early discharge and functional recovery across the continuum. Using a logic model to design service delivery, the REDi pilot was implemented in June 2011 and included:
A screening and referral process to promote early identification of inpatients that were appropriate for an early supported discharge program.
A Service Coordinator to support and facilitate transitions between rehabilitation settings.
A capacity expansion of comprehensive outpatient rehabilitation services with access to a multidisciplinary team of Allied Health staff. Results: Evaluation of the service delivery revealed that all intended outcomes identified in the logic model were achieved.
Client benefits included:
Equal or greater functional improvements
More timely access to Rehabilitation Services
Improved access to frequent, intensive, interdisciplinary outpatient therapy
Reduced length of stay in an inpatient rehabilitation setting
Reduction of impairment and prevention of disability, including the need for future care and system resources.
System benefits include:
Increasing capacity in the Rehabilitation Program through improving access and flow
Reducing the cost of Rehabilitation services Conclusions: Efficient use of inpatient rehabilitation resources after stroke is supported by the availability of comprehensive and coordinated outpatient rehabilitation. REDi is an effective model to facilitate early discharge to the community, increase access to rehabilitation, improve the efficiency of inpatient rehabilitation, and support functional recoveryof appropriate stroke patients in an ambulatory setting.
Stroke Units in Ontario: The 2013 Ontario Stroke UNit (OSUN) Survey
Fan, I1 Ieraci, L1 Hall, R2 Kelloway, L3 van der Velde, G1 Rac, V1 Kapral, M4, 2 Bayley, M4 Krahn, M1; 1. THETACollaboroative, Toronto, ON; 2. ICES, Toronto, ON; 3. Ontario Stroke Network, Toronto, ON; 4. UHN, Toronto, ON
Patient admission to stroke units (SUs) is associated with lower morbidity and mortality. However, the degree of implementation of known essential components of SUs in Ontario requires further investigation. A detailed survey of SU components (e.g. SU type, number of beds, etc.) would help characterize the variation in care and assist in identifying areas for further improvement. The Ontario Stroke UNit (OSUN) questionnaire was administered as a telephone interview with SU staff based on FY 2013. The survey determined Ontario SU characteristics, which will assist future analysis of (cost-) effectiveness and associations with improved patient- and system-level outcomes. Once completed, the survey will represent a census of all 32 SUs in Ontario as identified in January 2013. Questionnaire responses were not always consistent with the definition of SU care. SU managers were able to identify the type of SU, however, examination of the dedicated beds reported implied a different SU definition; some locations had no dedicated beds reported. FTE information for stroke team resources was difficult to obtain. Managers tended to include non-hospital staff (e.g. CCAC, district stroke coordinators, etc.) as “stroke team” resources creating discrepancies with the stroke team Canadian Stroke Strategy (CSS) criteria. Diagnostic equipment was often reported as being available irrespective of the corresponding location (i.e. equipment was on-site, or off-site). Meetings and staff education were difficult to document as meetings with patients varied case-by-case, or meetings were held as hallway conversations (i.e. informal meetings). Education included both conferences and in-house talks, the frequency of which was difficult to determine. Ontario SUs have implemented standard components of stroke care to varying degrees. Some SUs self-identify as a SU, however, the characteristics of the stroke team and dedicated resources are different from the CSS’s criteria for establishing a SU. Greater standardization of necessary SU components is required.
The Use of an Audit-Feedback Loop to Address Adherence to Stroke Best Practice Recommendations for Hypertension Management
Allen, L1 Janzen, SE1 Mehta, S1 Britt, E2 Meyer, M1 Teasell, R2; 1. Lawson Health Research Institute, Parkwood Hospital, London, ON; 2. St.Josephs Healthcare, Parkwood Hospital, London, ON
Objective: This study aimed to improve blood pressure (BP) monitoring and the management of hypertension on a stroke rehabilitation unit in accordance with the Canadian Best Practice Stroke Recommendations. Methods: Baseline data was collected through a retrospective chart audit of consecutive admissions from October 2010 to March 2011. An evidence-practice gap was identified regarding the monitoring and management of hypertension. Guided by published knowledge translation principles, the research and rehabilitation teams collaborated on the development and implementation of a hypertension strategy. Clinical uptake of the strategy was evaluated 6-months post-implementation through a second chart audit of consecutive admissions from May to November 2012. Abstracted information included: BP readings, leaves of absence, and anti-hypertensive medications administered. Results: 120 charts were initially reviewed, and 124 in the evaluation audit. Overall, the mean number of days without BP being taken/ recorded decreased significantly (p=0.0128) from the initial audit (M=4.9; 1-38, SD=4.74) to the second audit (M=1.27; 1-2, SD=0.47). The proportion of patients, for the initial and evaluation audits, experiencing ≥1 hypertensive day was 73.3% and 87.15%, respectively. Of those who had at least one hypertensive day, 52.3% in the initial audit had ≥1 untreated day, and 44.4% of patients in the follow-up. However, there was no significant difference (p=0.0708) in the mean number of untreated days between baseline (M=4.43, SD=3.83) and post-implementation (M=6.83; SD=8.07). Conclusion: Through the identification of an evidence-practice gap, and the development and implementation of a hypertension strategy, adherence to best practice guidelines regarding the monitoring of BP improved. Overall this study has assisted in establishing the value of, and expectation to, provide evidence-based care on the stroke unit.
Dynamic Characterization of CT Angiographic ‘Spot Sign’ in Intracerebral Hemorrhage
Chakraborty, S1 Alhazzaa, M1 Wasserman, J1 Stotts, G1 Demchuk, A2 Aviv, RI3 Dowlatshahi, D1; 1. Universitty of Ottawa, Ottawa, ON; 2. University of Calgary, Calgary, AB; 3. University of Toronto, Toronto, ON
Background and purpose: Static CT angiography is usually used to identify the intracerebral hemorrhage (ICH) spot sign. We used dynamic CT-angiography to describe spot sign characteristics and measurement parameters over 60-seconds of image acquisition. Methods: We prospectively collected consecutive patients with acute ICH presenting within 6 hours of symptom onset who underwent whole brain dynamic CT-angiography (dCTA). Spot parameters (earliest appearance, duration, Maximum Hounsfield unit (HU), time to maximum HU, time to spot diagnosis (based on HU>100 or >120) and spot volume) were measured using OSIRIX. Hematoma volumes were measured using Quantomo software. Result: We enrolled 32 patients: three were excluded due to secondary causes of ICH. In the 29 patients with primary ICH, there were 12 males with median age 70 and baseline hematoma volume 31 ml. Eleven patients (38%) had positive dCTA spot sign. The spot was visualized as an expanding 3-dimensional structure that temporally evolved in its morphology over the scanning period. Median time to spot appearance was 19.4s of contrast injection (range 15-23 seconds). This method allowed tracking spots where they continued until end of venous phase (persistent leak) with median duration of 40.6s (range 37-45 seconds). The median maximum HU was 211, and median time to maximum HU was 27.6s. Median time to spot diagnosis was 19s using either the HU 100 or 120 definitions. Conclusion: Dynamic CT Angiography allows a 3-dimensional assessment of spot sign formation during acute ICH; this is the first study to quantitatively describe spot sign formation and morphology using dCTA.
Acute Stroke Patients Treated with Stent Retrievers in Carotid “T” Occlusions Have Improved Recanalization and Outcome
Orton, T1 Alhazzaa, M2, 3 Iancu, D1 Lesiuk, H1 dos Santos, MP1 Lum, C1; 1. University of Ottawa, Diagnostic Imaging-Neuroradiology Section, Ottawa, ON; 2. University of Ottawa-Department of Medicine (Neurology), Ottawa, ON; 3. King Fahad Medical City, Riyadh, Saudi Arabia
Background: Acute carotid-T occlusions typically have large clot burden that can be resistant to interventional therapy. Recently, higher recanalization rates have been found with stent-retriever use in acute large vessel stroke compared to prior techniques. We sought to evaluate the efficacy and outcomes in a subgroup of acute stroke patients treated with stent retrievers for Carotid-T occlusions. Methods: A retrospective chart review was performed in 60 consecutive patients who underwent intra-arterial therapy for acute stroke in our center between 2010 and 2012. We dichotomized the patients into two groups based on intervention as: stent-retriever (group 1) and non-stent-retriever (group 2). Demographic and radiological characteristics and clinical outcome were presented. A good outcome was defined as a 30-day modified Rankin score < 2 or 10-point decrease in NIHSS. Symptomatic intracranial hemorrhage (ECASS-III definition) and 30 days mortality were reported. Result: Twenty-three patients treated with stent-retrievers were compared to 37 cases received other modalities (Penumbra, MERCI, angioplasty, or intra-arterial tPA;either alone or in combination). There was a higher baseline median NIHSS score in the stent-retriever group (18 versus 16, p = 0.034). Overall, there were higher recanalization rates in group 1 (87% vs. 51% in group 2, p = 0.005). Use of stent-retriever was associated with good 30 days mRS (78% vs. 43%, p = 0.008), lower mortality (4% vs. 32%, p=0.011) and no symptomatic hemorrhages. Among patients with carotid “T” occlusions (52% in group 1 vs. 30% in group 2), stent retriever demonstrated higher recanalization rates (83% vs. 38%, p=0.0123), favorable clinical outcomes (67% vs. 22%, p=0.036) and shorter time to recanalization (69 vs. 191 minutes, p=0.0023). Conclusion: In this small cohort, using stent-retriever offered better recanalization rate and clinical outcome with remarkable safety profile in acute carotid “T” occlusions when compared to previous multimodal therapy.
Not All Successful Reperfusion PatiNot All Successful Reperfusion Patients Are Equal: The Need for a TICI2c Scoreents Are Equal: The Need for a TICI2c Score
Almekhlafi, MA1, 2 Mishra, S1 Desai, J1 Nambiar, V1 Eesa, M1 Volny, O1 Menon, BK1 Demchuk, AM1 Goyal, M1; 1. University of Calgary, Calgary, AB; 2. King Abdulaziz University, Jeddah, Saudi Arabia
Objective: Many recent endovascular studies have used the TICI grading system for evaluating angiographic outcomes and have used TICI 2B and 3 for successful recanalization as long as the final perfusion defect was < 50% of the MCA territory. We propose a new scoring system that separates successful but incomplete reperfusion into 2 categories taking into account the size of the reperfusion defect. Methods: This is a longitudinal cohort including of anterior circulation stroke patients treated using intra-arterial stentrievers in our center between Jan 2011 to Dec 2012. Failed reperfusion was defined as per the standard TICI score (TICI 0-2a). Successful reperfusion was defined as 2b: substantial perfusion with distal branch filling of ≥ 50% of territory visualized, 2c: near complete perfusion except for slow flow in a few distal cortical vessels, or presence of small distal cortical emboli, 3: complete perfusion with normal filling of all distal branches. Angiograms were scored by a single reviewer blinded of the patients’ outcomes. Results: In a cohort of 101 patients, 78 achieved successful reperfusion (77.2%). The results of patients with successful reperfusion is presented according to the reperfusion score (Table). The proportion of patients who had significant improvement of their clinical deficits in 24 hours (24-hour NIHSS score drop by 75%) was significantly higher with TICI2c reperfusion than those with TICI2b (50% vs. 24%, Fisher’s exact p 0.04). Conclusions: Categorizing successful but incomplete reperfusion into 2 different classes according to the area of perfusion defect has merits. In this cohort, there was evidence toward different short-term clinical and imaging outcomes in patients with TICI2b vs. TICI2c scores. These findings need to be validated in larger cohorts.
Imaging-to- Stent deployment Time Interval Is Shorter during Daytime Hours’ Vs. Evening Times in Endovascular Therapy for Acute Ischemic Stroke
Almekhlafi, MA; Desai, J; Nambiar, V; Mishra, S; Volny, O; Eesa, M; Demchuk, AM; Menon, BK; Goyal, M; University of Calgary, Calgary, AB
Background: Stentrievers can establish immediate by-pass effect by delivering blood to the ischemic tissue once the stent is deployed. A potential factor that may introduce delays in achieving a short imaging to first stentriever deployment time is the timing of the intervention. Method: This is a longitudinal cohort of acute ischemic stroke patients treated with endovascular therapy in our center between Jan 2011 to Dec 212. The imaging to first stentriever deployment time was defined as the time from the completion of CT angiogram to the first angiographic run that shows that the stentriever has been deployed in the target occluded artery. This time interval was compared between patients treated during the daytime hours (0700-1800 hours) vs. outside these hours. Results: 99 patients were analysed. The median imaging to first stentriever deployment time was 86 minutes (80.5 minutes during the daytime vs. 97 minutes outside these hours; U-test p value 0.038). The proportion of patients treated during daytime hours with imaging to first stentriever deployment time < 120 minutes was 86% compared to 65.8% outside these hours (Chi-square p 0.02). The proportion of patients with successful reperfusion (TICI 2b or 3) treated during the daytime was 76.7% compared to 76.9% outside daytime hours. The proportion with a favourable discharge modified Rankin Scale (mRS <3) in those with an imaging to first stentriever deployment time < 120 minutes was 68% vs. 44% in those who did not meet that time (Chi-square p 0.018). Conclusions: An imaging to first endovascular stentriever deployment time < 120 minutes is feasible and was achieved more consistently during daytime hours. It was associated with better functional outcome.
A ‘Reduce-To-Quit’ Pilot Program for Smokers with Cerebrovascular Disease: Transitioning Smokers to Set a Quit Date
Armstrong, A1 Reid, R1 Sharma, M2 Stotts, G2 Aitken, D1 Mullen, K1 Papadakis, S1 Gocan, S2 Bourgoin, A2 Laplante, M2 Houbraken, D2 Pipe, AL1; 1. University of Ottawa Heart Institute, Ottawa, ON; 2. The Ottawa Hospital, Ottawa, ON
Background: Smoking cessation is a life-saving intervention for patients with cerebrovascular disease, however, only 35% of smokers with TIA or stroke are ready to make a quit attempt after their event. The aim of this review was to assess whether reducing daily cigarette consumption leads to a quit attempt in those smokers who are not ready to quit. Methods: The Stroke Prevention Clinic (SPC) ‘reduce-to-quit’ (RTQ) pilot program offers smokers who have experienced a stroke or TIA, and who are not ready to quit, a 4-week supply of nicotine replacement therapy (NRT) patch. Since December 2009, 181 smokers with stroke or TIA attending the SPC were not willing to set a quit date; 49 (27%) were willing to participate in the RTQ program. Results: Forty-nine individuals participating in the RTQ program were included in the current review (48% male, mean age = 59.5 +/- 10.6). The average number of cigarettes smoked per day was 23.5 +/-11.9. Eight-two percent of smokers in the program reduced the number of cigarettes they were smoking per day, the average smoker in the program reduced daily consumption by 13.2 cigarettes (SD +/- 9.7). Overall, 15 smokers (30%) in the RTQ program set a quit date at one month follow up, with those who had reduced cigarette consumption becoming “ready-to-quit” at a higher rate (33%) then those smokers who did not reduce their cigarette consumption (22%). Of those RTQ patients who set a quit date, the abstinence rates (bio-chemically confirmed) for those reached at follow-up were 25% and 38% at 6 and 12 months respectively. Conclusions: The results from the RTQ pilot program suggest that offering treatment to smokers who are not ready to quit can lead to an increase in quit attempts as well as 6 and 12 month cessation success in this population.
Protocole d’interventions visant le dépistage et la prise en charge de l’incontinence urinaire auprès de la clientèle ayant subi un AVC
Balg, C1 Mathieu, S1 Rousseau, G1 Dallaire, M1 Dallaire, C2; 1. CHU de Québec - Hôpital Enfant-Jésus, Québec, QC; 2. Faculté des sciences infirmières - Université Laval, Québec, QC
Problématique: Une proportion importante des patients ayant subi un AVC présente de l’incontinence urinaire (40-60%) et près de 25% d’entre eux le seront encore lors du congé de l’hôpital (Barrett, 2001, Cochrane, 2009). Le temps d’attente afin de recevoir l’aide requise et la crainte de ne pas pouvoir se retenir motivent certains patients à demander d’avoir une culotte d’incontinence alors que ce n’est pas requis (Pilcher & McArthur, 2012). Les recommandations pour les pratiques optimales des soins de l’AVC (2010) préconisent par ailleurs le dépistage et la prise en charge de l’incontinence (incluant la rétention urinaire) afin de prévenir les complications et diminuer la morbidité chez cette clientèle. Méthode: La démarche vise à documenter les pratiques actuelles à l’aide d’un questionnaire, d’une rencontre des équipes (infirmières, infirmières-auxiliaires, préposés aux bénéficiaires), d’une entrevue de patients ayant subi un AVC et vécu une expérience d’incontinence urinaire. Également, une revue succincte de la littérature sera effectuée. Un devis de recherche d’interventions sera utilisé (Sidani et al., 2012). Résultats: L’expérience tacite du personnel, les besoins de la clientèle et la revue de littérature ont permis d’établir un protocole d’interventions applicable au contexte de pratique. Les résultats seront présentés de façon préliminaire. Conclusion: Cette démarche a un effet mobilisateur auprès du personnel soignant, et améliore la qualité des soins.
Secular Trends in Ischemic Stroke Subtypes
Bogiatzi, C1 Hackam, DG1 McLeod, I2 Spence, JD1; 1. Robarts Research Institute, Stroke Prevention and Atherosclerosis Research Center (SPARC), London, ON; 2. Western University, Department of Statistical and Actuarial Sciences, London, ON
Background: With the aging of the population, and with increasing prevalence of therapy for hypertension and hyperlipidemia, it might be expected that stroke subtypes would be changing over time. Limited information exists on the distribution of ischemic stroke subtypes in Canada. Methods: Patients referred to Urgent TIA Clinic, in London, Ontario from 2002 to 2012 were included. Secular trends were analyzed using Poisson regression analysis. Ischemic stroke subtype classification was validated. Results: 3445 consecutive patients with mean age+SD of 64.76+14.9 were included; 51% were women, 81% had hypertension; 18% had diabetes; 9% had atrial fibrillation; 14% had open patent foramen ovale; 20% were current smokers. Cardioembolic strokes increased significantly from 21% in 2002 to 56% in 2012, whereas all other ischemic stroke subtypes decreased (p<0.01). Additional analyses showed a decrease in blood pressure, LDL and pack years of smoking, and an increase in medications used to treat hyperlipidemia (p<0.05). Conclusions: The decrease in atherosclerotic risk factors resulted in fewer strokes caused by large artery atherosclerosis and small vessel disease. Cardioembolic strokes have increased significantly as a proportion of first-ever ischemic strokes. This has important implications for more intensive investigation and treatment to reduce the risk of recurrent embolic stroke.
[18F]-fluorodeoxyglucose, but not C-reactive Protein, is Related to Intraplaque Inflammatory Burden in Human Carotid Plaque: A Sub-study of the Canadian Atherosclerosis Imaging Network (CAIN)
Cocker, MS1 Mc Ardle, B1 Hammond, R2 deKemp, R1 Lum, C3 Youssef, G1 Yerofeyeva, Y4 Karavardanyan, T4 Adeeko, A4 Hill, A3 Stotts, G3 Nagpal, S3 Renaud, J1 Kelly, C1 Brennan, J1 Garrard, L1 Alturkustani, M2 Hammond, L2 DaSilva, J3 Tardif, J5 Beanlands, R1 Spence, J6; 1. University of Ottawa Heart Institute, Ottawa, ON; 2. Western University, London, ON; 3. The Ottawa Hospital, Ottawa, ON; 4. Sunnybrook Research Institute, Toronto, ON; 5. Montreal Heart Institute, Montreal, QC; 6. Robarts Research Institute, London, ON
Background: Inflammation underlies the development and progression of atherosclerotic plaque. An actively inflamed plaque is considered to be a ‘vulnerable’ high-risk, rupture-prone lesion. It is imperative to develop surrogate biomarkers that enable for the early detection of disease. C-reactive protein (CRP) is a marker of systemic inflammation and a risk factor associated with cardiovascular events. Alternatively, radiolabelled glucose or -fluorodeoxyglucose (18FDG) imaged with hybrid positron emission tomography (PET) and computed tomography (CT) may serve as an imaging-derived biomarker of inflammatory burden within plaque. In this investigation, we directly compared systemic CRP and 18FDG carotid uptake to intraplaque inflammatory burden using CD68 immunohistology. Methods: Thirty-four patients (67±10 years, 27 male) scheduled for carotid endarterectomy were prospectively recruited. Patients underwent FDG-PET and CT angiography of carotids. Prior to imaging, blood was collected for the assessment of CRP. Maximum 18FDG uptake at the left and right internal carotids was quantified and normalized to blood, resulting in a tissue to blood ratio (TBR). Following endarterectomy, excised plaque was fixed, sectioned and immunostained for CD68. CD68 expression was quantified semi-automatically. Results: Carotid endarterectomy was performed in 34 patients; one patient received a 2nd carotid endarterectomy due to bilateral disease. Immunohistology was performed in 23 excised plaques. The extent of inflammation, as quantified with CD68 immunohistology, was related to maximum 18FDG uptake (r=0.636, p=0.001). However, there was no association between CD68 expression and CRP (r=0.190, p=0.42). Furthermore, CRP was not associated with maximum 18FDG uptake of the endarterectomy lesions (r=0.179, p=0.34). Conclusion: As opposed to systemic CRP, 18FDG uptake is strongly related to the extent of inflammatory burden within high-risk carotid plaque. However, CRP may not be useful for detecting vulnerable carotid plaque (based on histopathology and 18FDG uptake). Large prospective outcomes-based studies are required. 18FDG may serve as a robust and direct biomarker of carotid plaque vulnerability.
The Predictive Ability of the CTA Spot for Hematoma Enlargement is Dependent on Time Since ICH Onset: a Systematic Review and Patient-Level Meta-Analysis
Dowlatshahi, D1 Brouwers, B2 Demchuk, A3 Hill, M3 Aviv, R4 Ufholz, L1 Wintermark, M5 Hemphil III, J6 Murai, Y7 Wang, Y8 Zhao, X8 Wang, Y8 Li, N8 Greenberg, S2 Romero, J2 Rosand, J2 Goldstein, J2 Sharma, M9; 1. University of Ottawa & Ottawa Hospital Research Institute, Ottawa, ON; 2. Massachusetts General Hospital, Boston, MA, USA; 3. University of Calgary, Calgary, AB; 4. University of Toronto, Toronto, ON; 5. University of Virginia, Virgina, USA; 6. UCSF, San Francisco, CA, USA; 7. Nippon Medical School, Tokyo, Japan; 8. Capital Medical University, Beijing, China; 9. Population Health Research Institute, Hamilton, ON
Background: Hematoma expansion (HE) occurs in up to 40% of patients with intracerebral hemorrhage (ICH), and predicts poor outcome. Contrast extravasation following CT-angiography (CTA), termed “spot-sign”, identifies patients at risk of HE. However, the prevalence and predictive values of the spot sign varies across studies, possibly due to differences in onset-to-CTA time. We performed a patient-level meta-analysis to define the relationship between onset-to-CTA time and the predictive performance of spot-sign. Methods: We searched the Cochrane Central Register, the Cochrane Library Database, MEDLINE and EMBASE for studies of spot sign. We pooled data on the prevalence and predictive values for significant HE (6mL or 33% growth) for patients with ICH stratified by onset-to-CTA time: <3hours, 3-6 hours, >6hours. We used chi-square analysis and two-way ANOVA to compare within and across time strata. Results: Of 1240 studies reviewed, 9 met criteria for analysis: we have received patient-level ICH spot-sign data from 8 countries and 16 centers (n=705). Prevalence of spot-sign decreased with increasing onset-to-CTA time (p<0.001). The subset with follow-up scans used for HE analysis (n=582) revealed spot-sign performance was best in early time strata, whereas specificity and NPV were highest in late time strata. Spot-positive patients had greatest absolute HE in the earlier CTA time strata (p<0.001). Conclusion: Prevalence, predictive values and magnitude of effect of the spot-sign are dependent on onset-to-CTA timing.
Hypertensive Disorders in Pregnancy and Future Risk of Stroke: A Systematic Review
Ganesh, A; Sarna, N; Mehta, R; Smith, E; University of Calgary, Calgary, AB
Background: Many risk factors are currently targeted in the primary prevention of stroke; however, the role hypertensive disorders in pregnancy in predicting future stroke risk has yet to be elucidated. Currently women are monitored throughout pregnancy for changes in blood pressure, but no specific recommendations have been made regarding stroke-related screening or preventative measures postpartum. In this regard, we conducted a systematic review to assess whether women with a history of hypertension in pregnancy are more likely to experience stroke in later life compared to women with normotensive pregnancies. Methods: The electronic databases Medline and Pubmed were searched combining the MeSH terms “hypertension, pregnancy-induced”, “pre-eclampsia”,”eclampsia”, “HELLP syndrome”, or “toxemia” with the terms “Stroke” or “stroke, lacunar” using the AND modifier, with all terms auto-exploded, while clinical trials registries and conference proceedings were similarly searched for unpublished studies. This generated a total of 90 results in Medline and 172 results in Pubmed, of which 9 studies (2 prospective cohort, 4 retrospective cohort, 3 case-control) met inclusion criteria of involving women with hypertensive disorders in pregnancy; involving a prospective follow-up, retrospective review of records, or a case-control design; and reporting stroke as a clinical outcome. Results: There is consistent case-control and retrospective cohort evidence, both international and multi-racial, of an increased risk of stroke and of mortality from stroke in women with hypertensive disorders of pregnancy, in particular for those with pre-eclampsia/eclampsia, as demonstrated by both prospective cohort studies. There is weaker evidence of an increased incidence of stroke in later life with gestational hypertension alone. Conclusions: Hypertension in pregnancy likely carries an increased risk for stroke in later life, but the risk is much more significant for gestational hypertension associated with pre-eclampsia/eclampsia. There may be benefit in targeting these women for close risk-factor monitoring and control beyond the post-partum period.
Effect of Chronic Resveratrol Pretreatment on Astroglial GFAP/GLT-1 Expression Following Global Cerebral Ischemia
Girbovan, C; Pitre d’Iorio, M; Plamondon, H; University of Ottawa, Ottawa, ON
Background: Perisynaptic astrocytes express important glutamate transporters, especially GLT-1 to regulate extracellular glutamate levels and modulate synaptic activation. Evidence is now accumulating that astrocytes play an active role in the pathophysiology of cerebral ischemia and that down-regulation of astroglial GLT-1 expression in the CA1 subfield of the hippocampus may contribute to neurotoxic levels of glutamate post ischemia. Resveratrol (RSV), a naturally occurring polyphenol phytoalexin mainly found in grapes, has been shown to protect the brain against ischemic injury. While a number of mechanisms of action of RSV in preventing neuronal damage have been proposed, it remains to be determined if the polyphenol affects astroglial GLT-1 expression following an ischemic insult. The present study examined the effects of 21-day RSV pre-treatment (1 or 10mg/kg dose; i.p.) on GFAP and GLT-1 expression in the DG, CA1 and CA3 layers of the hippocampus 7 days following 10 min global ischemia. Methods: Male Wistar rats were divided into five groups; sham/saline, ischemia/saline, ischemia /1 mg/kg RSV, ischemia/10 mg/kg RSV and sham/10 mg/kg RSV. 7 days post surgery, brains were perfused and GFAP and GLT-1 immunohistochemical assessment performed. Results: Our findings indicated significant increase in GFAP expression in ischemic compared to sham-operated animals and a reduction in GFAP activation by RSV-treated rats in the CA1. Accordingly, ischemic rats showed a downregulation of GLT-1 expression compared to sham-operated rats in the CA1, while RSV significantly increased GLT-1 expression in ischemic animals compared to saline-treated ischemic rats. Conclusion: The higher expression of GLT-1 in the CA1 of RSV-treated ischemic rats may contribute to this group’s inherent resistance to neuronal cell loss following cerebral ischemia.
Underuse of Cardiac Rhythm Monitoring After Ischemic Stroke and TIA: Missed Opportunities for Detection and Treatment of Atrial Fibrillation
Gladstone, DJ1 Fang, J2 Dorian, P3 Hachinski, V4 Mamdani, MM3 Laupacis, A3 Lindsay, M5 Edwards, JD1 Spring, M6 Saposnik, G1 Silver, FL1 Kapral, M7 On behalf of the Investigators of the Registry of the Canadian Stroke Network; 1. University of Toronto, Toronto, ON; 2. Institute for Clinical Evaluative Sciences, Toronto, ON; 3. St. Michael’s Hospital, Toronto, ON; 4. University of Western Ontario, London, ON; 5. Heart and Stroke Foundation, Ottawa, ON; 6. Institutional Affiliation: Trillium Health Centre, Mississauga, ON; 7. University Health Network and Institute for Clinical Evaluative Sciences, Toronto, ON
Background: Detection and treatment of atrial fibrillation (AF) is a major goal in secondary stroke prevention, but it is unclear how intensively ischemic stroke/TIA patients are screened for paroxysmal AF in practice. Guidelines recommend cardiac monitoring post-stroke, and current evidence indicates that monitoring for substantially longer than 24h is often necessary to detect paroxysmal AF. This provincial audit evaluated the type and duration of monitoring provided post-stroke/TIA as a quality indicator for secondary stroke prevention. Methods: We analyzed data from Ontario stroke centres in the Registry of the Canadian Stroke Network (07/2003-03/2009). We included consecutive patients presenting to hospital with a first acute arterial ischemic stroke or TIA in sinus rhythm who were candidates for AF screening: no history of AF, no AF documented in hospital, no pacemaker, survival to discharge home or inpatient rehabilitation (discharges to nursing homes/palliative care excluded). Cardiac monitoring was captured through database linkages (Ontario Health Insurance Plan). Primary outcomes were the proportion of patients receiving Holter monitoring within 90 days post-stroke/TIA and monitoring duration per patient. Results: Among 11,153 patients (mean age 68±14 years; 58% admitted to hospital; median LOS 3d ), 3213/11,153 (29%) received Holter monitoring within 90 days post-stroke/TIA: 2403/11,153 (22%) had 24h monitoring only, 611/11,153 (5%) had 48h monitoring, and 199/11,153 (2%) had >60h monitoring (includes multiple monitors). An event loop recorder was prescribed in 64/11,153 (0.6%). Subgroup results for TIA patients and elderly (aged >75 years) were consistent with overall findings. Conclusions: A large proportion of patients do not receive any Holter monitoring within 90 days following ischemic stroke/TIA. Most monitoring performed was limited to 24h, with very few patients undergoing prolonged monitoring. These results may contribute to an overdiagnosis of stroke events as ‘cryptogenic’, an underdiagnosis of AF, and missed anticoagulant treatment opportunities for secondary stroke prevention.
The Brain in Motion Study: Progress Report
Tyndall, AV1, 2 Davenport, MH1 Wilson, BJ1 Burek, GM1, 2 Haley, E1, 2 Eskes, GA4 Friedenreich, CM5, 6, 7 Hill, MD2, 2 Hogan, DB9, 8, 2 Longman, R10, 2 Anderson, TJ11 Leigh, R1, 3, 12 Smith, EE8, 13, 2 Poulin, MJ1, 7, 2; 1. Department of Physiology & Pharmacology, Faculty of Medicine, University of Calgary, Calgary, AB; 2. Hotchkiss Brain Institute, University of Calgary, Calgary, AB; 3. Department of Medicine, University of Calgary, Calgary, AB; 4. Departments of Psychiatry, Medicine (Neurology), and Psychology, Dalhousie University, Halifax, NS; 5. Department of Population Health Research, Alberta Health Services-Cancer Care, Calgary, AB; 6. Departments of Oncology and Community Health Services, Faculty of Medicine, University of Calgary, Calgary, AB; 7. Faculty of Kinesiology, Calgary, AB; 8. Department of Clinical Neurosciences, Faculty of Medicine, University of Calgary, Calgary, AB; 9. Professor and Brenda Stafford Foundation Chair in Geriatric Medicine, Faculty of medicine, University of Calgary, Calgary, AB; 10. Psychology, Alberta Health Services, Foothills Hospital, Calgary, AB; 11. Libin Cardiovascular Institute of Alberta, Department of Cardiac Sciences, Calgary, AB; 12. Airway Inflammation Research Group, Snyder Institute for Chronic Diseases, Faculty of Medicine, University of Calgary, Calgary, AB; 13. Departments of Radiology and Community Health Sciences, University of Calgary, Calgary, AB
Background: It is estimated that 60% of older adults lead sedentary lifestyles and consequently do not to achieve the favorable health benefits from regular aerobic fitness. Physical inactivity is a well-accepted modifiable risk factor for cerebrovascular disease and the decline in cognitive functions seen in older adults. Preliminary data from our laboratory suggest that the association between physical fitness and cognitive function may be mediated in part, by improvements in cerebrovascular function. Methods: 250 men and women aged 55 years and older are being recruited through poster, newspaper and media advertisements. The 18 month study consists of three 6-month phases: 1) baseline control; 2) aerobic exercise intervention; and 3) post-intervention follow-up. Testing measures include: 1) anthropometric characteristics; 2) cardiorespiratory fitness test (VO2max); 3) fasting blood sample; 4) neuropsychological test battery; and 5) assessment of cerebrovascular reserve using transcranial Doppler ultrasound. All tests are conducted upon entry of the study (Phase 1A), 6-months following the first measurements for second baseline measurements (Phase 1B), at the midpoint (3 months) and end of the aerobic exercise intervention, and finally 6-months following the completion of the aerobic exercise intervention for the follow-up assessment. Results: Currently 162 participants are actively enrolled in the study. Of these participants, 52 are in the baseline control phase, 55 are in the aerobic exercise intervention, and 55 are in the follow-up phase or have completed the study. Conclusion: To our knowledge, this is the first study to investigate the effects of a six-month aerobic exercise intervention on cerebrovascular and cognitive function in a healthy older population. The results of this study will provide physiologic mechanisms whereby exercise promotes benefits to cognitive function. In addition, the study may also promote the development of adjunct therapies to reduce the cognitive decline accompanied by normal brain aging.
Rapid Referral Program of the Niagara Health System - District Stroke Centre
McCallum, C; Hammond, L; Rusnak, M; Chew, DL; Niagara Health System, Niagara Falls, ON
Early therapeutic intervention post TIA (pharmacological, diagnostic, surgical) has been proven to decrease risk for future strokes/TIAs. Niagara’s District Stroke Team has developed a Rapid Referral strategy to ensure timely access to stroke expertise providing thorough assessment and intervention by a stroke team member within 24 hours post TIA symptoms. This new program will result in improved patient outcomes and decreased readmission to hospital. The new clinic protocol, devised in April 2010 resulted from a review of the Canadian Best Practice Recommendations for Stroke Prevention by the Stroke Team (District Stroke Coordinator, Neurologist, Acute Care Stroke NP and Stroke Prevention NP). The Stroke Team reviewed “Time from Referral to Initial Consult” and wait times averaged 14 days. With Canadian Best Practice Recommendations for urgent and emergent cases of 24-72 hours, this was unacceptable. From 5pm- 8am patients in any Emergency Department in Niagara experiencing a TIA or suspected TIA may be referred to the Rapid Referral Program. Three key criteria must be met to be considered for Rapid Referral: speech disturbance, unilateral weakness and symptoms occurring in the last 24 hours. Since the implementation of the Rapid Referral, 76.6% of urgent and emergent patients are seen within the recommended guidelines of 24 hrs and 72 hours respectively (1). Practice change based on Canadian Best Practice Recommendations for Stroke Prevention has allowed the Niagara Health System to become a leader in preventative stroke care. As evidenced by the Ontario Stroke Evaluation Report 2013: Spotlight on Secondary Stroke Prevention and Care released in June 2013, Niagara Health System’s District Stroke Prevention Clinic is the high performer for proportion of emergent and urgent SPC visits where the patient was seen within recommended guidelines. The concept of the Rapid Referral is a proven strategy to reduce wait times thereby improving quality of care.
Accuracy of ICD-10-CA Codes to Identify Paediatric Stroke
Maclagan, L1 Khan, F1 Pontigon, A1 Kapral, M2 Hall, R2 deVeber, G1; 1. Hospital for Sick Children, Toronto, ON; 2. Institute for Clinical Evaluative Sciences, Toronto, ON
Background: The 2012 Ontario Stroke Evaluation Report estimates a paediatric stroke incidence of 5.9 per 100,000 population under the age of 18 in Ontario. Using the results of the 2010/11 OSA as the gold standard we determined the accuracy and yield of ICD-10-CA codes for paediatric stroke to characterize the process for identifying paediatric strokes using administrative data. Methods: Paediatric stroke patients were identified for inclusion into the 2010/11 OSA using ICD-10-CA codes listed in the Canadian Stroke Strategy Performance Indicator 2010 Update and additional codes identified by a paediatric stroke neurologist. Cases were identified if any of the ICD-10-CA codes were found in any of the diagnostic code fields in FY2010/11 CIHI-DAD and National Ambulatory Care Reporting System (NACRS) databases. Trained abstractors reviewed the medical charts of the cases and determined if it was a true stroke/TIA based on information in the medical chart. The overall and individual ICD-10-CA codes accuracy was defined as the proportion of cases that were a true stroke upon chart review among all cases selected for inclusion into the OSA. We calculated a yield for each ICD-10-CA code and yield was defined as the percentage of total true strokes captured by a specific code. Results: In FY2010/11, 479 potential paediatric stroke/TIA cases were identified in CIHI-DAD or NACRS and 136 (28%) were considered to be true strokes/TIAs. Accuracy rates of stroke-specific codes ranged from 6.7 - 76.6% and yield ranged from 1.8% - 29.5%; highest accuracy and yield was achieved using I63. Non-specific codes ranged widely from 0-66.7% accuracy and 0-10.2% yield. Conclusion: The accuracy and yield of ICD-10-CA codes in paediatric stroke is low and underlines the need for prospective data collection. Further work will explore other ICD-10-CA codes or processes that may improve the identification of paediatric stroke using administrative databases.
Stroke in Saskatchewan: A Regional Sample
Kwiatkowski, BM1 Bharadwaj, L2; 1. Royal University Hospital, Saskatoon, SK; 2. University of Saskatchewan, Saskatoon, SK
The latest evidence indicates that 50,000 Canadians will experience a stroke in 2013. The associated hospital, rehabilitation, and long term care of stroke patients place a significant burden on our health care system. National statistics have been utilized in the development of guidelines to improve care and reduce the impact of stroke. Small less populated regions, such as Saskatchewan, may be underrepresented in national data utilized in the development of stroke prevention and treatment strategies. A retrospective descriptive chart review was conducted to provide a profile of stroke and transient ischemic attack cases admitted to Royal University Hospital, regional stroke centre for central and northern Saskatchewan, to determine similarity or difference to national statistics and to assess the acute management of these cases as defined in the Canadian Best Practice Recommendations for Stroke Care (Canadian Stroke Network and Heart and Stroke Foundation of Canada, 2011). A randomized sample of 200 cases was selected for review of adult stroke case records on personal demographics and healthcare performance through the use of the measures provided in the guidelines. Similarities in the study results and national information on the type of stroke, risk factors, gender, and age were found. Other findings included rural inequality in access to treatment and an apparent underutilization of medications for the treatment of risk factors. There were no cases from remote regions that arrived within the window for thrombolytic therapy. Hospital adherence to national guidelines comparing selected indicators was met in most areas and exceeded in some. The remaining indicators provide an opportunity for improvement and possibly more research. This regional information supplements the available Canadian information and could be used to guide planning and care strategically targeting Saskatchewan residents and increasing their potential for success.
I Saw the Sign: Improving Stroke Awareness in Canada
LeGrand, C; Arango, M; Joiner, I; Heart and Stroke Foundation of Canada, Ottawa, ON
Background: Stroke is a leading cause of death and disability in Canada. About 50,000 strokes occur each year and over 315,000 Canadians are living with the effects of stroke. Early identification of stroke signs and action to obtain immediate medical attention are critical to achieving the best possible outcomes for those experiencing stroke. The Heart and Stroke Foundation (HSF) has led the development and implementation of stroke public awareness campaigns in Canada. Despite efforts, research indicates that public knowledge of stroke signs remains sub-optimal and that Canada lags behind other countries. While there are many contributing elements to successful recall and recognition, messaging is critical to an effective awareness campaign. Methods: A one-day meeting was convened to provide feedback to existing stroke signs campaigns. Meeting participants represented a broad cross-section of HSF staff, clinicians/neurologists, cognitive, behavioural, communications and marketing experts from across Canada. Participants evaluated three stroke signs campaigns - ‘Suddens’ (Canada), Give Me 5 for Stroke (US) and F.A.S.T. (UK and Australia) - through a series of table exercises and large group dialogue. Results: Research and clinical data indicate that motor and speech signs are the most frequently reported stroke signs. Marketing best practices, emotional connection with the audience and a compelling ‘call to action’ are key elements for success. Current HSF messaging contains too many elements. Evidence from the F.A.S.T campaign should be considered when developing future campaign messages. Conclusions: Improvements to HSF signs of stroke campaign messages are advised. Shortening the number of signs and ensuring inclusion of speech, motor and Act Now/call 9-1-1 elements are recommended to improve recall and recognition. The Foundation will use the feedback from the one-day meeting to inform development of future signs of stroke multimedia public awareness campaign.
Emergency Department Transient Ischemic Attack Clinical Pathway: Improving Quality of Care and Patient Safety Using Etiology-based Triage
Treasurywala, K; Fung, W; Wang, A; Kolesnik, J; Cheung, J; Sahlas, D; Lin, D; McMaster University, Hamilton, ON
Background: Recent evidence suggests tools such as the ABCD2 score can fail to identify patients at high risk for recurrent stroke, including those in whom evidence-based interventions for time-sensitive stroke mechanisms exist, such as carotid artery stenosis (CAS) or atrial fibrillation. Methods: A novel clinical pathway was devised based upon potential etiologic mechanisms, in order to better integrate Emergency Department (ED) management of patients diagnosed with Transient Ischemic Attack (TIA) with subsequent outpatient Stroke Prevention Clinic (SPC) follow-up, with an emphasis on identifying symptomatic moderate to high-grade CAS. All adult patients diagnosed with TIA in our ED and who were referred to our SPC from November 5, 2012 to February 28, 2013 were prospectively identified and their clinical outcomes followed for one month. A historical cohort of patients diagnosed with TIA in the ED prior to the protocol was reviewed from January 1 to December 31, 2011. Results: Prior to the protocol, the median time to carotid ultrasound for ED patients referred to the SPC in whom it was subsequently ordered (49/94) was 6 days. After the protocol, the median time to carotid ultrasound dropped to 1 day, (p<0.001) despite more carotid ultrasounds being requested (77/81) Moreover, 96.3% of those diagnosed with TIA in the ED had brain imaging compared to 86.2% prior to the protocol (p=0.03). There was no change in rate of the ordering of EKGs 93.6% before and 92.6% after (p=1.00). Of the patients without atrial fibrillation, 96.1% were discharged with an antiplatelet agent compared to 46.2% prior to the protocol (p<0.001). Conclusions: Our clinical pathway for ED patients evaluated for TIA is based upon potential vascular etiology of TIA and resulted in an increase in patients undergoing brain imaging, expedited carotid imaging, and an increase in prescription of antiplatelets, all prior to their SPC appointment.
Should Patients with First Cryptogenic Stroke Undergo Routine Tumor Screening?
Maynard, S; Thiel, A; Jewish General Hospital, Montreal, QC
Background: Occult malignancy presenting with stroke (OMPS) is predominantly thought to be caused by chronic disseminated intravascular coagulation (DIC), non-bacterial thrombotic endocarditis (NBTE) and putatively arterial embolic disease (AED). The incidence of stroke as the first presentation of occult malignancy is exceedingly rare, ranging from 0.4-3.0% (ischemic stroke population). We present three such cases from our stroke unit that we have encountered within the past 12 months and discuss possible consequences for diagnostic procedures. Methods: A retrospective chart review was performed for all three cases that were diagnosed with solid tumor, occult malignancies in the setting of first acute embolic CVA. These cases were then compared and contrasted to the available literature both on this specific subject and on the subject of stroke and malignancy in general. Results: According to the literature regarding OMPS, the most common solid tumor primary site is pulmonary (30%) followed by colorectal (15%), with adenocarcinoma being the most frequent histopathology. Equally, the most common etiology of OMPS is NBTE followed by DIC; AED has not been clearly reported. Reported median survival was 4.5 months. Two of our cases had confirmed adenocarcinoma of the lung (one did not undergo biopsy), one patient presented with NBTE whereas the other two had neither NBTE nor DIC and were presumed to represent AED. Two of the patients died within 6 weeks of diagnosis and had recurrent embolic events on antiplatelets/unfractionated heparin. One patient who survived beyond median survival time, responded to single antiplatelet therapy. Conclusions: Our case series is representative of the literature with respect to primary site and histopathology, but most common etiologies (NBTE and DIC) were underrepresented. Our and other such cases underline the need for general criteria from a prognostic approach, and raise questions as to the efficacy of antiplatelet and anticoagulation therapy in this population.
Degree of Ischemic Vasculopathy in Lateral Cholinergic Projections is Associated with Set-Shifting Executive Dysfunction in Post-Stroke Cognitive Impairment
Muir, RT3, 2, 1 Honjo, K1, 2 Lam, B4, 2, 3 Gao, F1, 2, 3 McNeely, AA1, 2, 3 Harry, RD1, 2, 3 Ganda, A1, 2, 3 Scott, CJ1, 2, 3 Zhao, J1, 2, 3 Ramirez, J2, 1, 3 Graham, SJ2 Rangwala, N5 Marola, J5 Stebbins, GT6 Gibson, E1, 2 Lobaugh, NJ2 Stuss, DT1, 7 Nyenhuis, DL5 Kang, Y9, 8 Black, SE4, 3, 2; 1. Brain Sciences Research Program, Sunnybrook Research Institute, University of Toronto, Toronto, ON; 2. Heart and Stroke Foundation Centre for Stroke Recovery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON; 3. L.C. Campbell Cognitive Neurology Research Unit, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON; 4. Department of Medicine, Division of Neurology, University of Toronto, Toronto, ON; 5. Hauenstein Neuroscience Centre, Saint Mary’s Health Care, Grand Rapids, MI, USA; 6. Rush University Medical Centre, Chicago, IL, USA; 7. Rotman Research Institute, Baycrest, University of Toronto, Toronto, ON; 8. Department of Psychology, Hallym University, Seoul, Korea; 9. Department of Neurology, Hallym University Sacred Heart Hospital, Seoul, Korea
Background: Post-stroke cognitive impairment is typified by decreased processing speed and executive dysfunction. The potentially distinct influences of territorial stroke and subcortical ischemic vasculopathy (SIV) on these executive subcomponents are not well understood. Here we use the Trail-Making-Test (TMT), which assesses processing speed (TMT-A) and set-shifting executive function (TMT-B, and TMT-B-minus-A-time), to define these relationships. Methods: Neuropsychological testing and volumetric MRI from two independent stroke samples were studied: patients with an Acute/Sub-Acute Ischemic Stroke (ASIS) (South Korea; n=50) and Chronic Ischemic Stroke (CIS) (North America; n=66). Trail Making Tests (TMT), which assess processing speed (TMT-A) and set-shifting (TMT-B and TMT-B-minus-A-time) were administered. MRIs were processed using a semi-automated imaging pipeline, including stroke tracings and quantification of global white matter hyperintensities (WMH) volume. Cholinergic WMH were assessed using the Cholinergic Pathways HyperIntensities Scale (CHIPS). Results: Linear regression analysis of infarct volume, global WMH volume, and CHIPS, as predictors of TMT-A and TMT-B-minus-A-time, was performed, controlling for age, sex, education, global atrophy and stroke location in the executive network. For ASIS patients, infarct volume (β=0.700, p=0.0001, r2=0.44) and global WMH (β=0.207, p=0.002, r2= 0.06) were associated with TMT-A, while only CHIPS was associated with TMT-B-minus-A-time (β=0.386, p=0.001, r2= 0.11). Similarly, for CIS patients, infarction volume (β=0.267, p=0.015, r2=0.07) and global WMH (β=0.360, p=0.003, r2=0.11) were associated with TMT-A, and only CHIPS was associated with TMT-B-minus-A-time (β=0.413, p=0.001, r2= 0.15). Conclusion: Here we report, and replicate the differential associations of processing speed and set shifting with cortical/subcortical lesion measures in two stroke cohorts. The degree of SIV within cholinergic projections was associated with impaired set-shifting ability, while global SIV and infarction volumes were associated with reduced processing speed. This suggests that the cholinergic system could be a substrate for set-shifting executive function deficits and a target of cognitive neurorehabilitation and cholinergic pharmacotherapy.
Cerebral Vasospasm and Delayed Cerebral Ischemia in Subarachnoid Hemorrhage: a Contemporary Case Series
Ng, KH2, 1, 3 Algird, A1, 3 Martin, C3 Jichici, D1, 3 Sahlas, DJ1; 1. McMaster University, Hamilton, ON; 2. Population Health Research Institute, Hamilton, ON; 3. Hamilton Health Sciences, Hamilton, ON
Background: Focal or diffuse cerebral vasospasm can occur in up to 30% of patients with aneurysmal subarachnoid haemorrhage (SAH). 20% to 40% of patients develop neurological symptoms or secondary ischaemic stroke due to vasospasm despite therapy. Delayed cerebral ischaemia (DCI) is defined as symptomatic vasospasm or infarction on CT attributed to vasospasm. Transcranial Doppler (TCD) monitoring enables identification of patients at risk of developing DCI and triggers aggressive early medical treatment. Whilst TCD parameters for proximal middle cerebral artery (MCA) vasospasm are well established, the parameters for the anterior (ACA) and posterior cerebral artery (PCA) are less well defined. Methods: This is a retrospective consecutive case series of patients with SAH and subsequent DCI (22/98) admitted between April 2010 to March 2012 at the Hamilton General Hospital. Serial TCDs of the major intracranial vessels were performed and parameters including mean blood flow velocity (mBFV) were recorded for every patient. Results: 50% of intracranial aneurysms in this case series were anterior communicating artery aneurysms. 34 DCI events were confirmed on brain imaging, with 31 events involving the anterior circulation. Those patients with MCA DCI had average and median mBFV of 186 cm/s and 197 cm/s respectively (range 62 cm/s to 337 cm/s). In patients with ACA DCI, the average and median mBFV were 115 cm/s and 114 cm/s respectively (range 64 cm/s to 175 cm/s). In patients with PCA DCI, the average and median mBFV were 102 cm/s and 54 cm/s respectively (range 50 cm/s to 201 cm/s). Conclusions: TCD is a simple bedside test that can guide the management of patients following SAH at risk of DCI due to vasospasm. Our case series involving contemporary intensive care management reports mBFV parameters in patients with DCI following SAH in each of the major arterial territories.
Meta-analysis of Albumin in Acute Stroke (ALIAS) Parts 1 and 2 Trials
Palesch, YY1 Martin, RH1 Hill, MD2 Tamariz, D3 Jauch, EC1 Weng, Y1 Speiser, JL1 Woolson, RF1 Barsan, WG4 Moy, CS5 Ginsberg, MD3; 1. Medical University of South Carolina, Charleston, SC, USA; 2. University of Calgary, Calgary, AB; 3. University of Miami, Miami, FL, USA; 4. University of Michigan, Ann Arbor, MI, USA; 5. National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
Background: The international multicenter (including several Canadian sites) Albumin in Acute Stroke (ALIAS) Parts 1 and 2 Trials randomized patients with acute ischemic stroke (NIHSS ≥ 6) within 5 hours from symptom onset to treatment with 25% human albumin (ALB) at 2 g/kg infused intravenously over 2 hours or to equivolemic normal saline similarly infused. The Part 1 Trial had randomized 434 out of the expected maximum 1,800 subjects when it was terminated due to safety concerns raised by the DSMB. During the subsequent year, upon analyzing the safety data, some of the eligibility criteria were modified with a few minor changes to the protocol, and the trial was re-started as a new study, i.e., as Part 2. After 841 of the anticipated 1,100 subjects were enrolled in Part 2, the DSMB recommended stopping the study because the pre-specified futility boundary was crossed. Methods: The primary outcome for both trials was the favorable outcome defined as mRS 0-1 and/or NIHSS score 0-1 at 90 days from randomization. Because the two trials were conducted under a similar protocol at mostly the same clinical sites and coordinated by the same group of investigators, we conducted one-stage meta-analysis using the participant level data from both trials. As a sensitivity analysis, two-stage meta-analysis, where the summary measures from each trial are combined, was performed. Results: In general, the baseline characteristics were similar between the trials overall as well as between the treatment groups within each trial. These characteristics will be presented by trial and in aggregate along with the primary outcome analysis results from each trial and from the meta-analyses. Conclusion: TBA since the results from the Part 2 Trial, and consequently, from the meta-analysis cannot be disclosed at this time.
Late Life Migraine Accompaniments Presenting to the Stroke Clinic: How Much Investigation is Necessary?
Pim, H; Aube, M; Cote, R; Vieira, L; McGill University, Montreal, QC
Background: Transient ischemic attacks (TIA) can be associated with a 10% risk of stroke in 90 days and urgent investigation and treatment is recommended (1). Fisher described patients in the stroke age bracket with transient neurological symptoms, late-life migraine accompaniments (LMA) that could be benign and potentially related to migraine aura-like phenomena (2). The Framingham study (3) found that most of these patients did not need to undergo extensive investigations. The decision as to what investigations are necessary, in these individuals, remains a common clinical problem. Methods: Our study will be nested within a larger retrospective review of the files of all patients referred to the McGill University Stroke Prevention clinic with a diagnosis of TIA from 2008 to 2012. The clinic sees between 2500 and 3000 patients with per year. Patients with LMA will be identified by using a modification of the original Fischer criteria for the diagnosis of LMA (2). Other symptoms that may help to support the diagnosis of LMA will be documented. We will evaluate the clinical symptomatology, vascular risk factors, migraine history (where available), investigations carried out and their results. We will document the incidence of vascular events and the treatment decisions made in these patients. Expected Results: The study is ongoing and the final results will be presented at the Canadian stroke congress. We expect to be able to demonstrate a correlation between certain clinical presentations and the risk of cerebrovascular events. Conclusions: We expect to demonstrate that a careful history and follow up may obviate the need for extensive cerebrovascular investigations in many patients with LMA.
Johnston, S.C., et al., JAMA, 2000. 284: 2901-2906
Fisher CM. Can J Neurol Sci 1980;7:9-17
Wijman et al., Stroke. 1998;29:1539-1543
Unilateral Surgical Revascularization Improves Cerebrovascular Reactivity of the Non-intervened Hemisphere in Patients with Bilateral Steno-occlusive and Moyamoya Disease
Sam, K1 Poublanc, J2 Crawley, AP2 Fisher, JA1 Mikulis, DJ2; 1. University of Toronto, Department of Physiology, Toronto, ON; 2. Toronto Western Research Institute, Department of Medical Imaging, Toronto, ON
Background: Unilateral hemodynamically significant large-vessel intracranial stenosis may be associated with reduced BOLD cerebrovascular reactivity (CVR), an indicator of autoregulatory reserve. Reduced CVR has, in turn, been associated with ipsilateral cortical thinning and loss in cognitive function. These signs and clinical effects have been shown to be reversible following revascularization. Our aim was to study the effects of unilateral revascularization on CVR in both hemispheres in the presence of bilateral steno-occlusive or moyamoya disease. Methods: In this exploratory observational study, 20 patients with either moyamoya disease (n=14) or bilateral severe stenosis of the ICA (n=6) underwent BOLD CVR MRI at 3T (GE Healthcare, Milwaukee), and using RespirAct™ (TRI, Toronto, Canada) to control the PCO2 stimulus, before and after unilateral revascularization (extracranial-intracranial bypass, carotid endarterectomy, or encephaloduroarteriosynangiosis). Pre- and post-revascularizaion CVR was assessed in both hemispheres. Results: As expected, the CVR improved in the intervened hemisphere (0.098 ± 0.018 to 0.201± 0.010, P<0.01). There was also a significant post-revascularization improvement in CVR of the non-intervened hemisphere (0.140 ± 0.020 to 0.205 ± 0.011, P<0.01). Discussion: The interdependence of hemispheric blood flow is mediated by the interconnections via the circle of Willis and other collateral blood vessels. It makes sense that resupply of one hemisphere reduces the draw of blood flow from the other, improving its autoregulatory reserve, as reflected in the CVR. Conclusion: Unilateral revascularization can improve vascular reserve in the non-intervened hemisphere. Bilateral revascularization may not be necessary for restoring global hemodynamic function.
Fallibility, History and Endovascular Stroke Trials: A New Perspective on Equipoise
Shamy, MC; Stahnisch, FW; Hill, MD; University of Calgary, Calgary, AB
Background: Equipoise is an ethical principle that justifies the enrollment of patients into randomized clinical trials (RCTs) on the basis of conflicted medical opinion, either on the part of individual physicians or of the community. In light of the results of recent stroke trials that have contradicted the prevailing opinions of the community, we question the relevance of equipoise to clinical trial enrollment, particularly in stroke. Methods: We apply examples from stroke medicine to demonstrate the limitations of equipoise that arise due to its reliance on medical opinion. We discuss the complex development and instability of medical opinion, in general and in relation to clinical trials. We review the justifications for RCT enrollment that are not related to opinion, and seek a more ethically and epistemically robust alternative. Results: We propose the “fallibility principle” as a new approach to ethical decision-making about RCTs that acknowledges the fallibility of every opinion and that contextualizes recent questions about the ethics of clinical experimentation within a broader perspective informed by the history of medicine. Through the lens of fallibility, the dual ethical and epistemic imperative of medicine – providing best care from best evidence – is conceived as a continuous challenge navigated through a combination of humility, skepticism and caring. Conclusions: We propose a revision of equipoise in the form of the historically-informed fallibility principle. Fallibility extends concepts from the history and philosophy of science to advance our understanding clinical research ethics in a novel way.
Atrial Fibrillation Prediction Score in Cerebrovascular Disease
Shuaib, A1 Yaseen, I1 Ghrooda, E1 Mohammad, A1 Dobrowolski, P1 Hasan, M1 Hussain, G2 Ahmad, A1; 1. University of Alberta, Department of Medicine, Division of Neurology, Edmonton, AB; 2. University of Alberta, Department of Medicine, Division of Cardiology, Edmonton, AB
Introduction: Paroxysmal Atrial Fibrillation (PAF) is an important cause of preventable embolic stroke. Recent studies have shown that PAF is much more likely to be diagnosed with prolonged cardiac monitoring. We designed a PAF prediction score (including: Recurrent stroke, Pattern of infarction on imaging, Etiology,Premature atrial beats and Palpitations) and tested in patients with TIAs and acute stroke. Methods: Patients seen at University of Alberta stroke program in whom Holter monitoring was negative for PAF were prospectively enrolled in a study to monitor for PAF between July 2012 and May 2013. A PAF prediction score (low, medium and high) was tested to determine the risk for the arrhythmia. Results: 54 patients had 10 (±4) days of monitoring (SpiderFlash-t™ monitor, Sorin, Italy). PAF was seen in no patients with low score (0/5), 30% of patients with medium score (3/10) and 36% of patients with high score (14/39). In addition, atrial flutter was seen in two patients with high score (embolic risk in 41% patients). The diagnosis resulted in initiation of anticoagulation in 13 patients. Conclusions: The risk of potential PAF can be calculated with a clinical score. This may allow for the selection of patients where more focused prolonged cardiac monitoring arrhythmias and change in prevention therapies.
Sensitivities and Specificities of the Doc Screen for Depression, Obstructive Sleep Apnea and Cognitive Impairment on Gold Standard Testing
Sicard, MN1 Lien, K1 Lanctot, K1 Murray, B1 Herrmann, N1 Thorpe, K2 Swartz, R1; 1. Sunnybrook Health Sciences Centre, Toronto, ON; 2. Applied Health Research Centre of the Li Ka Shing Knowledge Institute, Toronto, ON
Background: 30-50% of patients post-stroke are affected by each of the following comorbidities: depression, obstructive sleep apnea (OSA), and cognitive impairment (DOC). The DOC screen is a simple, evidence-based screen that can be done in stroke patients in ≤5 minutes. The primary objective of this study is to assess the validity of the DOC screen for identifying individuals at high-risk of DOC conditions in a large-volume stroke/TIA clinic. Methods: The sensitivity and specificity of individual DOC sub-screens (PHQ-2 for depression, STOP for OSA and Mini-MoCA for cognitive impairment) were assessed compared to gold standard research assessments in consenting patients at the Sunnybrook Stroke Prevention Clinic. Results: Over eleven months, 205 patients consented to gold standard testing; not all patients completed every assessment. The PHQ-2 sub-screen was both specific (88%) and sensitive (72%) compared to the Structured Clinical Interview for the DSM-IV Depression Module (n=193). The mini-MoCA was equivalent to the full MoCA in predicting cognitive impairment of ≥1 domain on the neuropsychological test protocol (mini-MoCA, 52% specificity and 80% sensitivity; MoCA, 60% specificity and 81% sensitivity, n=170). Only 26% of enrolled patients consented to polysomnography. Compared to polysomnography (n=47), the STOP sub-screen was sensitive (86%), but lacked specificity (30%). Conclusion: The PHQ-2 and mini-MOCA results are valid compared to gold standard assessments. They may be useful in the clinical setting for identifying those at high-risk for depression and cognitive impairment. The low specificity of STOP, along with low enrollment in polysomnographys highlights the need for additional simple OSA screening tools. The sensitivity for detecting OSA was adequate, and sensitivity is preferred for a screening tool. The DOC screen is a sensitive and valid tool to screen for depression, OSA, and cognitive impairment in the stroke population.
tPA Door to Needle Reduction: The Impact of Nurse Stroke Specialists
Tebbutt, TD; Hammond, L; Grand River Hospital, Kitchener, ON
Background: The Central South Stroke Region consists of one Regional Stroke Centre and three District Stroke Centres (DSCs). Improving door to needle times for tPA was identified as a Central South Stroke regional priority in 2011/2012 and 2012/2013. The Greater Niagara General Site (GNG) of the Niagara Health System is a DSC in Central South. The Stroke Team at GNG have consistently exceeded the provincial benchmark with door to needle times for tPA through a unique “Nurse Stroke Specialist” model of care; 39 minutes for the last three years. Waterloo/Wellington District Stroke Centre collaborated with the Niagara Health System to determine if this model of care could be applied with success in another district that has a different medical model. Methods: A site visit was organized to Niagara Health System for Waterloo/Wellington Stroke Team. This resulted in implementation of the GNG Nurse Stroke Specialist model which includes several strategies: tPA feedback letters for internal stroke team members and Emergency Services Network (EMS) staff identifying door to needle times and patient outcomes, pre-alert by EMS, EMS transporting patient straight to CT, and offering additional training for Emergency Department (ED) nurses utilizing Hemispheres which is an eight module online stroke training program. Results: Grand River Hospital has reduced median door to needle times from 72 minutes to 58 minutes since April 2011-December 2012. In addition, we have 33 ED nurses who have signed up for the online Hemispheres Stroke Education series. Conclusions: The Nurse Stroke Specialist model of care was successfully applied in Waterloo/Wellington and has facilitated more efficient and timely provision of tPA. This suggests that this model of care is transferable and could be effective at other sites.
FLAIR Hyperintense Vessel Sign on MRI brain (HVS) Does Not Predict Any Intracranial Hemorrhage or Symptomatic Hemorrhage(sICH) in Acute Strokes with Proximal Vessel Occlusions Treated with Intravenous or Intra-Arterial Lytic/Mechanical Therapy
Adatia, S1 Almekhlafi, M1 Nambiar, V1 Trivedi, A1 Sohn, S2 Menon, B1 Al-sereya, A1; 1. Foothills Medical Hospital, Calgary, AB; 2. Keimyong University, Korea, Korea
Background and Purpose: Hyperintense vessels (HV) have been observed in fluid- attenuated inversion recovery imaging (FLAIR) MRI sequence in patients with acute ischemic strokes in region of diffusion positivity. They have been linked to slow flow in collateral arterial circulation and proximal arterial occlusions. We aim to study its correlation with intracranial hemorrhage. Methods: We retrospectively reviewed 95 patients from prospectively collected acute ischemic strokes with proximal occlusions on CTA. The HV sign was defined by presence of flair bright vessels on MRI in the region of diffusion restriction. Two independent/blinded clinicians identified it. sICH was defined by SITS-MOST criteria. Results: 59 patients had HVS and 36 did not. Interrator agreement was good. (Kappa 0.92). Proportion of age, sex, NIHSS, diabetes and smoking was comparable in both. The patients were offered IV tpa, intra arterial therapy (lytic/ mechanical thrombectomy) or both based on judgment of treating team. In the HVS group, 14 received IV tpa and 44 underwent IA with IV therapy. In the non HVS group, 19/36 had IV tpa, 14 had IA alone and 2 received both. (1 missing). The groups were comparable for rates of recanalization (TIMI 2/3). 8/36 patients in the non HVS group had any ICH and 1 had sICH. 22/59 had any ICH and 5 sICH in the HVS group. (p=0.2785) In the multivariate regression analysis model for prediction of sICH, high glucose levels, age and NIHSS emerged as significant predictors. For any ICH, glucose and initial NIHSS were significant. Conclusion: Presence of HVS is not uncommon in patients with proximal vessel occlusions. In present study, its presence was not significant for prediction of intracranial hemorrhage. Glucose levels, age and NIHSS were significant predictors of sICH. Larger sample with pretreatment MRI needs to be studied for correlation of HVS and intracranial hemorrhage.
Spontaneous or Traumatic Cervical Artery Dissection: a Distinction with Therapeutic Impact?
Tsai, JP1 Swartz, RH1, 2; 1. Division of Neurology, Department of Medicine, University of Toronto, Toronto, ON; 2. Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Center, Toronto, ON
Background: The literature classifies cervical artery dissection (CAD) into two etiological categories: spontaneous or traumatic. This distinction is primarily based on presenting history, but recent studies and reports suggest that these groups share many similarities. Best evidence-based management for both spontaneous and traumatic CAD remains unclear, as on-going randomized controlled trials are challenged by difficulties meeting sufficient power for conclusive results. We hypothesize that spontaneous and traumatic CAD are mainly differentiated by their respective risks for ischemic and hemorrhagic complications, and that determination of this risk profile is key in devising a rationalized approach to management. Method: We reviewed the medical literature through MEDLINE and PubMed from 2003 to 2013, with review of references. The search was limited to “English language” and “Human”, with exclusion of articles solely pertaining to intracranial dissections. Through articles identified, we compared and contrasted key characteristics between spontaneous and traumatic CAD. Results: A total of 246 articles pertaining to spontaneous carotid or vertebral artery dissection, and 117 articles on traumatic ones, were identified. Review of reported characteristics showed overlaps between spontaneous and traumatic CAD, including inciting event, histopathology, natural history, mechanism of distal embolism, and treatment options. Rates of thromboembolic and hemorrhagic complications account for their major differences, and are highest early after dissection in both groups. Conclusion: Few differences and many similarities exist between spontaneous and traumatic CAD. Major distinguishing factors are the embolic and hemorrhagic risks, and a balance of the two should be accounted for in the treatment decision for CAD, which often involves antithrombotic agents. This principle is likely key in devising a common rationalized approach to therapy for all cervical artery dissections.
Integrated Vascular Management Clinic (IVMC) – A Comprehensive Approach to Vascular Management
Shipley, C2 White, JL1 Hill, C1; 1. Peterborough Regional Health Centre, Peterborough, ON; 2. Peterborough Regional Vascular Health Network, Peterborough, ON
Background: In 2006, Haliburton Kawartha Pine Ridge (HKPR) was facing the future: a rapidly aging, medically complex vascular patient population and limited resources in terms of the availability of specialists to provide comprehensive assessment and treatment. The IVMC model was established in 2006 to streamline vascular referrals through a coordinated intake process. The goal of the clinic was to increase accessibility for patients in order to improve the detection, management and treatment of vascular disease while improving resource utilization through a collaborative, patient-centred approach. Method: IVMC is a community-based, nurse led and physician supervised clinic designed to be responsive to the needs of patients in the HKPR District presenting with a manifestation of any type of vascular disease. Clinics included under the IVMC umbrella are: TIA Clinic, Chest Pain Fast Track Clinic, Heart Function, Rapid Access Clinic and Vascular Risk Optimization Clinic. Patients are referred directly from the Emergency Departments (ED), specialists’ offices, and family practice organizations across HKPR. Result: Efficient and successful navigation of patients through the vascular care continuum using standardized, evidence-based protocols. In 2012/2013, over 3000 patients across the HKPR District were referred to IVMC Clinics for the detection, management and treatment of vascular disease. Partnerships have been established between a variety of care providers to ensure effective integration of acute, sub-acute, specialty and primary care for patients with all manifestations of vascular disease. Conclusion: This comprehensive, community-based model of care has been effective in developing and deploying unique and highly efficient services within the HKPR District. The model aligns with broader provincial targets for the management of vascular disease; providing rapid access to vascular diagnostic tests, investigations, and intervention. The efficiencies achieved have resulted in improved coordination of care for patients requiring multiple vascular investigations, ultimately improving patient outcomes and reducing health care resource utilization.
Chinese or South Asian Ethnicity is not Independently Associated with Delayed Treatment in Acute Stroke: Observations from the Vancouver Stroke Program
Wilson, L; Mann, S; Murray, K; Yip, S; University of British Columbia, Vancouver, BC
Background: Various pre-hospital and hospital factors have been implicated in delaying time to treatment with tissue plasminogen activator (tPA) in acute ischemic stroke. However, in a multicultural city such as Vancouver, it is unclear if ethnicity is a predictor of a prolonged door to needle time (DTN). Methods: A retrospective chart review was performed of all patients (n=250) treated with tPA consecutively at Vancouver General Hospital (VGH) from January 2009 to March 2011. Demographic features along with times of symptom onset, arrival, CT scan and treatment with tPA were recorded for Chinese, South Asians and all other ethnic groups (“Others”). As the 2013 AHA guidelines recommend a DTN of <60 minutes, multivariate logistic regression analysis was used to determine independent variables associated with a DTN ≥60 minutes. Results: The final study population included 203 patients with 20% Chinese (n=40) and 14% South Asian (n=29) patients. The mean DTN for Chinese and South Asians was not significantly different from Others (77 and 60 vs. 70 minutes, p=0.26 and p=0.12 respectively). Multivariate logistic regression identified only hospital transfer (p<0.001) as an independent predictor of DTN less than 60 minutes. Ethnicity was not an independent factor associated with a prolonged DTN (p=0.25). Conclusions: This study did not identify ethnicity as an independent variable in delay to treatment with tPA for acute ischemic stroke at Vancouver General Hospital. However, hospital transfer was shown to be an independent variable associated with a shorter DTN and this requires further study as it may alter future local treatment protocols.
The Effect of Antalarmin on the Expression of Brain Derived Neurotrophic Factor mRNA in the Hippocampus and Basal and Stessed-Induced CORT Secretion Following Transient Cerebral Ischemia in the Rat
Barra de la Tremblaye, P; University of Ottawa, Ottawa, ON
Background: Recently, we demonstrated persistent changes triggered by forebrain ischemia in corticotropin releasing hormone (CRH) and CRH type 1 receptor (CRH-R1) immunoreactive expression in the paraventricular nucleus of hypothalamus, central amygdala and the CA1 subregion of the hippocampus. CRH-R1 receptors have been shown to mediate brain plasticity by acting on brain-derived neurotrophic factor (BDNF) in a region specific manner following various stressors. The current study investigated whether inhibition of CRHR1 activation alters basal and stress-induced CORT levels as well as BDNF and TrkB mRNA expression in the hippocampus following global cerebral ischemia. Methods: Male Wistar rats (N = 30) received intracerebroventricular infusion of either Antalarmin (2µg/2µl) or saline 30 minutes prior to being subjected to 10 minutes global ischemia or sham occlusion. CORT levels were determined by RIA at multiple basal intervals before and after reperfusion and after 15 minutes restraint stress. Animals were killed 30 days after reperfusion and thymus, adrenal glands and seminal vesicles weighed. BDNF and TrkB mRNA expression were assessed by RT-PCR in the dorsal hippocampus. Results: Statistical analysis of the thymus and adrenal gland weight revealed significant differences between Ischemic and Sham groups. Only the seminal vesicles reduction was prevented by Antalarmin administration in ischemic rats. However, persistent elevations in basal CORT levels post ischemia were significantly reduced by Antalarmin at short and longer–term intervals and after restraint stress. The expression of BDNF and TrkB mRNA was attenuated in the hippocampus 30 days post ischemia, independent of antalarmin treatment. Conclusions: Our findings suggest that forebrain ischemia dysregulate the endocrine system with sensitized CORT responses at multiple baseline time intervals and following acute restraint. This phenomenon was attenuated by a single Antalarmin administration prior to ischemia. Decreased hippocampal expression of BDNF and TrkB mRNA may play a role in functional deficits observed following global ischemia.
Identification of a Novel Transcription Regulator that Controls Macrophage Polarization and Cholesterol Uptake
Chen, H1, 2, 3 Keyhanian, K4, 2, 3 Pandey, NR4, 2 Zhou, X4, 2 Ho, T5, 3 Wen, K4, 2 Lu, M4, 2 Stewart, AF5, 3; 1. Ottawa Hospital Research Institute, Ottawa, ON; 2. Centre for Stroke Recovery, Ottawa, ON; 3. University of Ottawa, Ottawa, ON; 4. Ottawa Hospital Research Institute, Centre for Stroke Recovery, Ottawa, ON; 5. University of Ottawa Heart Institute, Ottawa, ON
Background: A meta-analysis published in Lancet Neurology (2009) that included more than 165,000 patients showed that for every 39-mg/dL decrease in LDL-cholesterol (LDL-C) levels, there was a 21% reduction in the relative risk of stroke. Two independent genome-wide association studies (GWAS) found that IRF2BP2 polymorphisms affect LDL-C levels. IRF2BP2 is the co-repressor of interferon regulatory factor 2, a transcription factor that regulates innate immune response and suppresses interferon alpha (IFNα) expression. IFNα primes macrophages to become polarized to an M1 inflammatory phenotype (producing pro-inflammatory cytokines). Macrophages can also become polarized to an M2 phenotype (producing anti-inflammatory cytokines) important for tissue repair, depending on other external stimuli. Macrophages are important regulators of cholesterol metabolism and emerging evidence indicates that regulation of M1/M2 polarization influences LDL-C uptake. Methods: To address how IRF2BP2 influences macrophage handling of LDL-C, we generated a mouse model LysMCre/IRF2BP2flox that specifically ablates IRF2BP2 in macrophages. Results: IRF2BP2 expression is elevated in M2 macrophages and reduced in M1 macrophages. Ablation of IRF2BP2 in macrophages skews polarization to the M1 phenotype, with elevated expression of TNFα and IL-1β. Quantitative RT-PCR analysis showed that IRF2BP2 suppresses the expression of scavenger receptors MSR1 and SCARB1 that uptake LDL-C to macrophages. IRF2BP2 deficient macrophages accumulated significantly higher levels of oxidized LDL-C. Importantly, altered nutrients and stress affected IRF2BP2 expression in cultured cells and in the brain. Conclusion: IRF2BP2 is important to control macrophage polarization and LDL-C uptake and is likely to affect susceptibility to stroke injury.
Loss of MAPK Phosphorylation of Connexin43 is Neuroprotective in Stroke
Freitas-Andrade, M1 Bechberger, J1 MacVicar, B2 Lampe, P3 Naus, C1; 1. Department of Cellular and Physiological Science, Life Sciences Institute, University of British Columbia, Vancouver, BC; 2. Brain Research Centre, Department of Psychiatry, University of British Columbia, Vancouver, BC; 3. Fred Hutchinson Cancer Research Center, Seattle, WA, USA
Astrocytic interactions involving gap junction proteins has been reported to be a mechanism associated with neuronal survival in ischemic conditions. In astrocytes, gap junctions are composed primarily of the channel protein, Connexin43 (Cx43). These channels provide a substrate for the formation of a functional glial syncytium. While several reports have demonstrated that Cx43 is an important factor in cerebral ischemia, the molecular mechanisms involved remains elusive. The transmembrane regions of Cx43 are relatively conserved with other connexins, however, the cytoplasmic region is divergent and has been shown to be critical for the regulation of Cx43. Recently, a study showed that in response to atherogenic stimuli and vascular injury, Cx43 is phosphorylated at its C-terminus mitogen-activated protein kinase (MAPK) residues and that this is a key regulator of vascular smooth muscle cell (VSMC) proliferation and vascular scar tissue formation in vivo. In this study, wild-type (WT) mice and mice containing Cx43-MAPK null phosphorylation (MK4) mutation were subjected to permanent unilateral middle cerebral artery occlusion (MCAO). After 4 days of recovery, brain sections were histologically evaluated for infarct volume. Immunofluorescent analysis of astrocyte reactivity, microglial activation, Cx43 expression, vascular elements and apoptosis was also performed. A significant, ~2-fold, decrease in infarct volume was measured in MK4 mice, compared to WT littermates. While a sharp delineation between infarct and non-infarct tissue was observed in WT mice, the MK4 group did not exhibit a typical delineation; “islands” of GFAP positive astrocytes, within the infarct region, were observed in MK4 mice. In the penumbra, an increase in astrocyte reactivity was observed in MK4 animals, compared with WT mice. Consistent with the infarct volume data, a significant reduction in cell death in the MK4 group was measured, compared to corresponding controls. This study suggests that inhibiting MAPK-Cx43 interaction is associated with neuroprotection in ischemic conditions.
The Cognitive Underpinnings of Confabulation Following Anterior Communicating Artery (ACoA) Aneurysm Rupture
Ghosh, V1, 2 Moscovitch, M1, 2 Gilboa, A1, 2; 1. University of Toronto, Toronto, ON; 2. Rotman Research Institute, Baycrest, Toronto, ON
Background: Due to high sensitivity of the anterior communicating artery (ACoA) for aneurysm rupture, and the relatively focal ventromedial prefrontal cortical (vmPFC) damage that ensues, an associated triad of symptoms have been labeled the “ACoA syndrome” (Alexander & Freedman, 1984; Damasio et al., 1985; DeLuca, 1993). Recent evidence of vmPFC’s role in representing schemas (Kumaran et al., 2009; Tse et al., 2011; Van Kesteren et al., 2010) could account for the most elusive of the ACoA syndrome symptoms: confabulation. This experiment probed the impact of vmPFC damage following ACoA rupture on schematic representation, specifically testing whether vmPFC lesions would differentially impact activation of a relevant schema and inhibition of an irrelevant one, even when memory was not required for the task. Methods: Eight ACoA patients, with three demonstrating confabulation, and a group of healthy adults had to decide quickly whether words were closely related to a schema (visiting a doctor). Ten minutes later they repeated the task for a new schema (going to bed) with some words related to the first schema included as lures. Lastly, they rated the degree of association of targets and lures to the second schema. Results: Non-confabulating ACoA patients performed comparably to healthy adults: high accuracy overall and longer response latencies to reject lures related to the irrelevant schema than lures unrelated to both schemas. Patients with confabulation were less efficient in rejecting irrelevant schema lures. Damage to a vmPFC sub-region—sub-callosal cingulate cortex—may have in part been responsible for the differing performance of patients with and without confabulation, as this region was spared in non-confabulating patients. Conclusion: The findings support the hypothesis that the sub-callosal cingulate cortex is pertinent to confabulation (Schnider, 2003; Gilboa, 2004), and suggest that confabulation in these cases of ACoA syndrome is associated with poor suppression of irrelevant schemas.
Sex Differences in Cognitive Rehabilitation Efficacy in a Rat Model of Vascular Dementia
Langdon, KD1 Granter-Button, S1 Harley, CW1 Moody-Corbett, F1 Peeling, J2 Corbett, D1; 1. Memorial University, St. John’s, NL; 2. University of Manitoba, Winnipeg, MB
Background: Dementia is a major contributor to morbidity throughout western society. To date, pharmacological interventions have provided modest benefit in treating resultant cognitive impairments. We report the evaluation of a treatment paradigm consisting of a combination of physical and cognitive activity (PA/CA) in both male and female rats using a well-characterized model of vascular dementia. Methods: Early middle-aged (~6mo) Sprague-Dawley rats underwent permanent bilateral carotid artery occlusion (2VO) and were exposed to either a combination of PA (voluntary wheel running) and CA (modified Hebb-Williams maze exposure) or sedentary housing. Female animals were ovariectomized prior to 2VO, controlling for possible neuroprotective influences of estrogen. Learning and memory abilities were assessed using the Morris water maze. Results: Male PA/CA rats demonstrated significant cognitive improvements compared to sedentary controls, beginning at 16wks following surgery and extending until the end of behavioural assessments (24wks). Improved cognitive ability was accompanied by normalization of hippocampal CA1 cell soma size (area and volume) that had been altered as a result of 2VO. Interestingly, there were no differences between PA/CA and sedentary females in any of the learning and memory assessments, nor histopathological outcomes. Conclusions: This study describes a cytoarchitectural abnormality of hippocampal CA1 neurons in early middle-aged male rats subjected to a surgical procedure that induces cognitive decline. A novel combination of PA and CA promoted cognitive recovery, an area rarely explored in preclinical studies. Interestingly however, the positive effects were limited to male animals. Females did not display altered CA1 cell structure nor did they benefit from the rehabilitation paradigm. Clearly, failure to employ female animals is a potentially important factor contributing to the ‘translational roadblock’ between basic and clinical science outcomes. The present results are intriguing because the differential response to the intervention may provide a means for identifying critical mechanisms underlying PA/CA rehabilitation efficacy.
In Vivo Channelrhodopsin-2 Stimulation and Voltage-Sensitive Dye Imaging in a Mouse Model of Stroke Reveals Preserved Functional Connections Posterior to the Lesion
Lim, DH; LeDue, J; Mohajerani, MH; Murphy, TH; University of British Columbia, Vancouver, BC
Background: Understanding the recovery of cortical function following stroke is important to develop treatment strategies. While it is known that cortical damage may extend beyond the stroke core to the peri-infarct region, direct functional assessment of this area has been challenging because most methods have relied on peripheral stimulation, which is limited to sensory or motor cortex activation, or have used invasive cortical stimulation, which may cause further damage. Methods: Recently, we have developed a method to map functional connections in vivo with high spatial and temporal resolution using voltage-sensitive dye (VSD) imaging combined with Channelrhodopsin-2 (ChR2) stimulation in a transgenic mouse line (Lim et al., 2012). Here, we examine long-term changes in functional connectivity after a stroke by discretely stimulating multiple sites within the peri-infarct. Results: In animals with a stroke targeted to the forelimb area of the primary somatosensory cortex (FLS1), the peak VSD response after sensory stimulation was significantly delayed and reduced, as expected from previous studies (Brown et al., 2009). The homotopic VSD response to photostimulation was reduced in amplitude, however it was not significantly delayed, suggesting that the cortical and callosal connections activated by the phostostimulation were still functional. To further examine which areas were most affected by stroke, 25 cortical sites within the peri-infarct were targeted for photostimulation and the homotopic VSD response was recorded. After stroke, photostimulation of cortical sites 200 μm away from the stroke core resulted in little or no VSD response except for the site posterior to the stroke core, which resulted in VSD responses similar to sham animals. Conclusion: We present this method as a useful tool for investigating recovery after stroke. We suggest that after stroke connections may be spared, and this distribution likely occurs in a non-random order.
Do Reduced Leptomeningeal Collaterals in Humans Result in Leukoaraiosis, Lacunes and Brain Atrophy?
Nambiar, VK1 Sohn, S2 Goyal, M1 Demchuk, AM1 Menon, BK1; 1. University of Calgary, Calgary, AB; 2. Keim Yong University, Keimyong, Korea
Introduction: We seek to identify if reduction in leptomeningeal collaterals results in leukoaraiosis, lacunar disease and brain atrophy. In addition, we seek to explore an association between amyloid angiopathy and reduced leptomeningeal collaterals. Methods: Data are from the Keimyung Stroke Registry. Consecutive patients with M1 segment middle cerebral artery (MCA) ± intracranial internal carotid artery (ICA) occlusions on baseline CT-angiography (CTA) from May 2004 to July 2009 were included. Only patients with baseline CTA and MRI (FLAIR, T1 and GRE) were included in the current study. Two raters assessed leptomeningeal collaterals on baseline CTA by consensus, using a previously validated regional leptomeningeal score (rLMC). Brain volume=, volume of periventricular hyperintensity on FLAIR (PVH), number of lacunes (T1) and microbleeds (GRE) were assessed by consensus, blinded to collateral assessment. Brain volumes were measured using Quantomo and data analyzed using Stata 12.1. Results: Baseline characteristics (n=120) were: mean age 67.3 years, median baseline NIHSS 14 (IQR 10) and median stroke symptom onset to CTA 118.5 minutes (IQR 117). There was a significant difference in PVH in those with poor collateral status vs. those without (median volume 7. 5 ml vs 4.4 ml, p=0.04). No difference was noted in brain volume, number of lacunes or number of microbleeds by collateral status. (Table 1) Nonetheless, we noted significant correlation between brain volume, PVH and number of lacunes. Cerebral microbleeds were not associated with collateral status, PVH, brain atrophy and lacunas. Conclusion: Our results establish an association between poor collateral status and leukoaraiosis. Correlation between leukoaraiosis, brain atrophy and number of lacunes points towards a common pathophysiological mechanism with reduced collateral status potentially being causal. Insert
The Effects of Diabetes on Blood Brain Barrier Integrity and Functional Recovery from Stroke
Reeson, P; Wang, J; Brown, CE; University of Victoria, Victoria, BC
Diabetics are 2-4 times more likely to suffer a stroke and have poorer recovery resulting in serious long-term disabilities. Recently it was shown that functional rewiring in the peri-infarct cortex was impaired in the diabetic brain. Our hypothesis was that diabetes causes maladaptive vascular responses to stroke that severely impair neuronal plasticity and functional recovery. To understand the vascular response to stroke, we induced a unilateral ischemic photothrombotic stroke in the forelimb somatosensory (FLS1) cortex of diabetic and non-diabetic mice. Using Evans blue, a fluorescent dye impermeable to an intact blood-brain-barrier (BBB), we quantified dye extravasation in the peri-infarct cortex as a marker of BBB dysfunction. At 3 days following stroke we found the cerebrovasculature in the diabetic peri-infarct cortex was significantly more permeable compared to controls. By 7 days there was no difference between groups and leakage was resolved by 4 weeks. Since most angiogenic signals are transduced by vascular endothelial growth factor receptor-2 (VEGF-R2), we assessed VEGF-R2 protein expression in the peri-infarct cortex with immunohistochemistry and western blots. Diabetic mice exhibited a heightened and abnormally prolonged expression of VEGF-R2 in peri-infarct vasculature. We then asked whether administration of a VEGF-R2 inhibitor (SU4516) one hour post stroke could restore BBB integrity. Diabetic mice treated with SU5416 had significantly lower vascular extravasation. Diabetic and non-diabetic mice receiving chronic administration of either SU5416 or vehicle injections were assessed with adhesive tape and horizontal ladder behavioral task following stroke. Preliminary testing indicates that VEGF-R2 inhibition may improve recovery in diabetics. These results indicate that excessive post-ischemic loss of BBB integrity in diabetics is partially mediated by VEGF signaling, which can be ameliorated with inhibitors of VEGF-R2. Given the deleterious effects of excessive plasma leakage on neuronal health, restoring BBB integrity offers a promising approach to restore adaptive plasticity in diabetics following stroke.
Endothelial Ectosomes and the Progression of Small Vessel Disease
Schock, SC1 Burger, D2 Edrissi, R1 Cadonic, R1 Hakim, AM1 Thompson, C1; 1. OHRI Neuroscience and the University of Ottawa, Ottawa, ON; 2. Kidney Research Centre, Univerity of Ottawa, Ottawa, ON
Background: Cerebral small vessel disease (CSVD) is a progressive condition and a major cause of vascular dementia. An early pathological feature of CSVD is an increase in blood brain barrier (BBB) permeability. Ectosomes (microparticles) are small, membrane bound vesicles that are released into the circulation by a variety of cell types and have been found to increase in several cardiovascular disorders. In the present study circulating levels of ectosomes were measured in a rodent model of CSVD and some of their properties characterized in vitro. Methods: Chronic cerebral hypoperfusion (CCH) was induced in male Long Evans rats by permanent bilateral common carotid artery occlusion. Circulating ectosomes were examined by flow cytometry and electron microscopy. Purified ectosomes were added to cultured rat brain microvascular endothelial cells, cell viability assessed by LDH assay and barrier permeability assessed by measuring electrical resistance (TEER). BBB permeability was assessed in vivo using the Evans Blue assay. Results: Following the induction of CCH circulating levels of annexin V + and VE-cadherin + ectosomes were significantly elevated. When added to cultured endothelial cells ectosomes induced caspase 3-dependent cell death. A TNF-α receptor blocker and a neutralizing antibody against TRAIL significantly reduced apoptosis. When ectosomes were added to artificial endothelial barriers there was a significant decrease in electrical resistance and when injected into the circulation of unoperated rats there was an increase in BBB permeability. Conclusions: Cerebral ischemia causes an increase in circulating ectosomes. Purified ectosomes induce apoptosis in cultured endothelial cells and a reduction in TEER when added to artificial endothelial barriers. When injected into the circulation of unoperated rats the ectosomes cause a decrease in BBB permeability. Ectosomes may be involved in the disruption of the BBB that accompanies human CSVD and a variety of other neurological conditions and may participate in the progression of CSVD.
The Role of BNIP3 in Brain Ischemia/Reperfusion:Regulating Autophagy and Apoptosis in Delayed Neuron Damage
Shi, R; Zhu, S; Kong, J; University of Manitoba, Winnipeg, MB
Introduction: Physiological level of autophagy is essential for the cellular recycling and homeostasis, and is believed to promote neuronal survival in ischemic stroke. The pathological role of apoptosis (type I programmed cell death) in delayed neuronal death in stroke has been well-established by many studies. In this study, we show that the pro-apoptotic BNIP3 is an important upstream regulator for both processes. Specifically, deletion of BNIP3 gene is neuroprotective by affecting both autophagy and apoptosis pathways. Methods: Immunohistochemistry, western blot, and cell transfection were performed on cortical neurons and ischemic brains. Both BNIP3 wild-type and knock-out transgenic mice were used for tissue collection. Results: In primary neuronal cultures exposed to oxygen and glucose deprivation (OGD) and reperfusion (RP), the death-inducing gene BNIP3 was highly expressed in primary cortical neurons, and the time course and expression levels of apoptosis-related proteins (i.e. active caspase-3, cytochrome C, and BAX) as well as autophagy-related proteins (i.e. LC3, Beclin-1, and LAMP-2) were positively regulated by BNIP3 expression. Promoting or inhibiting autophagy activities by using specific inducer or inhibitor didn’t affect the expression patterns of BNIP3. Thus, BNIP3 is an upstream regulator of the elevated neuronal apoptosis and autophagy in ischemia/hypoxia (I/H). Then, we measured the brain damage of neonatal cerebral I/H in transgenic animals. By using TTC staining, we found that the infarct volume of the ischemic brains was significantly reduced in BNIP3 knock-out mice compared to wild-type mice upon 3-7 days recovery. Furthermore, deletion of BNIP3 gene in cortical neurons of knock-out mice activated a robust autophagic response. This increased autophagic response in BNIP3-null neurons was accompanied by a decreased apoptotic response, which may coordinately contribute to the neuroprotection in the knock-out animals. Conclusions: Our results indicate that BNIP3 is an important upstream regulator for both autophagy and apoptosis processes in delayed neuron damage in stroke.
The Influence of Post-Stroke Lower-Limb Spasticity on the Control of Standing Balance: Short-Time Cross-Correlation and Coherence Between Individual Limb Centres of Pressure
Singer, JC1 Mansfield, A1, 2, 3 Danells, CJ1, 3 McIlroy, WE1, 2, 4 Mochizuki, G1, 2, 3; 1. Heart and Stroke Foundation Centre for Stroke Recovery, Sunnybrook Research Institute, Toronto, ON; 2. Toronto Rehabilitation Institute, Toronto, ON; 3. Department of Physical Therapy, University of Toronto, Toronto, ON; 4. Department of Kinesiology, University of Waterloo, Waterloo, ON
Background: Temporal synchronisation of force output from each lower-limb is an important index of standing balance control post-stroke1, which appears to be altered by post-stroke lower-limb spasticity (LLS)2. While previous work has focussed on inter-limb temporal synchronisation (time-domain), this study examines the time-varying fluctuations in inter-limb centre of pressure (COP) synchrony in both the time- (short-time cross-correlation) and frequency-domains (short-time coherence) to help identify the mechanisms underlying the challenges to stability associated with post-stroke LLS. We hypothesized that individuals with LLS would exhibit greater temporal desynchronisation, which would be associated with periods of reduced high-frequency coherence, signifying difficulty executing balance corrections with the affected limb. Methods: A retrospective analysis of 127 stroke survivors (43 with LLS (LLS); 74 without LLS (No-LLS); 10 without spasticity, low impairment (No-LLS-LI)) was performed. Individual-limb and net-COP displacements in both anteroposterior and mediolateral directions were calculated during 30 seconds of quiet-standing on adjacent force platforms. The time-varying relationship between individual limb COP displacements in the time- and frequency-domains was assessed using short-time cross-correlation and magnitude-squared short-time coherence (MS-STC) functions, respectively. Average MS-STC was calculated within successive 1 Hz frequency bands (0-5 Hz). Results: The LLS group exhibited desynchronisation over a greater percentage of the trial duration than the No-LLS or No-LLS-LI groups (52.4%;29.1%;7.1%;p<0.001). Contrary to our hypothesis, time-varying inter-limb temporal synchrony was related to low-frequency (<1Hz) MS-STC for all groups. There was no relationship between temporal desynchronisation and either the time-varying weight-bearing symmetry ratio or the net-COP displacement. Conclusions: Reduced low-frequency, rather than high-frequency, MS-STC suggests that stroke patients with and without LLS may experience difficulty modulating the affected-limb COP in response to centre-of-mass dynamics3. While the precise mechanisms remain unknown, stroke patients with LLS appear to experience such challenges more frequently than those without spasticity.
Mansfield A, et al. NNR;2012;26:627-635.
Singer J, et al. Clin Biomech;2013,submitted.
Zatsiorsky V. et al. Motor Control;1999;3:28-38.
Dynamic Control of Pannexin 1 Expression Following Stroke
Swayne, L; Wicki-Stordeur, LE; Boyce, AK; University of Victoria, Victoria, BC
Background: In the face of considerable cell death, the brain has a remarkable capacity for recovery following stroke. Currently, we are largely unable to optimize this innate process in part due to knowledge gaps in our understanding of the underlying cellular and molecular mechanisms. Pannexin 1 (Panx1) is a large pore ion and metabolite permeable channel that is thought to play a major role in mediating vulnerability of neurons in ischemia, in part through dysregulation of ion fluxes and by initiating inflammatory responses that contribute to expansion of injury. In addition to previously reported expression in mature neurons, and astrocytes, recent work from our lab indicates that Panx1 is also highly expressed in developing neurons and can modulate their behaviours. Notably, Panx1 is activated by several stimuli in the post-stroke brain. Given that activation of ion channels can often trigger changes in their expression levels, we investigated whether stroke-associated stimuli alter the expression of Panx1, as this could have important implications for the innate recovery responses of several cell types following stroke. Methods: To model stroke in mice in vivo, we induced photothrombosis in the sensorimotor cortex. We also examined the effects of a variety of stroke brain stimuli (elevated extracellular potassium, adenosine triphosphate and oxygen and glucose deprivation) in several cell culture models. To determine Panx1 levels in these models, we used a combination of Western blotting and live and fixed cell confocal immunofluorescence microscopy. Results: Here we provide evidence that Panx1 levels are dynamically regulated in a cell-type and region-specific way in the post-stroke brain. These results were recapitulated in vitro. Conclusions: Together our data indicate that Panx1 levels change over time following stroke and that this dynamic regulation could play an important role in the innate repair and recovery processes.
The Effect of Cortical Lesion Size on the Reorganization of ispi and Contralesional Motor Representations
Touvykine, B1 Mansoori, BK1 Jean-Charles, L1, 2 Quessy, S1 Dancause, N1, 2; 1. Université de Montréal, Montréal, QC; 2. GRSNC, Montréal, QC
Following stroke, patients often have abnormal activation in the injured and intact hemispheres. The influence of lesion size on the reorganization of motor representations in the ipsilesional cortex has been previously supported. However, no study has yet investigated how lesion size affects cortical reorganization in both hemispheres. We thus investigated how the size of cortical lesions influences the reorganization of the caudal and rostral forelimb areas, the rat’s equivalent of the primary motor cortex (M1) and a premotor area respectively, in both the ipsi and contralesional hemispheres. In adult rats, endothelin-1 was used to induce lesions of either small or large volume in M1. The behavioral performance of the paretic and non-paretic forelimbs was evaluated with the Montoya Staircase task, twice the first week and then once a week until day 28 after lesion induction. At the end of the recovery period, the cortical organization of M1 and the premotor cortex was evaluated with intracortical microstimulation techniques. Motor maps of animals with small and large lesions were compared to each other and to normal, control rats. Effective lesion size was confirmed with histological reconstruction.
Rats with large lesions had greater behavioral deficits than rats with small lesions. The ipsilesional M1 was bigger in rats with small lesions than with large lesions. No change was observed in contralesional M1. Finally, size of the ipsi and contralesional premotor area changed compared to controls and significantly correlated with the size of the lesion in both groups. Our results show that larger lesions result in greater reorganization of the premotor areas in both hemispheres. In the contralesional hemisphere, the reorganization of the premotor cortex is more sensitive to lesion size than is M1, and this area may play a greater role in postlesion recovery of the paretic forelimb or compensation with the non-paretic forelimb.
Molecular Effects of Salt-Induced Hypertension on the Development of Acute Ischemic Stroke in Heterozygous ANP Gene-Disrupted (ANP+/−) Mice
Ventura, NM1 Peterson, NT1, 2 Tse, MY1 Wong, PG1 Jin, AY2, 1 Andrew, R1 Pang, SC1; 1. Queen’s University, Kingston, ON; 2. Kingston General Hospital, Kingston, ON
Background: Hypertension (HT) is one of the leading risk factors for ischemic stroke. Although previous investigations have shown the role of HT in myocardial infarction (MI), the effect of salt-sensitive HT on cerebrovascular events during and after stroke is unclear. Thus our objective was to assess cerebrovascular adaptations occurring in salt-induced hypertensive mice following acute ischemic stroke. Four major vasoactive systems were targeted for this study - the natriuretic peptide system (NPS), nitric oxide system (NOS), renin-angiotensin system (RAS) and endothelin system (ETS), to better understand the role of salt-sensitive HT in the development stroke. Methods: Salt-sensitive ANP+/− mice were fed a high salt (HS) (8.0% NaCl) or normal salt (NS) (0.8% NaCl) diet for 7 weeks to induce HT. Acute ischemic stroke was surgically induced by 30 min left middle cerebral artery occlusion (MCAO) via intraluminal filament. Sham operated mice were used for control. Brain slices (1mm) were obtained 24 hr post reperfusion and stained in 2,3,5-triphenyltetrazolium chloride (TTC). Infarct volume was measured using ImageJ software by two blinded observers. Systolic blood pressure (SBP) was measured by non-invasive tail cuff (Kent Scientific) to ensure development of HT in the HS treatment group. Vasoactive system peptides and peptide specific receptor mRNA were measured by real-time quantitative PCR in the fourth brain slice. Results: ANP+/− mice treated with HS developed HT, left ventricular hypertrophy and experienced significantly larger infarcts as compared to normotensive mice (P=0.0015). Infarct volume inter-observer correlation coefficients were R=0.9043 in HS and R=0.9920 in NS treatment groups. No significant differences in mRNA expression of the NPS or RAS were detected. The NOS and ETS both showed higher levels of expression in hypertensive mice (trends towards significance). Conclusion: Results suggest that the NOS and ETS may be the dominant systems controlling cerebrovascular changes in the post-stroke brain.
Hypothermia does not Influence Iron-induced Injury in Rat Models of Intracerebral Hemorrhage
Wowk, S; Ma, Y; Colbourne, F; University of Alberta, Edmonton, AB
Background: Hypothermia, used to treat cardiac arrest and neonatal hypoxic–ischemic encephalopathy, is undergoing clinical trials for ischemic and hemorrhagic stroke. Animal studies show a strong hypothermic neuroprotection against ischemia but little benefit for intracerebral hemorrhage (ICH). This is surprising because hypothermia attenuates several mechanisms of injury common to both stroke types such as inflammation and edema. This lack of benefit suggests hypothermia does not treat key secondary mechanisms of injury specific to ICH or results in harmful side effects. Thus, we are studying whether hypothermia mitigates oxidative damage caused by iron released from degrading erythrocytes. We evaluated whether hypothermia alters iron release and accumulation (i.e., hemoglobin breakdown), iron-induced cell death, and levels of iron-binding proteins and antioxidants. Methods: Rats were given a striatal ICH and parenchymal non-heme iron levels were measured either 3 or 7 days later. Behaviour was tested in those euthanized at 7 days. In all experiments rats received either 72 hours of hypothermia (33°C; starting 12 hours post-ICH or 1 hour after FeCl2 injection) or normothermia. A simplified model involving striatal injections of FeCl2 was used to evaluate iron-induced edema 1 and 3 days post-insult, as well as, tissue loss, neuronal degeneration, and behavioural impairment 7 days post-insult. Finally, rats were given a striatal ICH and ferritin and antioxidant levels were measured at 3 days. Results: Hypothermia did not delay the release of non-heme iron or improve behavioural impairments after ICH. FeCl2 caused edema, tissue loss, neuronal degeneration, and behavioural impairment which were not affected by hypothermia. Hypothermia’s influence on ferritin and antioxidant levels is currently being analyzed. Conclusions: These results suggest that hypothermia is not targeting iron-mediated damage and it is possible that hypothermia limits endogenous defense mechanisms (in progress). Through the use of combination therapies, future research will focus on maximizing neuroprotection against ICH.
Evaluating the Effectiveness of Southwestern Ontario’s Community Stroke Rehabilitation Teams
Allen, L1, 4 Richardson, M1 Meyer, M1, 4 Ure, D2 Jankowski, S2 Teasell, R3, 1; 1. Lawson Health Research Institute, ARGC, London, ON; 2. St. Joseph’s Health Care, London, ON; 3. St.Joseph’s Health Care, Department of Physical Medicine and Rehabilitation, Parkwood Hospital, London, ON; 4. Western University, Department of Epidemiology and Biostatistic, London, ON
Introduction: The Community Stroke Rehabilitation Teams (CSRT) provide a community-based interdisciplinary approach to stroke rehabilitation. Our objective was to assess the effectiveness of the teams with respect to functional and psychosocial outcomes experienced by clients served by these teams. Methods: Functional and psychosocial outcome data was available at intake and discharge from the program, as well as at six-month follow up. Repeated measures ANCOVA and paired t-tests were performed as appropriate to assess patient changes between time points for each outcome measure. Results: Data was available for 919 individuals (55% male) with a mean age of 69.3 (±13.1) years. Significant improvements were found between intake and discharge on the Hospital Anxiety and Depression Scale total score (HADS)(p<0.0001), HADS Anxiety subscale (p<0.0001), HADS Depression subscale (p=0.016), and Functional Independence Measure (p<0.0001). Significant gains were also observed on the communication (p=0.002), social participation (p<0.0001), memory (p=0.012), and physical (p<0.0001) domains of the Stroke Impact Scale (SIS). These improvements were maintained at 6 month follow up. Improvements on the Reintegration to Normal Living Index were significant between intake and discharge (p=0.037). Follow up data was not available for this measure. Conclusions: Results indicate that the CSRT’s were highly effective at improving the functional and psychosocial recovery of patients after stroke. Importantly, these gains were maintained at 6 month follow-up after discharge from the program. Additional analyses are planned to further explore the impact of the CSRTs on patient recovery and the caregiving experience. This study shows the benefit of interdisciplinary outpatient stroke rehabilitation provided in the patient’s home on functional and psychosocial outcomes.
Understanding the Experience of People with Communication Disability After Stroke Outside Their Home in Transaction Situations
Anglade, C1 Croteau, C2 Le Dorze, G2, 3; 1. Université de Montréal - CRIR - CRLB, Montréal, QC; 2. Faculté de médecine-Orthophonie et audiologie Université de Montréal, Montreal, QC; 3. Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal, Montréal, QC
Rationale: People with communication disability (PWCD) after stroke show decreased social participation, including fewer outings (Dalemans, De Witte et al 2010). However, few reports concern how PWA communicate outside their home intransactional situations with unfamiliar people. Since such transactions occur in natural communication contexts (Traverso, 2009), we anticipate that they will differ from traditional communication assessments undertaken by speech and language pathologists (SLP). Objectives: 1) Describe how PWCD interact/communicate when shopping; 2) understand the experience of PWCD when shopping; 3) understand the experience of shop-keepers when interacting with PWCD; 4) engage SLPs in reflecting on their practice based on the emerging results. Participants: The project includes three groups of participants: 10 PWCD post-stroke (aphasia / dysarthria), 20 storekeepers and five SLP working in rehabilitation. Design: We will undertake multiple qualitative case studies with PWCD. Participants WCD will be accompanied individually by the researcher during visits at two shops and interactions will be recorded as they occur naturally in a shopping outing. The researcher will employ participant observation for the analysis of the live portion of data collection and conversational analysis for the filmed interactions. After each transaction, a short qualitative interview will be conducted with shopkeepers to determine his/her views of the interaction with the PWCD. Before and after each outing, a semi-structured interview will be conducted with participants with PWCD to understand their experience. As the results emerge, these will be provided to SLP participants who will be invited to reflect upon them and discuss practice options for such communication interactions. Preliminary results from this Ph.D. research project will be provided.
Scope: This project will help to understand the experience of PWCD in natural communication situations and influence aphasia/dysarthria rehabilitation.
Effect of BMI on Inpatient Rehabilitation Outcomes after Stroke
Armstrong, R; Wang, H; Dessureault, L; Canadian Institute for Health Information, Ottawa, ON
Background: Studies have reported an inverse relationship between body mass index (BMI) scores and relative improvement of function in inpatient rehabilitation. High BMIs have also been associated with increased lengths of stay (LOS) and decreased FIM® efficiency. However, a growing body of clinical data suggests a survival benefit (e.g., decreased mortality rates) for overweight patients after stroke and, using the Barthel index, greater improvements in functional outcomes have been reported in obese patients compared to normal-weight patients. Given the variation in findings, this study sought to examine the impact of BMI on inpatient rehabilitation LOS and functional outcomes following stroke using a large pan-Canadian dataset. Methods: Using data from the National Rehabilitation Reporting System (NRS), stroke clients discharged in fiscal years 2010-2011 and 2011-2012 (n=9,380) were divided into 5 BMI groups: underweight (<18.5 kg/m2), normal (18.5 - 24.9 kg/m2), overweight (25.0 - 29.9 kg/m2), moderate obesity (30 - 39.9 kg/m2), and severe obesity (≥40 kg/m2). A Poisson regression model was used to analyze the effect of BMI group on LOS when adjusted for age, sex, stroke type, number of pre-admit comorbidities, discharge destination, province of residence, socio-economic status, and presence of depression, hypothyroidism, congestive heart failure, hypertension and diabetes. Results: Patients in this study sample had a mean age of 69.9 years. After adjusting for multiple covariates, overweight and moderately obese patients demonstrated shorter LOS compared with those in the normal BMI group (both p<.0001), whereas LOS was significantly longer in underweight (p<.0001) and severely obese (p<.01) patients compared to normal-weight patients. Moderate and severely obese patients experienced the greatest increases in FIM® scores from admission to discharge. Conclusions: Following stroke, overweight and moderately obese patients had shorter stays in inpatient rehabilitation with equivalent functional improvements compared to patients with a BMI in the normal range.
Residual Motor Deficits Revealed Using a Complex Reaching Task in Individuals with Good Arm Recovery After Stroke
Baniña, MC3, 4 McFadyen, BJ2, 1 Levin, MF3, 4; 1. Centre Interdisciplinaire de Recherche en Réadaptation et Intégration Sociale, Québec, QC; 2. Département de réadaptation, Faculté de médecine, Université Laval, Québec, QC; 3. School of Physical and Occupational Therapy, Faculty of Medicine, McGill University, Montreal, QC; 4. Feil-Oberfeld Research Centre, Jewish Rehabilitation Hospital site of Centre for Interdisciplinary Research in Rehabilitation, Montreal, QC
After stroke, individuals with good clinical recovery of their affected arm may still report decreased use in ADLs. Decreased use may be associated with undetected deficits identified when individuals attempt higher-order motor tasks requiring complex coordination. One higher-order motor task, avoiding obstacles while reaching, commonly occurs in everyday environments but is not routinely assessed by clinical scales. We hypothesized that well-recovered people after stroke would be less successful in avoiding an obstacle in the reaching path compared to healthy controls. Obstacle avoidance ability during reaching in a virtual environment was compared between groups. The environment simulated a commercial refrigerator with shelves and sliding doors. Subjects reached as fast as possible with their affected/dominant arm for a bottle on one shelf (n=60 trials). In random trials (20/60) the door ipsilateral to the reaching arm closed and partially obstructed the bottle at reach initiation. Subjects were instructed to touch and retrieve the bottle without hitting the door. Overall success rates, movement performance and quality variables for unobstructed (T), successful avoidance (Succ), and failed avoidance (Fail) trials were recorded. In T trials, stroke subjects used less wrist flexion, wrist abduction and shoulder rotation compared to controls. For obstructed trials, 36% of controls and 12% of stroke subjects were successful >65% of the time. For both groups, successful door avoidance was characterized by changes in the trajectory path occurring closer to the starting position. However, the margin of error in the stroke group was about half that of the controls. In addition, stroke subjects significantly increased endpoint trajectory length compared to controls to achieve success. Results suggest that stroke subjects had residual movement deficits revealed through a challenging motor task. The potential of using challenging tasks to identify higher order motor control deficits should be considered when assessing post-stroke motor recovery.
“Care” and “Cure”
Barreau, J; Belson, L; Villa medica, Montreal, QC
The aim of the study was to measure patients’ expectations of Villa Medica Rehabilitation Hospital in terms of humanism: the “care”. The survey was conducted from June to December 2012. Data collection was made possible through questionnaires given to interested patients and was stored using Excel 2010. Statistical analysis were made using SPSS 16.0 for Windows. Divided in two strata, the questionnaire looked, in the first place, patients’ satisfaction; while it opened, in the second place, to the patients’ expectations in terms of humanism. Three indices emerged. The first index is the “active listening”. 80 % of the questioned patients wanted to put “active listening” at the center of their cure. Indeed, the study shows the urgency for the patients to put into words their troubles in a humanistic professional listening. The second index is the “group talk”. 20 % of the patients expressed a desire to share with one (or more) of their fellow(s) their experienced trauma. Onset or ongoing of the “active listening”? The third index is the “interiorization”. 37 % of the questioned patients mention their desire to proceed to a way of interiorization, conscious that it might order or conduct the cure. Via these three indices, the study highlights the necessity to set up a “care” which not only accompanies the “cure” but also carries it. Besides, this study raises the question of the feature of interdisciplinarity: is it only controlled by the sharing of expertise or, more exactly, is it unified by the principle of humanism?
Validation de contenu d’un outil d’évaluation de la compréhension syntaxique de personnes ayant une aphasie
Bergeron, A3 Bourgeois, M3 Fossard, M2 Desmarais, C1 Lepage, C3; 1. Université Laval, Québec, QC; 2. Université de Neuchâtel, Neuchâtel, Switzerland; 3. Institut de réadaptation en déficience physique de Québec, Québec, QC
L’aphasie est la perte partielle ou totale du langage qui peut survenir à la suite d’une lésion cérébrale. Les personnes ayant une aphasie peuvent présenter des difficultés de compréhension touchant spécifiquement les phrases. La recherche a montré que le processus de compréhension de phrases se fait en plusieurs étapes, et que les personnes avec une aphasie peuvent éprouver des difficultés à l’une ou l’autre de ces étapes. Or, en clinique, ces distinctions sont rarement prises en compte lors de l’élaboration des épreuves d’évaluation. Pour pallier cette lacune, un nouvel outil a été créé à l’Université Laval: la « Batterie d’évaluation de la compréhension syntaxique » (Caron, LeMay & Fossard, 2010). L’objectif de la présente étude a été de documenter la validité de contenu de la batterie. Pour ce faire, un questionnaire de validation a été élaboré afin d’évaluer différents aspects de la batterie tels que la clarté des consignes et des images, la qualité des items-tests et la pertinence clinique. Trois chercheurs et neuf orthophonistes ont été sollicités pour compléter le questionnaire. Les données recueillies ont ensuite été soumises à une analyse quantitative et qualitative. Les résultats obtenus ont permis de démontrer la validité de contenu de la batterie et d’en identifier les éléments à améliorer. Ceux-ci concernent entre autres l’ambiguité de certaines images, les explications théoriques, le choix de certains items-test, la formulation des consignes et la configuration des grilles de notation du test. L’équipe de recherche a effectué les modifications à l’outil initial afin d’en arriver à une version qui pourra être utilisée par des cliniciens. Cette batterie permettra de mieux cibler les difficultés de compréhension des personnes ayant une aphasie et de choisir des méthodes d’intervention plus spécifiques. Des étapes ultérieures de validation et de normalisation sont également envisagées.
Common Forms of Vascular Cognitive Impairment in a Canadian Inpatient Stroke Rehabilitation Sample
Carter, SL1, 2 DeFreitas, VG1; 1. QEII Health Sciences Centre, NS Rehabilitation Centre, Halifax, NS; 2. Dalhousie University, Halifax, NS
Background: Canadian best practice recommendations for stroke care include screening and assessment for vascular cognitive impairment (VCI). Specific forms of VCI may be under-identified in Canadian inpatient rehabilitation units given high screening rates but low comprehensive assessment rates (McClure et al., 2012). Identifying common forms of VCI in inpatient settings could improve post-stroke assessment and rehabilitation. Methods: Common forms of VCI were examined in a convenience sample of 47 stroke patients from an inpatient rehabilitation facility who completed a brief neuropsychological assessment (NAB Screening Module). Two cases were excluded due to language barriers. Mean age was 55.4 years, mean education was 12.3 years, 62% were male, 87% were right-handed, and 78% had ischemic strokes (bilateral 22%; left 42%; right 36%). Frequency of scores < 5th percentile was examined for NAB index and subtest scores; correlates of low scores were investigated via Pearson-r. Results: Compared to age and education-corrected norms, impairment rates were highest on indices of attention/speed (A/S; 51%) and executive functions (EF; 24%), with lowest mean scores on timed cancellation subtests. Mean indices of language, memory, and visuospatial skills were average. 34% of the sample scored < 5th percentile on a summary index of global cognitive function. Speeded attention and mental flexibility was strongly correlated with global cognitive function (Trails B r=-0.74, p<0.01), A/S (r=-0.52, p <0.01), and EF (r=-0.51, p<0.01) indices. Global cognitive function was also correlated with simple speeded attention and sequencing (Trails A r=-0.46, p<0.01). A/S and EF indices correlated modestly with letter fluency (r=0.42 p<0.01 and r=0.36 p<0.05, respectively); only EF correlated with animal fluency (r=0.43, p<0.01). Conclusions: A/S and EF are most frequently affected in a Canadian inpatient stroke rehabilitation sample, consistent with domain-specific classification rates in chronic stroke (Stricker et al, 2010). These findings guide targeted cognitive rehabilitation programming for inpatient stroke survivors.
The Journey to Better Stroke Care at North York General (NYG)
Chin-Curtis, LA; Carley, T; Ramdeyall, S; Villar-Guerrero, E; North York General, Toronto, ON
Background: As part of the Stroke Flow Initiative, North York General (NYG) dedicated funding for the development and implementation of a Stroke Assessment and Treatment Team (SATT) to improve outcomes for newly diagnosed stroke patients by aligning with Canadian Best Practice Recommendations for stroke care. Past practices at NYG had stroke patients being assessed by Speech-Language Pathology (SLP) within 24-72 hours of admission, an inter-professional team assessment, as time and resources permitted 5 days/week, completion of the Alpha-FIM when patients were rehab ready, and inconsistent use of E-Stroke referral system, as the primary referral system for patients requiring stroke rehab. Methods: As part of the initiative, NYG now has 10 designated stroke beds allotted within a 32 bed medical unit; the Toronto Bedside Swallowing Screening Test (TOR-BSST) is completed within 24 hours of admission for newly diagnosed stroke patients; an assessment by an inter-professional team (SATT) is completed within 48 hours of admission; the Alpha-FIM is completed on Day 3 of admission; and E-stroke is exclusively used for all stroke patients requiring rehabilitation. Results: The development of SATT promotes early inter-professional team involvement, which in turn allows for early mobilization and facilitates expedited discharge to rehab and/or community integration through CCAC in-home supports. NYG seeks to meet and exceed Stroke Flow Initiative targets by aiming to send 30 – 40% of stroke patients to rehab by Day 5 for ischemic stroke patients, and Day 7 for hemorrhagic stroke patients from the time of admission. Conclusions: Currently, NYG is meeting Canadian best practice guidelines for stroke care with the aspiration for better outcomes for stroke patients. An educational roll-out is planned for the next phase of this initiative. Internal processes within the organization (i.e. access to diagnostics, bed control processes) are being evaluated, in order to improve the stroke flow initiative targets/expectations.
The Activities Balance Confidence Scale: Longitudinal Changes and Its Relation to Other Measures Post Stroke
Cohen, EJ1 Danells, CJ1, 2 McIlroy, WE3, 1; 1. Centre for Stroke Recovery, Toronto, ON; 2. Sunnybrook Health Sciences Centre, Toronto, ON; 3. University of Waterloo, Waterloo, ON
Background: The Activities Balance Confidence Scale (ABC) is a valid and reliable tool for the stroke population. It explores one’s confidence ratings in maintaining balance while completing various community-based functional tasks. Studies have shown its relation to some physical measures. There is little data present in the literature about how confidence changes over time and how it relates to changes that occur in other measures. Methods: Patients (n = 28) were selected from the Centre for Stroke Recovery Rehabilitation Affiliates Longitudinal Stroke database. Patients living in the community were asked to complete the ABC. There were 48 completed assessments and 14 patients had completed 2 or more ABC assessments longitudinally. As well assessments of cognition (MoCA), depression (CES-D), balance (Berg Balance Scale), function (FIM) and walking speed (2 minute walk) were completed. Results: Cross sectional results revealed correlations to walking speed (r=0.59) and Berg (r= 0.69) as previously indicated in the literature. In contrast there was no association between ABC and time post stroke (r=0.18), MoCA (r=0.15) or the CES-D (r=-0.07). Those who answered yes to “do you have a fear of falling” had a lower average confidence score. Longitudinal data revealed a weak relationship between ABC changes and changes in: gait speed (r =-0.39), Berg (r=0.13), CES-D (r=-0.30), FIM (r=-0.37) and MoCA (r=0.14). In addition, for the 3 participants who made the largest improvements in their ABC, there were no related improvements in the other domains. Conclusions: Confidence is often overlooked in assessments post stroke and may be an independent factor contributing to functional outcomes. Longitudinally, the lack of association between physical recovery and change in confidence supports the idea that confidence is not simply a product of physical ability and is a potentially important and independent characteristic that may influence stroke recovery.
A Randomized Controlled Study Assessing the Effectiveness of Aphasia-Friendly Schedules on Therapy Attendance
Collins, D1 Marcoux, C1 Modha, G1 Poirier, B1 Silverberg, ND1, 2 Louie, S1; 1. Vancouver Coastal Health-GF Strong Rehab, Vancouver, BC; 2. Division of Physical Medicine & Rehabilitation, Faculty of Medicine, University of British Columbia, Vancouver, BC
Background: A person living with aphasia faces language-based barriers, analogous to people with physical disabilities living in inaccessible environments. Although stroke rehabilitation centers are physically accessible, clients with aphasia may have difficulty navigating them. Frequent tardiness or missed therapy appointments may limit rehabilitation gains. The purpose of this study was to compare the ability of clients with aphasia in an inpatient stroke rehabilitation setting to independently attend therapy appointments when provided with a picture-based schedule versus a traditional text-based schedule. Methods: A parallel group open-label design was utilized. Twenty seven participants with post-stroke moderate to severe aphasia, as indexed by the Boston Diagnostic Aphasia Examination, were randomly assigned to a control group (text-only schedule; n=15) or an experimental group (picture and text schedule; n=12). Over the 15-day study period, therapists completed an attendance record for each participant. The primary outcome was the proportion of independently attended therapy sessions. Independent attendance could involve physical assistance by another person if directed by the participant. Results: The intervention effect was not significant (F=2.02, p=.17), with a trend favouring the control group. Further analysis demonstrated that participants in both groups with severe aphasia attended fewer sessions independently (n=12; M=0.66, SD=0.62) than those with moderate aphasia (n=12; M=0.92, SD=0.12), F=8.25, p=0.009. Conclusions: The results from this pilot study suggest that the addition of pictures to a text-based therapy schedule may not be sufficient to improve independent therapy attendance in clients with aphasia after stroke. Further environmental supports and/or accommodations may be required, particularly for people with more severe aphasia.
Development of a Clinical-Research Platform: Baseline Portrait of the Intensity of Interventions in the Stroke Unit of the Institut de Réadaptation en Déficience Physique de Québec (IRDPQ)
D’Amours, L1 Durand, A2 Malouin, F3 Pelletier, F2 Richards, C3; 1. Institut de réadaptation en déficience physique de Québec, Quebec, QC; 2. IRDPQ, Quebec, QC; 3. Université Laval, Québec, QC
Background: One of the projects of the (CIHR) Sensorimotor Rehabilitation Research Team (SMRRT) is the development and implementation of clinical-research platforms to promote interactions between clinicians and researchers to optimize rehabilitation post stroke. To evaluate the impact of this platform a portrait of clinical practice pre and post project was required. Methods: On the last week of April 2012 (five days), the intensity of rehabilitation interventions provided to 18 in-patients with stroke was recorded from 8am to 9pm.The clinicians (OT, PT, kinesiologist, nursing staff and physical rehabilitation technician (PTT)) recorded the duration of their interventions (one to one or in groups) on discipline-specific log sheets. The time spent with a rehabilitation assistant and practice by the patients outside of official therapy time was also included. Results: The patients received an average of 13 hours of rehabilitation interventions per week (range: 9 to 22 hours). Eleven of the 13 average weekly hours were dedicated to supervised individual therapy (an average of 9 hour were given by OT, PT, PTT and the assistant and an average of 2 hours of rehabilitation activities were given by nursing staff). Lower FIM scores were correlated (r = -.75, p<.000) with more time with the nursing staff. Nine patients (50%) also participated in group therapy, thus adding an average of 1 hour per week. The 60% of patients who practiced outside of official therapy time also increased the intensity by an average of 1 hour per week. Conclusions: This project has allowed us to document the actual intensity of interventions received by the patients in our stroke unit and has helped us target gaps for improvement.
Walking Activity During Inpatient Stroke Rehabilitation: Exploring the Relationship Between Amount of Practice and Recovery of Gait Control
DePaul, VG1 Wong, J2 Patterson, KK3, 2 McIlroy, WE5, 4, 2 Mansfield, A2, 4, 3; 1. McMaster University, Hamilton, ON; 2. Toronto Rehabilitation Institute, University Health Network, Toronto, ON; 3. Department of Physical Therapy, University of Toronto, Toronto, ON; 4. Heart and Stroke Foundation Centre for Stroke Recovery, Toronto, ON; 5. Department of Kinesiology, University of Waterloo, Waterloo, ON
Background: Abundant task-specific practice is commonly recommended as an essential ingredient of rehabilitation; however, there has been limited research that specifically examines the relationship between ‘everyday’ walking and improved control of walking after stroke. The purpose of this study was to explore the association between amount of daily walking activity and change in temporal-spatial gait parameters following stroke. Methods: This study is a subgroup analysis from an ongoing rehabilitation trial. Participants were ambulatory individuals undergoing inpatient stroke rehabilitation. Amount of walking was recorded using bilateral accelerometers over an average of 10 days per individual. Temporal-spatial gait parameters were assessed at study enrolment and rehabilitation discharge using the GAITRite walkway. Spearman correlation was conducted to explore associations between amount of walking activity and change scores in gait pace, symmetry, and variability. Results: Initial analysis revealed that the first 19 participants took an average of 4553 steps (SD 2292; MAX 11891; MIN 2367) and spent 55.18 minutes (SD 20.27; MAX 100; MIN 27) walking per day. Over the study period, participants changed velocity (mean +40%), cadence (+10%), step length (+13%), and variability of step length (-17%), step width (+19%), and step time (-6%). Gait symmetry ratios did not change. While there was evidence of possible relationships between measures of walking activity and change in step width variability (r=-0.41, p=0.09) and step time variability (r=0.41, p= 0.08), associations between measures of amount of walking activity and change in indicators of gait control were not statistically significant. Conclusions: In this study, amount of daily walking activity was quite variable across individuals in inpatient stroke rehabilitation. Importantly, the amount of daily walking activity was not significantly associated with improvements measured in temporal-spatial gait outcomes. Further research is needed to explore the relationship between both the amount and quality of practice and recovery of walking after stroke.
Development of a Clinical-Research Platform: Baseline Portrait of the Clinical Approach and Outcomes Measures in the Stroke Unit of the Institut de Réadaptation en Déficience Physique De Québec (IRDPQ)
Durand, A1, 2 D’Amours, L1 Malouin, F2, 3 Pelletier, F1, 2 Richards, CL2, 3; 1. Institut de réadaptation en déficience physique de Québec, Québec, QC; 2. Centre interdisciplinaire de recherche en réadaptation et intégration sociale, Québec, QC; 3. Université Laval, Québec, QC
Background: Clinicians from stroke units in 3 Rehabilitation Centers of Quebec have collaborated with the CIHR SensoriMotor Rehabilitation Research Team (SMRRT) to create clinical-research platforms (CRP) to promote best practices. To evaluate the impact of the CRPs, a portrait of clinical practice before their creation was required. This presentation describes the baseline clinical portrait at IRDPQ. Methods: Baseline clinical practice was documented by 1) therapy intensity, 2) a chart audit and 3) clinicians’ perceptions of their practice. Findings from the chart audit and clinicians’ perceptions are reported. Twenty of 74 charts were audited with a standardized assessment grid. Selected charts were representative of stroke severity based on FIM scores of patients admitted to the stroke unit April 1st, 2011 to March 31st, 2012. To document practice perception, 12 clinicians (7 OT and 5 PT) were administered a questionnaire (based on Canadian best practice recommendations) on the SurveyMonkey web-platform. Results: Generally, clinicians applied recommended best practice modalities (100% of patients were engaged in task-oriented gait training and 85% in task-specific training of the upper extremity). Based on the chart audit, the most frequently used outcomes measures were the FIM (100%), the Chedoke activities inventory (100%), the Berg Balance Scale (100%) and walking speed (70%). Conversely, the CAHAI was never used. Although clinicians perceived that modalities such as constraint-incuded movement therapy, mental practice, functional electrical stimulation or body weight supported treadmill walking were applicable with 8 to 26 % of their patients, they used these modalities with only 0 to 12%. Clinicians’ perceptions were corroborated by the chart audit. Conclusions: In addition to providing a baseline for the evaluation of the effects of the CRP on clinical practice and patient outcomes, this portrait will serve as a guide for closing the gaps to tend towards best practices.
”Connections”; Peer to Peer support linking acute care to community reintegration
Elton-Smith, GM1 Palashniuk, E2; 1. Alberta Health Services, Edmonton, AB; 2. Stroke Recovery Association of Alberta, Red Deer, AB
Background: Post-discharge from hospital care is reported by stroke survivors as a stressful and challenging time (Canadian Best Practice Guidelines 2010). Peer Support enables survivors to assist one another in adjusting to new roles and potentially altered functional and cognitive abilities. (Clarke Institute 1997). The Stroke Program Edmonton Zone (SPEZ) developed a Peer Support Program within Edmonton area hospitals to address post-discharge needs of stroke survivors by connecting survivors and their caregivers to the on-going support of the Stroke Recovery Association of Edmonton (SRAE). Methods: Phase 1 of the program occurred from August 2011-May 2012 and involved developing and implementing the Volunteer Training Program using support and funding from the Stroke Recovery Association of Alberta (SRAA). A curriculum for the training program was developed based on the SRA Support Group Handbook, Ottawa’s Peer-to-Peer Training Manual, Calgary’s Inspires Educational PowerPoint, and in consultation with SRAE members. Peer Volunteers were recruited from the SRAE and screened by SPEZ and the Hospital Volunteer Departments. Referral procedures and processes for hospital visits were created in consultation with each Stroke Team. Phase 2 occurred from September 2012-May 2013 and involved orienting Volunteers to the units, and implementing hospital visits of stroke patients. Results: Six volunteers were recruited and trained to visit patients at 3 acute care hospitals. 179 patients received visits and were provided with emotional support and community resources. 149 of these requested follow-up by phone upon discharge, and more information regarding SRAE. Conclusions: Peer Support volunteers provide a vital link to support groups in the community, assisting with community reintegration. Uptake of the Program has been successful with implementation in all sites containing stroke units. In Phase 3, we will evaluate patient satisfaction with visits as well as the effectiveness of using Peer Support to connect stroke patients with community support.
Acute post-stroke aphasia management: Multiple perspectives on a single patient journey
Foster, AM1, 2 Worrall, LE3, 2 Rose, ML4, 2 O’Halloran, R4, 2; 1. The University of Queensland, Brisbane, QLD, Australia; 2. NHMRC Centre for Clinical Research Excellence in Aphasia Rehabilitation, Brisbane, QLD, Australia; 3. The Univerisity of Queensland / NHMRC Centre for Clinical Research Excellence in Aphasia Rehabilitation, Brisbane, QLD, Australia; 4. La Trobe University / NHMRC Centre for Clinical Research Excellence in Aphasia Rehabilitaiton, Melbourne, VIC, Australia
Background: While previously the focus of acute speech pathologists was the management of communication disorders, their primary role is now in dysphagia. This shift has prompted growing interest and an increasing body of evidence about aphasia management in the acute post-stroke phase. Little is known about the factors influencing speech pathologists’ clinical practice in acute post-stroke aphasia management, or about how people with aphasia and their close-others perceive speech pathology during this time. Methods: A purposive sampling approach was utilised to recruit speech pathologists working in acute post-stroke aphasia within Australia. Following this, a convenience sampling method was used to recruit, from the caseload of the speech pathologist, patients with acute post-stroke aphasia and their close-other. A focussed ethnographic approach was implemented, using a variety of qualitative data collection methods. Observation took place throughout the person with aphasia’s acute inpatient journey, with concurrent recording of a reflective diary by the speech pathologist. Afterwards, semi-structured interviews explored the perceptions of this admission with each participant. The collected data were thematically analysed. Results: Results from a single triad – a speech pathologist, person with aphasia, and their close-other – will be presented, exploring the perceptions of acute aphasia management from multiple perspectives. Themes will be discussed, with reference to the literature, to describe the perceptions of acute post-stroke aphasia management. Thematic commonality and divergence between the different participant groups will be discussed. Conclusions: This study provides preliminary, in-depth information regarding the perceptions of the speech pathology management of acute post-stroke aphasia from multiple perspectives. By exploring the experiences of healthcare service providers and consumers, this study aims to contribute to the understanding of how to effect change in acute aphasia management, allowing for the creation of person-centred approaches to care and decreasing the sense of an evidence-practice gap for clinicians in this setting.
Quantitative Evaluation of Dynamic Balance After Stroke: Development of a Novel Balance Assessment Toolkit
Fraser, JE1, 2 Jones, SA2 Mansfield, A2, 3, 1 Inness, EL1, 2 Wong, J2 McIlroy, WE4, 2, 1; 1. University of Toronto, Toronto, ON; 2. Toronto Rehabilitation Institute, Toronto, ON; 3. Heart and Stroke Foundation Centre for Stroke Recovery, Toronto, ON; 4. University of Waterloo, Waterloo, ON
Background: Current clinical assessments of fall risk and balance control post-stroke rely largely on observational rating scales, which offer a general overview of balance ability but provide little insight into underlying control that may help inform clinical decisions. Recent developments of sensitive, yet low-cost technology, such as the Nintendo® Wii Balance Board (NWBB), have made it possible to quantitatively assess specific kinetic features of static balance control within clinical settings. The aim of the current work is to develop and evaluate a novel toolkit and protocol using multiple NWBBs, to assess dynamic balance control for clinical use post-stroke. Methods: Outcome measures of reactive balance control (i.e. center of pressure excursion and temporal components of movement) were captured and extracted in a sample of healthy and post-stroke adults. The protocol included a specific set of tasks ranging from static standing conditions to more challenging, dynamic transitions and rapid stepping tests. Results: Initial results exploring the measurement properties in healthy adults (n=15) reveal good within- and between-trial consistency across task conditions. For example, rapid step test performance resulted in a mean step time duration of 0.47 ± 0.018 sec, with consistent variability between-individuals (mean step time duration variability = 0.043 ± 0.018 sec). Conclusion: Preliminary findings from this study suggest that the toolkit and protocol provide consistent performance outcomes of both static and dynamic balance control in a healthy adult population. Ongoing work is focused on validating the protocol in a sample of sub-acute stroke inpatients by comparing the outcome measures of the toolkit to a ‘gold standard’ assessment of balance control using research-grade force plates. Ultimately, this work will lead to a more comprehensive clinical assessment of fall risk and the underlying control systems involved.
Is the FIM® a Sufficient Measure of Communication Change in Stroke?
Barr, LG; Ansley, B; Kubilius, B; Whiteman, R; Hamilton Health Sciences, Hamilton, ON
Background: In Ontario, the Functional Independence Measure (FIM®) and supplementary Canadian Institute for Health Information (CIHI) scales are mandated for use to measure for change in stroke patients upon admission into and discharge from rehabilitation programs. In this study we sought to learn whether the FIM® and CIHI cognitive and communication items are sensitive enough to capture the actual communication gains made in inpatient rehabilitation or whether implementation of an adjunct Speech-Language Pathology outcome measurement is required. Methods: We completed a retrospective analysis of 1252 stroke patients who were discharged alive between 2006 and 2011. The purpose of the analysis was to determine whether statistically significant National Rehabilitation Reporting System (NRS)- FIM® comprehension/expression and CIHI communication scores changes could be found between admission and discharge. Results: Statistically, significant increases in all total matched FIM® scores (M= 72.68 to M= 96.39, p < 0.000) and for each expression (M= 4.61 to M=5.35 p< 0.000) and comprehension (M= 4.69 to M= 5.33 p < 0.000) subscales. Conclusions: Clinicians must determine how FIM® and the supplementary CIHI data inform their practice. Although, the results are statistically significant it remains to be known if the results are clinically significant. Future analysis will explore whether demographics influence improvements and whether there exists inter-relationships between the mild, moderate and severe severity groups within the FIM®.
Efficacy of Cyclosporin-Rehabilitation Combination Therapy in a Model of Neonatal Hypoxia-Ischemia
Pedrini Schuch, C2, 3, 4 Jeffers, M3, 4 Nguemeni, C3, 4 Gomez-Smith, M1 Corbett, D3, 4, 5; 1. University of Ottawa, Ottawa, ON; 2. Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil; 3. Heart and Stroke Foundation Centre for Stroke Recovery, Ottawa, ON; 4. Cellular and Molecular Medicine, University of Ottawa, Ottawa, ON; 5. Faculty of Medicine, Memorial University, St. John’s, NL
Every year nearly 13 million infants are born prematurely. 10% of survivors subsequently develop hypoxia-ischemia (HI)-induced cerebral palsy with damage to both white and grey matter and causing life-long impairments in motor function. It was previously shown that the immunosuppressant Cyclosporin-A (CsA) promotes proliferation and migration of neural precursor cells to the site of injury in rodent stroke models. Our intention was to develop a novel treatment paradigm for cerebral palsy by combining CsA with rehabilitation that could be used in the clinic. At post-natal day (PND) 7, the Levine-Rice model was used to produce unilateral brain injury by permanently occluding the left carotid artery. 2.5 hours later, the rat pups were placed in a hypoxia chamber for 90 minutes (8% O2). On PND 21, pups were implanted with osmotic pumps delivering CsA (420 mg/mL) and divided into 5 groups: CsA+Rehabilitation; CsA+No Rehabilitation; Vehicle+Rehabilitation; Vehicle+No Rehabilitation and sham. Animals receiving rehabilitation were housed in an enriched environment and received reach training for 4h/day, 5 days/week over 4 weeks. During reach training, animals had access to food rewards that were obtainable using only the impaired limb (right). Motor function was assessed pre- (PND 17) and post-rehabilitation (PND 49) using the Montoya Staircase, cylinder and open field tests. Prior to rehabilitation, all animals were significantly impaired in cylinder (p<0.001) and open field (p=0.03). Following four weeks of rehabilitation, all rehabilitation groups had increased activity in the open field compared to uninjured shams. Non-rehabilitated rats were significantly less active than both rehab (p=0.038) and sham animals (p=0.015). Similarly, rehabilitated animals recovered to sham level in the Montoya Staircase while non-rehabilitation animals showed significant impairments compared to all other groups (p < 0.001).
In conclusion, enriched rehabilitation significantly improved motor function in rats following hypoxia-ischemia, while Cyclosporin-A did not impact functional recovery.
Normal Appearing Tissue Volume is Related to Post-Stroke Cognitive Impairment
Honjo, K7, 3 Nyenhuis, DL2 Gao, F7, 3 Scott, CJ7, 3 Ganda, A1 Lobaugh, NJ3 Graham, SJ3 Zhou, XJ4 Rangwala, N4 Stebbins, GT5 Marola, J4 Gibson, E3 McNeely, AA7, 3 Stuss, DT3, 6 Black, SE7, 3, 6; 1. Sunnybrook Health Sciences Centre, Toronto, ON; 2. Hauenstein Neuroscience Center, Saint Mary’s Health Care, Grand Rapids, MI, USA; 3. Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON; 4. University of Illinois College of Medicine at Chicago, Chicago, IL, USA; 5. Rush University Medical Center, Chicago, IL, USA; 6. Rotman Research Institute, Baycrest, Toronto, ON; 7. Heart and Stroke Foundation Centre for Stroke Recovery (Sunnybrook site), University of Toronto, Toronto, ON
Background: Vascular cognitive impairment (VCI) is common in post-stroke patients, affecting two-thirds of stroke survivors (Hachinski, 2006). Neuropsychological testing in this population usually shows executive dysfunction. However, relationships between lesion volume and remaining brain and cognition have been little studied in this population. This study examined relationships between normal appearing brain tissue and cognitive function in chronic stroke patients. Methods: Gray matter (GM), White matter (WM), cerebrospinal fluid, and white matter lesions were delineated by in-house software (Ramirez, 2011). Infarct volumes were traced on 3D-T1 3T-MRI for 58 patients 6–36 months post-stroke. Brain parenchymal fraction (BPF) was equated to the normal appearing tissue. Z-scores were computed for the VCI-60 and 30minute protocols,1 each domain, and MoCA. Multiple linear regression modeling forced age and education in first, and then assessed brain volumetric measures. Results: 1) BPF contributed significantly to the regression model predicting MoCA, 60 min, 30 min, Executive, and Spatial functions (R2=0.163,0.335,0.250,0.354,0.168, p<0.05). 2) Normal appearing WM (NAWM) predicted MoCA, 60min, 30min, Executive, Visuospatial, and Memory functions (R2=0.283,0.450,0.280,0.393,0.262,0.161, p<0.05). 3) Left-NAWM predicted MoCA, 60min, 30min, Executive, Spatial, and Language functions (R2=0.382,0.351,0.206,0.204,0.181, p<0.05). 4) Right-NAWM predicted Spatial function (R2=0.154, p<0.05), and improved the model significantly over age for 60min, 30min and Executive function (R2=0.289,0.226,0.274, p<0.05). 5) NAGM improved the model significantly over age for Executive function (R2=0.225, p<0.05), and Left-NAGM for 60min and Executive function (R2=0.238,0.239, p<0.05). 6) Right-NAGM had no contribution. Conclusions: BPF and NAWM showed a strong correlation with the neuropsychological scores, whereas, NAGM itself did not. Language scores were predicted only by Left-NAWM, and memory by total NAWM. Right-NAWM only showed contribution to spatial function. Loss of healthy WM may be an important substrate of VCI. Memory and language functions showed expected laterality only in WM. Compromise of regional WM connections may be key for understanding VCI.
Where is the Balance in Task-Oriented Circuit Training Interventions?
Inness, EL1, 2 McIlroy, WE1, 2, 3; 1. Toronto Rehabilitation Institute - University Health Network, Toronto, ON; 2. University of Toronto, Graduate Department of Rehabilitation Science, Toronto, ON; 3. Heart & Stroke Foundation Centre for Stroke Recovery, Toronto, ON
Background: Balance is an essential feature of safe and independent performance of daily activities and a key priority in stroke rehabilitation. Therapies are increasingly making use of task-oriented circuit class training (TO-CCT) as a cost-effective approach to increase practice opportunity for functional skill acquisition. However, such approaches have failed to demonstrate superior outcomes or improvement in balance. The purpose of this review is to identify and describe the treatment elements of TO-CCT that may influence balance outcomes after stroke. Methods: A scoping review was conducted. A comprehensive search was performed for randomized controlled (RCT) studies that included the adult stroke population, an intervention of TO-CCT and at least one outcome evaluating balance. Data was extracted using a charting framework and qualitative content analysis used to identify emerging themes. Results: Nine studies were included in the review: 1823 studies identified; 45 papers retrieved; 37 excluded; 1 study added from hand-search of reference lists. All studies identified that improving balance was a central feature of the TO-CCT. The majority of studies referred to balance as a singular/general construct. There was considerable overlap of tasks across interventions but no clear consensus or rationale for identified ‘balance’ tasks. Task progression to challenge balance varied across studies as did the balance outcome measures. The most common tool was the Berg Balance Scale though some used instrumented measures, self-efficacy questionnaires or documented falls. Conclusions: Task selection and progression to improve balance within TO-CCT appears arbitrary. Commonly-used balance measures may demonstrate changes in functional task performance but not changes in underlying balance control. Further, such changes may not translate to a broader range of activities of daily life. Both research and clinical practice would benefit from a unified framework of balance that could support the development of theoretically-informed treatment elements and corresponding measurement of therapeutic interventions.
Development and Evaluation of a Health Economics Measure for Quality of Life in Aphasia Post-Stroke
Kagan, A1 Simmons-Mackie, N2 Hoch, J3 Victor, JC4 Mok, A1 Kant, L1 Streiner, D5 Sharp, S6; 1. Aphasia Institute, Toronto, ON; 2. Southeastern Louisiana University, Hammond, LA, USA; 3. St. Michael’s Hospital Keenan Research Centre, Toronto, ON; 4. Institute for Clinical Evaluative Sciences, Toronto, ON; 5. McMaster University, Hamilton, ON; 6. Toronto West Regional Stroke Network, Toronto, ON
Background: Aphasia, a stroke-related language problem, masks general competence and has a profound impact on quality of life (QOL). Health economists typically use a numerical index, a Quality Adjusted Life Year (QALY) to determine the impact of various health conditions on QOL. There are significant challenges when evaluating cost-effectiveness for aphasia, because of the language barriers posed in using traditional methods such as the Time Trade Off (TTO) to establish QALY’s. We therefore developed and evaluated the reliability of a pictographic version of the TTO method of trading years of life for improved health (picTTO). Methods: An aphasia-friendly method (picTTO) to depict hypothetical exchange of life years for an aphasia cure was developed using focus group input from people with aphasia, speech-language pathologists (SLPs), and volunteers. To establish reliability, a trained SLP administered the picTTO twice to 50 participants with aphasia. Each participant estimated the years s/he would give in exchange for an aphasia cure at present time and at the time of his/her stroke. QALY utility weights were calculated and correlated across the two administrations with intraclass correlation coefficients (ICCs) to establish test-retest reliability. Results: ICCs were low for utility weights (0.00 to 0.26, p > 0.05), with low agreement between participants’ willingness to trade-off life years between administrations (multi-rater kappa: 0.20 and 0.33 respectively). Potential reasons for low reliability were examined in post-hoc analysis e.g., challenges related to recall, and through qualitative analysis of participants and SLPs (e.g., holding consistent timeframes in mind at both administrations, and self-reflection between administrations). However, participants with aphasia were able to answer the questions and the direction of change was as expected, showing increase in QOL post-stroke and after aphasia interventions. Conclusion: The picTTO is worthy of further investigation; in particular, the methodology used to establish validity and reliability requires simplification.
The Experience of Rehabilitation Professionals as a Source of Information in an Evidence-Based Reconfiguration of a Poststroke Rehabilitation Continuum
Lamontagne, M1 Richards, CL2 Clément, L2 Azzaria, L3; 1. CIRRIS, Québec, QC; 2. Ministère de la santé et des services sociaux, Québec, QC; 3. Université Laval, Québec, QC
Background: The Province of Quebec is in the process of reconfiguring its poststroke rehabilitation continuum. The committee mandated to propose an optimal continuum recognized the importance of obtaining the perceptions of rehabilitation professionals of the present system and their suggestions for improvements. Methods: With the support of the 16 regional health agencies, a survey was sent to managers and rehabilitation clinicians working in acute care, in rehabilitation centers or in the community. It sought participants insights with regard to 28 items related to accessibility, information, patient implication, coordination and overall satisfaction with the actual continuum of care and requested suggestions for improvement. Results: A total of 211 rehabilitation professionals with an average of 12 years experience working with personspost stroke, in the majority clinicians (63%) who working in the community (39%), completed the questionnaire. They rated accessibility as rather good (mean score (ms): 8/10), continuity (ms: 8/10), information provided (ms: 8/10), and patient implication (ms: 8/10). Within each dimension, some items were more and less positively perceived, such as accessibility at non-traditional moments and accessibility to services for close relatives. Individuals with poor prognoses, complex or intensive needs, geriatric profiles or with only cognitive / language impairments were deemed to be less well served. The mean overall satisfaction score was 70%. The differences were larger between the perceptions of rehabilitation professionals working in the different phases of the continuum than between those in rural and urban settings. The participants had many experience-related explanations to justify their scores. Conclusions: The perceptions and suggestions of the rehabilitation professionals confirmed the need to improve the accessibility of services for persons poststroke living in the community and for persons with atypical strokes or more complex needs. These perceptions were taken into account by the committee in formulating their recommendations for a patient oriented rehabilitation continuum.
A Volunteer-Led Evening and Weekend Activity Program for Clients with Stroke in Inpatient Rehabilitation
French, EH1 Frowen, A2 Adams, M2; 1. Thunder Bay Regional Health Sciences Centre, Thunder Bay, ON; 2. St. Joseph’s Care Group, Thunder Bay, ON
Background: Daily activity that is intensive, challenging and meaningful, as well as additional practice outside of scheduled therapy improves outcomes for people with stroke. Contrary to best practices, hospitalized clients with stroke spend most of their waking day inactive and alone. Evenings and weekends offer a prime opportunity for clients with stroke to practice activities taught during therapy. Methods: In this program evaluation initiative, clients with stroke on an inpatient rehabilitation unit were offered opportunities to practice stroke rehabilitation activities on evenings and weekends. Activities were provided for one-hour, in a small group setting, and supported by a trained volunteer. Activities included: seated exercises, sit-to-stand practice, arm ergometer, cognitive, language and recreation tasks. Information was collected during a six-week pilot phase to determine the feasibility and acceptability of the program. Results: Five volunteers supported a total of 32 one-hour sessions. Fifteen clients with stroke participated with an average of four clients attending each session. On average the program operated at 65% capacity. Reasons provided for non-participation included: pain, fatigue, not available and visitors. The clients described a positive impact of the program on their mood and enjoyed the social aspect. Both clients and volunteers did suggest incorporating more challenging tasks and individualized support for activities. Staff indicated that the program did not negatively impact upon their current responsibilities and were generally satisfied with the program. Conclusions: Implementation of the program was feasible and acceptable to volunteers, staff and clients on an inpatient stroke rehabilitation unit. Minor revision to improve client and volunteer satisfaction with the program, as well as to streamline administrative processes is indicated. The limited scope of the volunteer, as compared to a rehabilitation staff member, does not meet the needs of all clients. Resources for a dedicated lead to oversee implementation and evaluation are essential.
Rehabilitation Intensity: Capturing Stroke Patient Improvement One Minute at a Time
Linkewich, E1, 3 Brien, H2; 1. North & East GTA Stroke Network, Toronto, ON; 2. Ontario Stroke Network, Toronto, ON; 3. Sunnybrook Health Sciences Centre, Toronto, ON; 4. Northern Ontario School of Medicine, Thunder Bay, ON
Background: Increased activity and environmental stimulation is important to neurological recovery after stroke. Stroke best practices recommend at least three hours of therapy per patient day in inpatient rehabilitation. Rehabilitation intensity (RI) was identified as a key system driver in the Ontario Stroke Network’s (OSN) Report Cards, yet a mechanism for data collection is a gap. Initial exploration identified an option to collect this data through workload measurement (WM). Method: A review of rehabilitation WM systems in Ontario was conducted via survey. Interviews and focus groups were conducted with diverse representation of stakeholders across the province to inform the definition and feasibility of RI data collection. Using evidence and stakeholder input, definition and principles were compiled and brought to the provincial Stroke Reference Group for endorsement. Using the endorsed definition and principles, 2 pilot sites implemented RI collection for 2 one-week periods. Review of technical feasibility to upload WM into rehab data database (NRS) was initiated. Results: ~66% of organizations collect WM by patient, 28%, include diagnosis, with a minimum of nine systems (44% using 2 vendors). The RI definition was established and included the time a patient spends in active individual goal-directed therapy over a 7 day/week period that is monitored and guided by a therapist. Initial results for RI collection indicated little impact on clinician time and distribution of RI increasing with stroke severity. Conclusions: Initial results support the feasibility of RI collection for clinicians in WM. Further work is required to explore technical feasibility to integrate into NRS.
Stroke Rehabilitation in BC: Using Action-Research to Identify Gaps in Care and Promote Improvements
LoChang, J; Aikman, P; Stroke Services BC, Vancouver, BC
The National Stroke Audit (2008/09) highlighted some important areas for improvement in care in British Columbia. In terms of rehabilitation, only 8% of patients were admitted to a rehabilitation facility following acute care, well below the national average of 19%. As a result, a provincially coordinated gap analysis was conducted to further identify the most pressing needs for stroke rehabilitation in the BC. The project utilized an observational action-research methodology to collect quantitative and qualitative information about stroke rehabilitation in the Province. A tracking tool was developed, to measure clinical practices against the Canadian Best Practice Guidelines. Questions regarding rehabilitation practices from all phases of the stroke continuum (acute, inpatient rehabilitation, and community) were included. A total of 238 stroke patients were followed for 6 weeks during the study period of November 2011 – February 2012. The process used was found to be valuable not just in terms of documenting gaps in stroke care, but in understanding the underlying reasons why a gap exists. In addition, the involvement of front line staff in the methodology was a catalyst for rapid improvements to address issues that were identified. Key findings:
The methodology and analysis identified both province-wide and health authority specific gaps in availability of services and inconsistencies in practice; on a positive note, leading practices were also identified that can be shared and expanded upon;
The process allowed not only the identification of a gap in practice, but also the contributing contextual factors;
The process engaged care providers as active participants in improving the stroke system of care;
The methodology enabled clinicians at the point of care to see these inconsistencies and immediately begin formulating actions plans for improvement;
The methods used have resulted in positive change at the site, health authority, and Provincial levels
BDNF and COMT Genetic Polymorphism Effects on Motor Function and Corticospinal Excitability in Chronic Stroke
Mang, CS; Brown, KE; Ross, CJ; Boyd, LA; University of British Columbia, Vancouver, BC
Introduction: The basic neural mechanisms underlying post-stroke motor recovery depend on the expression of specific genes. There is limited research considering how neuroplasticity-associated gene variants relate to motor recovery after stroke. The present study examines the impact of the brain-derived neurotrophic factor (BDNF) gene val66met and catechol-O-methyl transferase (COMT) gene val158met polymorphisms on hemiparetic arm grip strength and ipsilesional corticospinal excitability in chronic stroke. Methods: To date, 15 individuals with chronic stroke have been genotyped for the BDNF and COMT polymorphisms from DNA extracted from saliva samples. Investigators blinded to genotype assessed: 1) grip strength of the hemiparetic hand (n=15), and 2) ipsilesional corticospinal excitability via transcranial magnetic stimulation (TMS)-based recruitment curves (RCs) (n=12). For RCs, TMS was applied over ipsilesional motor cortex at intensities ranging from 90-150% active motor threshold (AMT) in 10% increments. Motor evoked potentials (MEPs) were recorded from the hemiparetic wrist extensors. Higher linear slope of the RC plot of stimulus intensity (%AMT) by MEP amplitude (mV) indicates greater corticospinal excitability. Results: Individuals carrying the met allele for the BDNF gene (n=3) demonstrated lower grip strength (mean±SD; 12.4±3.5) and lower recruitment curve slope (5.3±7.5) compared to val/val individuals (grip: 18.8±11.4; slope: 13.0±20.5). Additionally, those participants that were homozygous val/val COMT genotype (n=4) demonstrated lower grip strength (6.3±7.8) and lower recruitment curve slope (5.3±7.5) than COMT met allele carriers (grip: 21.6±8.3; slope: 17.0±23.7). Conclusion: Although preliminary, the present findings suggest that common variants of the BDNF and COMT genes may impact post-stroke motor recovery both functionally and physiologically, consistent with previous findings of BDNF and COMT genotype effects on neuroplasticity in healthy individuals. Additional research is underway to enhance power and more fully characterize motor function of participants. Improved understanding of genetic factors that influence stroke recovery will facilitate the development of novel, personalized post-stroke rehabilitation strategies. Insert
Outcomes in People Following Stroke Attending an Adapted Cardiac Rehabilitation Exercise Program: Does Time from Stroke Make a Difference?
Marzolini, S4, 3 Tang, A1 McIlroy, W2, 3 Oh, P4, 3 Brooks, D5, 3; 1. School of Rehabilitation Science, McMaster University, Hamilton, ON; 2. Department of Kinesiology, University of Waterloo, Waterloo, ON; 3. Heart and Stroke Foundation Centre for Stroke Recovery, Toronto, ON; 4. Toronto Rehabilitation Institute Cardiac Rehabilitation and Secondary Prevention/UHN, Toronto, ON; 5. Department of Physical Therapy, University of Toronto, Toronto, ON
Background: Individuals referred to cardiac rehabilitation programs (CRP) following stroke have demonstrated post-program improvements in cardiovascular fitness (VO2peak). However, the effect of CRPs on other outcomes and effect of time-from-stroke have not been investigated. Purpose: 1) To evaluate effects of a 24-week CRP of resistance and aerobic exercise in 120 participants with motor impairment following stroke; 2) to explore effects of elapsed time-from-stroke. Methods: Primary outcomes included 6-minute walk distance (6MWD), VO2peak, timed repeated sit-to-stand performance, and affected-side isometric knee extension strength (IKES). Secondary measures included gait characteristics (cadence, step lengths, and symmetry), walking speed, balance (Berg Balance Scale), affected-side range-of-motion, elbow flexion and grip strength, anaerobic threshold, and perceptions of participation/social re-integration. Results: After adjusting for multiple comparisons, participants demonstrated significant improvements (all p<0.001) in 6MWD (283.2±126.6 to 320.7±141.8 meters), sit-to-stand performance (16.3±9.5 to 13.3±7.1 seconds), affected-side IKES (25.9±10.1 to 30.2±11 kg as % body mass), and VO2peak (15.2±4.5 to 17.2±4.9 mL·kg·min-1). Participants also demonstrated post-CRP improvements in secondary outcomes: anaerobic threshold, balance, affected-side hip/shoulder range-of-motion, grip and isometric elbow flexion strength, participation, walking speed, cadence (all p<0.001) and bilateral step lengths (p<0.04). In a linear regression model, there was a negative association between change in 6MWD and time-from-stroke (ß=–42.1; p=0.002) independent of baseline factors. Conclusion: A CRP yields improvements over multiple domains of recovery; however those who start earlier demonstrate greater improvement in functional ambulation independent of baseline factors. These data support the use of adapted CRPs as a standard of care practice following conventional stroke rehabilitation.
Virtual Reality Rehabilitation After Stroke Study (Vrrass): an Inpatient Blinded Randomized Control Trial
McEwen, DW1 Taillon-Hobson, A2 Bilodeau, M2, 1 Sveistrup, H1 Finestone, HM2, 1; 1. University of Ottawa, Ottawa, ON; 2. Bruyere Research Institute, Ottawa, ON
Background: Exercise training using virtual reality (VR) improves balance in adults with traumatic brain injury and adults with chronic hemiparetic stroke. Rigorous randomized studies regarding its efficacy, safety and applicability are lacking. The objectives of this study were to determine whether VR therapy, as an adjunct treatment to conventional in-patient stroke rehabilitation, 1) is safe and feasible and 2) improves balance and weight bearing on the affected side. Methods: A blinded randomized controlled trial was implemented in an inpatient stroke rehabilitation unit. Sixty patients who: 1) had ischemic or hemorrhagic, cortical or subcortical strokes, 2) had resultant mobility deficits and 3) could stand independently for >1 minute were randomized into either a control group (seated VR training) or an experimental group (standing VR training). The seated group performed the various VR exercises without their balance being challenged. Clinical balance and mobility measures, including the Two-Minute Walk Test, Timed Up and Go Test and Berg Balance Scale, were recorded before, immediately after and 1 month after training. Training consisted of 10 to 12, 30 minute sessions of VR exercises which were in addition to the regular in-patient rehabilitation program. Results: No adverse events occurred during the study. Preliminary data analyses showed significant improvements in VR gaming scores and overall measures of motor function, but no significant between-group differences were noted. Majority of participants reported a positive experience. Conclusions: VR exercise for stroke rehabilitation inpatients is safe and enjoyable. Since the average total FIM scores on admission were significantly higher for study participants than for inpatients who did not participate (93 vs. 75, p < 0.05), the inclusion criterion of standing unaided for > 1 minute limited the sample selection to high-functioning stroke survivors. Further studies need to include the stroke rehabilitation inpatient with greater motor impairments.
Development of the Community Re-engagement Cue to Action Trigger Tool (CR CATT)
McKellar, J1 Cheung, D2; 1. Toronto West Stroke Network, Toronto Western Hospital, Toronto, ON; 2. South East Toronto Stroke Network, St. Micheal’s Hospital, Toronto, ON
Background: The needs and issues faced by persons with stroke are multi-dimensional and complex. They feel dependent on healthcare providers to guide their care and recovery but often have difficulty obtaining the support they need. The work presented herein builds on previous research (Cheung and McKellar, 2012) that evaluated the impact of a community re-engagement (CR) education intervention, which integrated concepts of interprofessional collaborative care and a CR framework, on healthcare providers’ day-to-day practice. The eight components of CR were used to create a trigger tool to facilitate discussion between healthcare providers and persons with stroke across the care continuum. One recommendation from this study was to develop a patient-mediated trigger tool for persons with stroke, using the same eight components of CR, to facilitate a self-management approach to their care. Methods: The trigger tool was modified for persons with stroke and caregivers and renamed: Community Re-engagement Cue to Action Trigger Tool (CR CATT). Following a review by the institution’s patient education department, modifications were made including: larger font, spacious layout with images, health literacy principles at grade 4-6 level, and wording questions in the first person. The tool was subsequently reviewed by healthcare providers from various professions in multiple settings and persons with stroke in the community (n=30) to gauge its usefulness, comprehensiveness and readability. Results from this enquiry were positive and the tool was perceived to be useful and comprehensive in anticipating and addressing CR needs. Results: A mixed-methods study was designed to determine whether exposure to the CR CATT through a patient- mediated intervention, results in self reports of improved anticipation of needs and increased re-engagement in valued activities post-stroke. Data analysis is ongoing. Conclusions: The CR CATT may provide an easy to use and implement tool to facilitate persons’ with stroke re-engagement in community living.
Power Mobility Training for Persons with Stroke: a Randomized Control Trial
Mountain, AD1 Kirby, R1 Eskes, GA1 Smith, C2 Thompson, K2; 1. Dalhousie University, Halifax, NS; 2. QEII Health Sciences Centre, Halifax, NS
Background: Persons with stroke are often overlooked as candidates for power mobility especially when the person has a co-existent perceptual or cognitive impairment. The purpose of this study was to examine whether persons with stroke can benefit from power mobility training and thus be potential candidates for power wheelchair use. Methods: Seventeen participants (12:5 male:female) from an inpatient stroke rehabilitation program completed baseline cognitive and perceptual tests and were randomly allocated to the intervention (n=9, 5 with neglect) or control (n=8, 4 with neglect) groups. They all completed an initial assessment of their baseline power wheelchair skills using the Wheelchair Skills Test – Power Mobility version (WST-P #1). The intervention group completed up to five 30-minute power mobility training sessions. Following completion of all training sessions a second WST-P (WST-P #2) was done. Control-group participants did not receive any training sessions and completed WST-P #2 two weeks after WST-P #1. No participants used a power wheelchair nor received power wheelchair skills training outside of the study. Results: Mean age of participants was 54 yrs (range 25 - 86 yrs). There was no significant difference in the WST-P score between the control (57%) and intervention groups (56%) at baseline (wilcoxon p value = 0.89). However, the score on WST-P #2 for the intervention group (75%) was significantly better than the control group (55%) after training (wilcoxon p value = 0.04). The Wilcoxon Rank Sum test was used to compare the magnitude of change in WST-P raw scores for participants with and without neglect and was non-significant (-2.5 for participants with neglect; p value = 0.33). Conclusions: Many people with stroke, with or without visuospatial neglect, can improve their power wheelchair skills with appropriate training.
“Until you’re there… you don’t know how you’ll be” The influence of beliefs, attitudes and experience on patient behaviour
Nelson, ML1 Torchia, M2 Mactavish, J3 Grymonpre, R2; 1. Bridgepoint Health, Toronto, ON; 2. University of Manitoba, Winnipeg, MB; 3. Ryerson University, Toronto, ON
Background: Health care providers and system administrators are driving and experiencing a paradigm shift; moving from paternalism and toward an egalitarian approach. In order to practice patient centred care, health care providers must prioritize patient needs; provide information regarding treatments, while taking patient preferences and expectations into account. While there is a growing body of literature regarding patient centredness, there is scant information from the patient perspective about the experience of being a patient and the subsequent influence on behaviour. Methods: Using phenomenological research methods and the theory of planned behaviour as a theoretical framework, this study addressed the questions: a) what is the essence of being a stoke rehabilitation patient, and b) what influence do beliefs, attitudes, and experience have on people’s behaviour as a patient? Ten stroke survivors were interviewed on three occasions over the course of inpatient rehabilitation - admission, mid treatment and prior to discharge. Results: Seven shared elements of being a rehabilitation patient were identified. The experience of being a rehabilitation patient is socially oriented, governed and reinforced. Patients’ behaviour was focused on the goal of recovery and discharge. Patients described themselves as actively engaged in their treatment; they did not however approach stroke rehabilitation with a predetermined set of behavioural beliefs about being a patient. During their rehabilitation patients identified, developed and adopted strategies to assist in achieving their goal, and evaluated those strategies more positively. Conclusion: Being a patient was not a single, observable behaviour, but rather a set of contextually dependent strategies patients’ directed at a situation specific goal. The theory of planned behaviour was unsuitable for understanding peoples’ beliefs, attitudes and behaviour about being a patient.
Is running induced neurogenesis important for post-stroke recovery?
Nguemeni, C1, 2 Gomez-Smith, M3, 2 Jeffers, M3, 2 Corbett, D3, 2, 4; 1. Heart and Stroke Foundation Centre for Stroke Recovery- University of Ottawa, Ottawa, ON; 2. Cellular and Molecular Medicine, University of Ottawa, Ottawa, ON; 3. Heart and Stroke Foundation Centre for Stroke Recovery- Cellular and Molecular Medicine, University of Ottawa, Ottawa, ON; 4. Memorial University of Newfoundland, St John’s, NL
Background: Rehabilitation offers the greatest hope for stroke patients to regain function. Recent evidence suggests that aerobic exercise can enhance brain health and improve post-stroke recovery by a number of mechanisms including neurogenesis. For example,voluntary wheel running increases neurogenesis in the hippocampal dentate gyrus (DG). Unfortunately, most preclinical exercise studies provide animals with unlimited access to running wheels and rodents often run at excessive levels (6-16 km/day). Such a paradigm is not easily translated to stroke patients who are typically older and have physical limitations. We designed a moderate exercise paradigm where animals would run in bouts totalling ~ 20 minutes or 30-60 minutes (in 4hr or 8 hr access)/day that allow us to investigate dose-response effects of exercise on neurogenesis. Methods: Male Sprague Dawley rats were assigned to 5 groups: Sedentary (Sed) rats, 4 hr (4HR), 8 hr (8HR) and 24 hr alternate day runners (AR) that had access to the running wheel every other day and 24 hr runners (UR) that had unlimited access to the wheel every day. During the first week, we labelled newborn cells with bromodeoxyuridine (BrdU, 50mg/kg/day, i.p.). Then, we used the immature neuronal marker doublecortin (DCX) to characterize new cells in the DG after two weeks of running. Results: The AR and UR groups ran significantly more than any other group. We found a significant increase in BrdU+ cells in the DG of AR and UR groups. Surprisingly, there was no difference in the percentage of BrdU/DCX+ cells across all the groups. Notably the moderate runners (i.e. 4 & 8hr access) did not show altered neurogenesis even though moderate exercise levels such as these improve post-stroke recovery in animal and human studies. Conclusion: These data suggest that the increased neurogenesis induced by intensive unlimited running wheel access may not be contributing to post-stroke recovery.
Brain Stimulation Combined with Rehabilitation in Acute Stage Improves Upper Limb Function
Paquette, C1 Reigel, M1 Anglade, C2 Fung, J1 Thiel, A3; 1. McGill University - CRIR, Montreal, QC; 2. Université de Montréal, Montreal, QC; 3. McGill University/Jewish General Hospital-LDI, Montreal, QC
Activity in the contralesional primary motor cortex (M1) in acute stage of stroke is increased due to a reduction of transcallosal inhibition from the affected hemisphere. Brain imaging studies suggest that this persisting contralesional activity in M1 may limit the functional recovery. Thus, down regulation of contralesional M1 activity might benefit motor recovery by facilitating recruitment of motor networks within the affected hemisphere. Two types of non-invasive brain stimulation: repetitive transcranial magnetic stimulation (rTMS) or transcranial direct current stimulation (tDCS) can be used to down regulate activity. Our aims were to 1) determine whether modulation of contralesional M1 activity in acute stage can improve motor function and 2) determine if rTMS and tDCS have comparable effects on motor function recovery. Stroke subjects were randomized to receive rTMS, tDCS or sham stimulation (Figure 1). Subjects received up to 10 days (mean 8 days ) of double-blind inhibitory stimulation over unaffected M1, combined with physiotherapy (PT). Treatment began on average 12 days after stroke. On each treatment day, subjects first received 15 minutes of real or sham rTMS immediately followed by real or sham tDCS during the 40-60 minutes PT session. Motor function was assessed with the Chedoke Arm and Hand Activity Inventory (CAHAI). CAHAI scores were similar at recruitment (p=0.994) but were significantly higher after treatment (p<0.05) for subjects in the rTMS group (19 ) than for subjects receiving tDCS (11 ) or sham stimulation (6 ), as shown in Figure 2. There was no difference at 3 and 6 months post treatment (p=0.330). Inhibitory rTMS over unaffected M1 significantly improved upper limb motor recovery when given early after stroke. These preliminary results suggest that rTMS in acute stroke may increase rehabilitation potential and possibly shorten length of stay in rehabilitation clinics.
The Effects of Verbal or Manual Cues on Gait Parameters During the Rehabilitation Phase of Stroke: a Randomized Cross-Over Trial
Ploughman, M1 Shears, J2 Quinton, S2 Flight, C2 O’Brien, M2 Peacock, M2 Byrne, JM1; 1. Memorial University of Newfoundland, St. John’s, NL; 2. Eastern Health Authority, St. John’s, NL
Background: When retraining walking after stroke, therapists can use a variety of forms of feedback (e.g. manual cues, verbal instruction or vicarious performance) to guide movement and activate hemiplegic muscles. Like many therapeutic interventions, feedback choice is based primarily on clinical experience. This research aimed to compare two therapeutic techniques (verbal vs. manual cues) to determine their effects on hemiplegic muscle recruitment and gait. Methods: Nine individuals (6 females; average age 61 years), within 9 months post-stroke (average 121 days post), visited the laboratory twice (separated by at least 7 days). In each session subjects performed a total of 16 walking trials. An experienced physiotherapist either delivered verbal or manual treatment during 4 of these walking trials. The remaining trials included four trials each prior to, immediately following and 20 minutes following the intervention. The treatment delivered in each session was randomized. During all trials lower limb kinematics were captured using a Vicon system. Electromyography (EMG) was used to record activity of gastrocnemius, tibialis anterior, vastus lateralis, medial hamstrings, gluteus medius and gluteus maximus (hemiplegic side only). Kinematic data was used to quantify joint angles at key gait cycle points. EMG magnitude during stance phase was quantified using root mean square (RMS) activation. RMS values during post and retention trials were expressed as percentage change relative to pre-intervention values. Results: Preliminary analysis indicated that verbal instruction increased lower limb stance phase EMG activity by 4.2 to 23% (p=.05-.58). Manual cues were less facilitative (-16% to 8%) and in some cases reduced EMG activity. Verbal instruction also increased ankle plantarflexion range at toe-off on the hemiplegic side (p<.04). Conclusions: Early results suggest that verbal instruction by experienced physiotherapists improves muscle recruitment and gait kinematics during the rehabilitative phase of stroke. This finding could be important in optimizing gait symmetry after stroke.
Effects of a Free Water Protocol on Inpatients in a Neurological Rehabilitation Setting
Pooyania, S1 Galimova, L1 Buchel, C2 Daun, R3 Lenton, L3; 1. Faculty of Medicine, University of Manitoba, Winnipeg, MB; 2. Private Speech Therpist, Winnipeg, MB; 3. WRHA, Winnipeg, MB
Dysphagia, or difficulty swallowing, is common among stroke and acquired brain injury (ABI) patients and may result in aspiration. Aspiration has, in turn, been associated with aspiration pneumonia and a number of subsequent health effects. To reduce the risk of thin liquid aspiration, patients are often restricted to thickened fluids. However, this type of restriction may also result in complications including dehydration, decreased compliance with swallowing guidelines, an increased risk of pneumonia when aspiration takes place, and decreased quality of life (QOL). Certain research suggests that aspiration pneumonia requires not only aspiration, but also that aspirated material contain a respiratory pathogen and that the pathogen then overwhelms the immune system. Some clinicians have, therefore, argued for controlled thin water intake combined with aggressive oral care. Though increasingly common in clinical practice, limited evidence exists on the ability of such free water protocols to address the complications of thin fluid restriction while maintaining patient safety. A controlled pilot study of a free water protocol was undertaken at Riverview Health Centre, in Winnipeg, Manitoba. The study examined 17 individuals with stroke or ABI who were randomly assigned to either a control group on thickened fluids or a treatment group that followed a free water protocol. The study compared instances of complications including aspiration pneumonia, fluid intake, swallowing related QOL and QOL related to care received from participants’ swallowing clinicians. Although unable to identify statistically significant differences between the two groups, the results identified significant improvements in swallowing related QOL among the treatment group and improvements in swallowing related care from their swallowing clinician among both. Neither group developed aspiration pneumonia during the study.
Given these promising results, the pilot study suggests the need for larger scale work in order to more accurately identify the effects of free water protocols.
Functional Electrical Stimulation Therapy Compared with Conventional OT/PT Therapy for the Restoration of Reaching and Grasping Function in Acute Severe Hemiplegic Patients: a Randomized Controlled Trial
Thrasher, T1 Zivanovic, V2, 3 McIlroy, W4, 2, 3 Popovic, MR2, 3; 1. University of Houston, Houston, TX, USA; 2. Toronto Rehabilitation Institute, Toronto, ON; 3. University of Toronto, Toronto, ON; 4. Sunnybrook Health Sciences Centre, Toronto, ON
Background: The purpose of this study was to establish the efficacy of a therapeutic intervention based on functional electrical stimulation (FES) therapy to improve reaching and grasping function after severe hemiplegia due to stroke. The therapy consisted of task-specific upper-limb movements with a combination of pre-programmed FES and manual assisted motion. Methods: A total of 21 subjects with acute stroke were randomized into 2 groups, FES plus conventional occupational therapy and physiotherapy (FES group) or only conventional therapy (control group) 5 days a week for 12 to 16 weeks. Pre–post training changes were compared. FES was applied to proximal and then distal muscle groups during specific motor tasks involving reaching and grasping. At baseline and at the end of treatment, function was assessed using the Rehabilitation Engineering Laboratory Hand Function Test, the Functional Independence Measure (FIM), and the Fugl–Meyer Assessment (FMA), along with more standard measures of rehabilitation outcome. Results: The FES group improved significantly more than the control group in terms of object manipulation, palmar grip torque, pinch grip pulling force, Barthel Index, Upper Extremity Fugl–Meyer scores, and Upper Extremity Chedoke–McMaster Stages of Motor Recovery, as well as the Self Care subset of the FIM. Overall FIM scores were trending towards a significant improvement in the test group. Conclusions: FES therapy with upper extremity training may be an efficacious intervention in the rehabilitation of reaching and grasping function during acute stroke rehabilitation.
2012-2013 Post Stroke Complications During Inpatient Rehabilitation – The Experience in Calgary
Reimer, EA1 Dukelow, S4, 3 Kashyap, D2 Suddes, M4 Knox, J5; 1. Carewest, Calgary, AB; 2. Calgary Stroke Program, Calgary, AB; 3. University of Calgary, Calgary, AB; 4. Calgary Stroke Program, U of C, Calgary, AB; 5. Alberta Health Services, Calgary Stroke Program, Calgary, AB
Background: Complications following stroke have been summarized in the Canadian Best Practice Recommendations, Fourth Edition, 2010. McLean (2004) reports that depression (26%), patient falls (20%), shoulder pain (24%) and urinary tract infections (15%) are the most common complications observed in hospital. Canadian Best Practice Recommendations related to post stroke complications exist for acute stroke. To gain an understanding of the rate of complications experienced by the local stroke patient population, the Calgary Stroke Program and partners, including the Neuro-Rehabilitation Unit at Carewest Dr. Vernon Fanning Centre, have worked collaboratively to document the incidence of post stroke complications both in an acute inpatient setting, and during inpatient rehabilitation. Methods: Post stroke complications including: recurrent stroke, hemiplegic shoulder pain, falls, pressure ulcers, spasticity, urinary tract infection, urinary retention, urinary incontinence, depression, deep vein thrombosis, pulmonary embolism, dysphagia and pneumonia were selected as complications to be documented in each client file. This data was entered into a database, with results being shared across the continuum, and compared to current literature. Complication outcomes are also useful to inform process change and staff education with the goal of minimizing post stroke complications. Results: Preliminary data indicates that the top five post stroke complications in inpatient rehabilitation include falls, dysphagia, urinary incontinence, depression and urinary tract infection. Results of the data related to all documented complications in 2012-2013, and analysis of the available data will be shared. Conclusion: Documentation and analysis of the incidence of post stroke complications and the relationships between complications is valuable to establish standards, understand trends, and develop best practice recommendations to minimize all post stroke complications across the continuum of stroke care.
The Sensorimotor Rehabilitation Research Team of the Canadian Institutes of Health Research (CIHR): a Model for Knowledge Translation and Evidence-Based Rehabilitation of Persons After Stroke
Richards, CL1 Rossignol, S2, 3 Nadeau, S2, 3 Fung, J4, 3 Doyon, J2; 1. Université Laval and CIRRIS Research Center, Quebec, QC; 2. Université de Montréal, Montreal, QC; 3. CRIR Research Center, Montreal, QC; 4. McGill University, Montreal, QC
Background: This CIHR Emerging Team regroups researchers from Université de Montréal, Université Laval and McGill University, and Research Centers (RCs: CRIUGM, CRIR and CIRRIS), as well as the stroke units of 3 rehabilitation centers (RC: IRGLM, JRH and IRDPQ) and neuroscientists on campus. The team aims to develop a research-clinical model of knowledge translation (KT), to promote evidence-based rehabilitation post stroke, to implement clinical-research platforms in the RCs and to evaluate innovative therapeutic approaches. Methods: Led by five Principal Investigators (PIs) with Dr Serge Rossignol as the designated PI, the team includes 25 researchers (neuroscientists and clinical researchers) with expertise in the recovery of sensorimotor function and imaging of the brain. Clinicians from various disciplines in the RCs are collaborators. Graduate students and post-doctoral fellows are competitively funded. The PIs hold monthly meetings by Skype and to date have organized four day-long meetings and planned an International symposium in 2014. Results: The team is well-established halfway into its funding cycle. The clinical research platforms are functional and clinicians are using a common set of outcome measures to document the clinical profile and to evaluate change over time. Clinical evaluations are complemented by research laboratory evaluations and imaging to characterize the patient`s pathophysiological and biomechanical deficits and lesions. The findings help identify appropriate interventions and stimulate ongoing research protocols. Innovative approaches under development include multisensory stimulation, strengthening specific muscle groups during walking, pain relief, and the integration of mental practice into usual clinical practice. The implementation of routine magnetic imaging and transcranial magnetic stimulation techniques, as well as parallel experiments in animal stroke models are being investigated. Conclusions: Basic and clinical researchers have developed innovative and complementary research to optimize stroke rehabilitation. The challenge now is to demonstrate that such a KT model promotes improved rehabilitation outcomes.
Caregiver Outcomes in a Community-Based Stroke Rehabilitation Setting: Results and Tool Selection
Richardson, M1 Allen, L1, 2 Meyer, M1, 2 Ure, D3 Jankowski, S3 Teasell, R1, 3, 4; 1. Lawson Health Research Institute, London, ON; 2. Department of Epidemiology and Biostatistics, Western University, London, ON; 3. St. Joseph’s Health Care London, Parkwood Hospital, London, ON; 4. Department of Physical Medicine and Rehabilitation, Western University, London, ON
Background: The caregiving experience has implications for both carer and patient health following stroke. There is currently no consensus regarding the best tool to evaluate the experience of caring for a stroke survivor. This study reviewed the use of two caregiver outcome measurement tools in a community-based rehabilitation setting post stroke. Methods: Data was derived from a population of 919 patients receiving care from the Community Stroke Rehabilitation Teams (CSRT) in Ontario. Caregiver outcomes were assessed between February 2009 and December 2012, at baseline, discharge from the program, and 6-month follow-up. In September 2010, the Bakas Caregiving Outcomes Scale (BCOS) replaced the Caregiver Assistance and Confidence Scale (CACS) to evaluate caregiver outcomes. Repeated measures ANCOVA were performed to assess changes in scores. Reasons for switching outcome measurement tools were also addressed. Results: 67 patients had a completed CACS at all three time points; 17 for the BCOS. The level of assistance required of caregivers decreased significantly from admission to discharge (P=0.001), with maintenance at follow-up (P=0.645). There were no statistically significant changes in a caregiver’s confidence in providing care from admission to discharge (P=0.724), or discharge to follow-up (P=0.904). The BCOS revealed that caregivers experienced a significantly greater degree of positive change as a result of caregiving from admission to discharge (P=0.019) from the program. These gains were not maintained at follow-up (P=0.048) but remained higher than admission scores (P=0.098). Clinical usefulness and client-friendliness were the reasons given for the transition from the CACS to the BCOS. Conclusions: Home-based stroke rehabilitation has a significant effect on the level of assistance provided by caregivers and their overall caregiving experience. Reasons for the relatively low response rate have yet to be explored. Transition to the BCOS was supported by the psychometric properties of the scale and feedback from clinicians.
Best Practices when Facing Daily Challenges After a First Mild Stroke: You Call or We Call?
Rochette, A1, 3 Korner-Bitensky, N2, 3 Bishop, D4 Teasell, R5 White, C6 Bravo, G7, 8 Côté, R2 Green, T9 Lebrun, L1 Lanthier, S1 Kapral, M10 Bayley, M10, 11 Wood-Dauphinee, S2; 1. Université de Montréal, Montréal, QC; 2. McGill University, Montreal, QC; 3. Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal, Montreal, QC; 4. St-Lukes Hospital,, RI, USA; 5. University of Western Ontario, London, ON; 6. University of Texas, San Antonio, TX, USA; 7. Université de Sherbrooke, Sherbrooke, QC; 8. Research Center on Ageing, Sherbrooke, QC; 9. University of Calgary, Calgary, AB; 10. University of Toronto, Toronto, ON; 11. Toronto Rehabilitation Institute, Toronto, ON
Background: In most circumstances, individuals with a “mild” stroke are discharged home directly from acute care without referral for rehabilitation. The purpose was to compare a multimodal intervention WE CALL (phone support/information provision) with a passive intervention YOU CALL (resource person) in individuals with first mild stroke. Methods: Single-blinded RCT where primary outcomes were unplanned use of health services (participant diaries) for adverse events and quality of life (Euroquol-EQ5D, Quality of Life Index). Secondary outcomes included planned use of health services (diaries), mood (Beck Depression Inventory II) and participation (Assessment of Life-Habits (LIFE-H). Blind assessments were done at baseline, 6 and 12 months. A mixed model approach for statistical analysis on an intention-to-treat basis was used where the group factor was intervention type and occasion factor time, with a significance level of 0.01. Results: We enrolled 186 patients (WE = 92; YOU = 94) with a mean age 62.5 ± 12.5 and 42.5% female. The majority (98.8%) of participants visited a physician in the first six months (i.e. during active intervention) but fewer than 20% received rehabilitation services. No significant differences were seen between groups at six months for any outcomes with both groups improving from baseline on all measures (effect sizes ranged from 0.25 to 0.7). The only significant change for both groups from 6 months to one year (n=139) was in the social domains of the LIFE-H (increment in score=0.4/9±1.3; ES=0.3). Qualitatively, the WE CALL intervention was perceived as reassuring, increased insight and problem solving while decreasing anxiety. Only 6/94 (6.4%) of YOU CALL participants availed themselves of the intervention. Conclusion: While the two groups improved equally over time, WE CALL intervention was perceived as helpful whereas the passive YOU CALL intervention was not utilized.
Clinical Trial Registration: http://www.controlled-trials.com unique identifier: ISRCTN95662526
Funding: Canadian Stroke Network/CIHR
Extending PCA Aphasia Treatment to an Individual with Bilateral Lesions: A Pilot Study
Rochon, E1 Marcotte, K3, 2 Laird, L1 Simic, T1 Grady, C4, 1 Meltzer, J4, 1 Leonard, C5, 1; 1. University of Toronto, Toronto, ON; 2. Toronto Rehabilitation Institute, Toronto, ON; 3. Universite de Montreal, Montreal, QC; 4. Rotman Research Institute, Baycrest, Toronto, ON; 5. University of Ottawa, Ottawa, ON
Background: Our phonological components analysis (PCA) treatment approach has been shown to improve naming performance in patients with chronic nonfluent aphasia after left hemisphere stroke. Consistent with the literature, improved naming after PCA treatment was associated with neural activation changes in perilesional left hemisphere areas, and in right hemisphere areas, to a lesser extent. Most studies have focused on patients with left hemisphere lesions. Here we report behavioural and imaging results for a patient with bilateral lesions who underwent PCA treatment. We predicted improved naming and bilateral neural activation changes, with perilesional left hemisphere activation changes for treated words in particular, after PCA treatment. Methods: In this pilot study, ten days of intensive PCA treatment was administered to a right-handed, 49 year-old male, five years post-onset. He suffered a left, then right hemisphere stroke, resulting in a mixed aphasia. An event-related fMRI session was administered pre- and post-treatment, during which he participated in an overt naming task. Pre-processing and statistical analysis were performed using AFNI. Neuroimaging data analyses were performed only on correct responses. Results: After treatment the participant demonstrated a significant difference in correct production of treated versus untreated words. This difference was maintained at four and eight weeks. In comparison to untreated words, preliminary fMRI findings showed enhanced activation in left hemisphere perilesional areas as well as left parietal and occipital regions after treatment. Right hemisphere perilesional activation was seen only for untreated words. In addition, after treatment there was a posterior shift in activation for treated words. Conclusions: In addition to benefits for patients with left hemisphere lesions, PCA treatment was beneficial for treating anomia in an individual with bilateral lesions. Neuroimaging data indicate that improved naming performance for treated items is associated with increased neural activity in left perilesional cortex during naming of those items.
Speed Determinants of Mobility Post Stroke Revealed by Optical Brain Imaging
Sangani, S; Fung, J; Lamontagne, A; McGill University, Montreal, QC
Background: Mobility problems among stroke survivors have a serious impact on their functional independence and quality of life. Over the last decade, researchers and clinicians have acknowledged the importance of incorporating intensive task-specific practice in gait retraining paradigms after stroke. Speed-intensive gait training has been shown to provide beneficial effects, both in terms of improved walking speeds as well as in the overall kinematics of hemiparetic gait. Recent studies utilizing EEG demonstrate that the motor cortex and the corticospinal tract contribute directly to muscle activation in lower limbs observed during steady-state treadmill walking. However, cortical mechanisms underlying the efficacy of incorporating different self-imposed speeds during self-paced treadmill locomotion remain unclear. Objective: To determine cortical mechanisms underlying the control of gait speed, near-infrared spectroscopy (NIRS) is used to investigate and characterize hemodynamic activity in terms of oxy-hemoglobin (Oxy-Hb) concentrations in both the frontal and sensorimotor cortices during self-paced treadmill locomotion at three different gait speeds (slow, comfortable, and as fast as possible). Methods: We have recruited 6 healthy control subjects and will target testing 10 post-stroke and 10 control subjects in all. NIRS measurement was performed using the Hitachi ETG-4000 system with a custom-built optode cap (44 channels) covering the frontal and sensorimotor cortices. A custom-built self-paced treadmill was utilized wherein the speed of the treadmill can be servo-controlled by the subject’s voluntary acceleration and deceleration via an eletropotentiometer and thus subjects had full control of their own walking speed. Results: Changes in concentrations of Oxy-Hb in the sensorimotor and frontal cortex demonstrated increased activation during different phases of fast and slow walking conditions as compared to walking at a comfortable speed. Conclusion: Minimal cortical activation is required to control steady-state walking at comfortable speed, but any deviation from the optimal speed requires conscious effort and hence increased cortical activation.
An Interdisciplinary Approach to Activity-Based Stroke Rehabilitation
Siebold, T; ARBI, Calgary, AB
Background: Survivors of Stroke are often told that the majority of recovery will occur in the first six months. However, plasticity research is confirming what many therapists have believed and experienced: long term recovery is possible and often significant. This case report will demonstrate the long-term recovery for a client 2 years post stroke. A poster will illustrate an interdisciplinary activity- based rehabilitation approach to optimize engagement in this later stage of recovery. Methods: ET, a 44 year old male, suffered a significant left MCA stroke causing right hemiparesis and expressive aphasia. He started his rehabilitation program at the Association for the Rehabilitation of the Brain Injured (ARBI) 20 months after his stroke, and after receiving traditional inpatient and outpatient therapies. To match his motivation to return to playing ice hockey, an activity-based interdisciplinary approach was implemented. Therapists used the various component tasks within hockey to address his upper extremity, lower extremity, balance, and coordination impairments. The activity analysis provided opportunities for ET to improve his communication and social skills. Results: On admission, ET demonstrated a lack of motivation and social participation. With the introduction of hockey activities, he became engaged with the program, his attendance improved and he initiated social interactions. Outcome measures included the Canadian Occupational Performance Measure, Community Balance and Mobility Scale, Action Research Arm Test, Arm Function Test, Boston Diagnostic Aphasia Examination, and the Leisure Competency Measure. These quantified his many improvements, including highlighting his return to skating. Conclusions: The interdisciplinary activity-based approach, ET’s age, and motivation to return to sport, all contributed to his long-term functional recovery. The rehabilitation community should remain optimistic about recovery potential even two years post stroke. Therapy will be most effective when the intervention ideas and strategies are imbedded within the client’s activity goals.
The Effect of Interventions on Balance Self-Efficacy in the Stroke Population: a Systematic Review and Meta-analysis
Tang, A2 Tao, A1 Soh, M1 Tam, C1 Tan, H1 Thompson, J1 Eng, JJ1; 1. University of British Columbia, Vancouver, BC; 2. McMaster University, Hamilton, ON
Background: Impairments in balance and mobility are common after stroke, and fall rates are two-times higher than age- and gender-matched counterparts. Decreased balance self-efficacy after stroke may be a more important predictor of falls than balance or mobility performance. This study was a systematic review and meta-analysis of the effectiveness of various interventions on balance self-efficacy among individuals with stroke. Methods: Searches of MEDLINE (1948-present), CINAHL (1982-present), EMBASE (1980-present) and PsycINFO (1987-present) were completed in January 2013. Reference lists of selected papers were hand-searched to identify further relevant studies. Controlled intervention trials in adult stroke populations with balance self-efficacy as a primary or secondary outcome measure were included. Two independent reviewers performed data extraction and assessed the methodological quality of the studies using the Physical Therapy Evidence Database scale. The weighted effect size of multiple studies was calculated with RevMan 5.0 using random effects models. Results: Thirteen studies involving 513 participants met the eligibility criteria for inclusion. Of these, 11 had interventions involving physical activity and 2 used motor imagery training. Study quality ranged from fair (n=4) to good (n=9). All studies used balance self-efficacy as a secondary outcome. The Falls Efficacy Scale-International was used in 1 study; all others used the Activities-specific Balance Confidence Scale. A medium standardized mean difference (SMD) for the 13 studies was found (SMD 0.61 95% CI 0.16-1.05, P=0.008). In secondary analyses, motor imagery interventions (2 studies, 63 participants) were not effective (SMD 1.16, 95% CI -1.26-3.58, P=0.35), but with studies using physical activity interventions (11 studies, 450 participants), the medium effect size was maintained (SMD 0.52, 95% CI 0.07-0.97, P=0.02). Conclusions: Physical activity interventions appear to be effective in improving balance self-efficacy after stroke. Randomized controlled trials using larger sample sizes and with a primary goal of improving balance self-efficacy are needed.
Kinematic Upper Limb Stroke Assessment Using the Kinect Sensor
Tran, J1 Danells, CJ2 McIlroy, WE1, 2; 1. Univeristy of Waterloo, Waterloo, ON; 2. Heart and Stroke Foundation Centre for Stroke Recovery, Sunnybrook Health Sciences Centre, Toronto, ON
Introduction: Control of the upper limb is often impaired post-stroke and significantly affects an individual’s independence and quality of life. Thus there is considerable interest in improving assessment and treatment techniques post-stroke. Kinematic motion analysis has been suggested to be a more revealing and sensitive technique for identifying impairments in the upper limb. However the implementation of kinematics in clinical settings is often limited by financial and time barriers. Advancements in low-cost sensor technology (Microsoft Kinect) have led to renewed interest in the incorporation of kinematics as part of clinical assessment. Validity studies have suggested clinical utility for capturing motion for the upper limb end-point, and trunk. The purpose of this study was to determine the feasibility of using the Kinect to assess upper limb kinematics as part of a clinical stroke assessment. Methods: Four stroke patients (CMSA: 3, 3, 5, 6) were recruited for this study. Patients performed two tasks with the affected and non-affected arm. 1) Reach-to-touch a centrally located target and 2) drawing a large circle in the transverse plane. Tasks were selected to examine upper limb coordination and effective work-reach area. Main measures were displacement, velocity, and area (drawing task). Results: Reach-to-touch: Slow movement velocities and lower displacement for the affected versus non-affected limb. Trunk displacement and velocity was increased with non-affected limb use. Across patients, lower CMSA scores showed decreased limb movement and increased trunk movement quantitatively. Circle-drawing: Decreased hand area and increased trunk displacement was shown with affected-limb use. Conclusion: Preliminary results demonstrate the ability of the Kinect to detect differences between affected and non-affected limbs in stroke patients of varying impairment levels. Kinect data provides an objective metric of movement quality and quantifies the use of compensatory strategies. Future studies should investigate the ability of the Kinect to detect performance changes over time.
A Systematic Review of Alternative Mind-Body Approaches to Stroke Rehabilitation
Wadden, KP1 Short, M2 Boyd, LA1 Mazmanian, D2; 1. University of British Columbia, Vancouver, BC; 2. Lakehead University, Thunder Bay, ON
Background: There is an increasing focus on integrating complementary and alternative therapies during the stroke recovery process. More specifically, mind-body interventions (e.g., mindfulness, yoga) are growing in popularity in rehabilitative centers across Canada. Daily functions demand both cognitive and motor resources, thus therapeutic interventions that strengthen the mind-body connections are proving to be a valuable rehabilitative approach. This review examines the efficacy of commonly used mind-body interventions in stroke rehabilitation. Methods: A systematic review of the literature on mind-body approaches to stroke rehabilitation was conducted. Randomized controlled trials (RCTs) and controlled clinical trials were included. Results were not statistically pooled due to vast heterogeneity between study designs (e.g., varying outcome measures). Results: A total of 12 studies were included in the review. Mind-body interventions included mindfulness, relaxation, yoga, and tai chi. Overall, there is evidence of efficacy for mind-body interventions in stroke rehabilitation, particularly for improving mental fatigue, physical functioning, and overall quality of life. Conclusions: Although alternative mind-body approaches are highly integrated into the recovery from pathologies such as depression, chronic pain, and cancer, to date there is minimal research examining these approaches to stroke rehabilitation. The considerable evidence presented in the few studies that currently exist is promising. Findings from this review may help guide the future direction of studies examining complementary and alternative approaches to stroke rehabilitation.
Impaired Control of Balance and Gait Predict Fall Risk Post-Discharge From In-Patient Stroke Rehabilitation
Wong, J1 Inness, EL1, 2 Biasin, L1, 2 Brunton, K1, 2 Fraser, J1, 2 Bayley, M1, 2 McIlroy, WE4, 3, 2 Mansfield, A1, 2, 3; 1. Toronto Rehabilitation Institute - UHN, Toronto, ON; 2. University of Toronto, Toronto, ON; 3. Heart and Stroke Foundation Centre for Stroke Recovery, Toronto, ON; 4. University of Waterloo, Waterloo, ON
Background: Nearly 75% of individuals discharged home after stroke will fall1, which can lead to injury, fear of falling and activity restriction. While the causes of falls are often multifactorial, falls ultimately occur due to impaired balance control. Individuals with stroke have difficulty executing stepping reactions to prevent a fall following a loss of balance2. The purpose of this study is to identify measures of balance and gait that predict falls after discharge from stroke rehabilitation. Methods: Participants (n=93; age: 62.7±13.5 years) completed balance and gait assessment immediately before discharge from in-patient stroke rehabilitation. Assessment included: Berg Balance Scale (BBS), static standing and perturbation-evoked reactive balance measured using forceplates and spatio-temporal features of walking using a pressure-sensitive mat. Subjects reported falls and activity levels up to six-months post-discharge. Poisson regression was used to identify risk factors related to increased fall rates. Results: Thirty-five participants experienced 65 falls; 12 fell more than once. Lower balance scores (BBS; p=0.045), decreased gait velocity (p=0.044), and decreased step width variability (p=0.031) were related to increased fall rates. Participants were more likely to fall if the non-paretic limb had an increased contribution during quiet standing than the paretic limb (p=0.0087). For responses to postural perturbations, increased fall risk was related to increased need for external assistance or upper extremity reactions (p=0.026), faster foot-contact time (p=0.044), and increased attempts to step with a blocked limb (p=0.031). Fallers spent less time walking in the community than non-fallers (p=0.045). Conclusions: Impaired balance and gait control is related to increased fall risk post-discharge from stroke rehabilitation. These results suggest that training to improve both control of the paretic limb and responses to postural perturbations could reduce falls in community-dwelling stroke survivors.
1. Forster, Young. Br Med J. 1995;311:83-86
2. Inness et al. Phys Ther. 2013
Socioeconomic Characteristics of Toronto Neighbourhoods with High Prevalence of Stroke Survivors
Thom, R2 Bayley, M1, 2 Yaroslavtseva, O1; 1. Toronto Rehabilitation Institute, Toronto, ON; 2. University of Toronto, Toronto, ON
Background: Previous research suggests the possibility that the socioeconomic characteristics of the neighbourhood environment in which people live, may contribute to stroke risk. Further investigation of the sociodemographic characteristics of areas with high stroke prevalence could aid in directing city planning approaches in order to mitigate some of these risks and effectively deliver rehabilitation services. Knowledge of which Toronto neighbourhoods are at particularly high need for targeted community stroke rehabilitation programs may aid in stroke program planning which may decrease stroke risk and increase quality of life for stroke survivors. Objectives: This study is a needs assessment project that seeks to describe the socioeconomic characteristics of the Greater Toronto Area neighbourhoods with high prevalence of stroke survivors. The socioeconomic characteristics studied include: age, sex, income, level of education, ethnicity, immigration status, home ownership, and marital status. Methodology: The number of stroke survivors discharged from hospitals in the GTA from January 1, 2001 to December 31, 2006 were obtained from the Institute for Clinical Evaluative Sciences (ICES) Discharge Abstract Database for each of the GTA census tracts. Sociodemographic data characterizing each census tracts, including age, sex, income, level of education, ethnicity, immigration status, home ownership, and marital status, was obtained from the Canadian 2006 Census. ANOVA was used to identify sociodemographic variables characterizing the neighbourhoods with high stroke prevalence. Results: The project identified the census tracts within the GTA that have the highest prevalence of stroke survivors and examined the sociodemographic characteristics of these areas. Significant relationship has been found for stroke prevalence and the variables of age, sex, income, marital status, home ownership, education, and citizenship status. Conclusions: The data suggest that socioeconomic characteristics of urban neighbourhoods may explain and predict the differences in stroke prevalence.
Post Stroke Discharge Clinical Follow-up Call
Cole-Haskayne, AL; Gairdner, S; Ryan, L; Suddes, M; Foothills Medical Centre, Calgary, AB
Background: Post discharge calls to the Stroke Prevention Clinic (SPC) increased from patients requesting further information. Patients seen at their stroke prevention follow-up appointment had incomplete investigations and medication compliance was an issue. When the stroke unit was first established, nurse clinicians called patients after discharge. Calls did not follow a script. Calls were dropped due to time constraints, staffing and other demands. Calls were felt to be beneficial by nursing staff and client reports. Methods: A literature review was conducted on discharge clinical calls. Based on learnings from other centers and staff feedback, a clinical call followup script was developed. A goal of piloting the calls was to see if the number of calls to the SPC would decrease, followup investigations would be completed prior to their appointment, and medication compliance would increase. Results: A Registered Nurse working 0.5 FTE completed 78 one month post discharge calls. Medications and post discharge plan were reviewed with clients. 13% of patients described having new or worsened symptoms since discharge. 37% noticed a change in health, 51% had seen their family Dr, 92% had enough medication till their next appointment, 71% had checked their BP, 47% said their Physician did not advise what their BP should be, 91% knew 3 of the 5 signs of stroke and when to call 911, 19% had received our stroke patient passport, advice from management was sought on 3% of cases, no appointments had to be scheduled earlier in the SPC, and 3% of patients had questions about driving. Conclusion: Feedback from nursing staff conducting the calls is that it provided a valuable service and filled a gap. Medication compliance and followup with family Physicians and other service providers was encouraged and patients were connected with services when required.
Geographic Distribution and Transportation Times for Non-Ambulance Transported Acute Stroke Patients in the British Columbia Lower Mainland
Harrison, K; Curry, M; Fraser Health Stroke Strategy, Vancouver, BC
Background: Fraser Health services 1.6 million BC residents at twelve hospitals extending from the Vancouver suburb of Delta on the Pacific coast up over 220km through the Fraser Valley to rural Boston Bar. Currently all acute stroke patients in Fraser Health either present on their own or they are transported by ambulance to the closest hospital. Fraser Health is considering implementing a bypass protocol and centralizing stroke care at a limited number of sites. Methods: Four-weeks of acute stroke patients (n=40) presenting to Fraser Health facilities was analyzed. Transportation times were estimated based on usual driving times gleaned from Google Maps and that transport was from the patient’s residence. Transportation times were compared between a one-site, two-site, three-site or four-site model sited at the Royal Columbian Hospital in New Westminster, Surrey Memorial Hospital, Abbotsford Regional Hospital & Cancer Centre and Chilliwack General Hospital respectively. Results: A one-site model gave a mean transportation time of 46 minutes and a median of 42 minutes. A two-site model gave a mean transportation of 44 minutes and a median of 42 minutes. Seven patients would benefit from a reduced transportation time of, on average, seven minutes. A three-site model gave a mean transportation time of 30 minutes and a median of 27 minutes compared with 27 minutes and 25 minutes with a four-site model. On average 26 patients in a three- or four-site model would experience decreased transport times as compared to a one-site model and the average time savings would be 23 minutes in a three-site model and 27 minutes in a four-site model. Conclusions: A one-site centralized model of regional acute stroke care in Fraser Health leads to increased patient transportation time and delays in acute stroke care when compared to a multi-site model.
A Cross-System Approach to Building Expert Stroke Teams
Fortin, JE1 Skrabka, K2 Avinoam, G3 Linkewich, E1 Willems, J2 Sharp, S3; 1. North&East GTA Stroke Network / Sunnybrook Health Sciences Centre, Toronto, ON; 2. South East Toronto Stroke Network / St. Michael’s Hospital, Toronto, ON; 3. Toronto West Stroke Network / University Health Network -TWH, Toronto, ON
Background: The Toronto Stroke Networks (TSNs) Education and Knowledge Translation (KT) Implementation Plan utilizes a systems approach for implementation of Best Practices and fostering practice change. KT activities were implemented to support dedicated stroke teams by building expertise in foundational best practices and Interprofessional Collaborative (IPC) competencies. Methods: The Graham Knowledge to Action (KTA) cycle informed the structure to address the knowledge gaps and drive positive change. The Regional Education Coordinators pooled information from a two part collaborative process assessment that identified cross-system educational needs such as requesting regular stroke education and developing a team identity. Application of KT education best practices included using an interprofessional team building approach, completing a project together, learning in small groups, and sustaining learning through mentorship. Barriers and facilitators were considered to address the knowledge gaps. Results: A Cross-System KT Implementation Committee (CSIC) was formed with representation from the 15 healthcare organizations that provide acute and rehabilitative stroke care within the TSNs boundaries. The CSIC members act as stroke champions and have engaged in knowledge exchange and adaptation of the Education and KT plan for local implementation. An interprofessional collaborative team project included co-creation of posters on foundational topics (e.g. early mobilization, dysphagia, incontinence, neglect etc.) for cross-system learning and consistency. To support transfer of knowledge into practice evidence based small group learning and mentorship guides were developed. Implementation strategies were launched on the TSNs Virtual Community of Practice for efficient communication and access, as well as a means of sustainability of the cross-systems approach. Conclusion: The cross-system approach to build expert teams was developed using evidence based KT strategies to fulfill needs of dedicated stroke teams to improve implementation of best practices. Practice change will be evaluated over the next year with the anticipation of improved patient outcomes.
Improving Timely Administration of Lytic Therapy for Stroke Patients in Nova Scotia
Gill, N1 White, K1 Swinemar, S4 Goudey, K5 Mooney, M5 Vardy, T6 O’Handley, M7, 8 MacGrath, M9, 10 MacGillivary, T11 Christian, C3 Simpkin, W3 Phillips, S1, 2, 3; 1. Cardiovascular Health Nova Scotia, Halifax, NS; 2. Dalhousie University, Halifax, NS; 3. Capital District Health Authority, Halifax, NS; 4. South Shore District Health Authority, Bridgewater, NS; 5. South West Nova District Health Authority, Yarmouth, NS; 6. Annapolis Valley District Health Authority, Kentville, NS; 7. Colchester East Hants Health Authority, Truro, NS; 8. Cumberland Health Authority, Amherst, NS; 9. Pictou County Health Authority, New Glasgow, NS; 10. Guysborough Antigonish Strait Health Authority, Antigonish, NS; 11. Cape Breton District Health Authority, Sydney, NS
Background: Cardiovascular Health Nova Scotia (CVHNS), a program of the Nova Scotia Department of Health and Wellness, oversees stroke and cardiac care in the province, and monitors and reports outcomes to the District Health Authorities (DHAs). Significant improvements to stroke care have occurred in the last several years. However, a review of data in 2011 showed substantial room for improvement in the timeliness of lytic (tPA or tissue plasminogen activator) administration for ischemic stroke (IS). Methods: Since 2011, CVHNS and the DHAs have implemented a multifaceted quality improvement (QI) strategy, including: provincial stakeholder forums, audit and feedback, and local development of protocols, algorithms and other decision support tools. Data on selected time points related to all lytic administration cases (e.g. door to CT and needle) were collected locally, prior to implementing change. Ongoing data collection is being used to monitor change. Results: Additional results showing change since December 2012 will be available by summer 2013 and included in the poster
Conclusion: A provincially coordinated, district driven, QI initiative improved the proportion of IS patients who were treated with tPA in a timely manner. Improvement was seen within a short period of time after QI initiatives were undertaken. Ongoing data monitoring and QI strategies, both at the district and provincial level, are expected to show continued improvement in both proportions treated in target and median time to treatment.
Optimizing the Operational and Economic Impact of a Neurovascular Unit in an Acute Care Hospital
Hahn-Goldberg, S2 Chow, E2 Appel, E2 Abrams, H1; 1. University Health Network, Toronto, ON; 2. Centre for Innovation in Complex Care, Toronto, ON
Background: There is strong evidence that clinical outcomes are improved for stroke patients admitted to specialized stroke units. The TCLHIN is creating a stroke strategy to concentrate stroke care at specific hospitals. The Toronto Western Hospital (TWH) has created a Neurovascular Unit (NVU) using resources from general internal medicine (GIM), neurology, and neurosurgery to care for patients with stroke and acute neurovascular injury. Under resource-constrained conditions, the operational and economic impacts of the NVU were unknown. Methods: Using patient-level data for NVU-eligible patients from two years prior to the implementation of the NVU at TWH to a year post-implementation, descriptive analysis and non-parametric testing was conducted to determine differences in cost and LOS pre and post NVU implementation. A discrete event simulation was created and validated to study changes in patient flow and experiment with varying levels of patient volumes and resources to determine the ideal number of beds in the NVU under various conditions. Results: In the first year of operation, the NVU handled 77% of eligible patient volumes. Only 4% remained as GIM patients, dropping from 24% pre-NVU. With the introduction of the NVU, average cost per visit and per bed-day decreased by 5% and 12% respectively post-NVU for neurology patients with stroke and acute neurovascular injury. Acute LOS decreased by up to 16%. Scenario testing showed that the current level of 20 beds is appropriate for the current demand; however, there is capacity for an increase in demand of up to 20%. Conclusions: A NVU is possible within an acute care hospital and can be implemented using existing resources. The NVU at TWH achieved decreased acute LOS and lower total cost per year for the care of NVU-eligible patients. Ultimately, the created model could be a planning tool for other hospitals requiring stroke units.
Moving Forward on Best Practices for Stroke and Aphasia: a Canadian KTE Initiative
Kagan, A1 Bayley, M3 Le Dorze, G2 Cook, S1 Garcia, L6 Brenneman Gibson, J1 Hickey, E5 Kelloway, L7 Purves, B8 Rochon, E4 Simmons-Mackie, N9 Worrall, L10; 1. Aphasia Institute, Toronto, ON; 2. Université de Montréal, Montreal, QC; 3. Toronto Rehabilitation Institute, Toronto, ON; 4. University of Toronto, Toronto, ON; 5. Dalhousie University, Halifax, NS; 6. University of Ottawa, Ottawa, ON; 7. Ontario Stroke Network, Toronto, ON; 8. University of British Colombia, Vancouver, BC; 9. Southeastern Louisiana University, Hammond, LA, USA; 10. The University of Queensland, St. Lucia, QLD, Australia
The 2010 Canadian Stroke Strategy guidelines incorporate recommendations for most physical interventions but have limited reference to aphasia management across the continuum of care (Worrall et al, in press). Addressing this gap is important because stroke patients with aphasia have longer lengths of stay, higher costs of care, lower rates of returning home and less favorable outcomes overall (Ellis, Simpson, Bonilha, Mauldin & Simpson, 2012). In addition, aphasia is included in the ten top stroke research priorities (Pollock, St. George, Fenton & Firkins, 2012) and a large Canadian study identified aphasia as the primary factor that negatively impacts quality of life for stroke (Lam & Wodchis, 2010). This poster reports on the activities of a team of stroke and aphasia thought leaders who have started to develop best practice guidelines for aphasia in Canada, with the long-term goal of integration into the Canadian Stroke Best Practice Recommendations. The team has a specific interest in Knowledge Translation and Exchange (KTE) and successfully obtained a CIHR KTE planning grant to move this agenda forward (grant#290592, 2013). Key focus areas include:
Building reciprocity so that stroke researchers, clinicians and policy makers know about aphasia and understand the broad “implications” of aphasia intervention
Approaching and disseminating research by speech-language pathologists (SLP’s) in a way that makes sense to the stroke community
Evaluating existing evidence in relation to best practice guidelines, and
Identifying gaps in evidence
As a first step in ensuring that we are addressing issues that matter to key stakeholders, focus groups were conducted with individuals with aphasia and family, and Canadian SLPs were surveyed regarding their management of people with aphasia. These data along with a discussion of the gaps and misalignments between existing best practices guidelines, what SLPs report they are actually doing, and what people affected by aphasia want, will be the focus of the presentation.
Examining Ontario’s Stroke Report Card Indicator Relationships to Understand the Impact of Best Practice Implementation and Inform System Planning
Linkewich, E1, 4, 5 Khan, F2 Hall, R2, 3; 1. North & East GTA Stroke Network, Toronto, ON; 2. Ontario Stroke Network, Toronto, ON; 3. Institute for Clinical and Evaluative Sciences, Toronto, ON; 4. Sunnybrook Health Sciences Centre, Toronto, ON; 5. Northern Ontario School of Medicine, Thunder Bay, ON
Background: In 2011 the Ontario Stroke Evaluation and Quality Committee created Ontario’s Stroke Report Card, consisting of twenty indicators with potential to influence system performance and flow of stroke patients across care continuum. Recognizing the anecdotal relationships between indicators we sought to determine whether there is evidence of statistical relationships among indicators to inform system planning and development. Methods: Using the FY 2009/10 regional stroke report cards, we performed Pearson correlation analysis, reporting statistical significance at < 0.05 for clinically relevant associations among indicators. Eight indicators used FY2008/09 Ontario Stroke Audit data and eight used FY2009/10 Canadian Institute for Health Information (CIHI) administrative databases and one used the Ontario Home Care Database, FY 2008/09. Results: Of the seventeen indicators, six had statistically significant correlations with other indicators, specifically: 1) arrival to the emergency department within 3.5 hours of symptom onset is associated with stroke unit admission (r=0.56, p=0.04) and2) referral to outpatient rehabilitation (r=0.55, p=0.04); 3) tPA administration is inversely associated with inpatient admissions (r=-0.55, p=0.04) and 4) 30-day readmissions (r=-0.56, p=0.04) in the subsequent year; and 5) access to inpatient rehabilitation is associated with higher FIM efficiency (r=0.53, p=0.05) and a higher FIM efficiency is associated with shorter time to admission into rehabilitation(r=-0.73, p=0.003). 6) We also observed an inverse relationship between the proportion of patients admitted into inpatient rehabilitation as well as the proportion of severe stroke patients admitted into inpatient rehabilitation and the proportion of patients being discharged to long-term care with (r=-0.57, p=0.03) and (r=-0.59, p=0.03), respectively. Conclusion: Opportunities exist to direct quality improvement, resource allocation, and system planning toward specific best practices, such as coordinated stroke care, to improve performance in multiple areas. Although strong correlations were observed between indicator performance, future research will examine change in indicator performance to assess whether the associations among indicators remain over time.
Positioning Primary Care to Improve Transition Experience for Persons with Stroke and Caregivers
McKellar, J5, 2 Sharp, S5, 2 Li, T1 Xiao, A1 Darling, S2 Linkewich, E4, 3 Willems, J6, 7; 1. University of Toronto, Toronto, ON; 2. Toronto Western Hospital, UHN, Toronto, ON; 3. Sunnybrook Health Sciences Centre, Toronto, ON; 4. North and East GTA Stroke Network, Toronto, ON; 5. Toronto West Stroke Network, Toronto, ON; 6. South East Toronto Stroke Network, Toronto, ON; 7. St. Michaels Hospital, Toronto, ON
Background and Objective: Provincial and local priorities in health care are driving change that focuses on better management of chronic conditions; matching services to patient needs and enhanced coordination of care across the continuum. Primary care has been identified as a focal point in this new integrated patient-centred healthcare system(1). The study sought to inform the iterative development of two new resources designed in Toronto to improve the transition experience for people with stroke and caregivers by better understanding the opportunities and requirements from primary care’s role within the recovery journey. These resources include: 1) Essential Professional Conversations (EPCs): a healthcare provider focused strategy to promote verbal exchange and learning about how to optimize care coordination and patient-centred care through transitions; 2) My Stroke Passport (MSP): a patient-mediated communication and navigation tool designed to promote enhanced patient interaction, meaningful care and self-management. Methods: Private practice, community health centres, and family health teams were invited to participate. An REB approved qualitative approach was used to collect narrative data through digitally recorded individual interview(s) or focus groups with primary care providers. A descriptive thematic approach was utilized to analyze the transcripts. Results: Preliminary data suggests that primary care plays multiple roles in the coordination of care and management of stroke patients. Opportunities identified to support their role and improve continuity of care include: timely and relevant communication of key information such as patient goals, medications, test results and further diagnostics. Additionally, tools to promote health literacy/numeracy and self-management and knowledge of resources are required to address cultural and psychosocial issues. Conclusion: EPCs and MSP have utility for primary care providers. Meaningful enhancements will be incorporated to create a comprehensive standard of care for transition management for stroke care in Toronto.
1. Drummond Report, Ontario Action Plan for Health, ECFA Act, TCLHIN Strategic Priority 2012
Distinction as a Quality Improvement Partnership in a Community Hospital
Reinholdt, F; Murray, J; Mackenzie Health, Richmond Hill, ON
Background: Accreditation Canada and the Canadian Stroke Network developed the Stroke Services Distinction program in 2010 to bridge the gap between what is known about best practice stroke care and what is applied. Mackenzie Health, the District Stroke Centre for York Region in Ontario, chose to participate in the Accreditation Canada Stroke Distinction program as a Quality Improvement initiative. The intent was to build on existing stroke best practice, to discover and address gaps in service, and to further our role as a leader in stroke care. Methods: Achieving Distinction standards across the acute and rehabilitation continuum was a challenging objective. Strategic engagement of Executive and Clinical Leadership was a purposeful tactic. A Steering Committee comprised of key clinical and operational leaders provided overall accountability and oversight for Distinction activities. Based on a gap analysis, four cross hospital working groups were created to address processes, protocols, and policy related to Metrics, Acute and Rehab Care Standards, Patient and Family Education and Community Partnerships. The Steering Committee leveraged learnings from the recently completed Hospital Accreditation to ensure success. Strategies to engage staff included daily stroke best practice information (Stroke of Genius), awareness campaigns, targeted education, and mock tracer sessions conducted by senior administrative and physician leaders. Results: Mackenzie Health received Distinction status March 19, 2013 achieving 98.3% (174/177) of acute and rehab standards, 100% of protocols, 100% for patient and family education and 100% for excellence and innovation. The level of organizational engagement and preparedness was evident throughout the onsite survey. Conclusions: Through the Distinction journey, Mackenzie Health truly became a “stroke aware” hospital. Our success was a result of leadership engagement, engaged champions, strategic partnerships, and an effective project leadership and management model.
Evaluation of the Perinatal Stroke Parent Support Group
Berscht, S1 Palashniuk, E2 Bemister, TB3; 1. Heart and Stroke Foundation, Calgary, AB; 2. Stroke Recovery Association of Alberta, Calgary, AB; 3. University of Calgary, Calgary Pediatric Stroke Program, Calgary, AB
Background: The Perinatal Parent Support Group was created to support parents of children living with the effects of perinatal stroke. Perinatal stroke occurs in up to 1 in 2300 live births and is the leading cause of hemiparetic cerebral palsy. Secondary disabilities of perinatal stroke include epilepsy, behavioral problems, and cognitive deficits. The support group focuses on empowering affected parents through education and support. In order to make meaningful changes to the group and plan for sustainability, the organizers/facilitators initiated a formal evaluation of the group. Methods: An outside evaluator, Objective Research and Evaluation Inc., was contracted to gather data from current group participants. The evaluator met with representatives from the collaborating institutions in order to create a survey as well as topics to discuss in a focus group. Objective Research and Evaluation Inc. ran the focus group independently to ensure participant answers were not influenced by the presence of the facilitators. Seven parents participated in the focus groups which involved five open ended questions and completed the survey which consisted of thirteen closed ended questions. Results: In terms of the logistics of the group, all parents indicated that these details were either good or excellent. The majority of parents agreed the group has given them the opportunity to participate in activities they otherwise would not have had the chance to, that the group has improved their overall health and wellness and that participation in the group has helped them feel more connected with their community. All parents strongly agreed that they feel less isolated since joining the group and indicated that they would recommend the group to other parents in similar situations. Conclusions: The evaluation of the support group was overwhelmingly positive and suggests an ongoing need to continue and expand on the Perinatal Parent Support Group.
Addressing Aphasia through Interprofessional Stroke Education
Purves, B; Petersen, J; Wood, V; University of British Columbia, Vancouver, BC
Background: Aphasia poses communication challenges for all health professionals working with people living with this condition. Emerging trends in healthcare training programs, including interprofessional education, community service learning, and the active involvement of patients as mentors, offer innovative strategies for giving students a range of opportunities to learn how to support effective communication with people with aphasia. This study describes two initiatives designed to integrate such learning into students’ professional programs. Methods: First, at an annual two-day camp developed through a university-community partnership, students were organized into interprofessional teams partnered with people with aphasia to take part together in social-recreational activities. Second, people with chronic aphasia participated in a program for mentoring speech-language pathology students. These mentors with aphasia created and led 3 workshops for students from a variety of health professions, describing what it means to live with aphasia and what health professionals can do to support them. Evaluations of both activities were conducted through post-activity student surveys. Results: A total of 85 students from 10 health professions have participated in the aphasia camp over the past three years. Approximately 28 participants with aphasia have taken part per year. Survey results yielded positive ratings of the camp both as an interprofessional learning opportunity and as a way to learn about communicating with people with aphasia. In the 3 mentoring workshops offered to date, a total of 45 students from 9 health professions have participated. Overall, they rated the workshops as an effective way to learn how to support people with aphasia in health-care interactions. Conclusions: Interprofessional education that includes people with aphasia as active partners and offers opportunities for communication in non-clinical settings provides effective strategies for training future health care professionals to support the communication of people with aphasia as a fundamental part of stroke care.
A Novel Rotational Advanced Practice Nursing Model to Increase Continuity of Care and Job Satisfaction
Armesto, A; Bouthillier, C; Runions, S; Linkewich, E; North & East GTA Stroke Network, Sunnybrook Health Sciences Centre, Toronto, ON
Background: Within the North and East Greater Toronto Area Stroke Network (NEGTASN) the Stroke Clinical Nurse Specialist (CNS) roles were set up to support three distinct practice areas (outpatient, inpatient, program development). As the value of the roles grew so did the demand to fulfill the associated responsibilities. A collaborative process to identify needs and possible solutions resulted in a novel 4-month rotational model. Method: The CNSs, along with the teams, outlined the roles and responsibilities within each area. These role profiles were further informed by the emerging needs of key organization and system stakeholders. Formal and informal communication supported the transition to the new rotational model. The model was implemented in 2010. To sustain the model an orientation period was included at the beginning of each rotation to support the transition. Weekly meetings were set up with the CNSs to discuss priorities, changes, challenges, and opportunities. These meetings ensured consistency within and across practice areas and alignment with best practices and regional priorities. Results: The CNS profile has risen within the organization and across the region, with increased recognition and opportunities to lead initiatives. Feedback from physicians, nurses, the interprofessional team at Sunnybrook and the NEGTASN was positive, identifying themes of improved collaboration and communication. The CNSs reported: enhanced expertise, stronger relationships within each area, increased personal satisfaction, and rejuvenation for the work. This has lead to improved clinical handover and additional quality improvement initiatives. The communication infrastructure put in place allows for more seamless transition and continuity in patient care, including coverage for vacation and illness. Conclusion: Overall, the experience of this model has demonstrated a benefit for the CNS, the patient, and the organization/system. An iterative process is necessary to ensure responsiveness to emerging needs.
Alberta Stroke Improvement Initiative: Collaboration and Quality Improvement
Taralson, CL1 Burley, T1 Garnier, S1 Kashyap, D1 Fang, S2 Bohm, V1 Jeerakathil, T1 Suddes, M3; 1. Alberta Health Services Stroke Program Edmonton Zone, Edmonton, AB; 2. Alberta Health Services Cardiovascular Health and Stroke Strategic Clinical Network, Edmonton, AB; 3. Alberta Health Services Calgary Stroke Program, Calgary, AB
Background: Alberta Stroke Improvement (ASI), a quality improvement (QI) initiative implemented by the Alberta Provincial Stroke Strategy (APSS) was designed to maintain gains made by the APSS, address and support any further improvement work, and test a model of collaborative QI. The initiative partnered APSS, The Cardiovascular Health and Stroke Strategic Clinical Network (SCN) of Alberta Health Services (AHS), and 18 Provincial Stroke Centres. Methods: ASI was comprised of three phases: Scope, Improve and Sustain, and was coordinated by a multi-professional team of individuals with stroke service leadership and QI expertise. In Scope, over 200 participants representing stroke centres across the province engaged in a site specific review of their performance against best practice standards. Scope generated a list of improvement priorities which were themed into 7 major areas of focus, including both clinical and supporting processes. During Improve, stroke centres selected 1 or 2 areas for improvement resulting in 20 projects provincially. Stroke teams were supported in their QI journey with 3 learning sessions, educational webinars and coaching calls to introduce QI tools and provide mentorship for the project work. Results: ASI was successful in building capacity within stroke centre teams and making measureable improvements in stroke service delivery. The initiative was also successful in providing transition, strategic direction and practical implementation across stroke centres as the APSS evolves into the Cardiovascular Health and Stroke Strategic Clinical Network. This paper/poster will present progress, outcomes from improvement projects and participant experience data. Two cases studies will be used to reflect the improvement approaches followed by different centres. Conclusions: Using a systematic, collaborative, provincially scoped approach to stroke care, ASI supported improvements in the quality of stroke service delivery. Further partnerships, including cross-provincial approaches, should be explored.
Comprehensive Education of Health Care Providers in Long Term Care: Improving Stroke Care
Thornton, M1 Jelley, W2; 1. Ottawa Hospital, Ottawa, ON; 2. University of Ottawa, Ottawa, ON
Introduction: Integrated Health Networks seek to optimize the care and achieve better outcomes for stroke survivors. To this end, workshops were implemented to train health care providers on aspects of ideal management post-stroke. Hypothesis: We hypothesize that participation of health care providers in comprehensive knowledge transfer workshops that encourage uptake of best practices would result in improved perception of their ability to manage post-stroke care effectively. Methods: A seven-hour workshop was offered by the local health network on three separate occasions, covering various topics related to stroke care. Workshops were taught by teams of content experts (Nurse Specialist, Occupational Therapist, Physical Therapist, Social Worker and Speech Language Pathologist). Workshop content included training in safe feeding, effective communication, handling of the hemiplegic arm, transfer strategies and positioning. Workshop content was developed by the provincial stroke network and offered to personal support workers. An 11-point questionnaire was used to gather participants’ perceptions on their abilities. To increase the sensitivity of the questionnaire, an “ipost-post testî design” was used after workshop completion, in which participants were asked to reflect on both their current and prior level of abilities in post-stroke management. Results: A total of 61 health care providers were trained, primarily personal support workers with a small number of Registered Nurses, Therapy Assistants and Paramedical Workers from various parts of the care continuum (acute care, community, long term care and rehabilitation.) The average level of perceived knowledge in stroke care before the workshop was 3.35/5. This increased to 4.4/5 perceived level of knowledge after the workshop. Overall ratings of the educational experience were excellent (46% of participants), or very good (48.3%). Conclusions: Participation in a knowledge transfer workshop to encourage uptake of best practices resulted in improvement in participants’ confidence, understanding and perceptions of their knowledge to manage post-stroke care effectively.
Evolution of Integrated Outpatient Rehabilitation Service
Parsons, J; Vance, S; Ng, V; Doull, K; Dawson, A; FH Stroke Strategy; Fraser Health, Surrey, BC
Background: Fraser Health piloted two programs for stroke survivors to support transitions across the rehabilitation continuum. The Rehab Early Discharge (REDi) pilot shifted the service delivery model from an inpatient care model to a coordinated intensive outpatient service. The pilot demonstrated measureable positive system impacts with efficiency, LOS and access while maintaining or improving patient functional outcomes. The second pilot, Stroke Assessment Rehabilitation and Transitions (Start) included strategic partnerships with Non-Government Organizations and local municipal programs, to support the delivery of community based services for stroke survivors that facilitated community transitions and self-management. The Rehabilitation Program sought to incorporate the two pilots into a new regional service; Community REDi. Methods: Regionalization of the service was completed using a developmental evaluation framework to identify critical elements, guide service design and ensure ongoing monitoring and enhancement of the service. The logic model is supported by tools such as PDSA (Plan, Study, Do, Act) cycles, staff and patient surveys and regular operational reporting. Results: Community REDi is now available in six communities across Fraser Health. Operational benchmarks are being established and validated against a capacity planning tool and operational utilization reports. Critical elements of the service include:
central intake and regional access
coordinated interdisciplinary care
clinic supervisor to support client care and program development
linkages to primary care physicians
community reintegration programming in partnership with NGO’s and muncipalities
a business model for community based services that supports ongoing sustainability with minimal fiscal responsibility for the health authority
evaluation framework for development of operational benchmarks Conclusions: Community REDi provides coordinated outpatient rehabilitation and community reintegration to promote early discharge and transition of stroke survivors across a continuum of care. Through ongoing data collection and anaylsis, evaluation is now embedded into the daily operations of the program and drives client flow and positive system impacts.
Constructing the Meaning of ‘Survivor’
Zwiers, AM; University of Calgary, Calgary, AB
Background: With advances in medicine and technology, patients are experiencing an increased ‘survival’ rate from acute stroke. ‘Survivor’ is a term often used to represent a person with a heroic disposition gained from overcoming adversity. However, the term survivor used in the context of illness may give patients a false sense of cure. Patients who suffer from acute stroke often experience chronic physical, psychological, social and cognitive deficits related to type of stroke, location, treatment and available support. Patients are also at higher risk for stroke recurrence. There is currently little qualitative research describing how patients adapt to a stroke survivor identity as they recover and rehabilitate within their communities. Methods: A qualitative grounded theory research design will be used to examine how adult patients with acute stroke understand the meaning of ‘survivor’, or define and identify with being a survivor. 15 participants, aged 40 and older, who experienced one or multiple acute strokes of varying degrees of severity, will be interviewed. Participants will also submit journal entries outlining their experiences and reasoning used to define, identify or de-identify with the term ‘survivor’. Results: The findings of this study will generate an emerging theory around the influences of survivor-ship on recovery among this population and what the term ‘survivor’ means for healthcare professionals, caregivers, and other patients. Conclusions: The language used in healthcare and communities can influence patient perspectives and outcomes. It is important to examine the terms we use to identify those who have had an acute stroke experience while providing appropriately contextualized and individualized care and support.
Timing it Right Stroke Family Support Program: Ongoing Randomized Controlled Trial
Cameron, JI1 Czerwonka, A1 Naglie, G2 Warner, G3 Green, T4 Gignac, M5 Bayley, M6 Huijbregts, M2 Cheung, A6 Silver, F6 Phillips, S7; 1. University of Toronto, Toronto, ON; 2. Baycrest Centre for Geriatric Care, Toronto, ON; 3. Dalhousie University, Halifax, NS; 4. University of Calgary, Calgary, AB; 5. Toronto Western Research Institute, Toronto, ON; 6. Toronto Rehabilitation Institute - University Health Network, Toronto, ON; 7. Capital District Health Authority, Halifax, NS
Background: Family caregivers play a central role in the recovery, rehabilitation, and community re-integration of stroke survivors. We developed the Timing it Right Stroke Family Support Program (TIRSFSP) to provide stroke families with timely education and support as they care for stroke survivors transitioning from acute care, through rehabilitation, and back to community living. The objective of this trial is to determine if receiving the TIRSFSP results in better stroke knowledge, support, and mental health outcomes for family caregivers. Methods: Family caregivers of stroke patients have been recruited from 12 acute care hospitals from across Canada to participate in a mixed methodology RCT. Caregivers are randomized to: 1) standard care, 2) Self-directed TIRSFSP, or 3) TIRSFSP delivered by a stroke support person for approximately the first 6 months post stroke. Participants complete standardized measurement instruments prior to randomization and 3, 6, and 12-months post-stroke. Six participants per research site are invited to participate in qualitative interviews. Stroke support persons are keeping journals to document each session with the caregivers. Progress To Date: Recruitment is now complete, with a total of 310 caregivers randomized. One hundred caregivers were randomized to receive standard care; 106 caregivers were randomized to receive the self-directed TIRSFSP; and 104 caregivers were randomized to receive the stroke support person delivered TIRSFSP. Of those randomized, 221 caregivers have completed their 3 month follow-up assessment, and 211 have completed their 6 month follow-up assessment. Final 12 month post-stroke follow-up data collection will be completed by October 2013. Implications: This research will help us determine if the TIRSFSP may benefit family caregivers. If proven effective, it could be recommended as a model of stroke family education and support that meets the Canadian Stroke Best Practice Guideline recommendation for providing timely education and support to families through transitions.
‘Spot Sign’ Selection of Intracerebral Hemorrhage to Guide Hemostatic Therapy (SPOTLIGHT): Rationale and Design of a Canadian Image-Guided Randomized Controlled Trial of Recombinant Factor VIIa
Gladstone, DJ1 Aviv, R1 Demchuk, A2 Hill, MD2 Flaherty, M3 Butcher, K4 Black, SE5 Mamdani, MM6 Thorpe, K6 Sahlas, DJ7 Spence, J6 De Masi, S6 Hall, J6 SPOTLIGHT Steering Committee and Investigators, O8; 1. University of Toronto, Toronto, ON; 2. Foothills Medical Centre, Calgary, AB; 3. University of Cincinnati, Cincinnati, OH, USA; 4. University of Alberta, Edmonton, AB; 5. Sunnybrook Health Sciences Centre, Toronto, ON; 6. St. Michael’s Hospital, Toronto, ON; 7. Hamilton Health Sciences, Hamilton, ON; 8. and the SPOTLIGHT Steering Committee and Investigators,
Background: Intracerebral hemorrhage (ICH) is a life-threatening stroke emergency without any approved hyperacute medical treatment. Some patients deteriorate rapidly after hospital arrival due to ongoing bleeding and hematoma expansion. Recombinant activated coagulation factor VII (rFVIIa) is a promising therapy to reduce ICH expansion, but previous trials did not select patients for treatment based on any markers of active bleeding. Focused trials targeting only the active bleeders are needed to develop this therapy further. Using CT angiography (CTA), it is possible to identify a subgroup at greatest risk for ICH expansion (‘spot sign positive’ patients) to target for hemostatic therapy; ‘spot sign negative’ patients have stopped bleeding and are not expected to respond to such treatment. This trial aims to test the feasibility, safety and preliminary clinical efficacy of a CTA image-guided emergency treatment protocol for ICH. Methods: SPOTLIGHT is an investigator-led Canadian phase II double blind multicentre randomized controlled trial approved by Health Canada. Eligible patients with an acute spontaneous spot-sign positive ICH are randomly assigned to receive rFVIIa 80µg/kg or placebo as quickly as possible within 60 minutes post-CTA and within 6 hours post-onset. Spot sign negative patients are not enrolled. Because ICH growth is highly time-sensitive and informed consent cannot always be immediately obtained, a waiver of consent option is proposed to enable expedited treatment for eligible incapacitated patients without a substitute decision maker immediately available. The primary endpoint is ICH expansion within 24 hours. Additional endpoints are scan-to-needle times, feasibility of recruitment, safety (thromboembolic SAEs), acute blood pressure protocol, neurological impairment, disability, cognition and depression. Trial recruitment is ongoing. Funded by peer-reviewed grants from Canadian Institutes of Health Research (CIHR), Ontario Stroke Network, and Ontario Ministry of Research and Innovation. ClinicalTrials.gov Identifier: NCT01359202
The INTERnational Study on Primary Angiitis of the CEntral nervous system (INTERSPACE): A Call to the World
Lanthier, S1 Calabrese, LH2 Ferro, JM3 Putaala, J4 Strbian, D4 Létourneau-Guillon, L5 Raymond, J1 Guilbert, F1 Frosch, M6 Chagnon, M7 Singhal, AB8, 6 Poppe, AY1; 1. Centre hospitalier de l’Université de Montréal, Montreal, QC; 2. Cleveland Clinic, Cleveland, OH, USA; 3. Hospital Santa-Maria, Lisbon, Portugal; 4. Helsinki University Central Hospital, Helsinki, Finland; 5. Department of Radiology, Université de Montréal, Montreal, QC; 6. Massachusetts General Hospital, Boston, MA, USA; 7. Department of Mathematics and Statistics, Université de Montréal, Montreal, QC; 8. Harvard Medical School, Boston, MA, USA
Primary angiitis of the CNS (PACNS) is a rare and life-threatening form of vasculitis confined to the CNS. Current knowledge on PACNS mainly derives from single-centre or small-sized series, implying potential biases. The affected vessel size, appropriate diagnostic process, optimal treatment, markers of treatment response, and prognosis remain controversial. INTERSPACE is an ongoing, international, multi-centre, prospective, cohort study, designed to describe clinical manifestations, investigation results, diagnostic process, misdiagnoses, current treatments, and outcomes (treatment failures and recurrences) in 200 PACNS patients. Its primary objective is to identify predictors of death or dependence (modified Rankin Scale: 3-6) following >1 year of clinical follow-up. Eligibility criteria are age >15 years, acquired neurological dysfunction consistent with PACNS, imaging study of CNS vessels or CNS histopathology consistent with PACNS, and exclusion of conditions that may mimic PACNS. Exclusion criteria are immunosuppressive therapy initiated before obtaining MRI of the CNS or >30 days before study enrolment, and study consent not signed. Data on INTERSPACE participants are collected in a web-based database (accessible at www.youngstrokenetwork.org) at baseline and during clinical follow-up. Diagnosis of PACNS and outcome events (treatment failure and recurrence) are adjudicated to maximize validity of INTERSPACE. Multivariate analysis will identify predictors of death or dependence. Assuming death or dependence at the end of follow-up in 60 participants (30% of 200 participants), as much as 6 predictors may be identified and integrated to the multivariate model. Since October 2012, 3 study subjects were enrolled from 2 active study sites. In 2013, 5 more sites were activated and 24 are in the process of ethics approval. Fourteen American, European and Asian countries are represented. Assuming recruitment of 0.5 participant/site/year, 69 additional sites must join INTERSPACE to complete enrolment and follow-up of 200 adjudicated PACNS patients in 5 years. Please contact firstname.lastname@example.org to submit your site candidature.
The Effect of Combined Upper Limb Rehabilitation and Botulinum Toxin Injections on Electrophysiological, Clinical, and Behavioural Outcomes in Post-Stroke Spasticity
Bhatt, H1 Danells, C1 Sharma, S2 Mochizuki, G1; 1. Heart and Stroke Foundation Centre for Stroke Recovery, Sunnybrook Research Institute, Toronto, ON; 2. Sunnybrook Health Sciences Centre, Toronto, ON
Background: Approximately 40% of stroke survivors will develop spasticity within the first year after stroke. Focal injections of Botulinum toxin (BoNT-A) into the affected muscles is a common option for spasticity management. This approach has been shown to reduce spasticity and pain; however, the evidence for improved functional outcomes using this management strategy remains equivocal. Contributing to this may be the type of adjunctive therapy used with the injections or the selection of outcome measures. The purpose of this study is to compare the effects of a combined BoNT-A/upper limb movement training approach versus a combined BoNT-A/functional rehabilitation approach on electrophysiological, clinical and behavioural outcomes in stroke survivors with spasticity in the upper limb. Methods: In this randomized single-blind crossover design study, participants are randomized to 10 weeks/3x week of movement training followed by a 12 week washout or 10 weeks/3x week of functional neurorehabilitation followed by a 12 week washout. Participants then cross over to the alternate therapy. Assessments are done at baseline then at 4, 8 and 10 weeks after the administration of BoNT-A. Primary electrophysiological outcomes are surface EMG amplitude and timing, EEG amplitude and frequency and single motor unit discharge rate and variability. Secondary outcomes include clinical (MAS, CMSA) and behavioural (kinetics, kinematics) measures. Results: To date, 11 participants have been enrolled in the study (mean age = 58.3±15.9 years, 7 male). The median elbow MAS score at intake is 1+ and the median CMSA hand and arm stages are 2 and 2, respectively. Rate of recruitment is 52.4% and study adherence is 100%. Conclusions: This clinical trial aims to identify a neurorehabilitation intervention that, when coupled with BoNT-A injections, enhances recovery in stroke survivors with upper limb spasticity. This will contribute to the growing body of work probing the capacity for functional recovery in individuals with spasticity after stroke.
Supporting Therapists to Integrate Virtual Reality Systems Within Clinical Practice: a Knowledge Translation Study
Levac, D1 Glegg, S2 Sveistrup, H1 Finestone, H3 Miller, P4 Brien, M5 Miller, P4 DePaul, V4 Wishart, L4 Harris, J4; 1. University of Ottawa, Ottawa, ON; 2. Sunny Hill Health Centre for Children, Vancouver, BC; 3. Bruyere Research Institute, Ottawa, ON; 4. McMaster University, Hamilton, ON; 5. Ottawa Children’s Treatment Center, Ottawa, ON
Virtual reality (VR) systems are promising treatment options for physical therapists (PTs) and occupational therapists (OTs) in stroke rehabilitation because they incorporate motor learning principles of task-oriented, challenging, and motivating practice. However, clinicians face challenges when integrating VR into clinical practice, including limited availability of training that supports the implementation of VR-based therapy with a motor learning focus. Untrained therapists may deliver sub-optimal intervention as they are unprepared to use VR systems effectively. Training support is required if therapists are to become competent at transferring gains made in VR-based therapy to better functioning in the real world. This poster describes the methods of an ongoing knowledge translation (KT) study to develop, implement and evaluate a KT strategy to promote motor learning-based integration of GestureTek’s Interactive Rehabilitation Exercise (IREX) and Gesture Xtreme (GX) systems into clinical practice in two stroke rehabilitation units. The KT initiative includes e-learning modules, experiential workshops, and audit and feedback. The 3 e-learning modules provide foundational knowledge about evidence for VR use in neuro-rehabilitation, neuroplasticity, motor learning principles, IREX/GX game characteristics, setting SMART goals, and implementing motor learning strategies. The format includes pre- and post-module confidence logs, interactive knowledge checks, and video clips. Experiential learning with the GestureTek system occurs in group and individual formats. Audit and feedback is provided to participants through individual practice sessions and video stimulated recall sessions. Outcome measures evaluate participant knowledge and skills and the feasibility of both KT methods and VR implementation. This is the first study to evaluate a KT strategy focusing on motor learning-based VR interventions. The KT strategy is generalizable to other VR systems and can be implemented on a wide scale. The goal is to provide clinicians with skills to utilize VR to yield high quality evidence and enhanced outcomes for stroke rehabilitation clients.
Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion with Emphasis on Minimizing CT to Recanalization Times ESCAPE)
Hill, MD1, 2 Demchuk, AM1, 2 Goyal, M1 Menon, BK1, 2 Eesa, M1 Al-mekhlafi, M1 Desai, J1 Mishra, S1 Ryckborst, KJ1 The ESCAPE Investigators1; 1. University of Calgary, Calgary, AB; 2. Hotchkiss Brain Institute, Calgary, AB
Background: There is no convincing, randomized trial evidence that modern endovascular therapy is better than routine care, including routine intravenous thrombolysis, for acute ischemic stroke. There is nevertheless, strong evidence that endovascular therapy can result in faster, more complete recanalization (high recanalization rates of about 80%) and that this should result in better stroke outcomes. Objective: The primary objectives are to show that rapid endovascular revascularization amongst radiologically selected (small core/proximal anterior circulation occlusion) patients with ischemic stroke results in improved outcome compared to patients treated in clinical routine. The secondary objectives of this study are to demonstrate the safety and feasibility of achieving rapid endovascular revascularization in this population of patients (<90 min CT-recanalization; <120 min ESCAPE-center door to recanalization). Design: A Phase3, randomized, open-label with blinded outcome evaluation, controlled design. Population Studied: The study will test the hypothesis that patients undergoing endovascular revascularization will show a 20% absolute risk benefit (RR = 1.5 relative benefit) over patients receiving clinical routine care. The assumed rate of good outcome in the control arm is 40% and 60% in the treatment arm. With 85% power and no interim analyses for efficacy, the sample size consists of 242 evaluable patients (141 in each group). Sample size is inflated to 250 for crossovers, loss to follow-up etc. Intervention: Subjects with a small core of infarction, proven large artery anterior circulation occlusion, good collaterals within a 12-hour window will receive routine guideline-based best medical care (including IV-tPA as appropriate in a 4.5h window). Control arm subjects will receive best medical care. Intervention/experimental arm subjects will additionally receive endovascular thrombectomy or thrombolysis. Outcome measures: Primary efficacy outcomes are NIHSS score 0-2 OR mRS 0-2 at 90 days.
Trial Status: Active, Recruiting - Email: email@example.com
Thrombolysis for Minor Ischemic Stroke with Proven Acute Symptomatic Occlusion Using TNK-tPA (TEMPO-1)
Mandzia, JL1 Coutts, SB1, 2, 3 Kenney, C1, 2 Hill, MD1, 2, 3; 1. Calgary Stroke Program, Calgary, AB; 2. University of Calgary, Department of Neuroscience, Calgary, AB; 3. Hotchkiss Brain Institute, Calgary, AB
Background: Minor stroke and TIA are associated with a risk of early major stroke, especially when a major vessel occlusion is present, seen acutely in 10-30% of these patients. TNK-tPA (TNKase) compared to alteplase is easier to administer, has a longer half life, higher fibrin specificity, and a possible lower rate of intracranial hemorrhage. Therefore it may be an ideal thrombolytic agent in this population. Methods: TEMPO is a multi-centre, prospective cohort, TNK-tPA dose-escalation, safety and feasibility trial. Patients with TIA or minor stroke with an NIHSS < 6 and within a 12h treatment window will be enrolled. Patients must have an arterial occlusion on CTA and not show signs of well-evolved infarction on NCCT. 50 patients will be enrolled. The first 25 patients will be treated at a dose of 0.1 mg/kg. Assuming safety, a second cohort of 25 patients will be treated at a dose of 0.25 mg/kg. Primary outcomes will be rate of symptomatic intracranial and extracranial hemorrhage and feasibility of enrolment and treatment. Secondary outcomes include complete neurological (NIHSS 0-1) and functional (MRS 0-1) recovery at 90 days, recanalization at 4-8 h and minor bleeding. Results: 16 patients (mean age 69.7, 50% males) have been enrolled at the University of Calgary since July 2012 with a mean baseline NIHSS of 2.4. Site of intracranial occlusions were: M1 (2), M2 (10), M3 (2), P2 (1) branches and vertebral artery/PICA (1). Recanalization rate between 4-8 h was 25 %. There were no complications. Conclusion: Assuming safety of this approach in both dose tiers, we will pick the higher of the two doses and proceed with a randomized trial in this population. An international trial would be required with 500 patients to show a 10% treatment effect size.
Funding: Heart & Stroke Foundation Alberta, Alberta Innovates Health Solutions.
- © 2013 American Heart Association, Inc.
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